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Slide 2 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
Slide 3 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD
Slide 4 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD
Slide 5 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD
Slide 6 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD
Slide 7 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD
Slide 8 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD
Slide 9 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD
Slide 10 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD
Slide 11 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD
Slide 12 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD
Slide 13 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD
Slide 14 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD
Slide 15 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD
Slide 16 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD
Slide 17 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD
Slide 18 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD
Slide 19 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD
Slide 20 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD
Slide 21 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD
Slide 22 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD
Slide 23 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD
Slide 24 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD
Slide 25 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD
Slide 26 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD
Slide 27 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD
Slide 28 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD
Slide 29 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD
Slide 30 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD
Slide 31 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD
Slide 32 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD
Slide 33 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD
Slide 34 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD
Slide 35 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD
Slide 36 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD
Slide 37 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD
Slide 38 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD
Slide 39 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD
Slide 40 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD
Slide 41 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD
Slide 42 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD
Slide 43 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD
Slide 44 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD
Slide 45 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD
Slide 46 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD
Slide 47 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD
Slide 48 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD
Slide 49 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD
Slide 50 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD
Slide 51 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD
Slide 52 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD
Slide 53 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD
Slide 54 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD
Slide 55 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD
Slide 56 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD
Slide 57 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD
Slide 58 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD
Slide 59 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD
Slide 60 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD
Slide 61 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD
Slide 62 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD
Slide 63 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD
Slide 64 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD
Slide 65 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD
Slide 66 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD
Slide 67 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD
Slide 68 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD
Slide 69 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD
Slide 70 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD
Slide 71 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD
Slide 72 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD Calcaneo Navicular Ligament Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular N A C MOB TCD c1f8
Slide 73 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD Calcaneo Navicular Ligament Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular N A C MOB TCD c1f8 Calcaneocuboid Ligament Intra-capsular CC joint Smaller than CNL, always present Hourglass shaped fibres, twisted medially MOB TCD
Slide 74 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD Calcaneo Navicular Ligament Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular N A C MOB TCD c1f8 Calcaneocuboid Ligament Intra-capsular CC joint Smaller than CNL, always present Hourglass shaped fibres, twisted medially MOB TCD Calcaneocuboid Joint Plane synovial Ligaments Capsular Ligament of neck of talus Long and short plantar ligament Bifurcate ligament MOB TCD
Slide 75 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD Calcaneo Navicular Ligament Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular N A C MOB TCD c1f8 Calcaneocuboid Ligament Intra-capsular CC joint Smaller than CNL, always present Hourglass shaped fibres, twisted medially MOB TCD Calcaneocuboid Joint Plane synovial Ligaments Capsular Ligament of neck of talus Long and short plantar ligament Bifurcate ligament MOB TCD The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint Calcaneocuboid Joint MOB TCD
Slide 76 - MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin Superior and Inferior Tibio-Fibular Joints Superior is synovial plane joint Inferior is a syndesmosis Interosseous tibiofibular ligament Anterior and posterior tibiofibular ligament MOB TCD Ankle Joint The ankle joint is one of the most common joints to be injured The foot is usually in the plantar flexed and inverted position when the ankle is most commonly injured Bröstrom, 1966 MOB TCD Tennis MOB TCD Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 Ankle Joint MOB TCD Uniaxial, modified synovial hinge joint Close pack Dorsiflexion Least pack Plantarflexion Williams & Warwick, 1980 Ankle Joint MOB TCD Proximal Articular Surface Distal surface of the tibia Medial malleolus has comma shaped facet Lateral malleolus triangular facet Williams & Warwick, 1980 MOB TCD Proximal Articulation Inferior transverse tibiofibular ligament Deepens it posteriorly Passes from the lower margin of the tibia To the malleolar fossa of the fibula Williams & Warwick, 1980 MOB TCD Proximally the articulation depends on the integrity of the inferior tibiofibular joint Syndesmosis Proximal Articular Surface MOB TCD Distal Articular Surface The superior surface of the body of the talus is wider anteriorly Convex from before backwards Concave from side to side Medial comma shaped facet Lateral triangular facet Frazer, 1965 MOB TCD Capsule Is attached just beyond the articular margin Except anterior-inferiorly Attached to the neck of the talus Williams & Warwick, 1980 MOB TCD The capsule is thin and weak in front and behind It is strengthened on either side by the collateral ligaments Williams & Warwick, 1980 Ankle Joint MOB TCD Medial (Deltoid) Ligament A strong triangular ligament Superiorly attached The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD The tuberosity of the navicular The edge of the spring ligament The sustentaculum tali The body of the talus Last, 1963 Medial Ligament MOB TCD Medial or Deltoid Ligament (Superficial) Cross two joints Anterior tibionavicular pass to the tuberosity of the navicular The free edge of the spring ligament The middle fibres The tibiocalcaneal are attached to the sustentaculum tali Williams & Warwick, 1980 MOB TCD Medial or Deltoid Ligament (Deep) The anterior tibiotalar to the nonarticular part of the medial surface of the talus The posterior tibiotalar to the medial side of the talus The medial tubercle of the talus Williams & Warwick, 1980 MOB TCD Lateral Ligaments of Ankle The anterior talofibular ligament (ATFL) The calcaneofibular ligament (CFL) The posterior talofibular ligament (PTF) They radiate like the spokes of a wheel Liu & Jason, 1994 MOB TCD Anterior Talofibular Ligament (ATFL) Is part of the capsule An upper and lower bands It is cylindrical 6-10 mm long 2 mm thick Liu & Jason, 1994 MOB TCD ATFL The anterior inferior border of the fibula runs parallel to the long axis of the talus when the ankle is neutral or dorsiflexion More perpendicular to the talus when the foot is equinus MOB TCD It is the weakest ligament Strain increases with increasing plantar flexion and inversion The AFTL is a primary stabiliser against inversion and internal rotation for all angles of plantar flexion Liu & Jason, 1994 ATFL MOB TCD Calcaneofibular Ligament (CFL) A long rounded 20-25 mm long, 6-8 mm in diameter It contains the most elastic tissue It is attached in front of the apex of the fibular malleolus To a tubercle on the lateral aspect of the calcaneus Williams & Warwick, 1980 MOB TCD CFL It is separated from the capsule by fibro-fatty tissue Part of the medial wall of the peroneal tendon sheath Crosses both the ankle and subtalar joints MOB TCD The CFL is perpendicular to the long axis of the talus Dorsiflexion and inversion result in an increased strain Talar tilt tests the CFL CFL MOB TCD Lateral Ligament The angle between the ATFL and CFL varies between 100o and 135o Increasing the potential instability of the lateral ligament Hamilton, 1994; Peters, 1991 MOB TCD Ankle Stability The ATFL is the main talar stabiliser and the CFL acts as a secondary restraint MOB TCD ATFL and CFL A difference of 10o between the two ankles is significant A talar tilt of more than 10o is a lateral ligament injury in 99% of cases The AFTL is injured in 65% and combined injuries of the AFTL and CFL occur in 20% The CFL is a major stabiliser of the subtalar joint Liu & Jason, 1994 MOB TCD Posterior Talofibular (PTL) The PTL is the strongest part of the lateral ligament It runs almost horizontally from malleolar fossa to lateral tubercle of talus MOB TCD PTL During plantar flexion the posterior talofibular and the posterior tibio fibular ligament are edge to edge They separate during dorsiflexion MOB TCD Ankle Joint The flexor hallucis longus lies in a grove between the smaller medial and larger lateral tubercles In 7% the lateral tubercle has a separate ossification and is called an os trigonum MOB TCD Synovial Membrane Lines the capsule and the non articular area Covers the neck of talus The fatty pads inside the capsule It extends upwards to the interosseous ligament of the inferior tibiofibular joint Plastanga et al., 1980 MOB TCD Blood Supply of Ankle Malleolar branches of the anterior tibial Perforating peroneal and posterior tibial arteries MOB TCD Nerve Supply of Ankle Nerve supply is via articular branches of the deep peroneal Tibial nerve from L4 - S2 MOB TCD Anterior Aspect Dorsiflexors Tibialis anterior Flexor hallucis longus Anterior tibial > dorsalis pedis artery Deep peroneal nerve Extensor digitorum longus Peroneus tertius MOB TCD Postero-Medial Aspect of Ankle Tibialis posterior Flexor digitorum longus Posterior tibial vessels Posterior tibial nerve and branches Flexor hallucis longus MOB TCD Posterior Aspect Posterolateral portal Lateral to achilles tendon, sural nerve, short saphenous vein at risk Posteromedial not used; flexor retinaculum structures at risk Jaivin & Ferkel, 1994 MOB TCD Lateral Aspect of Ankle The inferior extensor retinaculum Extensor digitorum brevis Peroneus longus and brevis Peroneal retinaculum Ligament of the neck of talus Bifurcate ligament MOB TCD Plantar flexor and evertor Peroneus longus Peroneus brevis Dorsiflexor and evertor Peroneus tertius Lateral Aspect of Ankle MOB TCD Nerves Related to Ankle Joint MOB TCD In the anatomical position the axis of the ankle joint is horizontal But is set at 20-25o obliquely to the frontal plane Running posteriorly as it passes laterally Plastanga et al., 1990 Ankle Joint MOB TCD The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) Ankle Joint MOB TCD Ankle Examination Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament Ankle Examination MOB TCD Tests for Ankle Ligament Injury MOB TCD Ottawa Ankle Rules Anteroposterior Oblique Lateral views Bone tenderness Medial or lateral Malleolus Unable to weight bear Four steps post injury MOB TCD Tibialis Posterior / Superficial Peroneal Nerve MOB TCD ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal Ankle Examination MOB TCD Inversion or supination Raising the medial border Sole faces medially Inversion and Eversion Eversion or pronation Raising the lateral border Sole faces laterally MOB TCD Initiated at the transverse tarsal joint Calcaneocuboid Anterior portion of the talocalcaneonavicular Last, 1963 Inversion and Eversion MOB TCD Main movement take place at the clinical subtalar joint i.e. talocalcaneal inferior portion of the talocalcaneonavicular The pivot is the ligament of the neck of the talus Last, 1963 Inversion and Eversion MOB TCD Axis passes through the middle of the convex posterior facet on calcaneus Upwards forwards and medially Through middle of convex articular facet of head of talus Last, 1963 Inversion and Eversion MOB TCD Talocalcaneal Synovial plane joint Articular surface Concave facet inferior body of talus Convex posterior facet, superior aspect of calcaneus MOB TCD Talocalcaneal Joint Capsule attached just beyond articular margin ligaments Interosseous Ligament of neck of talus MOB TCD Tarsal Canal and Tarsal Sinus MOB TCD Inversion or Supination Invertor and dorsiflexion Tibialis anterior Invertor and plantarflexion Tibialis posterior MOB TCD Eversion and Pronation Evertor and dorsiflexion Peroneus tertius Evertor and plantarflexion Peroneus brevis Peroneus longus MOB TCD Talocalcaneonavicular Joint Synovial ball and socket Ball head of talus Socket Posterior aspect of the navicular, two anterior facets on superior surface of calcaneus Spring ligament and CNL MOB TCD Synovial ball and socket joint Ball is anterior and inferior aspect of the head of the talus Talocalcaneonavicular Joint MOB TCD Socket Two anterior facets on the superior surface of the calcaneus Posterior aspect of the navicular Spring ligament LCN ligament Talocalcaneonavicular Joint MOB TCD Capsule attached just beyond the articular margin Interosseous ligament Spring ligament Superficial portion deltoid ligament LCL of bifurcate Ligament neck of talus Talocalcaneonavicular Joint MOB TCD Synovial membrane lines the capsule and non-articular structures Nerve supply Tibial nerve Deep and superficial peroneal nerves Talocalcaneonavicular Joint MOB TCD Subtalar Interosseosus Capsule of both talocalcaneal Posterior portion of the talocalcanoeonavicular joint MOB TCD Ligaments of Subtalar Joint Inferior extensor retinaculum Ligament of the neck of talus Interosseous ligament Bifurcate ligament MOB TCD Ligament of Neck of Talus Sinus tarsi Lateral aspect of neck of talus Pivot of inversion and eversion Last, 1963 * MOB TCD Tarsal Canal and Tarsal Sinus Fat Nerve endings Branches of posterior tibial and peroneal arteries Capsules and ligaments of talocalcaneal and talocalcaeonavicular joints MOB TCD Inferior Extensor Retinaculum Medial root inside the tarsal sinus Intermediate to talus with the interosseous ligament, inside sinus Lateral root to calcaneus outside sinus Klein & Spreitzer, 1993 MOB TCD Ligament Attachments MOB TCD Bifurcate Ligament Lateral calcaneo- navicular ligament (CNL) Medial calcaneocuboid ligament (CCL) MOB TCD Two individual ligaments Separate attachments Different fibre orientation Different histology Bifurcate Ligament MOB TCD Talocalcaneonavicular Joint Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis Talocalcaneonavicular Joint MOB TCD Calcaneo Navicular Ligament Folded and twisted appearance Prominent medial and lateral edges / folds Three groups of fibres Medial Lateral (deep) Intra-articular N A C MOB TCD c1f8 Calcaneocuboid Ligament Intra-capsular CC joint Smaller than CNL, always present Hourglass shaped fibres, twisted medially MOB TCD Calcaneocuboid Joint Plane synovial Ligaments Capsular Ligament of neck of talus Long and short plantar ligament Bifurcate ligament MOB TCD The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint Calcaneocuboid Joint MOB TCD “BMJ Publishing Group Limited (“BMJ Group”) 2012. 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