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MOB TCD Anterior and Lateral and Posterior Compartments of Calf Professor Emeritus Moira O’Brien...
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Transcript of MOB TCD Anterior and Lateral and Posterior Compartments of Calf Professor Emeritus Moira O’Brien...
![Page 1: MOB TCD Anterior and Lateral and Posterior Compartments of Calf Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.](https://reader036.fdocuments.net/reader036/viewer/2022062713/56649ccf5503460f9499a68c/html5/thumbnails/1.jpg)
![Page 2: MOB TCD Anterior and Lateral and Posterior Compartments of Calf Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin.](https://reader036.fdocuments.net/reader036/viewer/2022062713/56649ccf5503460f9499a68c/html5/thumbnails/2.jpg)
MOB TCD
Anterior and Lateral and Posterior Compartments of Calf
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Cutaneous Supply of Calf
• Saphenous first branch is infrapatellar branch it
• Supplies medial side of the calf and
• Medial side of foot to ball of the hallux
• Lateral cutaneous of calf• Superficial peroneal• Sural, lateral border of foot• Deep peroneal first cleft
MOB TCD
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Fascial Compartments in Calf
• Subcutaneous surface of tibia• Fascia anterior and posterior
intermuscular septa• Anterior compartment• Lateral compartment• Posterior compartment
Divided• Superficial• Deep• Deep posterior
MOB TCD
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Extensor Retinacula
• Superior retinaculum • Thickening deep fascia• Tibialis anterior pierces • Other tendons pass posterior• Inferior extensor retinaculum• Inferior stem attached to calcaneus• Upper limb to medial malleolus• Lower limb plantar aponeurosis
MOB TCD
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Anterior Compartment of Calf
• Tibialis anterior• Extensor hallucis longus• Extensor digitorum longus • Peroneus tertius• All muscles supplied by the
deep peroneal nerve• Dorsi flexors• Anterior tibial and
perforating peroneal arteries
MOB TCD
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Tibialis Anterior
• Upper two thirds• Lateral surface of tibia and
adjoining area of interosseous membrane
• And deep fascia
Inserted• Medial aspect of medial
cuneiform• And adjoing base of first
metatarsal
MOB TCD
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• Synovial sheath• Passes under superior and
both limbs of inferior extensor retinaculum
• Dorsi flexor and invertor• Eccentric pays out, prevents
foot slapping down• Supports medial arch• Deep peroneal nerve
Tibialis Anterior MOB TCD
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Extensor Hallucis Longus
• Middle two fourths• Anterior surface of fibula • Interosseous membrane• Base of distal phalanx of
hallux• Dorsiflexor big toe and
ankle• Deep peroneal nerve• Test for L5
MOB TCD
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• Upper three quarter anterior surface of fibula
• Except the area for the extensor hallucis longus
• Anterior intermuscular septum
• Passes under retinacula• Divides into four tendons• Joined by slips from brevis• Lumbricals and interossei
muscles
Extensor Hallucis Longus MOB TCD
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Extensor Digitorum Longus
• Main extensor tendon inserted into base of middle phalanx, of the lateral four toes
• Collateral slips formed by lumbricals and interossei inserted into distal phalanx
• Dorsiflexor ankle • Extends proximal phalanx lateral four
toes
MOB TCD
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Peroneus Tertius
• Lower quarter of anterior surface of the fibula
• Inserted into base and dorsum of shaft of fifth metatarsal
• Dorsiflexor and evertor
MOB TCD
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Extensor Digitorum Brevis
• Fleshy origin from calcaneus • Stem of inferior retinaculum • Divides into four tendons• First is extensor hallucis brevis • Other three join extensor
expansion of second, third and fourth toes
• Deep peroneal nerve
MOB TCD
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Deep Peroneal Nerve
• Branch of the common peroneal at neck of fibula
• Pierces anterior intermuscular septum• Runs between extensor digitorum longus and
tibialis anterior• Then tibialis anterior and extensor hallucis
longus
MOB TCD
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• In anterior compartment• Supplies• Tibialis anterior• Extensor hallucis longus• Extensor digitorum longus • Peroneus tertius• Extensor digitorum brevis• Skin first cleft
Deep Peroneal Nerve MOB TCD
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Anterior Tibial Artery
• Branch of popliteal• Enters above interosseous
membrane• Only supply of tibialis
anterior• Becomes dorsalis pedis at
ankle joint
MOB TCD
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Dorsalis Pedis
• Gives off• First dorsal metatarsal artery• Arcuate artery gives off• 2-4th dorsal metatarsal
arteries• At base of first
intermetatarsal space• Enters sole of foot• Joins lateral plantar artery to
complete plantar arch
MOB TCD
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Blood Supply of Dorsum
• Arcuate artery• Dorsal metatarsal arteries• Posterior and anterior perforating
branches from metatarsals• Communicate plantar arch• And its digital branches• Perforating veins drain into dorsal
venous arch
MOB TCD
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Perforating Peroneal Artery
• Perforating peroneal artery• Pierces interosseus membrane• Enters anterior compartment• May replace dorsalis pedis
MOB TCD
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Venous and Lymph Drainage of Foot
• Dorsal venous arch• Medial, long saphenous
vein • Anterior to medial
malleolus• Short saphenous vein• Posterior to lateral
malleolus• Lymphatics follow
superficial veins
MOB TCD
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Lateral Compartment of Calf
• Between anterior and posterior intermuscular septa
• Peroneus longus• Peroneus brevis
• Superficial peroneal nerve
MOB TCD
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Peroneus Longus
• Upper two thirds lateral surface of fibula • Adjoining area of interosseous
membrane• Passes under superior and inferior
peroneal retinaculum
MOB TCD
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• May have a sesamoid bone• Runs in groove in the cuboid• Inserted into• Lateral aspect of medial cuneiform• And adjoing base of first metatarsal
Peroneus Longus MOB TCD
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• Plantar flexor and evertor • Supports lateral arch• Superficial peroneal nerve• Cuboid syndrome• Torn peroneal retinacula• Snapping tendons
Peroneus Longus MOB TCD
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Peroneus Brevis
• Lower two thirds• Lateral surface of fibula in front of
longus• Passes under superior and inferior
peroneal retinacula• Above peroneal trochlea on calcaneus• Inserted into base of fifth metatarsal
MOB TCD
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Peroneus Longus and Brevis
• Plantar flexors and evertors
• Longus support the lateral longitudinal arch
• Superficial peroneal nerve
MOB TCD
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Superficial Peroneal Nerve
• Branch common peroneal• Neck of fibula• Supplies peroneus longus and brevis • Pierces deep fascia• Dorsum of foot supplies• Medial side of big toe • All clefts except first and lateral side of little
toe
MOB TCD
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Sensory Supply to Posterior Aspect of Calf
• Posterior cutaneous nerve of thigh• Lateral cutaneous of calf• Sural nerve• Saphenous nerve• Medial calcaneal
MOB TCD
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Dermatomes MOB TCD
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Posterior Surface of the Calf
• Short saphenous vein• Posterior to lateral malleolus
pierces the roof of popliteal fossa to enter popliteal vein
• Deep fascia thickened medial between medial malleolus and calcaneum
• Bursa anterior to achilles
MOB TCD
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Medial and Lateral Heads of Gastrocnemii
• Medial head arises from popliteal surface of femur above medial condyle
• Lateral is shorter, arises from posterior part of the lateral surface of the lateral femoral condyle and capsule of knee
• Fabella is a sesamoid bone in lateral head
MOB TCD
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• Bursa deep to the two heads • Medial belly is longer• Unite to form a tendinous raphe• Unites with soleus to form achilles• Fast twitch fibres• Flex knee and plantar flex ankle
Medial and Lateral Heads of Gastrocnemii
MOB TCD
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Plantaris
• Short fleshy origin from • The popliteal surface of femur
above the lateral femoral condyle
• Long tendon passes between gastronemii and soleus
• Inserted medial border of achilles
• Tibial nerve
MOB TCD
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• May be absent• May rupture• Used in tendon grafts• Sudden dorsiflexion
of ankle• Ballet dancing • Gymnastics• Basketball• Sprinting
Plantaris MOB TCD
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Soleus
• Broad flat pennate muscle• Arises from head and upper
fourth of posterior surface of the fibula
• Fibrous arch• Soleal line of tibia• Middle third of medial border of
tibia
MOB TCD
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• Two aponeurotic lamellae • Bulk of vascular multipennate muscle fibres• Deepest of achilles• Slow twitch fibres• Perforating veins from great saphenous enter
soleus• Acts as a peripheral pump
Soleus MOB TCD
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Achilles Tendon
• Extent of the fusion between the gastronemii and soleus varies
• Inserted into middle of posterior surface of the calcaneus
• Tendon twists• Gastronemii form the lateral and posterior
part of the tendon
MOB TCD
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• Rotation occurs above where the soleus tends to join
• Rotation is greater if minimal fusion
• Stress marked 2-5 cm above insertion
• Plantar flexor of ankle• Eccentric lower heels
Achilles Tendon MOB TCD
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• The achilles tendon is subjected to the highest loads in the body
• Tensile loads up to eight and ten times body weight are experienced during running jumping hopping and skipping
• The achilles tendon is subjected to stress when running up and downhill
• A tight achilles tendon also limits dorsiflexion of the ankle
Achilles Tendon MOB TCD
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• Superficial bursa may be found posterior to achilles between it and the deep fascia
• The retrocalcaneal bursa is just proximal to the insertion
• Between the tuberosity on the posterior surface of the calcaneus and the achilles tendon
Achilles Tendon MOB TCD
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Achilles Test MOB TCD
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Medial and Lateral Heads of Gastrocnemii
• Sprinting• Jumping• Hopping• Skipping• Stretched with knee
extended and ankle dorsiflexed
• Tibial nerve
MOB TCD
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The Retrocalcaneal Bursa
• The area of fibro cartilage on the tendon forms the posterior wall
• The anterior wall of the retrocalcaneal bursa is the 0.5 to 1 mm thick cartilaginous layer on the posterior aspect of the calcaneus
• The proximal wall of the synovial lined sac consists of folds, or villus synovial projections
• Allows alterations in its form, produced by varying degrees of pressure on the fat above it during flexion and extension of the ankle
MOB TCD
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Flexor Digitorum Longus
• Posterior surface of tibia • Below soleal line• Medial to vertical line• Variable origin by an
aponeurosis from fibula
MOB TCD
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Very extensive fibular origins of FDL
FHL
Fibular origin of FDL
FDL
Hislop M, 2003
Flexor Digitorum Longus MOB TCD
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• Crosses tibialis posterior in calf• Flexor hallucis longus in foot• Foot receives insertion flexor accessorius
and two slips from flexor hallucis longus• Divides four tendons• Give origin to four lumbricals
Flexor Digitorum Longus MOB TCD
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• In the foot the tendon passes through birfurcation of brevis
• Inserted into distal phalanges• Plantar flexes ankle• Plantar flexes lateral four toes• Supports medial arch• Tibial nerve
Flexor Digitorum Longus MOB TCD
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Flexor Hallucis Longus
• Bulkiest and most powerful, multipennate
• Arises from posterior surface of fibula
• Posterior to medial crest• Beef to heel• Most posterior under retinaculum
MOB TCD
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• Grooves posterior process of talus• Sustentaculum tali• Crossed in foot by flexor digitorum longus to
which it gives two slips• Inserted base of distal phalanx
Flexor Hallucis Longus MOB TCD
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• Tibial nerve• Plantar flexes ankle• Flexes big toe• Supports medial longitudinal arch• Take off muscle
Flexor Hallucis Longus MOB TCD
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Tibialis Posterior
• Deepest• Posterior surface of tibia • Below soleal line• Lateral to vertical line• Interosseous membrane• Arises from posterior surface of
fibula • Anterior to medial crest
MOB TCD
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• Crossed by flexor digitorum longus in calf• Posterior to medial malleolus
grooves bone, type II collagen, tends to have poor blood supply
• Most anterior under the flexor retinaculum
• Inserted into tuberosity of navicular• All bones of the tarsus except talus • Base of middle three metatarsals
Tibialis Posterior MOB TCD
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• Plantar flexor ankle• Invertor of foot• Supports medial arch• Avascular area behind
medial malleolus • Tibial nerve
Tibialis Posterior MOB TCD
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Posterior Tibial Artery
• Branch popliteal artery
• Lower border of popliteus
• Under fibrous arch of soleus
• Between flexor digitorum longus and flexor hallucis longus
• Vena commitans
MOB TCD
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• In the calf gives off • Nutrient artery to tibia• Peroneal artery• Nutrient artery to fibula• Perforating peroneal• Passes under flexor retinaculum• Gives off medial calcaneal artery which
pierces flexor retinaculum• Then ends under flexor retinaculum• Dividing into medial and lateral plantar
arteries
Posterior Tibial Artery MOB TCD
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Tibial Nerve
• Leaves the popliteal fossa• Runs in middle of calf• Deep to soleus• Accompaning artery• Branches to soleus• Flexor digitorum longus and flexor hallucis
longus• Tibialis posterior
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Flexor Retinaculum
• Medial malleolus to calcaneus• Anterior to posterior• Tibialis posterior • Flexor digitorum longus• Posterior tibial artery• Medial calcaneal artery pierces retinaculum• Divides into medial and lateral plantar arteries • Tibial nerve• Gives off medial calcaneal nerve which accompanies artery• Divides into medial lateral plantar nerves• Flexor hallucis longus
MOB TCD
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Causes of Compartment Syndromes
• May be acute or chronic• Sudden increase in exercise• Haematoma• Callus• Fracture
MOB TCD
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Compartment Syndromes
• Mainly anterior compartment• Tibialis anterior main muscle
affected as only supplied by anterior tibial, other muscles also supplied by perforating peroneal
• Increasing pressure causes loss of sensation of first cleft due to pressure on deep peroneal nerve
• Fasciotomy
Or• Posterior or lateral compartments
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Posterior Compartment
• Posterior compartment• Posterior border of tibia• Posterior intermuscular septum
Divided• Superficial• Deep• Deep posterior
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• Superficial compartment• Posterior intermuscular septum• Posterior border of tibia
Posterior Compartment MOB TCD
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Superficial Posterior Compartment
• Medial and lateral gastrocnemii• Plantaris• Soleus• Forming the achilles tendon• Tibial nerve
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Deep Posterior Compartment
• Popliteus• Flexor digitorum longus• Flexor hallucis longus• Deepest is tibialis posterior
MOB TCD
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Chronic Exertional Compartment Syndrome (CECS)
• Significant morbidity/limitation activity to athletes• Activity related, reversible, myofascial
intracompartmental pressure increase• Results in decreased tissue perfusion and
neuromuscular function abnormalities• Predilection for the lower leg
MOB TCD
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The fibular origin of FDL can partially (or sometimes almost completely) compartmentalize TP and acts to resist increases in intracompartmental volume and therefore cause increased pressure
The presence and extent of a fibular origin of FDL may act as an anatomical predisposition to the development of CECS
Chronic Exertional Compartment Syndrome (CECS)
MOB TCD
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