Leg, foot and ankle joint

1. Leg, foot and ankle joint MSK Revision SCRUBS ZahirMughal

2. Introduction • Leg • Osteology • Musculature • Neurovascular structures • Clinical correlates • Foot (brief) • Ankle • Anatomy • Clinical correlates • Pictures from Gray’s anatomy

3. Leg

4. Leg Osteology

5. Musculature of leg

6. Muscles of the leg • Anterior compartment • Tibialis anterior • Extensor hallucislongus • Extensor digitorumlongus • Fibularistertius

7. Lateral compartment • Fibularislongus • Fibularisbrevis

8. Posterior compartment • Superficial group • Soleus • Gastrocnemius • Plantaris • Deep group • Popliteus • Flexor digitorumlongus • Tibialis posterior • Flexor hallucislongus

9. Actions of leg muscles • Anterior compartment • Dorsiflex the foot at the ankle joint • Extend the toes • Invert the foot • Lateral compartment • Evert the foot • Posterior compartment • Superficial group • Plantarflex the foot at the ankle joint • Deep group • Popliteus unlocks the extended knee • Plantarflex and invert the foot and flex the toes

10. Compartment syndrome • Raised intra-compartmental pressure • Intra-compartmental pressure > intra-arterial pressure • Arterial occlusion  ischemia • Presentation  6Ps • 1. PAIN • 2. PAIN • 3. PAIN • 4. PAIN • 5. PAIN • 6. PAIN Medical Emergency

11. Arteries of leg • Popliteal artery is the major blood supply to the leg and foot. • Starts at the adductor hiatus • Traverses the poplitealfossa • Ends at inferior border of popliteus • Divides into anterior and posterior tibial arteries • Anterior compartment supplied by anterior tibial artery • Lateral compartment and posterior compartment supplied by posterior tibial artery

12. QUIZ - Arteries of leg Peroneal artery

13. Veins of leg • Deep veins follow arteries • Superficial veins • Long saphenous vein • Short saphenous vein

14. Varicose veins • Long, dilated, tortuous superficial veins • Incompetent valves • Sapheno-femoral junction • Sapheno-popliteal junction • Perforators • Risk factors • Prolonged standing, obesity, pregnancy, family history, oral contraceptive pill • Surgery

15. QUIZ – Veins of the leg Femoral vein • TRUE or FALSE • 1. Veins start proximally and end distally? • F • 2. Long saphenous vein is a branch of Femoral vein? • F • 3. Short saphenous vein is posterior to lateral malleolus? • T • 4. Superficial veins drain into deep veins via perforator veins? • T Popliteal vein Short saphenous vein Long saphenous vein Dorsal venous arch

16. Nerves of the leg • Sciatic nerve (L4-S3) divides into tibial nerve and common fibular nerve • Common fibular nerve divides into superficial and deep branches • Anterior compartment supplied by: Deep fibular nerve • Lateral compartment supplied by: Superficial fibular nerve • Posterior compartment supplied by: Tibial nerve

17. Nerve injury • Sciatic nerve • Loss of extension of thigh, flexion of knee, all motor function of foot and toes • Loss of sensation of lower leg and foot • Common peroneal nerve (bumper fractures) • Loss of extension of toes and foot (footdrop) • Loss of sensation of lateral lower leg and upper foot

18. PoplitealFossa • Boundaries • Superomedial – Semimembranosus/semitendinosus • Superolateral – Biceps femoris • Inferomedial – medial head of gastrocnemius • Inferolateral – lateral head of gastrocnemius and plantaris • Floor – femur, popliteus, capsule • Roof – popliteal fascia, skin • Contents – • Small saphenous vein • Popliteal artery and vein • Tibial and common fibular nerves • Posterior cutaneous nerve of thigh • Popliteal lymph nodes and lymphatic vessels

19. Poplitealfossa • Differentials for mass in the poplitealfossa • Lipoma • Bakers cyst • Popliteal aneurysm • Popliteal Abscess • Neoplasm • Lymphadenopathy

20. QUIZ - PoplitealFossa Medial Lateral

21. Foot

22. Foot osteology

23. Arches of the foot • Absorb and distribute downward forces • Ligaments and muscles support the arches of the foot

24. Blood supply • Arterial: • Posterior tibial and dorsalispedis supply the foot • Venous: • Deep veins follow the arteries • Superficial veins arise from dorsal venous arch

25. Nerve supply • The foot is supplied by the (1) tibial, (2) deep peroneal, (3) superficial peroneal, (4)sural, and (5)saphenous nerves • all five nerves contribute to cutaneous or general sensory innervation • the tibial nerve innervates all intrinsic muscles of the foot except for the extensor digitorumbrevis, which is innervated by the deep fibular nerve

27. Ankle

28. Ankle joint • Synovial joint • Movements: • hinge-like dorsiflexion and plantarflexion of the foot • Ankle is most stable when the foot is dorsiflexed • Strong ligaments stabilise the ankle joint

29. Subtalar joint • Articulation between: • inferior surface of the talus • superior surface of the calcaneus • Movement: • Inversion and eversion of the foot • Involved with inversion and eversion of the foot. • ( Talocalcaneonavicular and Calcaneocuboid joint joints )

30. Ligaments of ankle joint • Medial (deltoid) ligament • Large and very strong • Lateral ligament

31. Pott’s Fracture • Mechanism • Forced foot eversion • Deltoid ligament pulls on the medial malleolus and causes avulsion • Talus displaced laterally and posterior and causes avulsion of the lateral malleolus • Both malleoli are fractured (bimalleolar fracture)

32. Medial malleolus relations • Posterior: • Timothy Doth Vex All Nervous Housemaids (ML) • Tibialis posterior • Flexor digitorumlongus • Posterior tibial vein • Posterior tibial artery • Tibial nerve • Flexor hallucuslongus • Anterior: • Long saphenous vein • Saphenous nerve

33. Lateral malleolus relations • Posterior: • Short saphenous vein • Sural nerve • Anterior: • Peroneal artery

34. Conclusion • Anatomy of the leg • Compartments • Muscles • Vessels • Nerves • Clinical relevance • Anatomy of the foot and ankle joint • Brief overview • Questions?