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MOB TCD Tibifibular and Ankle Joint Complex Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin MOB TCD 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 Ankle Joint • • Dorsiflexion and plantar flexion take place at the ankle joint In plantar flexion there is some side-to-side movement Last, 1963 MOB TCD Ankle Joint • Uniaxial, modified synovial hinge joint • Close pack • Dorsiflexion • Least pack • Plantarflexion Williams & Warwick, 1980 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 Proximal Articular Surface • Proximally the articulation depends on the integrity of the inferior tibiofibular joint • Syndesmosis 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 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 MOB TCD Medial (Deltoid) Ligament • A strong triangular ligament • Superiorly attached • The medial malleolus of the tibia Williams & Warwick, 1980 MOB TCD Medial Ligament • The tuberosity of the navicular • The edge of the spring ligament • The sustentaculum tali • The body of the talus Last, 1963 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 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 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 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 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 Lateral Aspect of Ankle • Plantar flexor and evertor – Peroneus longus – Peroneus brevis • Dorsiflexor and evertor – Peroneus tertius MOB TCD Nerves Related to Ankle Joint MOB TCD 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 MOB TCD Ankle Joint • The ankle is most stable in dorsiflexion, with increasing plantar flexion there is more anterior talar translation (drawer) and talar inversion (tilt) MOB TCD Ankle Examination • • • • • • Anterior drawer Suction sign Inversion stress Squeeze test External rotation Test MOB TCD Ankle Examination • • • • • • • Achilles tendon Peroneal tendons Posterior tibial tendon Anterior process of calcaneus Talar dome Sinus tarsi Bifurcate ligament 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 Ankle Examination • • • • • • • • ATFL CFL Distal tibiofibular Syndesmosis Deltoid ligament Lateral malleolus Medial malleolus Base 5th metatarsal MOB TCD Inversion and Eversion • Inversion or supination • Raising the medial border • Sole faces medially • Eversion or pronation • Raising the lateral border • Sole faces laterally MOB TCD Inversion and Eversion • Initiated at the transverse tarsal joint • Calcaneocuboid • Anterior portion of the talocalcaneonavicular Last, 1963 MOB TCD 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 MOB TCD 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 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 Talocalcaneonavicular Joint • Synovial ball and socket joint • Ball is anterior and inferior aspect of the head of the talus MOB TCD Talocalcaneonavicular Joint • Socket • Two anterior facets on the superior surface of the calcaneus • Posterior aspect of the navicular • Spring ligament • LCN ligament MOB TCD Talocalcaneonavicular Joint • Capsule attached just beyond the articular margin • Interosseous ligament • Spring ligament • Superficial portion deltoid ligament • LCL of bifurcate • Ligament neck of talus MOB TCD Talocalcaneonavicular Joint • Synovial membrane lines the capsule and non-articular structures • Nerve supply • Tibial nerve • Deep and superficial peroneal nerves 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 calcaneonavicular ligament (CNL) • Medial calcaneocuboid ligament (CCL) MOB TCD Bifurcate Ligament • • • • Two individual ligaments Separate attachments Different fibre orientation Different histology MOB TCD Talocalcaneonavicular Joint • • • • • Invertors In dorsiflexion Tibialis anterior In plantarflexion Tibialis posterior MOB TCD Talocalcaneonavicular Joint • • • • • • Evertor In dorsiflexion Peroneus tertius In plantarflexion Peroneus longus Peroneus brevis 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 C A MOB TCD 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 Calcaneocuboid Joint • The long and short plantar ligaments support the calcaneocuboids portion of the transverse tarsal joint “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
