Ankle, Foot, Peripheral Pulses and Venous Drainage of the Lower Limb PDF

Ankle, Foot, Peripheral Pulses and Venous Drainage of the Lower Limb Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomesBy the end of this practical By the end of this lecture, session, you should be able you should be able to:...

Ankle, Foot, Peripheral Pulses and Venous Drainage of the Lower Limb Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomesBy the end of this practical By the end of this lecture, session, you should be able you should be able to: to: Discuss the ankle joint, including osteology, Identify the bones of the ankle and foot, including structure, structure, actions and neurovascular supply actions and neurovascular supply, arches supporting ligaments and tendons Describe the arches of the foot, including osteology, supporting ligaments and tendons Describe some traumatic injuries that may occur to the ankle joint or its related structures (i.e. lateral collateral Explain the movements of inversion and eversion, ligament strain) including participating joints and muscles Discuss radiological imaging of ankle joints and leg Outline the layers of the sole of the foot and the Locate the tarsal tunnel and its contents neurovascular structures within Describe the extensor retinacula overlying the anterior Identify the long tendons in the sole of the foot compartment tendons and their attachments Discuss the anatomy of the long and short saphenous veins Describe the surface anatomy of the peripheral pulses of the lower limb and identify these on Demonstrate the movements of inversion and eversion, examination including joints and muscles Review the anatomy of the long and short Identify the main ligaments of the foot (i.e. spring and saphenous veins plantar) Discuss the vascular supply of the sole of the foot and the Interpret radiological imaging of the foot and plantar arch ankle joint Demonstrate the surface anatomy of the peripheral pulses of the lower limb and identify these on examination Recommended reading Abrahams, Peter H. et al. McMinn & Abrahams’ Clinical Atlas of Human Anatomy. Seventh edition. Maryland Heights, Missouri: Elsevier Mosby, 2013. Print Drake, Richard L. Gray’s Anatomy For Students. 4th. ed. Philadelphia: Elsevier, Inc., 2020. Print. Moore, Keith L., Arthur F. Dalley, and A. M. R. Agur. Essential Clinical Anatomy. 4th ed. Philadelphia, Pa.; London: Lippincott Williams & Wilkins, 2011. Print. Netter, Frank H. (Frank Henry). Atlas of Human Anatomy. 5th ed. Philadelphia, Pa.; London: Saunders, 2010. Print. Smith, C., Dilley, A., Mitchell, B. and Drake, R.L., 2017. Gray’s Surface Anatomy and Ultrasound: Gray’s Surface Anatomy and Ultrasound E-Book. Elsevier Health Sciences. Spratt, J., Salkowski, L.R., Loukas, M., Turmezei, T., Weir, J. and Abrahams, P.H., 2020. Weir & Abrahams' Imaging Atlas of Human Anatomy. Elsevier Health Sciences. Tarsal bones The foot is made up of: 7 tarsal bones Phalanges 5 metatarsal bones 14 phalanges Proximal, middle and distal for digits 2-4 Metatarsals Proximal and distal for digit 1 Medial Talus Cuneiform Intermediate Navicular Lateral Calcaneus Intermediate Cuneiform Lateral Cuneiform Cuboid Navicular Calcaneus Cuboid Talus Ankle joint Synovial joint involving the talus of the foot and the distal ends of the Tibia Fibula tibia and fibula of the leg. Allows hinge like dorsi- and plantarflexion. Fibula Anterior Articular surface: Covered by hyaline cartilage Talus-wider anteriorly than Talus posteriorly (joint is more stable when the foot is dorsiflexed) Medial Posterior malleolus of Tibia Stablised by medial and lateral ligaments Ligaments Posterior Anterior talofibular Anterior tibiotalar Posterior ligament talofibular ligament tibiotalar ligament ligament Tibionavicular ligament Tibiocalcaneal ligament Calcaneofibular ligament The medial (deltoid) ligament of the ankle is large, strong and triangular in shape. It The lateral ligament of the ankle is is composed of four separate ligaments. composed of three separate Attaches to the medial malleolus apex ligaments. and sustentaculum tali of calcaneus, navicular and talus Ankle sprains Happens when ligaments of the ankle have been overstretched but not completely ruptured. Ranges from mild to severe Stepping on uneven surfaces may cause the foot to roll: Inward (inversion sprain): stretching the lateral ligaments The anterior talofibular ligament is injured first, then calcaneofibular and if particularly severe, the posterior talofibular ligaments Outward (eversion sprain-less likely): stretching the medial ligaments Pott’s fracture-bimalleolar ankle fracture 1. Foot everted forcibly 3 2. Medial ligament pulls on the medial malleolus and causes avulsion 2 fracture. 3. Talus moves 1 laterally, lateral malleolus fractures (or fibula fractures superior to the inferior tibiofibular joint) Pilon Fracture Multiple fractures of the tibia High axial forces (falling form high hight) Can involve the talus or the fibula Requires fixation (internal and/or external) Tarsal joints Subtalar: Allows gliding and rotation, which is involved in inversion Talocalcaneonavicula r Calcaneocuboid Calcaneocuboid joint Midtarsal/inter/transverse tarsal joint: Talocalcaneonavicular & calcaneocuboid joints (combined) Movements: inversion and eversion  Tarsal tunnel On the medial side of the ankle. Between the tarsal bones and the flexor retinaculum. Think: Tom, Dick and very naughty Harry!  Dorsiflexion: moving the top of the foot towards the leg Movements which is supplied by the deep fibularat the ankle Anterior compartment of the leg, nerve Plantarflexion: moving the planter surface of the foot away from the leg Posterior compartment of the leg which is supplied by the tibial nerve Inversion of the foot: directing the sole of the foot medially Tibialis anterior and posterior Extensor hallucis longus Eversion of the foot: directing the sole laterally Fibularlis (peroneus) longus, brevis and tertius Arches of the foot Bones of the foot do not lie in a Medial part of the horizontal plane Longitudinal arch Form longitudinal and transverse arches. Absorb and distribute downward forces during standing and moving Transverse arch Longitudinal arch Medial part: Involves the calcaneus, Lateral part of the talus, navicular, the 3 cuneiforms, and Longitudinal arch first 3 metatarsals Lateral part: Involves the calcaneus, cuboid and lateral 2 metatarsals Transverse arch: Junction of tarsals with metatarsals: includes the cuboid and the three cuniforms Maintenance of arches is via ligaments and muscles Planter ligaments Plantar calcaneonavicular (spring ligament) Strong ligament from anterior sustentaculum tali to inferior surface of Plantar calcaneocuboid navicular (short plantar ligament) Between calcaneus and cuboid Long planter ligament Planter Strong ligament between aponeurosis calcaneus, cuboid and bases of 2- 5 metatarsal Sole of the foot Thick skin, firmly bound to fascia Sensation: medial and lateral Lateral planter Medial planter nerve plantar nerves nerve Contains sweat glands Planter Deep fascia thickens to form aponeurosis Plantar aponeurosis Function: Firm attachment to the skin, protect neurovascular bundle, assist in maintaining arches Triangular shape, occupies the centre of the sole Apex attached to the calcaneus Sural nerve Saphenous nerve base divides into five slips Each further divides into two and Medial calcaneal diverges around the flexor Calcaneus nerve tendons  The sole of the foot Digital branches Organised into 4 layers of muscles. Terminal branches of Tibial Nerve Medial Plantar Nerve: Cutaneous to medial three and one-half toes. The nerves extend onto the dorsum and supply the nail beds and tips of the toes. Motor branches to muscles in the sole of the foot. Lateral Plantar Nerve: lateral one and one-half toes supply the nail beds and tips of toes. Motor branches to muscles in the Medial planter sole of the foot. Lateral planter Medial planter nerve nerve nerve Medial planter The posterior tibial artery divides into: Deep planter artery Lateral arch Medial Plantar Artery : Smaller – planter nerve supplies medial side of big toe. Lateral Plantar artery Larger – passes deep to muscles of sole of foot, forms the Lateral deep plantar arch. At the first planter Posterior tibial intermetatarsal space joins the dorsalis artery artery pedis artery. Supplies digital arteries to the Saphenous nerve toes Sural nerve Veins: Medial and lateral plantar veins Medial calcaneal nerve accompany the arteries.  Peripheral pulses Midway between the anterior superior iliac spine and the In the popliteal pubic symphysis. fossa when knee is Midinguinal partially flexed point Continuation of Passes behind anterior tibial the medial artery. Palpable in malleolus the proximal part of beneath the the first dorsal flexor metatarsal space retinaculum b/w b/w the tendons of the tendons of EHL medially & FDL & FHL. EDL laterally Pulsations b/w the medial malleolus and the heel Superficial veins of the lower limb Small saphenous vein Lateral side of the dorsal venous arch Pass posterior to the lateral malleolus Ascend in the posterior leg Drain into the popliteal vein Great saphenous vein Great saphenous vein Short Medial side of the dorsal venous arch saphenous vein Pass anterior to the medial malleolus Pass upward in the medial side of the leg, Dorsal venous knee and thigh arch Drain into the femoral vein Deep veins of the lower limb Deep veins accompany arteries Many perforating veins pierce the deep fascia to pass between superficial and deep veins Femoral vein Deep veins of the leg drain into the popliteal vein Popliteal vein becomes femoral after it passes into the adductor hiatus Profunda femoris and several perforating veins join the femoral in the thigh Femoral becomes external iliac when it passes underneath the inguinal ligament  Nerves Common Posterior cutaneous nerve of fibular Common the thigh fibular (from sacral plexus) Lateral cutaneous nerve of the calf Tibial (From Common fibular) Superficial fibular (from common Saphenous nerve Deep fibular fibular) (from femoral) Superficial Saphenous nerve fibular (from femoral) Sural nerve (from tibial nerve) Medial calcaneal Deep fibular branches (from tibial (from common nerve) Thank you