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LOWER LIMB > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

tibialis posterior

A

attaches to tuberosity navicular, 2-4 mets, all tarsals except the talus

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2
Q

extensor expansions

A

Extensor Expansions – produced by expansion of the extensor tendons
o Fibrous flexor sheaths- attached sides proximal/middle phalanges/ IPJ capsules
 Form inferior/ateral walls that house tnedons of flexor m
o Short Vincula- fibrous membrane like, connect bony phalanges w/ distal FDL & FDB tedons
 Carry blood vessels
o Long Vincula- proximal to the short
 Proximal & Distal portion
 Cord-like > attach dorsal aspect of tendon bone
 Carry blood vessels

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3
Q

superficial peoneal retinaculum

A

o Superior peroneal retinacula (14)
 crosses superficial to tendons of peroneus brevis and peroneus longus muscles
 common synovial sheath for peroneus longus and brevis
 Attachments:
• Anteriorly (begins) – posterior border of lateral malleoulus
• Posteriorly (attachment) - lateral surface of calcaneus & tendo calcaneus

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4
Q

inferior peroneal retinaculum

A

 Attachments:
• Anteriorly – lateral rim of sinus tarsi
• Posteriorly – lateral surface of calcaneus & peroneal trochlea
• Between ant & post attachments DEEP FIBERS form:
o Superior tunnel of peroneus brevis tendon
o Inferior tunnel for peroneus longus tendon
Note: Inferior peroneal retinacula often described as having deep and superficial fibers – only deep fibers form tunnels.

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5
Q

flexor retinaculum

A
  • Triangular in shape (attachments):
    o Apex – attached to anteromedial inferior surface of medial malleolus
    o Base – attached to superior border of abductor hallucis muscle & medial process of calcaneus
    o Anterior border – continuous with dorsal aponeurosis
    o Posterior border – continuous with deep fascia of leg
  • Forms roof of tarsal tunnel (talocalcaneal) – which houses:
    o 1st compartment
     tibialis posterior
    o 2nd compartment
     flexor digitorum longus tendon
    o 3rd compartment
     posterior tibial artery/vein
     tibial nerve
    o 4th compartment
     flexor hallucis longus muscle tendon
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6
Q

plantar aponeurosis

superficial

A

Origin: Calcanela Tuberosity 1-2 cm wide
Superifical Transvrse Metatarsal Ligament = ball of foot transverse fibers
o Superficial fascia
 Thicker in areas in contact with floor
 Connected to skin by connective tissue septa
 Fat – compartmentalized by fibers (connecting superficial fascia to skin & deep fascia)
• Act as shock absorbers

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7
Q

deep plantar aponeurosis

A

 Plantar aponeurosis – specialized, 3 part structure
• Thick, strong layer – fibers longitudinally orientated
• FDL pass through to insert on fibrous sheath
• Central part (9) – thickest
o Attachments:
 Posteriorly – medial process of calcaneal tuberosity
o Becomes thinner as approaches anterior aspect of the foot
o Metatarsal heads – divides into 5 processes – one for each digit
 digital processes divide: deep & superificial layers
• superficial stratum – attached to skin of transverse sulcus
• deep stratum – divides into 2 slips
o either side of flexor tendons, each digit
o ends by blending with tendon sheaths
Note: between processes – digital nerves, vessels, and lumbrical tendons become superficial.
Note: Laboratory term – digital slips of plantar aponeurosis
• Lateral part (11) – Calcaneometatarsal ligament
o superficial to abductor digiti minimi muscle
o thin distally; thicker proximally (forms strong band between lateral process of calcaneal tuberosity & base of 5th metatarsal)
• Medial part (10) –
o Superficial to abductor hallucis
o Posterior attachment: flexor retinaculum
Extend into Digital slips of the Plantar Aponeurosis
Superifical layer- attaches to skin
Depp layer- splits allowing FDL to pass through it
Termination: blend w/ fibrous digital sheaths

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8
Q

vertical intermuscular septa

A 
	Vertical septa
	pass deep into the foot from junction between lateral & central, medial & central parts of plantar aponeurosis
	divide plantar muscles into 3 compartments
•	medial compartment 
o	intrinsic muscles of the 1st digit
•	lateral compartment 
o	intrinsic muscles of the 5th digit
•	central compartment 
o	quadratus plantae
o	flexor digitorum brevis
o	lumbricals
o	interosseous muscles
Note:  the muscles of the foot are better described in layers (to follow).
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9
Q

transverse septa

A

 Transverse septa
• Arises from vertical septa
• Divides plantar muscles into four layers (superficial to deep)
o See below “Muscles of the Plantar Surface”

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10
Q

layer 1

abductor hallucis

A
  • Large muscle
  • Proximal expanded part
    o Covers entrance (porta pedis) of plantar vessels & nerves into foot
  • Origin:
    o Medial process of calcaneal tuberosity
    o Plantar aponeurosis
    o Flexor retinaculum
    o Intermuscular septum (between abductor hallucis & flexor digitorum brevis)
    Hint: “Think 4 things medial and superficial”
  • Insertion:
    o Passes distally, inserts via flattened tendon
     Medial side, plantar surface, base of proximal phlanax of 1st digit (same as flexor hallucis brevis)
    o Some fibers may attach – medial sesamoid of 1st metatarsophalangeal joint (yet again common with flexor hallucis brevis)
  • Innervation:
    o Medial plantar nerve
  • Action:
    o Abducts 1st digit
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11
Q

layer 1

flexor digitorum brevis

A
  • Deep to central part of plantar aponeurosis
  • Deep surface – lateral plantar vessels & nerve lie under it
  • Origin:
    o Medial process of calcaneal tuberosity
    o Plantar aponeurosis
    o Medial intermuscular septa
    o Lateral intermuscular septa
  • Insertion: (TA 413)
    o Passes distally – divides into 4 tendons (one for each lateral digit)
     Each tendon runs into tendon sheath of flexor digitorum longus
    • Reaches base of proximal phalanx – divide: two slips
    o Slips diverge, surround tendon of flexor digitorum longus
    o Slips reunite, lie deep to flexor digitorum longus
    o Slips re-diverge, insert into middle phalanges of lateral 4 digits
  • Innervation:
    o Medial plantar nerve
  • Function:
    o Flexor of proximal interphalangeal joints (digits 2-5)
    o Flexor of metatarsophalangeal joints (digits 2-5)
  • Variations:
    o Tendon to 5th digit may be absent
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12
Q

layer 1

abductor digiti minimi

A
  • Lies superficial, lateral margin of foot
  • Origin:
    o Lateral process of calcaneal tuberosity
    o Medial process of calcaneal tuberosity
    o Depression between lateral & medial tuberosity
    Hint: “the A in Lateral or Medial LAP or LA acronym”
  • Insertion:
    o Passes through groove on plantar surface of 5th metatarsal
    o Inserts into lateral side, plantar surface, base of proximal phalanx of 5th digit
    (same as flexor digiti minimi brevis)
  • Innervation:
    o Lateral plantar nerve branch to abductor digiti minimi (motor)
  • Functions:
    o Abduct 5th digit
    o Flex 5th digit
  • Variations:
    o Accessory insertion into base of 5th metatarsal (styloid process)
     If present forms separate muscle – abductor os metatarsi digiti minimi
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13
Q

layer 2

quadratus plantae

A
  • Origin:
    o Two heads – origins separated by long plantar ligament
     Medial head, larger – originates on medial process of calcaneus
     Lateral head, smaller – originates on lateral process of plantar surface of calcaneus
     Long planter ligament between
  • Insertion:
    o Fibers from two heads unite & insert on flexor digitorum longus tendon
  • Innervation:
    o Trunk of lateral plantar nerve (red)
  • Function:
    o Accessory flexor of lateral 4 toes
     Assists flexor digitorum longus
    • Puts tension on the tendon
    • Straightens the line of pull of long flexors
  • Variations:
    o Either lateral head or the entire muscle may be absent
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14
Q

layer 2

lumbricals

A
  • 4 muscles, numbered medial to lateral
  • Origin:
    o Flexor digitorum longus tendons
    o 1st lumbrical
     Medial side of most medial tendon (only)
    o 2-4th lumbricals
     Adjacent sides of flexor tendons
    o Course:
     Lumbricals pass distally w/ flexor tendon (forms lateral origin)
     Cross medial side of metatarsophalangeal joint -> continue along medial side of digits (2-5)
    • all cross superficial to deep transverse metatarsal ligament
    Note: Pass plantar side of ligament. Interossei pass on dorsal side.
  • Insertion:
    o Medial surface, extensor expansion (slightly dorsal to horizontal plane)
     1st lumbrical – extensor expansion of 2nd digit
     2nd lumbrical – extensor expansion on 3rd digit
     3rd lumbrical – extensor expansion on 4th digit
     4th lumbrical – extensor expansion on 5th digit
    Note: Their tendons form part of the “wing” of the extensor hood
  • Innervation:
    o 1st lumbrical medial plantar nerve
    o 2-4th lumbricals deep branch of lateral plantar nerve
  • Function:
    o Flex metatarsophalangeal joints
    o Extend interphalangeal joints
    Note: see extensor expansions for mechanism
  • Variations:
    o One or more lumbricals may be absent
    o 3rd or 4th lumbricals may be doubled
    o May insert directly into bone of proximal phalanx instead of extensor expansion
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15
Q

tendons of 2nd layer

A
  • Flexor Digitorum Longus

- Flexor Hallucis longus

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16
Q

3rd layer

flexor hallucis brevis

A
  • Origin: (two heads of origin)
    o Lateral head
     Cuboid (near peroneal groove)
     Lateral cuneiform (area adjacent to cuboid)
     Long plantar ligament (occasionally)
     Short plantar ligament (occasionally)
    o Medial head
     Deep fibers
    • Tibialis posterior tendon
     Superficial fibers
    • Intermuscular septum (between medial & central compartments)
  • Insertion: (TA 414)
    o Muscles pass towards 1st digit -> fibers fuse briefly -> fibers divide (2 bellies)
     Medial head
    • Medial side, plantar surface, base of proximal phalanx
    • Medial sesamoid bone
    • Plantar pad of hallux (same as abductor hallucis)
     Lateral head
    • Lateral side, plantar surface, base of proximal phalanx
    • Lateral sesamoid bone
    • Plantar pad of hallux (same as adductor hallucis)
-	Innervation:
o	Medial plantar nerve 
-	Function:
o	Flexes 1st metatarsophalangeal joint
-	Variations:
o	Attachment to cuboid may be absent 
o	Additional insertion into proximal phalanx of 2nd digit
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17
Q

3rd layer

adductor hallucis

A
  • Origin: (two heads)
    o Oblique head
     Plantar surface, bases of 2-4th metatarsals
     Peroneus longus tendon (in common with flexor digiti minimi brevis)
    o Transverse head
     Plantar plates
     Plantar metatarsophalangeal ligaments (3-5)
     Deep transverse metatarsal ligament
    Note: origin of both heads is highly variable
  • Insertion:
    o Lateral side, plantar surface, base of proximal phalanx
    o Lateral sesamoid bone
    o Plantar pad of hallux (same as abductor hallucis)
    o Note: all the same as Lateral head of Flexor Hallucis Brevis
  • Innervation:
    o Deep branch of lateral plantar nerve
  • Function:
    o Adducts 1st toe at 1st metatarsophalangeal joint
  • Variations:
    o Portion may insert into 1st metatarsal
     Forms opponens hallucis muscle
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18
Q

3rd layer

flexor digiti minimi brevis

A
  • Origin:
    o Plantar surface, base of 5th metatarsal
    o Tendon of peroneus longus
    o Plantar aponeurosis
  • Insertion:
    o Plantar surface proximal phalanx of 5th digit
    (same as abductor digiti minimi of 1st layer)
  • Innervation:
    o Superficial branch of lateral plantar nerve (motor)
  • Function: (Note: same actions as abductor digiti minimi)
    o Flex 5th digit
    o Abduct 5th digit
  • Variations:
     Deep fibers may form part of separate muscle - Opponens digiti minimi
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19
Q

4th layer

plantar interossei

A 
Plantar Interossei (3 muscles) 
-	Origin:
o	Medial sides base of shafts of 3rd, 4th, 5th metatarsals
-	Insertion: 
o	Each only attaches to one bone
	Medial side, bases, proximal phalanges
	Capsules of metatarsophalangeal joints
	Extensor expansions
-	Innervation:
o	Lateral plantar nerve (motor) 
	Deep branch – 1st and 2nd muscles 
	Superficial branch, Lateral Plantar – 3rd muscle 
-	Function:
o	Adductors of 3-5 digits
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20
Q

4th layer

dorsal interossei

A
  • Origin:
    o Adjacent sides of metatarsal bones
     1st dorsal interossei – from 1st and 2nd metatarsals
     2nd dorsal interossei – from 2nd and 3rd metatarsals
     3rd dorsal interossei – from 3rd and 4th metatarsals
     4th dorsal interossei – from 4th and 5th metatarsals
    Note: the bones that make up the web spaces they are in
  • Insertion:
    o Base of proximal phalanx & extensor expansions
     1st dorsal interossei – medial side 2nd digit
     2nd dorsal interossei – lateral side 2nd digit
     3rd dorsal interossei – lateral side 3rd digit
     4th dorsal interossei – lateral side 4th digit
  • Innervation:
    o Deep branch of lateral plantar nerve (1-3 dorsal interossei)
    o Superficial branch of lateral plantar nerve (4th dorsal interossei only)
  • Function:
    o Abductors of the digit
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21
Q

medial plantar n

A

o Largest of branches of tibial nerve in the foot
o Origin: under flexor retinaculum
o Courses: deep to abductor hallucis
o Branches off of trunk:
 1st Proper plantar digital nerve (to first digit)
• Between abductor hallucis and flexor digitorum brevis
Note: 1st layer muscles, between medial and central compartments
• Branches:
o Flexor hallucis brevis (motor)
o Terminates as sensory nerve to skin, medial side, first digit
 Supply two muscles:
• abductor hallucis
• flexor digitorum brevis
 Articular branches serve: tarsal & metatarsal joints

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22
Q

medial plantar n cont

A

 Common plantar digital nerves (3 from medial plantar n.)
• Course:
o Arise at bases of metatarsals
o Pass between divisions of plantar aponeurosis
o Each divides into 2 proper plantar digital nerves – supplies sensory to skin of sides of toes
• 1st common plantar digital nerve
o Branches:
 2nd proper plantar digital nerve
 3rd proper plantar digital nerve
 First lumbrical (motor branch)
o Articular branches: metatarsophalangeal (MTPJ) & interphalangeal joints (IPJ)
o Sensory branches: dorsum of foot – structures around nail
• 2nd common plantar digital nerve
o Branches:
 3rd proper plantar digital nerve
 4th proper plantar digital nerve
o Articular branches: metatarsophalangeal (MTPJ) & interphalangeal joints (IPJ)
o Sensory branches: dorsum of foot – structures around nail
• 3rd common plantar digital nerve
o Branches:
 4th proper plantar digital nerve
 5th proper plantar digital nerve
 Communicates with lateral plantar nerve
o Articular branches: metatarsophalangeal (MTPJ) & interphalangeal joints (IPJ)
o Sensory branches: dorsum of foot – structures around nail

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23
Q

medial plantar n overview

A

1) Flexor digitorum brevis
2) Flexor hallucis brevis
3) Abductor hallucis
4) 1st lumbrical

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24
Q

lateral plantar n

A

o Between first and second layers
o Smaller terminal branch of tibial nerve
o Distribution similar to ulnar nerve in hand
o Course:
 Accompanies lateral plantar artery
 Passes anteriorly to lateral side of foot
• Between flexor digitorum brevis & quadratus plantae (1st & 2nd layers)

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25
Q

superficial branch of lateral plantar n

A 
	Superficial branch
•	10th Proper plantar digital nerve
o	Sensory - skin of lateral surface of 5th digit
•	4th Common plantar digital nerve 
o	Divides:
	8th & 9th Proper plantar digital nerves
•	Adjacent sids of 4th and 5th digis
•	Muscular branches serve: 
o	flexor digiti minimi brevis
o	3rd plantar interossei
o	4th dorsal interossei 
(The 2 interossei of 4th intermetatarsal space)
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26
Q

deep branch of lateral plantar n

A

 Deep branch
• Accompany lateral plantar artery
• Pass to deep surface of tendons (flexor digitorum longus)
• Muscular branches:
o All interossei (except – those in 4th intermetatarsal space)
o 2-4 lumbricals
o adductor hallucis

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27
Q

lateral plantar n trunk

A
  • Quadratus plantae
  • Abductor digiti minimi
  • Abductor os metatarsi digiti minimi (when present)
28
Q

posterior tibial a

A

o Terminal branch of popliteal artery
o Origin: lower border of popliteus muscle (between tibia and fibula)
o Course & Relationship:
 Large artery
 Descends posterior aspect of leg
• Passing deep to soleus muscle
• Descends obliquely towards medial side
• Protected anteriorly by tibia
 Ankle joint
• Located posterior to medial malleolus (accompanied by tibial nerve)
• Travels in neurovascular fascial tunnel (tarsal tunnel)
o Deep to flexor retinaculum
o Artery and venae comitantes lie medial to tibial nerve
Hint: if dissecting out this area, you will encounter the artery and veins before the tibial nerve (superficial to deep)
o Tunnel lies superficial to flexor hallucis longus (fascial compartment )
• Divides into terminal branches (medial and lateral plantar arteries)
o Anywhere between proximal part – medial malleoulus & before entering foot (deep to abductor hallucis muscle
• Small communicating branch (before giving off branches)
o Anastomoses with peroneal artery
• Artery of tarsal canal
o Originates from posterior tibial before termination
o Blood supply to the talus
Hint: recall tarsal canal lies medially,
As does the posterior tibial artery

29
Q

branches of posterior tibial a

A 
o	Branches of posterior tibial supplying Ankle and Foot
	1) Peroneal (fibular)
	2) posterior medial malleolar
	3) medial calcaneal 
	4) Artery of the tarsal canal
	5) Medial Plantar 
	6) Lateral Plantar
30
Q

peroneal artery

A

 Origin: posterior tibial artery about 2.5cm below popliteus muscle
 Course:
• located deep on fibular side, posterior leg
• descends along medial border of fibula (between tibialis posterior & flexor hallucis longus)

31
Q

peroneal a pt1

A

 Branches:
• Leg – muscular, nutrient, perforating arteries
• Crosses posterior aspect of distal tibiofibular joint – then divides into:
o Perforating branch (of peroneal artery)
 Pierces interosseous membrane (5cm superior to lateral malleolus) to anterior leg
• Courses anterior side of distal tibiofibular joint / deep to peroneus tertius muscle tendon
 Anastomoses with anterior lateral malleolar branch of anterior tibial artery (while traveling distally and laterally)
• Contributes to lateral malleolar rete
 Terminal Branches:
• Anastomose with lateral tarsal branch of dorsalis pedis
• 1-5% cases – perforating branch continues along dorsum of foot as dorsalis pedis (on occasion – lateral tarsal artery)

32
Q

peroneal a pt2

A

o Posterior branch (of peroneal artery)
 Continues posteriorly – crosses ankle joint – terminates into two branches:
• Posterior lateral malleolar artery
o Small twigs, wind around lateral malleoulus – contribute to lateral malleolar arterial rete
 Provide blood to distal end tibia and fibula

• Lateral calcaneal arteries
o Terminal branch of peroneal a. (considered by some)
o Runs lateral aspect of heel
o Provides important connection between anterior lateral malleolar branch (of anterior tibial a.) and posterior lateral malleolar branches (of peroneal a.)
o Anastomoses with medial calcaneal branches (of posterior tibil a.)
 Important sources of blood to calcaneus

33
Q

Arteries 1

A

o 2) Posterior Medial Malleolar Artery
 arises from posterior tibial artery
 courses across tibialis posterior & flexor digitorum longus muscle tendons
 Anastomoses with anterior medial malleolar branch (of anterior tibial a.)
• Contributes to medial malleolar rete
o 3) Medial Calcaneal Branch(es)
 Origin: posterior tibial artery (posterior to medial malleolus, just proximal to terminal branches)
Note: occasionally can also originate from lateral plantar artery (which is the largest plantar artery) when the division is higher in the ankle
 Pierces flexor retinaculum – supplies tendo calcaneus and heel
 Termination – anastomoses with:
• posterior medial malleolar branches (of posterior tibial a.)
• lateral calcaneal branches (peroneal artery)
Note: both together form the calcaneal rete.

34
Q

Arteries 2

A

o 4) Artery of Tarsal Canal (see also blood supply to talus)
 Origin: posterior tibial artery (prior to bifurcation
into medial & lateral plantar arteries)
Hint: recall that the tarsal canal actually lies medially
o 5) Medial Plantar Artery
 Smaller terminal branch – posterior tibial artery (about 80% of time)
 Travels medial to medial plantar nerve
 Origin: deep to flexor retinaculum, between medial malleolus and calcaneus
• Course:
o Enters plantar surface -> courses medial compartment of foot
o Proximal part located deep to origin of abductor hallucis muscle
o Continues distaly, between abductor hallucis & tendons of flexor digitorum longus
o Small muscular branches to abductor hallucis muscle

35
Q

medial plantar a cont

A

 Branches:
• After crossing flexor digitorum longus tendon (lateral to medial) divides into superficial & deep branch
o A. Superficial Branch (of medial plantar artery)
 Course: between flexor digitorum brevis & abductor hallucis (superificial – 1st layer of muscles)
 Branches: (2 terminal branches)
• Superficial tibial plantar artery (medial marginal plantar artery)
o medial course
o superficial to flexor hallucis brevis m.
o lateral to abductor hallucis tendon
o usually small- if large replaces 1st plantar metatarsal artery
o becomes 1st proper planter digital A
o anastomoses:
 distal end, 1st metatarsal, w/ 1st plantar metatarsal artery
Note: 1st plantar metatarsal artery is a branch of the deep plantar arch.
• Common plantar digital artery
o Lateral terminal branch – superficial branch of medial plantar artery
o Stem: crosses obliquely across flexor hallucis brevis muscle (between flexor digitorum brevis & plantar aponeurosis)
o Gives rise to superficial plantar digital arch – by three small branches (superficial plantar digital arteries)
 Proceed distally
 Immedieately deep to distal plantar aponeurosis
 Terminate by anastomosing w/1-3 planatar metatarsal a. (of deep plantar arch)
o 30% cases - laterally anastomoses with superificial branch of lateral plantar artery (if present completes superficial arch on lateral side)

36
Q

medial plantar a pt 2

A

o B. Deep Branch (ramus profundus) (of medial plantar artery)
 Origin: near medial plantar artery origin (from posterior tibial artery)
 Course:
• deeper than superficial branch of medial plantar artery
• divides into two branches:
o tibial branch – travels medial side foot
 reaches base of 1st met
 anastomoses w/1st plantar metatarsal a.
o lateral branch –
 between 3rd & 4th muscle layers
 crosses peroneus longus tendo
 joins medial side – deep plantar arch (completes arch medially (with deep plantar branch of dorsalis pedis)

37
Q

lateral plantar a

A

 Larger than medial plantar branch (of posterior tibial)
 Nerve lies medial to the lateral plantar artery
 Enters deep to abductor hallucis muscle (portal into plantar foot)
 Course:
• Travels laterally
• Middle compartment of foot (between flexor digitorum brevis and quadratus plantae muscles) (1st/2nd layers)
• Base of 5th metatarsal bone – penetrates lateral intermuscular septum
o Passes into lateral compartment
 Proceedes distally – along medial side of abductor digiti minimi muscle

38
Q

lateral plantar a cont

A

 Branches: (close to base of 5th metatarsal bones – divides: lateral & medial br.
• A. superficial fibular plantar artery (lateral branch)
o Courses: fibular side – 5th metatarsal bone
o Lateral side 5th toe – becomes 10th proper plantar digital artery
• B. deep plantar arch (medial branch)
o Often appears as continuation of lateral plantar artery (large)
o Arises at Base of 5th metatarsal – after superficial fibular plantar artery is given off
o Course:
 Medially, deep to flexor digiti minimi brevis (3rd layer)
 Penetrates lateral intermuscular septum – enters middle compartment
 Crosses bases of 4th, 3rd, 2nd metatarsal bones – deep to oblique head of adductor hallucis & superficial to interossei muscles
 Medial side: 1st intermetatarsal space – anastomoses with :
• deep plantar branch (dorsalis pedis)
• lateral branch of ramus profundus (of medial plantar artery)
Note: If dorsalis pedis is missing – no contribution to deep plantar arch from dorsal side of foot. Some cases, perforating branch of peroneal artery may contribute to arch.

39
Q

lateral plantar a cont

A
  • Branches of deep plantar arch
    o many branches to deep muscles of plantar surface of foot.
    o Posterior perforating arteries & plantar metatarsal arteries
    o A. 3 posterior (proximal) perforating arteries
     Branches of deep plantar arch
     No posterior perforating in 1st interosseous space (due to deep plantar artery)
     Proceed to dorsum of foot
     Anastomose with dorsal metatarsal arteries
    o B. Plantar metatarsal arteries
     Originate from deep plantar arch
     4 in number (typically)
     Variations:
    • 1st plantar metatarsal –
    o can be branch from dorsalis pedis
    o can be branch from superficial tibial plantar branch of medial plantar artery
    • 2-3% of cases – plantar metatarsal arteries missing altogether
    o Superficial plantar arterial system well developed and compensates for digital blood supply.
     Course:
    • plantar side of medial 4 metatarsal bones
    o superficial to interossei muscles
    • close to webbing of toes – all 4 give off distal (anterior) perforating arteries
    o penetrate through interosseous muscles – reach dorsal side of foot
     anastomose with dorsal metatarsal arteries
    Distal to the anterior perforating arteries become Common Plantar Digital Arteries
    Usually about 1-2 mm in length
40
Q

lateral plantar a cont

A

 continues distally – short distance – divides into 2 proper plantar digital arteries
• proper plantar digital arteries:
o supply adjacent sides of each toe
o 8 in number (2nd – 9th proper plantar digital arteries)
o 1st proper plantar digital artery
 Usually branch from 1st plantar metatarsal artery
• Courses across 1st metatarsal bone
• Anastomoses (medial side) w/ superficial plantar tibial branch
o 1st proper plantar digital artery – common formed trunk
Note: sometimes contribution from 1st metatarsal artery is missing – superficial tibial plantar artery takes over as 1st proper plantar digital artery
o 10th proper plantar digital artery
 Contribution of superficial fibular plantar artery
• Along lateral side of 5th toe
Note: dorsal digital arteries to toes 2-5 often not well developed – main source of blood to toes often proper plantar digital arteries (especially true for lateral 2 toes)
o Anastomose with each other profusely
 Arteries on medial and lateral sides of toes form anastomotic network at proximal aspect of distal phalanx
• Continues to distal end of toes – known as terminal arborization

41
Q

superficial plantar veins

A

o Dorsal digital veins (on dorsum of foot) communicate with proper plantar digital veins
 Unite to form dorsal metatarsal veins
• Form dorsal venous arch – along distal ends of metatarsal bones
o Joined by lateral dorsal digital vein of 5th toe (lateral side)
 Forms lateral marginal vein
• Becomes small saphe nous vein
(posterior to lateral malleoulus)
o joined by medial dorsal digital vein of 1st toe (medial side)
 Forms medial marginal vein
• Becomes great saphenous vein (anterior to medial malleolus)
o Sole of foot – superficial veins form plantar cutaneous venous arch
 Drains into medial and lateral marginal veins

42
Q

deep plantar veins

A

o Proper plantar digital veins Communicate with dorsal digital veins
 Unite to form 4 plantar metatarsal veins
• In metatarsal space – send perforating branches to dorsum of foot
o Unite to form deep plantar venous arch
 Follows deep plantar arterial arch across interossei muscles
 Medial and lateral plantar veins originate from arch (Run along with arteries of same name)
• Usually communicating veins between medial and lateral plantar veins & small and great saphenous v eins
• Inferior to medial malleolus – medial and lateral plantar veins unite to form posterior tibial veins
Note: the anterior tibial vein(s) originates from venous plexus along dorsum of the foot.

43
Q

synovial joints

A

1) Hyaline cartilage covers articular surfaces
2) Synovial membrane lines the capsule and covers all
structures within the capsule except for the articular cartilage
3) Synovial membrane secretes synovial fluid
4) Articular capsule encloses the joint

44
Q

ankle joint

A

• Known as talocrural joint (crural =leg)
• Talus articulates with two bones of the leg
• Hinge or ginglymus type synovial joint (modified)
o triplanar motion, primarily sagittal plane
• Talus fits into a socket formed by:
o 1) tibia
o 2) fibula
o 3) anterior inferior tibiofibular ligament
o 4) inferior transerve ligament
(most distal portion of posterior inferior tibiofibular ligament)
• Distal (inferior) Tibiofibular joint – 3 ligaments associated with the joint:
o 1) Interosseous tibiofiblar ligament
 Lowermost portion of interosseous membrane – between tibia and fibula (not part of the ankle joint)
 anterior-distal portion does help makeup the ankle mortise
o 2) Anterior inferior tibiofibular ligament
 Helps form socket for the talus (Forms anterior portion of the socket)
 Triangular in shape
 Extends from anterior border of fibular notch (of tibia) – to – anterior border of shaft of fibula and lateral malleolus
o 3) posterior inferior tibiofibular ligament
 Helps form socket for the talus (posterior portin of the socket)
 Quadrilateral in shape

45
Q

ankle joint cont

A

 Extends from posterior border of fibular notch (of tibia) – to –> upper part of lateral malleolar facet
 Two portions – superficial and deep
• Deep portion
o Located inferiorly & deep
o Known as inferior transverse ligament
o Contains elastic fibers and fibrocartilage
o Helps form tibial plafond
Note: There are anterior and posterior superior tibiofibular ligaments also – associated with proximal tibiofibular joint.
• Three articulating surfaces of the body of talus (talar dome) at ankle joint:
o Dorsal surface – with inferior (distal) surface of tibia (tibial plafond)
o Medial surface – with lateral surface of medial malleolus (tibia)
 comma shaped or pear shaped facets (both articulating surfaces)
o Lateral surface – with medial surface of lateral malleolus (fibula)
 Triangular facets (both articulating surfaces)
• Fibrous capsule or articular capsule -
o Anteriorly and posteriorly – Thin
Hint: this would make sense as you want complete range of motion
dorsiflexing and plantarflexingthe foot, not limited by a thick capsule
o Medially and laterally – thick
 As medial collateral (deltoid) and lateral collateral ligaments
o Anteriorly – thin & broad
 Stretches to the neck of the talus
o Posteriorly
 Mainly transverse fibers (some blend with inferior transverse ligament)
Note: laterally the joint capsule may communicate with the peroneal tendon sheath

46
Q

deltoid ligament

A

o Medial collateral ligament of ankle joint
o Strong, triangular (deltoid-shaped)
o Attach to tibia superiorly (anterior surface, apex, posterior surface of medial malleolus) -> fan out inferiorly (attach): talus (x2), calcaneus, & navicular
 Composed of 4 ligaments:
• 1) Anterior tibiotalar (deep)
o Attachment: medial surface of talus
o Lies deep
• 2) Posterior tibiotalar (superificial)
o Attachment: medial tubercle (posterior surface of talus)
 Forms groove for flexor hallucis longus
• 3) Tibiocalcaneal (superificial)
o Attachment: sustentaculum tali (inferiorly)
o Strongest part of deltoid ligament
• 4) Tibionavicular (superificial)
o Attachment: tuberosity of navicular
o Blends with spring ligament
o Weakest part of deltoid ligament
o Superficial to anterior tibiotalar ligament
 Attachments:
• Superiorly – anterior surface (colliculus), apex, and posterior surface (colliculus) of the medial malleolus
• Inferiorly – fibers fan out
 2 superficial lying muscles:
• Tibialis posterior
• Flexor digitorum longus

47
Q

lateral collateral ligament

A

o No other name – general term for 3 ligmanets
 1) calcaneofibular (CFL)
• Extracapsular
• Long cord-like
• Attachment: apex (lateral malleolus), extends to unnamed tubercle on lateral surface of calcaneus
o resists inversion along with peroneal sheath
Clinical Note: Talar tilt test helps diagnose damage
• Covered by tendons:
o Peroneus longus
o Peroneus brevis
 2) anterior talofibular (ATFL)
• Intracapusular
• Blends with fibrous capsule of ankle joint
• Shortest (of 3 lateral ligaments), & weakest
• Attachment: anterior margin (lateral malleolus) to neck of talus
o resists ankle plantarflexion & anterior subluxation
Clincal Note: anterior drawer test helpful in diagnosing damage
• Overhangs the tarsal sinus
• ***one of most commonly injured in an inversion-type sprained ankle
 3) posterior talofibular
• Instracapsular
• Deepest, strongest (of 3 laterals)
• Fibers course almost horizontally
• Attachments: lateral malleolar fossa and lateral tubercle (of poster talus surface)
o Forms groove for flexor hallucis longus tendon

48
Q

fibulotalocalcaneal ligament

A

o Location: posterolateral ankle joint
 Not considered part of lateral collateral ligament
o Attachments:
 Superiorly – posterior border of lateral malleolus (blends with posterior inferior tibiofibular ligament)
• Closely related to fibrous sheath around the tendons of peroneus longus and peroneus brevis
 Inferiorly – divides into two laminae
• Superomedial (talar) – attaches to lateral tubercle (posterior process of talus)
o Helps form fibrous tunnel of flexor hallucis longus tendon
• Inferolateral (calcaneal) lamina – posterior 1/3 of dorsal surface of calcaneus
Note: this inferior attachment usually confined to dorsal surface of calcaneus – however may also attach to lateral surface of calcaneus (where blends with calcaneofibular ligament)
o Variations
 60%: well defined
 20%: poorly defined
 20%: replaced by deep fascia

49
Q

intertarsal joints

A

• Four Joints: Talocalcaneal, Talocalaneonavicular, Calcaneocuboid, Great Tarsal

50
Q

talocalcaneal joint

A

 One of two joints between talus and calcaneus
 Gliding or plane type of synovial joint
 Formed by:
• 1) concave posterior facet (plantar surface of talus)
• 2) convex posterior facet (dorsal surface of calcaneus)
 Tarsal sinus & tarsal canal
• Lie anterior to joint
• Separate joint from talocalcaneonavicular joint
 Articular capsule – strengthened by 5 ligaments:
• medial, lateral, posterior & anterior (cervical) talocalcaneal, + interosseous talocalcaneal
Note: the fibrous or articular capsule of any synovial joint forms an important ligament of that joint.
• 1) medial talocalcaneal
o Attachments:
 medical tubercle of talus
 posterior aspect of sustantaculum tali (“M.R. T.P.”)
 medial surface of calcaneus (posterior to sustentaculum tali)
o blends with deltoid ligament & interosseous talocalcaneal ligament (which lies in the tarsal canal)
 deltoid ligament lies superficial
 interosseous talocalcaneal ligament lies deep
• 2) posterior talocalcaneal
o Attachments:
 Lateral tubercle (posterior surface of the talus)
 Dorsal surface of calcaneus
Note: at times, it may also have attachment on the medial tubercle (posterior surface of the talus) – making it a Y-shaped band. When present the medial band forms a tunnel for tendon of flexor hallucis longus.
• 3) lateral talocalcaneal
o Attachments:
 Lateral surface of the talus
 Lateral surface of the calcaneus (anterior & superior to attachment of calcaneofibular ligament)

•	4) interosseous talocalcaneal
o	Lies within tarsal canal
o	Broad flat band, obliquely coursing
o	Attachments: 
	Sulcus tali
	Sulcus calcanei
o	Lies between subtalar and talocalcaneonavicular joints
	Subtalar joint – posterior
	Talocalcaneonavicular joint - anterior
•	5) anterior talocalcaneal (cervical ligament)
o	Attachment: 
	Neck of the talus (cervix)
	Strong ligament
•	Helps to check over-inversion
Hint: recall that the anterior talofibular ligament is often the first to rupture with over-inversion injuries, the cervical ligament will prevent further inversion.
51
Q

talocalcaneonavicular joint

A

 Complex – several articular surfaces
 Talus articulates with:
• 1) calcaneus (via two facets – anterior and middle)
• 2) navicular
• 3) fibrocartilaginous thickening in the superior part of spring (plantar calcaneonavicular) ligament
Note: the calcaneus does not articulate with the navicular
Hint: all in the name, talo –> articulates with calcaneus + navicular
 Talocalcaneal portion:
• Anterior & middle calcaneal facets – articulate with anterior & middle talar facets (of the calcaneus)
• Lies anterior to tarsal canal
 Talonavicular portion:
• Convex head of talus –articulates with concave proximal surface of navicular
Recall: the shape of this surface is a tear drop
• Ball and socket joint
• Articular capsule:
o Weak, irregular – except where reinforced by other ligaments
• 4 ligaments at this joint:
• 1) interosseous talocalcaneal ligament
o Located in the tarsal canal
 Ligament of subtalar joint & talocalcaneonavicular joint
• 2) dorsal talonavicular ligament
o Aka talonavicular ligament
o Located dorsally
o Broad thin band
o Attachments: neck of talus & dorsal surface of navicular
• 3) calcaneonavicular part of birfurcate ligament
o Splits or divides into two parts:
 A) calcaneonavicular
• Passes anteriomedially – to dorsal surface of navicular
• Associate with talocalcaneonavicular joint
 B) calcaneocuboid
• Courses anterolaterally – to medial surface of cuboid
• Part of calcaneocuboid articulation
o V or Y shaped ligament
 Stem blends with cervical ligament at tarsal sinus
• 4) Plantar calcaneonavicular (spring) ligament
o Forms articular surface of talocalcaneonavicular joint
o Attachments:
 Posterior – anterior border of sustentaculum tali
 Anteriorly – plantar surface of navicular & tuberosity of navicular
o Contains numerous elastic fibers
o Medially, Contacts – tibionavicular and tibiocalcaneal portions of deltoid ligament (lying medially)
 Both parts help support & strengthen spring ligament
o Interiorly, contacts – tendon of tibialis posterior
 Helps support the spring ligament
o Very strong ligament
 Function: support head of talus – maintaining medial longitudinal arch of foot
Note: if stretched the medial longitudinal arch flattens

52
Q

calcaneocuboid joint

A

 Saddle type synovial joint
 Articular capsule - 2 ligaments
• Thickened dorsally (dorsal calcaneocuboid ligament)
• Thicked laterally, at times (lateral calcaneocuboid ligament) – variable
 3 additional ligaments
• Calcaneocuboid part of bifurcated ligament
Courses anterolaterally – to medial surface of cuboid
Part of calcaneocuboid articulation
• Long plantar ligament
o Longest ligament of the foot
o One of strongest ligaments
o Attachments:
 Medial process (of calcaneus) “Medial LAP”
 Lateral process (of calcaneus) “Lateral LAP”
 Depression between processes (of calcaneus) “LA”
 Anteriorly (distally) – divides into deep and superficial fibers
• Deep fibers: attach peroneal ridge of cuboid
• Superficial fibers: cross peroneal sheath over tendon of peroneus longus
o Attach to bases of 2-4 metatarsals (sometimes 5th met)
• Plantar calcaneocuboid ligament (short plantar)
o Wide (wider than long plantar, so isn’t completely covered)
o Strong, Lies deep to long plantar ligament
o Attachment:
 Proximally - anterior tubercle of calcaneus
 Distally – cuboid
• Just posterior to peroneal ridge
• coronoid process (beak)
• Note: both short and long plantar ligaments support lateral longitudinal arch of foot.

53
Q

transverse tarsal joints

aka midtarsal joint

A
  • Talonavicular portion of TCN
  • Calcaneocuboid
  • Links Midfoot to Rearfoot
  • Everions/Inversion
54
Q

great or general tarsal joint

A

 Aka “Great Tarsal Synovial Membrane”
 Not a single joint – numerous articular surfaces
 all structures share the same synovial membrane & synovial fluid
 Involved bones:
• single articular capsule surrounds all bones involved
• all tarsal bones except talus and calcaneus
• 2-4 metatarsal bones

55
Q

great tarsal joint cont

A 
	Many articulations:
•	Navicular – medial cuneiform
•	Navicular – intermediate cuneiform
•	Navicular – lateral cuneiform
•	Medial cuneiform – intermediate cuneiform
•	Intermediate cuneiform – lateral cuneiform
•	Lateral cuneiform – cuboid
•	Medial cuneiform – 2nd metatarsal
•	Intermediate cuneiform – 2nd metatarsal
•	Lateral cuneiform – 2nd metatarsal
•	Lateral cuneiform – 3rd metatarsal
•	2nd metatarsal – 3 metatarsal
•	3rd metatarsal – 4th metatarsal
56
Q

great tarsal joint cont

A

 Two variations:
• 1) Articulation between 3rd and 4th – not part of great tarsal joint in some feet.
• 2) Articulation of cuboid and navicular (normally there is a fibrous – rather than synovial, joint between cuboid and navicular)
 Ligament Groupings:
• Proximal-distal surface articulations – two ligaments
o Dorsal ligament - weak
o Plantar ligament – strong (prevents arch from collapsing)
Note: each ligament named using dorsal or plantar as adjectives followed by names of two bones, recall rules: navicular and more distal bones named last. ex. Dorsal medial cuneonavicular ligament.
 Medial-lateral surface articulations – 3 ligaments
• Dorsal ligament - weakest
• Plantar ligament
• Interosseous ligament – strongest
Note: named as described at the beginning of the section.

57
Q

functional analysis

A

• Four anatomical joints – each with own articular capsule & synovial membrane
o Joints include:
 1) Talocalcaneal or subtalar joint
 2) Talocalcaneonavicular joint
 3) Calcaneocuboid joint
 4) Great tarsal joint
• Functionally, only two intertarsal joints:
o Separate joint capsules but function as a unit
o 1) Functional subtalar joint
 Movements
• Eversion and inversion
• Supination (plantar flexion, inversion, adduction) and pronation (dorsiflexion, eversion, abduction)
 Composition:
• 1) (anatomical) subtalar joint
• 2) Talocalcaneal portion of talocalcaneonavicular joint (makes sense)
Note: functional subtalar joint is the combination of two (anatomical) joints between talus and calcaneus.

58
Q

transverse tarsal joints

A

 Augments the action of the subtalar joint
 Functional joint – Eversion and inversion movements
 Aka midtarsal joint
 Links midfoot to rearfoot
 Commposition:
• 1) Talonavicular portion of talocalcaneonavicular joint
• 2) Calcaneocuboid joint
Note: the Great tarsal joint does NOT participate in either functional joint.

59
Q

tarsometatarsal joint

A

o Gliding Joint
o Five metatarsals articulate with four tarsal bones of distal row
o Bones involved:
 1) first metatarsal – medial cuneiform
 2) second metatarsal – medial cuneiform, intermediate cuneiform, lateral cuneiform
 3) third metatarsal – lateral cuneiform
 4) fourth metatarsal – cuboid and lateral cuneiform
Recall: the 4th metatarsal has a demi-face, medial side, articulating with 3rd met and lateral cuneiform, however there is no ligament attachment between the 4th met and lateral cuneiform
 5) fifth metatarsal – cuboid
o Tarsal-metatarsal junction - not a straight line
 2nd metatarsal and medial cuneiform set posteriorly
o Only three joint cavities for tarsometatarsal articulations
 1) medial tarsometatarsal joint
• 1st metatarsal articulates with medial cuneiform (reniform shaped facets)
 2) great tarsal joint
• 2nd metatarsal articulates with all three cuneiforms
• 3rd metatarsal articulates with lateral cuneiform
 3) lateral tarsometatarsal joint
• 4th metatarsal articulates with lateral cuneiform & cuboid
• 5th metatarsal articulates with cuboid

60
Q

tarsometatarsal joint cont

A

o Ligaments of joint cavities have similar named ligaments:
 Dorsal tarsometatarsal Ligaments
• Strong, flat bands
• 7 ligaments (usually)
o 1st (medial) – connects 1st metatarsal to medial cuneiform
o 2-4th – connects 2nd metatarsal to medial, intermediate, lateral cuneiforms, repectively
o 5th – connects 3rd metatarsal to lateral cuneiform
o 6th – connects cuboid to fourth metatarsal
 A Slip attaches to third metatarsal
o 7th – connects cuboid to 5th metatarsal
 Plantar tarsometatarsal Ligaments
• Weak, irregular
• Fibers course obliquely & longitudinally
• Ligaments blend with:
o Long plantar ligament (Recall: attaches to mets 2-4)
o Tendon of tibialis posterior
• Variable number of ligaments (3-5)
o 1st – connects medial cuneiform to 1st metatarsal
o 2nd – connects medial cuneiform to 2nd metatarsal
o 3rd – connects lateral cuneiform to 3rd metatarsal
o 4th – connects cuboid to 4th metatarsal
o 5th – connects cuboid to 5th metatarsal
• Variable strength of ligaments
o First 2, stronger than last 3.
 Interosseous tarsometatarsal Ligaments
• Three ligaments – attachments:
o 2nd metatarsal – medial cuneiform (Lisfranc’s ligament* (red))
 Most constant ligament
 Lies between medial tarsometatarsal joint and great tarsal joint
o 2nd metatarsal – lateral cuneiform (absent 10% of time)
o 4th metatarsal – lateral cuneiform
Note: 2 attach to 2nd metatarsal and 2 attach to lateral cuneiform
Hint: there are ligaments for each articulating demi-facet!
Note: these ligaments can be specifically named according to the two bones they attach – however more general term, tarsometatarsal, is more commonly used.

61
Q

lis franc

A

*** Lisfranc’s joint is the functional tarsometatarsal joint – refers to all 3 anatomical joints: medial & lateral tarsometatarsals + great tarsal

62
Q

intermetatarsal joints

A

o 1st & 2nd metatarsal bases do not articulate
 No ligaments between bases of bones
 Variability present:
• Bursa located between 1st & 2nd mets
• Pressure facets located on opposable surfaces of bases
• Weak interosseous ligament (few fibers)
o Articulations between 2-5 metatarsal bases
 2nd & 3rd, 3rd & 4th = portions of great tarsal joint
• Variable: articulation between 3rd & 4th mets part of lateral tarsometatarsal joint (rather than great tarsal joint)
 4th & 5th = lateral tarsometatarsal joint
o 3 ligaments support articulations
 1) plantar intermetatarsal
 2) dorsal intermetatarsal
 3) interosseous intermetatarsal
o Deep transverse metatarsal ligament – unites heads of all 5 metatarsals
Note: union between heads of 1st and 2nd metatarsals is unique in the human foot
 aka intercapitular ligament – blends with glenoid ligaments of metatarsophalangeal joints
Hint: “Intercapsule ligament – between capsules”
 separates the course of lumbricals (pass plantarly to the ligament) from interossei (pass dorsally to the ligament)

63
Q

metatarsophalangeal joints

A

o Ellipsoid type synovial joints
 Round, convex head of metatarsal articulates with concave base of proximal phalanx
o Metatarsal heads – trochlear-shaped surface
o Actions:
 Flexion & extension
 Abduction & adduction (some)
o Capsule:
 Medial & lateral sides – thickened
• Medial collateral & lateral collateral ligaments
 Dorsal surface – very thin
• Strengthened by extensor tendons
• Attaches close to articular surface of head of metatarsal
• NO DORSAL metatarsophalangeal ligaments
 Plantar surface
• Extends back proximally on head of metatarsal
• Plantar Metatarsophalangeal ligament blends with the capsule
o Aka glenoid ligaments
 Attachments: metatarsal heads (loosely), proximal phalanges (firmly)
 Each contains fibrocartilaginous pad (plantar plate or plantar pad)
• Attachments: bases of proximal phalanges (firmly)
• Action: move with phalanges during flexion & extension
• Deep transverse metatarsal ligament blends with sides of plantar plates

64
Q

MTPJ

A

o Each of 5 MTPJs contain 4 ligaments:
 1) articular capsule
 2) Medial collateral ligament
 3) lateral collateral ligament
 4) glenoid ligmanet
o First MPJ - 5 additional ligaments:
 Metatarsosesamoid ligament (to tibial sesamoid)
 Metatarsosesamoid ligament (to fibular sesamoid)
 Intersesamoid ligament
 Sesamoidophalangeal ligament (to tibial sesamoid)
 Sesamoidophalangeal ligament (to fibular sesamoid)
Note: Flexor hallucis brevis has two tendons (each contains a sesamoid bone at MTPJ of hallux) therefor the need of the additional 5 ligaments. Ligaments attach each sesamoid to the metatarsal, phalanx, and other sesamoid.

65
Q

interphalangeal joints

A

• Interphalangeal joints (IPJ)
o ALL are hinge joints (proximal and distal)
o Heads of proximal & middle phalanges (especially proximal) have pulley-shaped (trochlear) surfaces
o Ligaments (similar for each IPJ):
 1) articular capsule
 2) Medial Collateral ligament
 3) lateral collateral ligament
 4) plantar interphalangeal ligament
o Number of Joints variable by digit:
 Hallux (1 joint) – 2 bones: proximal & distal
 Digits 2-4 (2 joints: proximal & distal) – 3 bones: proximal, middle, distal
 Digit 5
• 60% of feet, 2 IPJs
• 40% of feet, middle & distal phalanges are fused (only 1 IPJ)

LOWER LIMB (4 decks)

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