Final Exam Review LEAII PDF

Review Exam 3 LEAII Dorsal Foot Layers 1. TA, EHL and EDL, peroneus tertius tendons Extrinsic tendons 2. Extensor digitorum brevis O: calcaneus I: EDL tendon Only intrinsic muscle; accessory extensor of MPJ and IPJs No tendon to 5th toe Includes extensor hallucis brevis, extends 1st MPJ; I: base pro...

Review Exam 3 LEAII Dorsal Foot Layers 1. TA, EHL and EDL, peroneus tertius tendons Extrinsic tendons 2. Extensor digitorum brevis O: calcaneus I: EDL tendon Only intrinsic muscle; accessory extensor of MPJ and IPJs No tendon to 5th toe Includes extensor hallucis brevis, extends 1st MPJ; I: base prox phalanx 3. Neurovascular Extensor expansions Dorsalis pedis artery & branches Vena commitantes Deep peroneal nerve Lateral branch – EDB 1st IS - cutaneous “AHAND” – know the order Plantar Foot Muscle Layers Layer 1 Abductor hallucis Medial Plantar nerve O: medial process I: base prox. phalanx hallux, medial sesamoid Flexor digitorum brevis O: medial process I: base middle phalanx 2-5, 2 slips A: Flex PIPJs 2-5 Abductor digiti minimi O: lateral process I: 5th prox. phalanx base Lateral plantar nerve FDB ADM AH Plantar Foot Muscle Layers Layer 2 FDL tendon & accessory muscles 4 lumbricals O: FDL I: medial wing, ext. exp. A: Flex MPJ; extend PIPJS Medial side of tendon Plantar to deep transverse metatarsal lig Quadratus plantae – med/lat heads O: calcaneus. I: FDL A: straightens pull Lateral plantar nerve Except 1st lumbrical FHL tendon Deep to FDL Master Knot of Henry – connect the 2 I: base of distal phalanx FHL A: Flex HIPJ FDL A: Flex DIPJs Transverse head Plantar Foot Muscle Layers Oblique head Flexor digiti minimi brevis Flexor Hallucis brevis Layer 3 Flexor digiti minimi brevis O: 5th met base. I: 5th prox phal. base Lateral plantar n (superficial branch) Adductor hallucis Transverse head O: plantar plates 3-5 & deep met lig Oblique head O: base 2-4 mets; PL tendon sheath I: lateral sesamoid, base prox phal. Lateral plantar n (deep branch) Flexor hallucis brevis O: cuboid, lat cun., PT tendon I: medial head – medial sesamoid; base prox phal Lateral head - lat sesamoid, base prox phal Medial plantar n Plantar Muscle Layers Layer 4 - Interossei 3rd plantar interossei 1st dorsal interossei Travel deep (superior) to deep transverse met ligs 3 plantar interossei “PAD” Unipennate Adduct 3-5 toes PL tendon TP tendon Short plantar ligament O: metatarsal shafts I: base prox phalanges; sling 4 dorsal interossei “DAB” Bipennate Abduct 2-4 toes Spring ligament Lateral plantar n (deep branch) 4th interosseous space – superficial branch Dorsal Foot Origins: *Extensor digitorum brevis/EHB Tubercle on dorsal anterior calcaneus Dorsal interossei (plantar foot 4th layer) Extensor hallucis longus Extensor hallucis brevis Extensor digitorum longus; terminal & central slips Dorsal interossei Metatarsal shafts Insertions: Peroneus brevis Dorsal interossei Peroneus tertius (2nd layer) Peroneus tertius Dorsal interossei Peroneus brevis Styloid process 5th metatarsal 5th metatarsal base, shaft Base prox phalanx, med 2nd, lat 2-4 Extensor hallucis brevis (2nd layer) Base of proximal phalanx hallux Extensor hallucis longus (1st layer) Base of distal phalanx hallux Extensor digitorum longus (1st layer) Central slip – base middle phalanx Terminal slip – base distal phalanx EHB Extensor digitorum brevis *Only intrinsic muscle* Flexor digitorum longus FDB FHL FHB, adductor Plantar interossei Abductor digiti minimi FHB, Abductor hallucis Flexor digiti minimi brevis Plantar interossei Adductor hallucis, Oblique head Peroneus longus Tibialis anterior Calcaneal tuberosity Medial process – FDB, Abductor hallucis Lateral process – Abductor digiti minimi 2 heads of quadratus plantae Cuboid, lat cuneiform, PT tendon Peroneus brevis Tibialis posterior FHB Base 5th metatarsal, plantar medial Flexor digiti minimi brevis Quadratus plantae Abductor digiti minimi Origins: Plantar calcaneus, distal Flexor digiti minimi brevis Flexor hallucis brevis Plantar Foot Abductor hallucis Flexor digitorum brevis Base of 2-4 metatarsals Adductor hallucis oblique head Plantar shafts 3-5 metatarsals Plantar interossei Flexor digitorum longus FDB FHL FHB, adductor hallucis Plantar interossei Abductor digiti minimi FHB, Abductor hallucis Flexor digiti minimi brevis Plantar interossei Adductor hallucis, Oblique head Peroneus longus Tibialis anterior Flexor digiti minimi brevis Tibialis posterior Peroneus brevis brevis Flexor hallucis Plantar Foot Insertions: TP, TA. PL Sesamoids/ base proximal phalanx hallux Medial – FHB, med; abductor hallucis Lateral – FHB, lat; adductor hallucis Base of 5th proximal phalanx Abductor digiti minimi brevis Flexor digiti minimi brevis 3rd plantar interosseous Base proximal phalanx 3rd, 4th 1st, 2nd plantar interossei, medial Middle phalanx 2-5 FDB, lateral slips Quadratus plantae Abductor digiti minimi Base distal phalanx hallux Abductor hallucis Flexor digitorum brevis FHL Base distal phalanx 2-5 FDL Muscles with Attachments Other than to Bone Quadratus plantae Lumbricals I: FDL tendon Lumbricals O: FDL tendon slips I: medial wing of extensor expansion FDL QP Adductor hallucis, transverse head Extensor expansion Sling Wing O: plantar plates, deep tran. met. lig. Extensor digitorum brevis, slips 2-4 I: EDL tendon, form wing laterally EDL Others that contribute to extensor expansion: EDL Interossei help to form the sling What Else Attaches to Bone? Retinacula – thickening of deep fascia Superior peroneal retinaculum Lat. mall. to calcaneus, 1 tendon sheath Inferior peroneal retinaculum Stem of inf. ext. retin. to calcaneus – 2 tendon sheaths (PB sup. PL) Flexor retinaculum (laciniate lig.) Med. mall. to calcaneus Forms tarsal tunnel 4 fibrous tunnels; 3 tendon sheaths “Tom Dick And Nervous Harry” 1. Tibialis posterior 2. Flexor digitorum longus 3. PT artery/ tibial n. -> med. & lat. plantar a/v/n -> porta pedis (deep to abd. hallucis) 4. Flexor hallucis longus Extensor Retinacula Sheath of EDL & per. tertious Sheath of TA Sheath of EHL Attach to bone Prevent bowstringing of tendons Superior extensor Tibia/medial malleolus Fibula/ lateral malleolus Inferior extensor Stem – dorsal, ant calcaneus Lat and inter. fibers form a loop around EDL/peroneus tertius Medial fibers form EDB Upper band (med mall) Lower band (navicular) Bifurcate ligament (BL) Cervical ligament (CL) Dorsal Calcaneus BL Lateral stem of inferior extensor retinaculum CL XX ITCL Medial slips Lateral and intermediate slips Origin of extensor digitorum brevis Ligaments: Bifurcate ligament EDB X X Tarsal canal = medial, narrow part of sinus tarsi Cuboid, navicular Cervical ligament Neck of talus Interosseous talocalcaneal ligament Connects sulcus tali to sulcus calcanei Non-articular areas Dorsal right calcaneus Sinus tarsi = tunnel formed by the sulcus tali & sulcus calcanei; Wider laterally Ligaments Intersesamoid lig IPJs Plantar and collateral ligs MPJ’s Plantar plates Plantar metatarsophalangeal lig Fibrocartilage Attachments - numerous Plantar plates Collateral and suspensory ligs Rearfoot & midfoot Calcaneocuboid ligs. (lateral long. arch) Long, short plantar ligs. PL Calcaneonavicular lig (med. long. arch) TP Long plantar lig FDL Short plantar lig FHL Spring lig Spring lig. Plantar aponeurosis (both long. arches) – deep fascia Calcaneal tuberosity to plantar plates and skin Plantar Aponeurosis Superficial transverse metatarsal ligaments Proper plantar digital arteries and nerves Central band Medial process of calc. tuberosity Fans out distally and forms digital slips Superficial slips Attaches to the skin anterior to the metatarsal heads Superficial transverse metatarsal ligaments connect the slips Deep slips Attach to plantar plates and deep transverse metatarsal ligaments Help form flexor sheaths Lateral band Lateral process of calc. tub., short Medial/lateral intermuscular septa attach to deep surface of plantar fascia Attach to bone – 1st and 5th metatarsals Transverse fasiculi Digital slips Plantar fascia superficial to abductor digiti minimi Lateral band Plantar fascia superficial to abductor hallucis Central band Dorsiflex MPJs à Increase arch height Compartments of the Plantar Foot True fascial compartments Separated by intermuscular septa Medial FHB, abductor hallucis FHL tendon Lateral Flexor digiti minimi brevis, abductor digiti minimi Central FDB, QP, lumbricals, adductor hallucis FDL tendon Interosseous Dorsal and plantar interossei Extensor Expansion Sling EDL Functions as a compound tendinous attachment of EDL EDB Lateral wing Lumbrical Medial wing Plantar to deep transverse metatarsal ligament Plantar/dorsal interossei Sling Dorsal to deep transverse metatarsal ligament Extensor expansion wing Extensor sling Coronal Plane 3rd, 4th Met Head EDL tendon EDB tendon Plantar interosseous tendon EDB EDL Medial, toes 3-5 Dorsal interosseous tendon Lateral toes 2-4 (medial 2nd toe) Plantar plate Deep transverse metatarsal ligaments Lumbrical tendon Dorsal interosseous Metatarsal head Medial toes 2-5 Plantar to deep transverse metatarsal ligament Plantar interosseous Flexor sheath FDL tendon FDB tendon Lumbrical FDL FDB 1st Metatarsal Phalangeal Jt. Plantar view: Lateral sesamoid Deep transverse metatarsal lig. Extensor expansion, sling only EHB tendon does not insert on EHL tendon No lumbricals or interossei FHB, abductor hallucis and adductor hallucis contribute plantarly Proximal phalanx AdH Medial sesamoid Joint capsule AbH FHB, medial head 1st metatarsal Lateral view: Sesamoids are located within their tendons Attached to 3 bones by suspensory, sesamoid phalangeal and intersesamoid ligaments (suspensory) Lateral sesamoid FHB, lateral head 1st Metatarsal Phalangeal Joint Coronal Section Metatarsal Head 1 Tendons: 1. EHL 2. EHB 3. FHL 4. Abductor hallucis 5. Adductor hallucis 2 6 7 9 5 4 Ligaments: 6. Intersesamoid 7. Medial suspensory 8. Lateral suspensory 3 8 9. crista Central slip Lateral slips become terminal slip EDL Coronal Sections of the Lesser Toes FHB EDL tendon: Lateral slips Centralslip..... Dorsal digital a/v Dorsal digital proper nerves Terminal slip of EDL.. Head of Proximal phalanx Lateral slips of FDB tendon.. PIPJ.. Head of middle phalanx.. FDL tendon FDL.... Plantar digital a/v plantar digital proper nerves FDL tendon DIPJ CORONAL PLANE: Mid-shaft metatarsal level Extensor Tendons: EDL EHB EDB EHL 1st DI 5th AbDM PI Adductor hallucis PI FHB AbH FDMB Flexor Tendons: 1st PI 4th DI L FDL L FDB L L FHL Innervation Dorsal Foot Superficial peroneal nerve Medial dorsal cut. N. 1st proper digital 2nd common digital Intermediate dorsal cut. n. 3rd, 4th common Sural nerve/ LSV Lateral calcaneal branches Lateral dorsal cut. N. -> 10th proper Saphenous nerve/ GSV Dorsal medial foot to base 1st met Deep peroneal nerve Lateral branch à EDB; dorsal metatarsal ns -> sensory to joints Medial branch -> cutaneous 1st interspace 1st common-> 2nd, 3rd proper Innervation Plantar Foot Tibial nerve 8-10 proper plantar Digital nerves Medial calcaneal branches Pierce flexor retinaculum 1-3 common Bifurcates into: Medial plantar nerve à AbH, FDB Medial branch -> FHB, 1st proper plantar n Lateral branch -> 1st common -> FHB, 1st lumbrical 2nd, 3rd common plantar digital ns Lateral plantar nerve à QP, AbDM Smaller of the 2, travels between FDB & QP Superficial branch -> FDMB, 3rd plantar interosseous, 4th dorsal interosseous -> 4th common, 10th proper Deep branch of lateral plantar n Between 3rd & 4th layers Adductor hallucis, lumbricals 2-4, interossei (except 4th dorsal, 3rd plantar) 4th common Superficial branch Abductor digiti minimi Media Planta nerve Medial Calcan. nerve Lateral plantar nerve Lateral calcaneal nerve Cutaneous Nerves Plantar Foot Medial plantar nerve 3 proper nerves 7 proper nerves Larger branch Sensory to medial 3 & 1/2 toes Terminates base of 1st metatarsal: Medial plantar digital nerve of hallux 1st plantar proper digital nerve Lateral branch gives off 1st – 3rd common plantar digital nerves (1st proper) (10th) Lateral plantar nerve Terminates base of 5th metatarsal: Superficial branch Sensory to lateral 1 & ½ toes Pierces deep facia and divides in two 4th common plantar digital nerve 10th plantar proper digital nerve Deep branch - motor, primarily Both innervate dorsal, distal toes Posterior Tibial Artery MEDIAL VIEW Anterior Tibial artery Branches before it bifurcates: Medial calcaneal branches Artery to the tarsal canal Anastomoses with sinus tarsi artery Branch DP artery or lateral tarsal/perf. peroneal arteries Sinus tarsi Artery to the tarsal canal Non-articular area between talus & calc Funnel-shaped, wide laterally Tarsal canal Dorsalis pedis Narrow medial part of sinus tarsi Tarsal tunnel Area deep to flexor retinaculum SUPERIOR TALUS Prone to AVN Mostly covered by articular cartilage No muscle attachments Terminal Branches of Posterior Tibial Artery Bifurcates near sustentaculum tali: 5 ST Deep branch Medial plantar artery (2) Superficial branch Lateral plantar artery (1) Smaller Deep branch joins deep plantar arch Larger Travels between FDB & QP -> lat. comp. Superficial branch - lateral 5th toe Deep plantar arch (5) -> central comp. 3-4 plantar metatarsal arteries 2 plantar digital arteries each Proximal/distal perforating arteries Anastomose with dorsal metatarsal arteries Medial Plantar Artery Superficial branch Medial marginal Crosses FHL tendon to lie medial to it 2 terminal branches Medial branch: Medial marginal plantar artery Lateral branch: Travels superficial to flexor digitorum brevis, deep to plantar fascia 3 branches Superficial plantar digital arteries Anastomose with the 1st-3rd plantar metatarsal arteries Dorsalis Pedis Artery Perforating peroneal artery Dorsalis pedis a. Branches: Medial tarsal aa. Lateral tarsal artery Deep to EDM Medial tarsal arteries Lateral tarsal a. Usually 2 small branches Arcuate artery Present 54% of the time Arises at base of 2nd metatarsal 2nd-4th dorsal metatarsal arteries Dorsal metatarsal aa. EDB Arcuate a. Deep plantar a. 1st dorsal metatarsal a. Superficial to dorsal interosseous muscles Bifurcates into two terminal branches: Deep plantar artery Perforates two heads of the 1st dorsal interosseous muscle 1st dorsal metatarsal artery Dorsal digital proper aa. Veins of the Foot Deep veins Vena commitantes of DP and PT arteries Superficial veins Plantar venous plexus Numerous small veins plantarly Drain to marginal veins primarily Thru perforator veins Dorsal venous arch drains to Medial marginal vein à great saphenous vein Travels with saphenous nerve Lateral marginal vein --> lesser saphenous vein Travels with sural nerve Located at the level of the metatarsals Superficial to cutaneous nerves Dorsal Venous Arch Medial malleolus Lateral malleolus Receives: 4 superficial dorsal metatarsal veins Dorsomedial vein of the hallux Dorsolateral vein of the 5th toe Lateral marginal vein Dorsolateral vein of 5th toe Medial marginal vein Dorsal venous arch Dorsomedial vein of hallux Dorsal digital veins Clinical Correlations Radiculopathy Digital blocks Neuropathy Ankle block Nerve root compression (L4-S1) Mononeuropathy Nerve compression Tibial (tarsal tunnel syndrome) Peripheral polyneuropathy Many/ all nerves are affected i.e. Diabetes – all 3 nerve fibers Morton’s neuroma Common plantar digital nerve (3 rd) Lumbar sympathectomy What nerves? What nerves? Where are they located? Reflexes Achilles Patellar Babinski Compartment syndrome Skin Dorsal vs plantar