Tibiofibular and Ankle Joint Complex BMJ

7/28/2019 Tibiofibular and Ankle Joint Complex BMJ

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MOB TCD

Tibifibular and Ankle Joint Complex

Professor Emeritus Moira OBrien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin


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Superior and Inferior

Tibio-Fibular Joints

Superior is synovial plane joint

Inferior is a syndesmosis

Interosseous tibiofibular

ligament

Anterior and posterior tibiofibular

ligament

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Ankle Joint

The ankle joint is one of the mostcommon joints to be injured

The foot is usually in the plantar

flexed and inverted position when

the ankle is most commonly injuredBrstrom, 1966

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TennisMOB TCD


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Dorsiflexion and plantarflexion take place at the

ankle joint

In plantar flexion there is

some side-to-sidemovementLast, 1963

Ankle JointMOB TCD


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Uniaxial, modified synovialhinge joint

Close pack

Dorsiflexion

Least pack PlantarflexionWilliams & Warwick, 1980

Ankle JointMOB TCD


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Proximal Articular Surface

Distal surface of the tibia Medial malleolus has comma

shaped facet

Lateral malleolus triangularfacet

Williams & Warwick, 1980

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Proximal Articulation

Inferior transverse tibiofibular ligament Deepens it posteriorly

Passes from the lower margin of the

tibia

To the malleolar fossa of the fibulaWilliams & Warwick, 1980

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Proximally the articulationdepends on the integrity of the

inferior tibiofibular joint

Syndesmosis

Proximal Articular SurfaceMOB TCD


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Distal Articular Surface

The superior surface of the body ofthe talus is wider anteriorly

Convex from before backwards

Concave from side to side

Medial comma shaped facet Lateral triangular facetFrazer, 1965

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Capsule

Is attached just beyond the articularmargin

Except anterior-inferiorly

Attached to the neck of the talusWilliams & Warwick, 1980

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The capsule is thin and weak in frontand behind

It is strengthened on either side by the

collateral ligamentsWilliams & Warwick, 1980

Ankle JointMOB TCD


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Medial (Deltoid) Ligament

A strong triangular ligament Superiorly attached

The medial malleolus of the

tibiaWilliams & Warwick, 1980

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The tuberosity of thenavicular

The edge of the spring

ligament

The sustentaculum tali The body of the talusLast, 1963

Medial LigamentMOB TCD


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Medial or Deltoid Ligament

(Superficial)

Cross two joints

Anterior tibionavicular pass

to the tuberosity of the

navicular

The free edge of the springligament

The middle fibres

The tibiocalcaneal are attached to

the sustentaculum taliWilliams & Warwick, 1980

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Medial or Deltoid Ligament

(Deep)

The anterior tibiotalar to thenonarticular part of the

medial surface of the talus

The posterior tibiotalar to the

medial side of the talus The medial tubercle of the

talusWilliams & Warwick, 1980

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Lateral Ligaments of Ankle

The anterior talofibularligament (ATFL)

The calcaneofibular

ligament (CFL)

The posterior talofibularligament (PTF)

They radiate like the spokes

of a wheelLiu & Jason, 1994

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Anterior Talofibular Ligament (ATFL)

Is part of the capsule An upper and lower bands

It is cylindrical

6-10 mm long

2 mm thickLiu & Jason, 1994

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ATFL

The anterior inferior border ofthe 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

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It is the weakest ligament Strain increases with

increasing plantar flexion

and inversion

The AFTL is a primarystabiliser against inversion

and internal rotation for all

angles of plantar flexionLiu & Jason, 1994

ATFLMOB TCD


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Calcaneofibular Ligament (CFL)

A long rounded 20-25 mmlong, 6-8 mm in diameter

It contains the most elastic

tissue

It is attached in front of theapex of the fibular malleolus

To a tubercle on the lateral

aspect of the calcaneusWilliams & Warwick, 1980

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CFL

It is separated from thecapsule by fibro-fatty tissue

Part of the medial wall of the

peroneal tendon sheath

Crossesboth the ankle andsubtalar joints

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The CFL is perpendicular tothe long axis of the talus

Dorsiflexion and inversion

result in an increased strain

Talar tilt tests the CFL

CFLMOB TCD

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Lateral Ligament

The angle between theATFL and CFL varies

between 100o and 135o

Increasing the potential

instability of the lateral

ligamentHamilton, 1994; Peters, 1991

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Ankle Stability

The ATFL is the main talarstabiliser and the CFL acts

as a secondary restraint

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ATFL and CFL

A difference of 10o

betweenthe 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 jointLiu & Jason, 1994

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Posterior Talofibular (PTL)

The PTL is the strongest part of thelateral ligament

It runs almost horizontally from

malleolar fossa to lateral tubercle of

talus

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PTL

During plantar flexion the posteriortalofibular and the posterior tibio

fibular ligament are edge to edge

They separate during dorsiflexion

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Ankle Joint

The flexor hallucis longus liesin 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

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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 jointPlastanga et al., 1980

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Blood Supply of Ankle

Malleolar branches of the anteriortibial

Perforating peroneal and posterior

tibial arteries

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Nerve Supply of Ankle

Nerve supply is via articularbranches of the deep peroneal

Tibial nerve from L4 - S2

O C

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Anterior Aspect

Dorsiflexors Tibialis anterior

Flexor hallucis longus

Anterior tibial > dorsalis pedis artery

Deep peroneal nerve Extensor digitorum longus

Peroneus tertius

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Postero-Medial Aspect of Ankle

Tibialis posterior Flexor digitorum longus

Posterior tibial vessels

Posterior tibial nerve and

branches Flexor hallucis longus

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Posterior Aspect

Posterolateral portal Lateral to achilles tendon, sural

nerve, short saphenous vein at

risk

Posteromedial not used; flexorretinaculum structures at riskJaivin & Ferkel, 1994

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Lateral Aspect of Ankle

The inferior extensorretinaculum

Extensor digitorum brevis

Peroneus longus and brevis

Peroneal retinaculum Ligament of the neck of talus

Bifurcate ligament

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Plantar flexor and evertor

Peroneus longus

Peroneus brevis

Dorsiflexor and evertor

Peroneus tertius

Lateral Aspect of Ankle

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Nerves Related to Ankle Joint

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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 laterallyPlastanga et al., 1990

Ankle Joint

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The ankle is most stable in

dorsiflexion, with increasing

plantar flexion there is more

anterior talar translation

(drawer) and talar inversion

(tilt)

Ankle Joint

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Ankle Examination

Anterior drawer

Suction sign

Inversion stress

Squeeze test

External rotation Test

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Achilles tendon

Peroneal tendons

Posterior tibial tendon

Anterior process of calcaneus

Talar dome

Sinus tarsi

Bifurcate ligament

Ankle Examination

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Tests for Ankle Ligament Injury

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Ottawa Ankle Rules

Anteroposterior

Oblique

Lateral views

Bone tenderness

Medial or lateral Malleolus

Unable to weight bear

Four steps post injury

Tibi li P t i / S fi i lMOB TCD


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Tibialis Posterior / Superficial

Peroneal Nerve

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ATFL

CFL

Distal tibiofibular

Syndesmosis

Deltoid ligament Lateral malleolus

Medial malleolus

Base 5th metatarsal

Ankle Examination

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Inversion or supination

Raising the medial

border

Sole faces medially

Inversion and Eversion

Eversion or pronation

Raising the lateral

border

Sole faces laterally

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Initiated at the transverse

tarsal joint

Calcaneocuboid

Anterior portion of the

talocalcaneonavicularLast, 1963


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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 talusLast, 1963


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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

talusLast, 1963


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Talocalcaneal

Synovial plane joint Articular surface

Concave facet inferior body

of talus

Convex posterior facet,superior aspect of calcaneus

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Talocalcaneal Joint

Capsule attached just beyond

articular margin ligaments

Interosseous

Ligament of neck of talus

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Tarsal Canal and Tarsal Sinus

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Inversion or Supination

Invertor and dorsiflexion

Tibialis anterior

Invertor and plantarflexion

Tibialis posterior

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Eversion and Pronation

Evertor and dorsiflexion

Peroneus tertius

Evertor and plantarflexion

Peroneus brevis

Peroneus longus

T l l i l J i tMOB TCD


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Talocalcaneonavicular Joint

Synovial ball and socket

Ball head of talus

Socket

Posterior aspect of the

navicular, two anterior facetson superior surface of

calcaneus

Spring ligament and CNL



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Synovial ball and socket

joint

Ball is anterior and inferior

aspect of the head of the

talus




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Socket

Two anterior facets on thesuperior surface of thecalcaneus

Posterior aspect of the

navicular Spring ligament

LCN ligament




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Capsule attached just beyond

the articular margin

Interosseous ligament

Spring ligament

Superficial portion deltoidligament

LCL of bifurcate

Ligament neck of talus




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Synovial membrane lines the

capsule and non-articular

structures

Nerve supply

Tibial nerve

Deep and superficial

peroneal nerves


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Subtalar Interosseosus

Capsule of both

talocalcaneal

Posterior portion of the

talocalcanoeonavicular

joint

Li t f S bt l J i tMOB TCD


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Ligaments of Subtalar Joint

Inferior extensor retinaculum Ligament of the neck of talus

Interosseous ligament

Bifurcate ligament

Li t f N k f T lMOB TCD


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Ligament of Neck of Talus

Sinus tarsi Lateral aspect of neck of talus

Pivot of inversion and

eversionLast, 1963

*

T l C l d T l SiMOB TCD


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Tarsal Canal and Tarsal Sinus

Fat

Nerve endings

Branches of posterior tibial

and peroneal arteries

Capsules and ligaments oftalocalcaneal and

talocalcaeonavicular joints

Inferior E tensor Retinac l mMOB TCD


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Inferior Extensor Retinaculum

Medial root inside the tarsalsinus

Intermediate to talus with the

interosseous ligament, inside

sinus

Lateral root to calcaneus

outside sinusKlein & Spreitzer, 1993

Ligament AttachmentsMOB TCD


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Ligament Attachments

Bifurcate LigamentMOB TCD


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Bifurcate Ligament

Lateral calcaneo-

navicular ligament (CNL)

Medial calcaneocuboid

ligament (CCL)

Bifurcate LigamentMOB TCD


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Two individual ligaments

Separate attachments

Different fibre orientation

Different histology

Bifurcate Ligament

Talocalcaneonavicular JointMOB TCD


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Invertors

In dorsiflexion

Tibialis anterior

In plantarflexion

Tibialis posterior

Talocalcaneonavicular JointMOB TCD


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Evertor

In dorsiflexion

Peroneus tertius

In plantarflexion

Peroneus longus Peroneus brevis


Calcaneo Navicular LigamentMOB TCD


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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

Calcaneocuboid LigamentMOB TCD


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Calcaneocuboid Ligament

Intra-capsular CC joint

Smaller than CNL, always

present

Hourglass shaped fibres,

twisted medially

Calcaneocuboid JointMOB TCD


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Calcaneocuboid Joint

Plane synovial

Ligaments

Capsular

Ligament of neck of talus

Long and short plantarligament

Bifurcate ligament

Calcaneocuboid JointMOB TCD


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The long and short plantar ligaments

support the calcaneocuboids portion of

the transverse tarsal joint

Calcaneocuboid Joint

Tibiofibular and Ankle Joint Complex BMJ

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