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The Foot and Ankle

The Foot and Ankle. Dr. Fadel Naim Orthopedic Surgeon Faculty of Medicine IUG. Bones of the Foot. The bones of the foot are: The tarsal bones The metatarsals The phalanges. TARSAL BONES. The tarsal bones are The calcaneum The talus The navicular The cuboid

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The Foot and Ankle

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  1. The Foot and Ankle Dr. Fadel Naim Orthopedic Surgeon Faculty of Medicine IUG

  2. Bones of the Foot • The bones of the foot are: • The tarsal bones • The metatarsals • The phalanges

  3. TARSAL BONES • The tarsal bones are • The calcaneum • The talus • The navicular • The cuboid • The three cuneiform bones. • Only the talus articulates with the tibia and the fibula at the ankle joint • unlike those of the carpus, start to ossify before birth. • By the fifth year, ossification is taking place in all the tarsal bones

  4. Calcaneum • The largest bone of the foot • The prominence of the heel • It articulates • above with the talus • in front with the cuboid.

  5. Calcaneum • It has six surfaces. • The anterior surface is small and forms the articular facet that articulates with the cuboid bone. • The posterior surface forms the prominence of the heel and gives attachment to the tendo calcaneus (Achilles tendon).

  6. Calcaneum • The superior surface is dominated by two articular facets for the talus • separated by a roughened groove, the sulcus calcanei.

  7. Calcaneum • The inferior surface has: • an anterior tubercle in the midline • a large medial tubercle • smaller lateral tubercle

  8. Calcaneum • The medial surface possesses a large, shelf like process,termed the sustentaculum tali, which assists in the support of the talus.

  9. Calcaneum • The lateral surface is almost flat. • On its anterior part is a small elevation called the peroneal tubercle, which separates the tendons of the peroneus longus and brevis muscles.

  10. Talus • The talus articulates: • Above at the ankle joint with the tibia and fibula • Below with the calcaneum • In front with the navicular bone. • It possesses • A head • A neck • A body • Numerous important ligaments are attached to the talus • No muscles are attached to this bone.

  11. TalusThe head • Directed distally • An oval convex articular surface for articulation with the navicular bone.

  12. TalusThe head • The articular surface is continued on its inferior surface • It rests on the sustentaculum tali behind and the calcaneonaviculr ligament in front.

  13. Talus Neck • Lies posterior to the head and is slightly narrowed. • Its upper surface is roughened and gives attachment to ligaments • Lower surface shows a deep groove, the sulcus tali • The sulcus tali and the sulcus calcanei in the articulated foot form a tunnel, the sinus tarsi,which is occupied by the strong interosseous talocalcaneal ligament.

  14. Talus The body • cuboidal • superior surface articulates with the distal end of the tibia • it is convex from before backward and slightly concave from side to side. • Its lateral surface presents a triangular articular facet for articulation with the lateral malleolus of the fibula.

  15. Talus The body • Its medial surface has a small, comma-shaped articular facet for articulation with the medial malleolus of the tibia. • The posterior surface is marked by two small tubercles, separated by a groove for the flexor hallucis longus tendon.

  16. Navicular Bone • The tuberosity of the navicular bone can be seen and felt on the medial border of the foot 1 in. (2.5 cm) in front of and below the medial malleolus • It gives attachment to the main part of the tibialis posterior tendon

  17. Cuboid Bone • A deep groove on the inferior aspect of the cuboid bone lodges the tendon of the peroneus longus muscle.

  18. Cuneiform Bones • The three small, wedge-shaped • Articulate proximally with the navicular bone and distally with the first three metatarsal bones. • Their wedge shape contributes greatly to the formation and maintenance of the transverse arch of the foot

  19. METATARSAL BONES AND PHALANGES • Resemble the metacarpals and phalanges of the hand • Each possesses a head distally, a shaft, and a base proximally • The five metatarsals are numbered from the medial to the lateral side. • The first metatarsal bone is large and strong and plays an important role in supporting the weight of the body. • The head is grooved on its inferior aspect by the medial and lateral sesamoid bones in the tendons of the flexor hallucis brevis.

  20. METATARSAL BONES AND PHALANGES • The fifth metatarsal has a prominent tubercle on its base that can be easily palpated along the lateral border of the foot. • The tubercle gives attachment to the peroneus brevis tendon. • Each toe has three phalanges except the big toe, which possesses only two.

  21. FRACTURES OF THE TALUS • Fractures occur at the neck or body of the talus. • Neck fractures occur during violent dorsiflexion of the ankle joint when the neck is driven against the anterior edge of the distal end of the tibia. • The body of the talus can be fractured by jumping from a height, although the two malleoli prevent displacement of the fragments.

  22. FRACTURES OF THE CALCANEUM • Compression fractures of the calcaneum result from falls from a height. • The weight of the body drives the talus downward into the calcaneum, crushing it in such a way that it loses vertical height and becomes wider laterally. • The posterior portion of the calcaneum above the insertion of the tendo calcaneus can be fractured by posterior displacement of the talus. • The sustentaculum tali can be fractured by forced inversion of the foot.

  23. FRACTURES OF THE METATARSAL BONES • The base of the fifth metatarsal can be fractured during forced inversion of the foot, at which time the tendon of insertion of the peroneus brevis muscle pulls off the base of the metatarsal.

  24. FRACTURES OF THE METATARSAL BONES • Stress fracture of a metatarsal bone • common in joggers and in soldiers after long marches • It occurs most frequently in the distal third of the second, third, or fourth metatarsal bone. • Minimal displacement occurs because of the attachment of the interosseous muscles.

  25. ANTERIOR ASPECT OF THE ANKLE • Structures That Pass Anterior to the Extensor Retinacula from Medial to lateral • Saphenous nerve and great saphenous vein (in front of the medial malleolus). • Superficial peroneal nerve (medial and lateral branches)

  26. Structures That Pass beneath or through the Extensor Retinacula from Medial to lateral • Tibialis anterior tendon • EHL tendon. • Anterior tibial artery with venae comitantes. • Deep peroneal nerve. • EDL tendons. • Peroneus tertius. • The tendons pass beneath or through the extensor retinacula • The tendons of EDL and the peroneus tertius share a common synovial sheath.

  27. POSTERIOR ASPECT OF THE ANKLEStructures That Pass behind the Medial Malleolus from Medial to lateral • Tibialis posterior tendon • FDL • Posterior tibial artery with venae comitantes • Tibial nerve • FHL

  28. Structures That Pass behind the lateral Malleolus Superficial to the Superior Peroneal Retinaculum • The sural nerve • Small saphenous vein

  29. Structures That Pass behind the lateral Malleolus beneath the Superior Peroneal Retinaculum • The peroneus longus and brevis • Share a common synovial sheath • Beneath the inferior peroneal retinaculum, they have separate sheaths.

  30. Structures That Lie Directly behind the Ankle • The fat and the large tendo calcaneus lie behind the ankle

  31. The Foot • The foot supports the body weight • Provides leverage for walking and running • It serves as a resilient spring to absorb shocks, such as in jumping. • It is constructed in the form of arches, which enable it to adapt its shape to uneven surfaces.

  32. THE SOLE OF THE FOOTSkin • Thick and hairless. • Firmly bound down to the underlying deep fascia • By numerous fibrous bands • The skin shows a few flexure creases at the sites of skin movement. • Sweat glands are present in large numbers.

  33. The sensory nerve supply to the skin of the sole • medial side of the heel • The medial calcaneal branchof the tibial nerve • medial two thirds of the sole • Branches from the medial plantar nerve • lateral third of the sole • Branches from the lateral plantar nerve

  34. Deep Fascia The plantar aponeurosis • A thickening of the deep fascia • Triangular and occupies the central area of the sole • The apex is attached to the medial and lateral tubercles of the calcaneum • The base divides at the bases of the toes into five slips • Each slip divides into two bands • One passing superficially to the skin • The other passing deeply to the root of the toe • Divides into two, which diverge around the flexor tendons • Finally fuse with the fibrous flexor sheath and the deep transverse ligaments

  35. The medial and lateral borders of the thick aponeurosis are continuous with the thinner deep fascia covering the abductors of the big and little toes. • Fibrous septa pass superiorly into the sole and take part in the formation of the fascial spaces of the sole.

  36. The Function Of The Plantar Aponeurosis • To give firm attachment to the overlying skin • To protect the underlying vessels, nerves, and tendons and their synovial sheaths • To assist in maintaining the arches of the foot.

  37. PLANTAR FASCIITlS • Occurs in individuals who do a great deal of standing or walking • Causes pain and tenderness of the sole of the foot. • Caused by repeated minor trauma. • Induce ossification in the posterior attachment of the aponeurosis, forming a calcaneal spur.

  38. Muscles of the Sole of the Foot • Four layers from the inferior layer superiorly. • The sole muscles have few delicate functions • Chiefly concerned with supporting the arches of the foot. • Their names would suggest control of individual toes • Rarely used in most people.

  39. Muscles of the Sole of the Foot • First layer: • Abductor hallucis • Flexor digitorum brevis • Abductor digiti minimi

  40. Muscles of the Sole of the Foot • Second layer: • Quadratus plantae • Lumbricals • Flexor digitorum longus tendon • Flexor hallucis longus tendon

  41. Muscles of the Sole of the Foot • Third layer: • Flexor hallucis brevis • Adductor hallucis • Flexor digiti minimi brevis.

  42. Muscles of the Sole of the Foot • Fourth layer: • Interossei • Peroneus longus tendon • Tibialis posterior tendon

  43. Flexor Digitorum Longus Tendon • Passing behind the medial malleolus beneath the flexor retinaculum • Across the medial surface of the sustentaculum tali and then crosses the tendon of flexor hallucis longus, from which it receives a strong slip. • It receives on its lateral border the insertion of the quadratus plantae muscle.

  44. Flexor Digitorum Longus Tendon • Divides into its four tendons of insertion • Giving origin to the lumbrical muscles. • Enter the fibrous sheaths of the lateral four toes • Perforates the corresponding tendon of flexor digitorum brevis • Passes on to be inserted into the base of the distal phalanx.

  45. Flexor Hallucis Longus Tendon • Enters the sole by passing behind the medial malleolus beneath the flexor retinaculum • Below the sustentaculum tali • Crosses deep to the flexor digitorum longus tendon • To which it gives a strong slip. • Enters the fibrous sheath of the big toe • Inserted into the base of the distal phalanx

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