RCSI Knee Joint, Leg, Tibiofibular Joint, and Dorsum of Foot PDF

Knee Joint, Leg, Tibiofibular Joint and Dorsum of Foot Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: ▪ Discuss the knee joint, including structure, actions, stability and neurovascular supply ▪ Describe the bones...

Knee Joint, Leg, Tibiofibular Joint and Dorsum of Foot Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: ▪ Discuss the knee joint, including structure, actions, stability and neurovascular supply ▪ Describe the bones of the leg and foot ▪ Explain how to identify ligamentous injuries to the knee joint and their clinical significance ▪ Define the superior and inferior tibiofibular joints ▪ Discuss the muscles and innervation of the anterior, posterior and lateral compartments of the leg ▪ Describe the trifurcation of the popliteal artery and the course of the resulting branches ▪ Identify the tarsal tunnel and extensor retinacula and their underlying tendons ▪ Interpret radiological imaging of the knee and leg 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. Osteology-distal end of the femur Posterior View Anterior View Supracondylar line Lateral epicondyle of the femur Patellar surface Medial epicondyle of the femur Lateral condyle of the femur Medial condyle of the femur Intercondylar fossa Patella • Base pointing upward • Apex pointing downward Quadriceps tendon Patellar ligament Bones of the leg Proximal tibiofibular joint Apex (styloid process) Intercondylar eminence Lateral condyle Medial condyle Proximal tibiofibular joint Head of the fibula Neck of the fibula • • Tibial plateau: Articular surfaces of the medial and lateral condyles and the intercondylar region Fibula is not weightbearing bone Tibial tuberosity Interosseous border Lateral Soleal line Posterior surface Lateral Medial surface Anterior border Medial border Distal tibiofibular joint Distal tibiofibular joint Medial malleolus Lateral malleolus Lateral malleolus Knee joint • Largest synovial joint (Hinge) • Articulation between the femur and tibia • Articulation between femur and patella • The articular surfaces between femur and patella are V-shaped • Articular surfaces-covered with hyaline cartilage: • Two femoral condyles • Tibial condyles • Menisci accommodate the changes of the shape of the femur. • The fibula does NOT take part in the knee joint • Two menisci-fibrocartilaginous Cshaped • Medial: attaches to the capsule and tibial collateral ligament • Lateral: unattached to the capsule (thus, more mobile) • Connected to the tendon of the popliteus • Interconnected anteriorly by the transverse ligament of the knee • Functions: • Deepens the articular surface and provides stability to the joint • Act as cushion-shock absorption Menisci Synovial membrane • Lines the fibrous capsule • Attaches to the margins of the articular surfaces and outer margins of the menisci. Bursae around the knee • Bursae are flattened sacs that contain synovial fluid, which function to reduce friction. • 12 bursae around the knee joint. The main ones are: • Prepatellar – anterior to patella • Infrapatellar - superficial and deep to patellar ligament • Suprapatellar - large bursa, lies behind quadriceps tendon. Continuous with the joint capsule. • Popliteal • Semimembranosus - Between the semimembranosus tendon and the joint Bursitis • Inflammation of bursa surrounding knee • Cause: repeated frictional forces in chronic inflammation thus, the bursa becomes distended and filled with fluid • Example: • Prepatellar bursitis (housemaid's knee)-Bursitis of the subcutaneous prepatellar bursa can affect those who work on their knees (a knee pad is recommended to protect the knee). • Infrapatellar bursitis (clergyman's knee)-if weight or impact routinely occurs on the tibial tuberosity, the infrapatellar bursa becomes inflamed and swell. Infrapatellar bursitis Fibrous capsule • Extensive • Reinforced by tendons of the surrounding muscles • Medial: blends with tibial collateral ligament and attaches to the medial meniscus • Lateral: separated by a space from the fibular collateral ligament. NOT attached to the lateral meniscus • Anterolaterally: reinforced by a fibrous extension from the iliotibial tract • Posteromedially: extension from the semimembranosus (oblique popliteal ligament) Ligaments • Extracapsular Ligaments • Tibial (medial) collateral • Broad and flat • Medial femoral epicondyle to medial tibia • Attaches to the capsule (and indirectly to the medial meniscus) Quadriceps tendon Fibular collateral ligament • Fibular (lateral) collateral • Thin and cord-like • Lateral femoral epicondyle to head of the fibula • NOT attached to the lateral meniscus or capsule Tibial collateral ligament • Patellar ligament • Tendon of the quadriceps muscles Patellar ligament Intracapsular ligaments • Anterior cruciate ligament (ACL) • Attachments: • Lateral femoral condyle • Anterior tibial plateau • Functions: • Prevents tibia sliding anterior (forward) on the femur • Limits the hyperextension of the knee • Posterior cruciate ligament (PCL) • Attachments: • Medial femoral condyle • Posterior tibial plateau • Lies medial to anterior cruciate Anterior cruciate ligament Lateral • Functions: • Prevents tibia sliding posteriorly (backward) on femur • Especially in flexed knee e.g. when walking downhill Posterior cruciate ligament Medial Injuries to the knee Rupture of the anterior cruciate ligament • Cruciate ligament injuries • Collateral ligament injuries • With the leg straight–abduct and adduct the knee. • Meniscal injuries • Medial:lateral at a ratio of 20:1 • Reason: The medial meniscus is attached to the medial collateral ligament Rupture of the posterior cruciate ligament Just for Fun! Just for Fun! Short video of the injury: https://twitter.com/i/statu s/1714446626683556225 Testing for ligamentous injuries Anterior drawer test • Cruciate ligament injury: Excessive direct force is applied to the knee • ACL: • More common than PCL injury • Test: anterior drawer or Lachman test • PCL: • Test: posterior drawer test (downhill) Think: Anterior cruciate ligament, prevents Anterior displacement of tibia, tested by Anterior drawer test. Posterior drawer test Knee movements-flexion and extension • Flexion • Hamstring muscles • Biceps femoris • Semimembranosus • Semitendinosus • Sartoris • Gastrocnemius • Extension • Quadriceps femoris • • • • Rectus femoris Vastus lateralis Vastus intermedius Vastus medialis Locking and unlocking the knee • When standing, the knee joint is locked into position-reducing the amount of muscle work needed to maintain the standing position. • Locking mechanism is achieved by: • The change in the shape and size of the femoral surfaces that articulate with the tibia during extension. • The joint surfaces become larger and more stable in extension. • Medial rotation of the femur on the tibia during extension that tightens all the associated ligaments. • Knee becomes rigid • Center of gravity crosses anterior to the knee • Unlocking • The popliteus muscle unlocks the knee by initiating lateral rotation of the femur on the tibia. Arterial supply to the knee • Five genicular arteries from the popliteal artery • • • • • Superior medial genicular artery Superior lateral genicular artery Inferior medial genicular artery Inferior lateral genicular artery Middle genicular artery Superior medial genicular Superior lateral genicular Interior lateral genicular • Recurrent branch of anterior tibial artery • Two descending genicular arteries • One from the femoral artery • One from the lateral circumflex Interior medial genicular Posterior view Nerve supply to the knee • Nerve supply • Hilton’s Law- “the nerve supplying the muscles extending directly across and acting at a given joint also innervate the joint” • Femoral nerve • Tibial nerve • Common peroneal nerve Tibiofibular joint • Superior • Synovial joint • Separate from knee joint • Inferior • Fibrous joint Leg Anterior compartment • • • • Extensor compartment Deep fibular (peroneal) nerve Anterior tibial artery Dorsiflex/extension of the foot Lateral compartment • • • Superficial fibular (peroneal) nerve Perforating branches from the fibular artery Eversion of the foot T F Posterior compartment • • • • Interosseous membrane Flexor compartment Tibial nerve Posterior tibial artery Plantarflex/flexion of the foot • Dorsiflexion: moving the top of the foot towards the leg • Anterior compartment of the leg which is supplied by the deep fibular 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 Movements at the ankle Lateral compartment of the leg Fibularis (peroneus) longus • From fibula to medial cuneiform and metatarsal 1 • Superficial fibular nerve • Action: • Eversion and plantarflexion of foot • Supports arches of the foot Fibularis (peroneus) brevis • From fibula to metatarsal 5 • Superficial fibular nerve • Action: Eversion of foot Anterior compartment of the leg and dorsum of the foot Think: Tall Happy Dancing Flamingoes Extensor digitorum longus • From fibula and tibia to bases of distal and middle phalanges of lateral 4 toes. • Deep fibular nerve • Actions: • Dorsiflexion of foot • Extension of lateral 4 toes Tibialis anterior • From tibia to medial cuneiform and metatarsal 1 • Deep fibular nerve • Actions: • Dorsiflexion and inversion of foot • Dynamic support of the medial arch of the foot Extensor hallucis longus Fibularis (peroneus) tertius • From fibula base of metatarsal 5. • Deep fibular nerve • Actions: Dorsiflexion and eversion of foot • From fibula to the base of the distal phalanx of the great toe. • Deep fibular nerve • Actions: • Dorsiflexion of foot • Extension of great toe Dorsum of the foot Extensor hallucis longus Extensor digitorum longus Extensor hallucis brevis Extensor digitorum brevis • From calcaneus to tendons of extensor digitorum longus of the lateral 4 toes. • Deep fibular nerve • Action: Extension of lateral 4 toes • From calcaneus to the base of the proximal phalanx of the great toe. • Deep fibular nerve • Action: Extension of metatarsophalangeal joint of the great toe The posterior compartmentsuperficial layer Gastrocnemius • Medial and lateral femoral epicondyles to calcaneus via calcaneal tendon • Tibial nerve • Planterflexes foot and flex the knee Calcaneal tendon Solus • Tibia to calcaneus via calcaneal tendon • Tibial nerve • Planterflexes foot Plantaris • Femur to calcaneus via calcaneal tendon • Tibial nerve • Planterflexes foot and flex the knee The posterior compartmentDeep layer Flexor digitorum longus • Tibia to bases of distal phalanges of the lateral four toes. • Tibial nerve • Flex the lateral 4 toes Fibular artery Tibialis posterior Flexor digitorum longus Tibial nerve Posterior tibial artery Tibialis posterior • Tibia and fibula navicular and medial cuneiform • Tibial nerve • Actions: • Inversion and plantarflexion of foot • Support of the medial arch of the foot during walking Flexor hallucis longus • Fibula to the distal phalanx of the great toe. • Tibial nerve • Flexes the big toe Arrangement of tendons in the tarsal tunnel: Tom, Dick and very naughty Harry! Flexor hallucis longus Tarsal tunnel • On the medial side of the ankle. • Between the tarsal bones and the flexor retinaculum. Think: Tom, Dick and very naughty Harry! Femoral artery Blood vessels Adductor hiatus The popliteal artery is the major blood supply to the leg and foot and enters the posterior compartment of the leg from the popliteal fossa behind the knee: Popliteal artery • Anterior tibial • Posterior tibial • Circumflex fibular • Fibular artery Circumflex fibular artery Anterior tibial artery Posterior tibial artery Fibular artery Nerves Common fibular Common fibular Posterior cutaneous nerve of the thigh (from sacral plexus) Lateral cutaneous nerve of the calf Tibial (From Common fibular) Superficial fibular Superficial fibular Deep fibular (from common fibular) Saphenous nerve Saphenous nerve (from femoral) (from femoral) Sural nerve (from tibial nerve) Deep fibular (from common fibular) Medial calcaneal branches (from tibial nerve) Thank you