Ankle and foot Flashcards
Components of ankle joint
inferior surface of tibia - transfers weight
lateral and medial malleolus - stablises
Superior surface of talus - transfer wt to calcaneous and fore foot
Medial and lateral surface concave
Describe the movement at the ankle joint
Tibia always in contact
Lateral malleolus changes in positions
Plantiflexion - joint relaxed and lateral malleolus not touch. Slight side movement possible
Dorsiflexion forces movement of fibula due to the talus being wider anteriorly and bigger then morest
Hinge joint = flex and extension only and supported by ligament due to this
Describe the ligaments of ankle
Deltoid ligament
- deep part: Posterior tibiotalar ligament
- Superficial part: Tibiocalcaneal ligament
attaches to the sustentaculum tali (Strongest), Anterior tibiotalar ligament, Tibionavicular ligament.
Lateral ligament
Posterior talofibular ligament
Anterior talofibular ligament
Calcaneofibular ligament
Posterior tibiofibular ligament
Anterior tibiofibular ligament
Joints of foots
Talocalcaneal joint Transfers wt Talocalcanonavicular joint transfers wt Inversion and eversion Ball and socket head of talus is ball Socket is form by the navicular, spring ligament and sustentaculum tali (at 2 sites) Talus articulates with calcaneous in 3 areas
Describe the cutaneous nerves of dorsal foot
Superficial nerve - dorsum of foot
pathway - divides above the ankle into medial and lateral branches
Sural - lateral foot and ankle
pieces crura fascia halfway down the calf
Saphenous - medial up to 2 MTP joint
divides into anterior and posterior above the medial malleolus
Deep fibular nerve - lateral of 1st digit and medial of 2rd digit.
cross lateral to dorsals pedis and then arises
Veins of dorsal of foot
Dorsal arch to greater and lesser saphenous
Describe the fascia of foot
Deep fascia over foot and thickening to produce reticulum
Tendons of the dorsal of foot
Tibialis anterior Extensor hallucus longest Extensor digitorum longest Fibularis tertius Each have a synovial sheath
Muscles of dorsal foot
Extensor hallucus brevis N - deep fibular nerve Extensor digitorum brevis N - deep fibular nerve dorsal Interosseos muscle
Artery of dorsal foot
Dorsalis pedis - lateral to extensor hallucis longest and then between 1 and 2rd metatarsal and divides deep to anastomosis
describe the skin on the plantar surface
Thin in arch and toe
Thick in ball and pad.
Fat for shock absorption
Anchored to plantar aponeurosis to allow grip
Describe the cutaneous innervation of plantar surface
Branches of tibial n
Medial calcanea nerve - heel of foot then divides
Medial plantar - Pink - Supplies the first plantar surface and 3 medial toe
Lateral plantar - Yellow. distal lateral surface and 1 and 1/2 toes
Saphenous - blue Medial proximal
Sural - Red. lateral proximal area.
Muscles of the 1st layer of plantar surface
Under plantar aponeurosis (o- calcaneous tubosity, inserts at digits, bifurcate to allow tendons through)
Abductor hallucis
Flexor digitoriumbrevis
Abductor digiti minimi
Describe the abductor hallucis
O medial tubercle of tuberosity of calcaneous + flexor retinaculum + plantar aponeurosis
I - medial side of base of proximal phalanx of 1st digit
N - Medial plantar nerve
A - Abd and flexes great toe
Describe Flexor digitorium brevis
O - Medial tubercle of tuberosity of calcaneous + plantar aponeurosis +intermuscular septa
I - Bother sides of phalanges of later four digits
N - Medial plantar nerve
A - Flexes lateral four digits
Describe Abductor digiti minimi
O - Medial and lateral tubercles of tuberosity of calcaneus +plantar aponeurosis + inter muscular septa
I - Lateral side of base of proximal phalanx of 5th digit
N - Lateral plantar nerve
A - Abd and flexes 5th digit
Muscles of 2rd layer of plantar aspect
Quadratus plantae
Lumbricals
Flexor Hallucis longus
Flexor digitorum longus
Describe Quadratus plantae
O - Medial surface and lateral margin of plantar surface of calcaneous
I - Posterolateral margin of tendon of flexor digitorum longus
N - lateral plantar nerve
A - assists flexor digitorium longus in flexing lateral four digits
Describe Lumbricals
O - tendons of flexor digitorum longus
I - medial aspect of expansion over lateral four digits
N - Medial one is medial plantar nerve and lateral three is lateral plantar nerve
Describe the muscles of the 3rd layer of plantar surface
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi
Describe Flexor hallucis brevis
O plantar surfaces of cuboid and lateral cuneiforms
I Both sides of base of proximal phalanx of 1st digit
N- medial plantar
A - flexes great toe’s metatarsophalangeal joint
Description: Covers metatarsal 1, splits into two bellies,
Describe Adductor hallucis
O - from bases of metatarsal 2-4 and from fibulas longs tendon sheath (oblique) from a ligament across metatarsophalageal joints
I - Base of proximal phalanx of great toe, lateral side
N - Lateral plantar nerve S2-3
A - Helps maintain the transverse arch of foot weak adductor of great toe
Description: Oblique and transverse heads, deep to lumbricals
Describe the flexor digiti minimi
O - Base of metatarsal 5 and tendon sheath of fibulas longs
I - base of proximal phalanx of toe 5
N - lateral plantar nerve
A - Flexes little toe at metatarsophalangeal joint
Description: covers metatarsal 5
Describe the contents of the 4th layer
Plantar and dorsal interossei O - Metatarsal I - proximal digits N Lateral plantar nerve Tendon of fibulas longus Tendon of tibialis posterior
Ligament of plantar foot
Long plantar ligament O - Calcanous tubosity I 4 metatarsal Short plantar ligament (Calcaneocuboid) O - same I - Cuboid bone Spring ligament (plantar calcaeonavicular ligament O - sustentaculum tali I Navicular Inmoble form joint
Innervation of plantar foot
Tibia nerve>medial and lateral plantar n Lateral plantar Medical plantar nerve Larger Skin >muscles Medial 3 digit Didgt nerve supplies the great toe
Arterial and veins supply of plantar foot
Posterior tibia artery > Medial and lateral artery
Medial plantar artery
Lateral plantar nerve
Curve medially to form an arch and joins dorsals pedis and form plantar arch
Gives raise to digit branches
Vena commatanie
Drain to deep veins unlike the dorsum which drain to superficial veins
Describe the medial longitudinal arch
Bone: Calcaneous, talus, navicular, 3 cunieform and 3 metatarsal bases
Bone not stabilise - shape of bones in arch
Ligament - inadequate
Plantar aponeurosis
Spring ligament - head of talus
Interoessuous ligament particular the talus and calcaneous one
Muscle
Flexor hallucis longus - most important
Short muscle of the foot -1st layer
Tibialis posterior and anterior - weaker
Describe the lateral arch
Calcaneous, talus, cuboid and 2 metatarsal bases - no stability
LIagment
Plantar aponeurosis - bow spring
Long and short plantar ligaments
Muscles
Fibularis longus Tendon - most important
Lateral 2 tendon of flexor digitorum longest
1st layer lateral muscles
Describe the Transverse arch
Cuboid and 3 cuneiform and base of all 5 metatarsals - none
Ligaments
Ligament of metatarsal and cuneiform bone together
Transverse metatarsal ligament
Muscles
Fibularis longus tendon - most important.
Components of the thoracic cage
Sternum Costal cartilage Ribs Thoracic vertebrae Intervertebrae disc
describe the sternum
Manubrium
Wider laterally
Jugular notch
Lateral is clavicular notch
Lateral to that is the costal cartilage attachment of 1st rib
Narrows inferiorly where it forms a synthesis with the body of sternum
Hyaline cartilage with fibrocartilage disc between. 2rdary cartilaginous joint.
2rd Rib articulation here
Body of stern
Flat and made of 4 bone that fuse at 25 yr old
lack of fusion of L to R =forament
Xiphoid process
Fuse to sternum at joint
Describe the costal margin
1-7 true 1st is usually fused 2-7 ribs: Synovial joint with fibrocartilagous joint to allow movement. Sternal costal ligament that strengthen the joint. 8-10 false 11-12 floating Function Allow movement during respiration
Describe the thoracic vertebrae
Body - heart shaped Articular facet Demi facet Vertebrae arch pedicle lamina Spinous process Transverse process Facet for tubercle of rib Vertebrae foramen
Describe Thoracic ribs
Head - widen with superior and inferior facet
Neck - narrow between head and tubercle
Tubercle
Facet and attachment of costotransverse ligament
Inferior edge
Costal groove - neurvascular bundle.
anterior end - cup shaped and costal cartilage here
Superior and inferior margin for muscles attachment except the 1st and 12th rib
1st rib = half the length and boarder and curved only articulate with T1 not C7
10-12 ribs only one facet as it only articulates with one vertebrae
11-12 ribs are short and have no neck or tubercle thus no articulation with transverse process
Describe the joints of thoracic cage
Costal joint - discussed above
Costovertebral joints
Head of rib articulates with superior facet of it’s own vertebrae and inferior facet of vertebrae above it.
Supported by interarticular ligament to IVD
Costotransverse joint (only on ribs 3-9) (1-2, 10-11-12 have larger ROM due to absence of this joint)
Transverse process articulates with tubercle of it own rib
Supported by costotransverse ligament and lateral costotransverse ligament (tubercle) and superior costotransverse ligament (neck of rib to transverse process of vertebrae above).
Muscles of anterior thoracic wall
External intercostal Internal intercostal Innermost intercostal Subcostal Transversus thoracis
Describe the external intercostal
Hands in pocket
Elevates ribs during forced inspiration
at the costal cartilage the muscle turns into the external intercostal membrane (aponeurosis)
Describe Internal intercostal
hands in opposite pockets
Interosseous part - depresses rib
Interchandral part - elevates ribs
Runs from sternum to angle of the rib where it become the internal intercostal membrane
Describe the innermost intercostal
same as internal intercostal muscle. Neurovascular bundle travels between.
Describe the subcostal
Lay on angle of the rib. Not always present and cross 2-3 ribs
Describe the transverses thoracis
4 to 5 splits
O - Xphoid process and posterior surface of lower sternum
I - internal surface of costal cartilages 2-6. Fan out
Describe the neurovascular bundle of the intercostal spaces
Sit in subcostal groove between internal intercostal muscle and innermost
Tube insertion position
Blocks need to be done and multiple levels due to innervation lap out
Intercostal nerve from spinal roots of T1-11,
intervertebral foramen then communications of sympathy chain (SNS and PNS)
Branches
Intercostal nerve - inferior margin of rib
Collateral branch - superior margin of rib
Lateral cutaneous branches (lateral thoracic wall) piece the external muscle and internal intercostal muscle then branch into posterior and anterior branch to supply lateral wall (not in first space)
Anterior cutaneous branches piece the external muscle aponeurosis and internal intercostal muscle then branch into medial and lateral branch to supply anterior and lateral wall. (not in first space)
Describe the areas that the nerve 5-12 supply
Skin Abdominal muscles Intercostal muscle subcostal Transversus thorscis Serratus posterior
Describe the dermatomes of the thorax
The thoracic and abdomen wall is supplied by intercostal and subcostal nerve
Umbilicus = T10
Nipple level = T4-5
Collar = C3
below collar but above sternal angle is C4
No overlap between C4 and T2
Arteries that supply thoracic wall
Branches of subclavian A: Internal thoracic artery and Supreme intercostal arteries
Posterior intercostal artery
Subcostal artery
axillary artery
Describe the internal thoracic artery
lays lateral to the sternum running inferiorly
supplies
anterior intercostal arteries to spaces 1-6
collateral branch - travel superior to rib
Larger than the posterior, anastomosis
Pericardium
Thymus
sternum
2-4 intercostal artery supplies breast?
Terminal branch - divides into superior epigastric and musculophrenic arteries at the 6th intercostal space
Describe the supreme intercostal arteries
supplies the 1st and 2rd intercostal spaces
there is no posterior intercostal branch at this level. the supreme branches from this subclavian and then head posterior prior to wrapping anterior to for fill a similar role as the posterior intercostal artery
Describe the posterior intercostal artery
travel in costal groove sandwich between the veins and nerve
give collateral artery as well
close to the angle of the rib the arteries enter the costal grooves, where they lie between the intercostal vein and nerve. At first the arteries run in the endothoracic fascia between the parietal pleura and the internal intercostal membrane then run between the two muscles.
Describe subcostal artery
supplies the 12th rib space and muscles of anterolateral abdominal wall
travel along the inferior border of 12th rib
Describe the venous drainage of thorax
each level has 1 posterior and 2 anterior veins
Anterior
drains into the muscophrenic and internal thoracic vessels
Posterior
1st intercostal vein drains straight into the brachicephelic vein bilaterally
Right 2rd and 3rd intercostal vein join to form the superior intercostal vein and drain into the azygos
2-3rd can drain either to brachiocephalic or accessory hemiazygos vein
4-8rd space drains to accessory hemiazygos vein
Hemiazygos starts in the abdomen at the L renal vein.
Left first rib can do either brachiocephalic or accessory hemiazygos vein
Others
Superficial vein radiate from umbilicus. if below the umbilicus they drain to great saphenous.
If above lateral thoracic then axillary
or to portal system
Boundaries and contents of superior apertures
Bourdaries: anterior jugular notch, clavicular notches of manlunum, 1st rib and vertebrae body
Contents: Trachea, oesophagus, great vessels, nerve.
boundaries and contents of inferior apertures
Boudaries: xiphisternal joint anterior, costal margins and 12th rib posterior
Closed by diaphragm
Position of chest tube
Chest tube: 4th intercostal space in anterior axillary line.
Avoids the long thoracic nerve and liver
inserted superior to the 5th rib
Describe the structure of diaphragm
Muscluar - radiate
anterior - horizontal
Posterior ventral
central Tendon - at level of xiphisternum
describe the structures that pass through the diaphragm
T8 = IVC
Via the central tendon. When diaphragm contracts the opening is opened and increase venous return to heart.
R phrenic n and Lymph vessel pass
T10 = Oesophagus
Muscular part
Anterior and posterior vagal trunks pass as well
vein and lymph as well
T12 = Aorta
Pass behind the median arcuate ligament
azygous vein and thorax duct
Hemiazygos vein passing through the L crura
Splenic nerve piece each crura
Sympathic trunk passing behind the medial arcuate ligament
subcostal nerve and vessel pass under the lateral arcuate ligament
Left phrenic nerve pieces the L dome lateral to pericardium
Neurovascular bundles T 7 to T 11 that pass between digitation of of the attachment to costal margins
Superior epigastric pass between the xiphisternum and costal margins of the diaphragm
Describe the attachment of diaphragm
Crura - attaches to L1-3 on R and L1-2 on L
R crura divides to the left to surround the oesophagus and together with L form the median arcuate ligament.
Lateral to mid line is the medial and lateral arcuate ligament that anchor the diaphragm to posterior wall. This allows the psoas major and quadrates lumborum muscles to pass.
Describe the blood supply of diaphragm
From the lower 5 intercostal and subcostal arteries
Abdominal side is supplied by inferior phrenic arteries from the aorta
Innervation of diaphragm
Phrenic nerve (C3,4,5)
Descend posteriolateral to internal jugular veins
Descend anterior to root of lungs on the surface of pericardium
R is associated with venous- descends Posterior to SVC, R artium of heart and then passes through the IVC of diaphragm
L is associated with arterial - descends between the carotid and subclavium arteries and lays of aortic arch and then the Left auricle and ventricle and pieces diaphragm lateral to pericardium through the muscles
Both divide into anterior, posterior and lateral branches
Describe the function of diaphragm
Inspiration
Opens IVC increase venous return
Sphincter to oesophagus
describe the movement of thorax
Increase in diameter in all three planes.
Pump- handle movements
Direction of movement. A-P.
Joint: Manbosternum joint, Costovertebral joints
True ribs
Muscles: Intercostal
Bucket handle movement
Direction of movement:Lateral, transverse
Joint: 8-12 ribs
Muscles: abdominal muscle hold 12th rib
Diaphragm
Direction of movement: vertical
Muscles: Diaphragm
Quiet inspiratory: intercostal and scalene
Deep inspiratory: Accessory muscles added
Expiratory : Abdominal muscle
