Transcript Tibiofibular and Ankle Joint Complex

MOB TCD
Tibifibular and Ankle Joint Complex
Professor Emeritus Moira O’Brien
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 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
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Tennis
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Ankle Joint
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Dorsiflexion and plantar
flexion take place at the
ankle joint
In plantar flexion there is
some side-to-side
movement
Last, 1963
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Ankle Joint
• Uniaxial, modified synovial
hinge joint
• Close pack
• Dorsiflexion
• Least pack
• Plantarflexion
Williams & Warwick, 1980
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Proximal Articular Surface
• Distal surface of the tibia
• Medial malleolus has comma
shaped facet
• Lateral malleolus triangular
facet
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 fibula
Williams & Warwick, 1980
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Proximal Articular Surface
• Proximally the articulation
depends on the integrity of the
inferior tibiofibular joint
• Syndesmosis
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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
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Capsule
• Is attached just beyond the articular
margin
• Except anterior-inferiorly
• Attached to the neck of the talus
Williams & Warwick, 1980
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Ankle Joint
• The capsule is thin and weak in front
and behind
• It is strengthened on either side by the
collateral ligaments
Williams & Warwick, 1980
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Medial (Deltoid) Ligament
• A strong triangular ligament
• Superiorly attached
• The medial malleolus of the
tibia
Williams & Warwick, 1980
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Medial Ligament
• The tuberosity of the
navicular
• The edge of the spring
ligament
• The sustentaculum tali
• The body of the talus
Last, 1963
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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 spring
ligament
• The middle fibres
• The tibiocalcaneal are attached to
the sustentaculum tali
Williams & Warwick, 1980
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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
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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
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Anterior Talofibular Ligament (ATFL)
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Is part of the capsule
An upper and lower bands
It is cylindrical
6-10 mm long
2 mm thick
Liu & Jason, 1994
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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
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ATFL
• 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
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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
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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
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CFL
• The CFL is perpendicular to
the long axis of the talus
• Dorsiflexion and inversion
result in an increased strain
• Talar tilt tests the CFL
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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
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Ankle Stability
• The ATFL is the main talar
stabiliser and the CFL acts
as a secondary restraint
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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
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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
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PTL
• During plantar flexion the posterior
talofibular and the posterior tibio
fibular ligament are edge to edge
• They separate during dorsiflexion
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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
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Synovial Membrane
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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
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Blood Supply of Ankle
• Malleolar branches of the anterior
tibial
• Perforating peroneal and posterior
tibial arteries
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Nerve Supply of Ankle
• Nerve supply is via articular
branches of the deep peroneal
• Tibial nerve from L4 - S2
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Anterior Aspect
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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
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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; flexor
retinaculum structures at risk
Jaivin & Ferkel, 1994
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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
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Lateral Aspect of Ankle
• Plantar flexor and evertor
– Peroneus longus
– Peroneus brevis
• Dorsiflexor and evertor
– Peroneus tertius
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Nerves Related to Ankle Joint
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Ankle Joint
• 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
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Ankle Joint
• The ankle is most stable in
dorsiflexion, with increasing
plantar flexion there is more
anterior talar translation
(drawer) and talar inversion
(tilt)
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Ankle Examination
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Anterior drawer
Suction sign
Inversion stress
Squeeze test
External rotation
Test
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Ankle Examination
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Achilles tendon
Peroneal tendons
Posterior tibial tendon
Anterior process of calcaneus
Talar dome
Sinus tarsi
Bifurcate ligament
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Tests for Ankle Ligament Injury
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Ottawa Ankle Rules
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Anteroposterior
Oblique
Lateral views
Bone tenderness
Medial or lateral
Malleolus
Unable to weight bear
Four steps post injury
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Tibialis Posterior / Superficial
Peroneal Nerve
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Ankle Examination
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ATFL
CFL
Distal tibiofibular
Syndesmosis
Deltoid ligament
Lateral malleolus
Medial malleolus
Base 5th metatarsal
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Inversion and Eversion
• Inversion or supination
• Raising the medial
border
• Sole faces medially
• Eversion or pronation
• Raising the lateral
border
• Sole faces laterally
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Inversion and Eversion
• Initiated at the transverse
tarsal joint
• Calcaneocuboid
• Anterior portion of the
talocalcaneonavicular
Last, 1963
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Inversion and Eversion
• 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
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Inversion and Eversion
• 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
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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
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Invertor and dorsiflexion
Tibialis anterior
Invertor and plantarflexion
Tibialis posterior
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Eversion and Pronation
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Evertor and dorsiflexion
Peroneus tertius
Evertor and plantarflexion
Peroneus brevis
Peroneus longus
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Talocalcaneonavicular Joint
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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
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Talocalcaneonavicular Joint
• Synovial ball and socket
joint
• Ball is anterior and inferior
aspect of the head of the
talus
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Talocalcaneonavicular Joint
• Socket
• Two anterior facets on the
superior surface of the
calcaneus
• Posterior aspect of the
navicular
• Spring ligament
• LCN ligament
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Talocalcaneonavicular Joint
• Capsule attached just beyond
the articular margin
• Interosseous ligament
• Spring ligament
• Superficial portion deltoid
ligament
• LCL of bifurcate
• Ligament neck of talus
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Talocalcaneonavicular Joint
• 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
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Ligaments of Subtalar Joint
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Inferior extensor retinaculum
Ligament of the neck of talus
Interosseous ligament
Bifurcate ligament
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Ligament of Neck of Talus
• Sinus tarsi
• Lateral aspect of neck of talus
• Pivot of inversion and
eversion
Last, 1963
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Tarsal Canal and Tarsal Sinus
• Fat
• Nerve endings
• Branches of posterior tibial
and peroneal arteries
• Capsules and ligaments of
talocalcaneal and
talocalcaeonavicular joints
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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
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Ligament Attachments
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Bifurcate Ligament
• Lateral calcaneonavicular ligament (CNL)
• Medial calcaneocuboid
ligament (CCL)
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Bifurcate Ligament
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Two individual ligaments
Separate attachments
Different fibre orientation
Different histology
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Talocalcaneonavicular Joint
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Invertors
In dorsiflexion
Tibialis anterior
In plantarflexion
Tibialis posterior
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Talocalcaneonavicular Joint
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Evertor
In dorsiflexion
Peroneus tertius
In plantarflexion
Peroneus longus
Peroneus brevis
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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
C
A
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Calcaneocuboid Ligament
• Intra-capsular CC joint
• Smaller than CNL, always
present
• Hourglass shaped fibres,
twisted medially
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Calcaneocuboid Joint
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Plane synovial
Ligaments
Capsular
Ligament of neck of talus
Long and short plantar
ligament
• Bifurcate ligament
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Calcaneocuboid Joint
• The long and short plantar ligaments
support the calcaneocuboids portion of
the transverse tarsal joint
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