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LOWER LIMB RECONSTRUCTION—ANATOMY Anatomy Sural nerve Only cutaneous branch of tibial nerve Exits popliteal fossa and lies between heads of gastroc Then pierces fascia (mid calf) and descends behind lat malleolus Distally joins peroneal communicating nerve—at level of gastroc tendon Short Saphenous Vein Runs with sural nerve Pierces deep fascia over popliteal fossa and drains into popliteal vein Communications with Great Saphenous vein Layers of sole of foot Popliteal artery last pg173 LEG 4 Compartments Anterior tib ant EHL EDL PT Lateral PL PB Posterior Gastroc Soleus Plantaris Popliteus +Deep Pos FHL FDL Tib post Tib ant type IV muscle from ant tib Deep peroneal n L4 Into med cuneiform and 1st MT EHL type IV muscle form ant tib Deep peroneal n L4,5 From mid fibula then becomes superficial between tib ant & EDL EDL type IV muscle from ant tib Deep peroneal L4,5 From upper ¾ fibula and i/m septum Splits into central slip and lateral bands (joined by lumbricals and interossei) Peroneus tertius Type IV muscle from ant tib Deep peroneal n L5 From distal fibula into base 5th MT Deep peroneal n arises in PL and then passes to lie on interosseous membrane (Lat to vessels) Artery---initially lies on I/M between tib ant and EDL, then crossed by EHL so at ankle 2 muscles on each side Peroneus Longus Type IV muscle from peroneal—perforators through FHL (drains into short saphenous) Sup peroneal nL5, S1 From fibula behind PB, into base 1st MT Peroneus Brevis Type IV from peroneal Sup peroneal n L5, S1 In front of PL and into base 5th MT Blood supply via peroneal artery via perforators running through FHL and Interosseous membrane Gastroc type I via sural arteries from popliteal Tibial n S1,2 From femoral condyles, medial is longer at each end Plantaris arises above gastroc (lat head) Runs between gastroc and soleus Soleus type II muscle peroneal to lat soleus and post tibial to medial Tibial n S1,2 2 branches one in pop fossa and one deep From tibia and fibula + fibrous arch Venous pump Popliteus unlocks tibia in extension FDL $$ branches of pos tib Tibial n S1,2 From both bones, crosses tib post in leg, crosses FHL in sole and divides into 4 Receives slips from flex accessorius , gives origin to lumbricals, perforates FDB—P3 FHL $$$$ branches of peroneal Tibial n S1,2 Powerful, from fibula into base P3, most impt in maintaining med longitudinal arch Tib Post $$$$$ mainly via peroneal perforators (through FDL) and also post tib Tibial n L4 From both bones, unipenate, tuberosity of navicular Both tibial vessels lie medial to respective nerves Pos tibial artery under fibrous arch of Soleus, between FDL & FHL, lies on fibular aponeurosis of FDL Nutrient artery passes through fibular aponeurosis of FDL and enter between origins of FDL and tib post pass behind med malleolus as TDAVNH Peroneal artery at ankle communicates with— Lat ant malleolar br of ant tib via perforating br that pierces interosseous m 5cm above ankle—pos tib via calcaneal branches Septocutaneous perforators from Peroneal pass between soleus and lat compartment Pos tibial pass between FDL and soleus Ant tibial pass between tib ant and EDL and EDL and lat compartment Pos tibial artery has 3 terminal branches Medial and lateral plantar + calcaneal Calcaneal branch (supplies heel) pierces flexor retinaculum and then connects with branches of peroneal artery FOOT Dorsum of foot Dorsal venous network drains into long and short saphenous veins EDB arises from calcaneus and gives 4 tendons to medial 4 toes The tendon to great toe is EHB Tendons pass deep to EDL and insert into ext expansions Deep peroneal n Dorsalis pedis is lateral to EHL and crossed by EHB Runs down 1st MT space as 1st dorsal MT artery to join lateral plantar artery Branches are Lateral tarsal—runs deep to EDB Arcuate—runs laterally beneath tendons of EDB giving branches to MT spaces Each has 2 branches—1 dorsal and 1 connects with plantar arch Plantar Aponeurosis From calcaneus via 5 slips into each toe Septum passes deeply from each side to separate FDB from abductors of 1st and 5th toes N/V structures pass between 1st and 2nd layers 4 layers generally type II muscles 1st Layer 3 short muscles FDB from calcaneus and splits to base P2 Medial plantar n Abd H from calcaneus to P1 Medial plantar n ADM from calcaneus to P1 Lateral plantar n 2nd Layer long flexors and their connections FHL crossed by tendon of FDL and gives of slips to 2 medial tendons FDL crosses superficial to FHL, receives flexor accessorius, gives off lumbricals, to P3 Flexor accessorius / Quadratus Plantae From calcaneus to FDL, flexes toes in full ankle plantarflexion Lateral plantar n Lumbricals Pass on medial side, plantar to deep transverse ligament into extensor expansions Medial plantar n—unicipital muscle—1st lumbrical to 2nd toe Lateral plantar n—bicipital muscles—2nd to 4th 3rd Layer 3 muscles FHB cuboid and cuneiforms to P1 Medial plantar n Adductor Hallicus Oblique and transverse heads to base P1 Lateral plantar n FDMB from base 5th MT to base P1 Lateral plantar n 4th Layer longitudinal axis of foot is 2nd MT Plantar Interossei—3 Tendons pass deep to deep transverse ligament to bases P1 and ext expansion Dorsal Interossei—4 Insert into P1 mainly and to ext expansion All by lateral plantar n 1st MT space has 1 muscle, rest have 2 PL Tib post Posterior tibial nerve 3 branches Calcaneal medial heel pad Med plantar n supplies Abd Hal, FDB, FHB and 1 lumbrical Medial 3½ toes Lateral plantar n rest Posterior tibial artery 3 branches Calcaneal anastomoses with branches from peroneal artery Medial plantar artery smaller of the 2, on medial side of nerve, under 1st layer Perforating branches run between Abd Hal and FDB No arch Lateral plantar artery perforators to sole travel between FDB and ADM Main trunk forms plantar arch—level of bases of MTs and joins DP through 1st interMT space
