Download 47-arches+venous&lymphatics (Updated 31 May)

Ankle Joint
Type : Hinge synovial surface.
Articular surfaces :
-lower end of tibia & both malleoli :
form a socket.
-body of talus… B
Inferior transverse tibiofibular
ligament runs between the lateral
malleolus & lower end of tibia, It
deepens the socket … A
The capsule : is thin anteriorly
& posteriorly, but is thickened
medially by medial strong
(deltoid) ligament // and laterally
by lateral ligament…. A & B
N.supply : deep peroneal N. +
tibial N.
Ligaments of Ankle joint
Medial (deltoid) ligament :
-it is strong, its apex : attached to tip
of medial malleolus… A
-its base : attached to the talus +
navicular bone + plantar calcaneonavicular (spring ligament) +
sustentaculum tali of calcaneum … A
Lateral ligament : is weaker than
the medial ligament ,
it consists of 3 bands : B
1-anterior talo-fibular ligament :
extends from lateral malleolus to
lateral surface of talus.
2-posterior talo-fibular ligament :
extends from lateral malleolus to
posterior tubercle of talus.
3-calcaneo-fibular ligament :
extends from tip of lateral malleolus to
lateral surface of calcaneum.
Movements of Ankle joint
 Dorsiflexion & plantar flexion at ankle joint , but
movements of inversion & eversion take place
at tarsal joints and not at ankle joint.
 Dorsiflexion : is performed by : tibialis anterior,
extensor hallucis longus, extensor digitorum
longus and peroneus tertius.
-It is limited by the tension of tendo-calcaneus,
medial ligament (posterior fibres) & lateral lig.
(calcaneo-fibular ligament).
-During dorsiflexion, the joint is locked and
lateral movement is prevented.
Movements of Ankle joint
 Plantar flexion : is performed by :
gastrocnemius, soleus, plantaris, / peroneus
longus & brevis, / tibialis posterior, flexor
digitorum longus, and flexor hallucis longus.
-It is limited by the tension of the opposing
ms., medial ligament (anterior fibres) & lateral
ligament (anterior talo-fibular ligament).
-During plantar flexion, the joint is loose and
unlocked with possible some lateral
movement.
Relations of Ankle joint
Anteriorly : the structures passing
deep to extensor retinaculum : medial
to lateral : tendons of tibialis anterior /
extensor hallucis longus / anterior tibial
vs. & deep peroneal nerve / extensor
digitorum longus / peroneus tertius.
Posteriorly : tendo-calcaneus +
plantaris.
Posterolaterally = behind lateral
malleolus : tendons of peroneus
longus & brevis.
Posteromedially = behind medial
malleolus = structures passing deep
to flexor retinaculum, medial to lateral :
tendons of tibialis posterior /
flexor digitorum longus / posterior tibial
vs. & tibial nerve / flexor hallucis longus
Function of Arches of
the Foot :
They act as a weight bearing.
They act as a locomotive part of the
body in walking & running.
They provide space in the sole of foot
to contain and protect the muscles,
nerves and blood vessels of the sole.
Arches of Foot
Medial longitudinal arch :
-it is formed of calcaneum, talus,
navicular, 3 cuneiform bones, and
first medial 3 metatarsal bones.
Lateral longitudinal ligament :
-it is formed of calcaneum, cuboid
and lateral 4th & 5th metatarsal
bones.
Transverse arch :
-lies at the level of tarso-metatarsal
joints, formed of bases of all
metatarsal bones, / cuboid and
3 cuneiform bones.
Factors maintaining
arches of Foot :
Medial longitudinal arch
Factors maintaining
medial longitudinal arch :
1- The shape of bones :
-The sustenticulum tali holds
up the talus.
-Concavity of proximal
surface of navicular bone
receives the rounded head of
talus, which is the keystone in
the center of the arch.
-Concavity of proximal
surface of medial cuneiform
bone receives the navicular.
Medial longitudinal arch
2-The bones of foot are tied
together by :
-Plantar ligaments, The most
important ligament is calcaneonavicular ligament,
(spring ligament).
-Tendon of tibialis posterior
insertion (enters sole of foot into
all tarsal bones except talus +
bases of 2,3,4 metatarsal bones).
Medial longitudinal arch
3-tying the ends of the
arch together by :
-Plantar aponeurosis (extends
from calcaneum to heads of
metatarsal bones)
-Medial parts of flexor digitorum
longus + flexor digitorum brevis.
-Abductor hallucis.
-Tendons of Flexor hallucis
longus +Flexor hallucis brevis.
4-Suspending the arch
from above by :
Tibialis anterior
-Tibialis anterior (descends in
front of tibia to be inserted into
medial sides of medial
cuneiform bone + base of 1st
metatarsal bone) + tibialis
posterior.
-Medial ligament (deltoid lig.)
of ankle joint.
Lateral longitudinal arch
Factors maintaining lateral
longitudinal arch :
1-shape of bones : minimal shaping of
distal end of calcaneum & proximal end
of cuboid. The cuboid is the keystone.
2-The bones are tied together by :
-long plantar ligament + short plantar
ligament (plantar calcaneo-cuboid) +
-short muscles of foot.
3-Tying the ends of the arch together
: by plantar aponeurosis + abductor
digiti minimi + lateral part of flexor
digitorum longus & brevis.
4-Suspending the arch from above :
peroneus longus & brevis.
Transverse arch
Factors maintaining transverse
arch:
1-Shape of bones : the wedge shape of
cuneiform bones + the bases of
metatarsal bones.
2-The bones are tied together by :
-dorsal interossei + transverse head of
adductor hallucis + short & long plantar
ligaments.
-Deep interosseus transverse ligaments.
3-Tying the ends of the arch together :
by peroneus longus tendon.
4-Suspending the arch from above : by
tendons of peroneus longus & peroneus
brevis.
Pes planus (Flat Foot)
The medial longitudinal arch is
depressed, so the forefoot is displaced
laterally and everted.
The head of talus descends downward &
medially between calcaneum & navicular bone
The plantar calcaneo-navicular ligament
(spring) + medial lig.of ankle (deltoid) become
permanently stretched + muscles & tendons
are also stretched + the bones change their
shape
The causes of flat foot : are both
congenital & acquired.
It occurs after diseases of the muscles of
the leg or foot, after long standing, long
walking, overweight or illness, so the weak
muscles & ligaments are stretched and pain is
produced after walking for a short distance.
Pes Cavus (Clawfoot)
The medial longitudinal
arch becomes too high.
It is produced by
muscle imbalance,
(shortening of muscles or
tendons of leg or sole), in
most cases due to
poliomyelitis.
Joints of Foot :
Subtalar (Talo-calcanean) Joint
Articulation :
:
1-inferior surface of body of talus.
2-facet on middle of upper surface
of calcaneum.
Type : plane synovial joint.
Ligaments : medial, lateral talocalcaneal ligaments +
interosseous strong (talocalcaneal) ligament between
sulcus tali & sulcus calcanei.
Movements : Gliding and
rotatory.
Talo-calcaneonavicular Joint
Articulation :
1-rounded head of talus.
2-upper surface of sustentaculum tali.
3-concave surface of navicular bone.
Type : ball and socket synovial.
Capsule : incompletely encloses the
joint.
Ligaments :
1-plantar calcaneo-navicular ligament
(Spring ligament) :
-strong, between sustentaculum tali
posteriorly & tuberosity of navicular
bone anteriorly.
Movements : Gliding & rotatory.
Calcaneo-cuboid joint
Articulation :
1-anterior end of calcaneum.
2-posterior surface of cuboid.
Type : plane synovial.
Ligaments :
1-bifurcated ligament :
-strong y-shaped, lying on upper
surface of joint.
-stem : is attached to upper surface of
anterior part of calcaneum.
-lateral limb : attached to upper
surface of cuboid bone.
-medial limb : attached to upper
surface of navicular bone.
Calcaneo-cuboid joint
2-Long plantar ligament :
-strong ligament lying on the lower
surface of joint.
-between : undersurface of
calcaneum & undersurface of cuboid
+ bases of 2nd , 3rd and 4th metatarsal
bones.
-it bridges over the groove for
peroneus longus tendon, coverting it
into a tunnel.
3-short plantar ligament :
- strong ligament between
undersurface of calcaneum and
cuboid bones.
Movements in Subtalar,
Talo-calcaneonavicular, and
Calcaneo-cuboid Joints :
 Talo-calcaneonavicular + calcaneo-cuboid joints
are referred to as midtarsal or transverse tarsal
joints.
 Inversion + eversion of foot take place in subtalar +
transverse tarsal joints.
 Inversion is performed by : tibialis anterior, tibialis
posterior, extensor H.L + medial tendons of
extensor D.L.
 Eversion is performed by : peroneus longus,
peroneus brevis, and peroneus tertius. Lateral
tendons of extensor digitorum longus assist.
Veins of the lower limb
Superficial veins :
1-Great & small saphenous veins +their tributaries.
-They have numerous valves along its course.
-They are situated in superficial fascia, the constant position
of great saphenous vein in front of medial malleolus should
be remmembered for patients recquiring blood transfusion,.
Deep veins :
1-venae comitantes of anterior & posterior tibial arteries.
2-Popliteal vein & Femoral vein + their tributaries.
-They have valves to allow blood to pass upwards only .
Perforating veins:
-Many of these veins are found in ankle & medial side of
lower part of leg.
-They connect superficial veins with the deep veins.
-They possess valves which allow blood to pass from
superficial to deep veins, But prevent passage of blood from
deep veins (high blood pressure) to superficial veins (low
blood pressure)…. Venous pump
Great Saphenous Vein
 In the foot : It drains the medial end of
dorsal venous arch of foot.
It passes upward in front of medial
malleolus.
In the leg : It ascends in company with
saphenous nerve in superficial fascia of
medial side of leg, then behind knee and
curves forward on medial side of thigh.
It pierces the cribriform fascia
of saphenous opening in the deep fascia of
thigh to join femoral vein.
It has numerous valves and is connected
to small saphenous vein by anastomotic
vein passing behind knee.
It is connected with deep veins via
perforating valved veins along medial side
of calf.
Great Saphenous Vein
 It receives 3 tributaries at
saphenous opening :
1-superficial circumflex iliac vein.
2-superficial epigastric vein.
3-superficial external pudendal vein.
Accessory vein, usually joins the
great saphenous vein about the middle
of the thigh.
Communicating veins which
connect it with the deep veins.
Varicose Veins
 A varicose vein is a vein which becomes
dilated, elongated and tortuous.
 It affects the superficial veins of the lower
limb.
 It is produced when the valves of the
perforating veins become incompetent
(so, allow blood to pass from deep veins to
superficial veins).
 As a result, the blood passes from deep
veins (high pressure) to superficial veins
(low pressure), so the superficial veins
become dilated, elongated and tortuous.
Small Saphenous Vein
In the foot : it arises from lateral part of
dorsal venous arch.
It ascends behind lateral malleolus,
in company with sural nerve.
It ascends over back of leg in the
superficial fascia, then pierces deep fascia
to pass between 2 heads of gastrocnemius
to end in popliteal vein.
It has numerous valves along its course.
Tributaries :
1-Numerous small veins from back of leg.
2-Communicating veins with deep veins of
foot.
3-Anastomotic branch that runs upward &
medially to join great saphenouds vein.
Dorsal venous arch
It lies in superficial fascia of dorsum
of foot , over heads of metatarsal
bones.
It drains medially into the great
saphenous vein, which ascends in front
of medial malleolus into medial side of
leg.
It drains laterally into the small
saphenous vein, which ascends behind
lateral malleolus into back of leg.
It receives blood from the foot via
digital & communicating veins, which
pass through the interosseous spaces.
Popliteal Vein
It begins at lower border of popliteus
muscle by union of venae comitantes of
anterior & posterior tibial arteries.
It passes upwards in the popliteal fossa.
It passes medial to popliteal artery at its
lower part, then behind at its middle part,
and lateral to the artery at its upper part.
It ends by passing through opening in
adductor magnus to become the femoral
vein.
Tributaries :
1-Small saphenous vein, which
perforates deep fascia to pass between 2
heads of gastrocnemius to end in popliteal
vein.
2-Veins that correspond to branches
of popliteal artery (5 genicular branches
to knee joint + muscular branches)
Femoral Vein
It enters the thigh by passing opening in
adductor magnus as a continuation of
popliteal vein.
It ascends in the thigh, lying at first on
lateral side of the artery,then posterior
,and finally on its medial side.
It leaves thigh in the intermediate
compartment of femoral sheath to become
external iliac vein.
Tributaries :
1-great saphenous vein.
2-veins that correspond to branches of
artery :
-Profunda femoris vein.
-Lateral & medial circumflex femoral veins
-Deep external pudendal vein.
-Muscular veins.
Femoral nerve injury (L2,3,4)
Causes : By stab or gunshot wounds,
but a complete division is rare.
Motor changes :
1-Paralysis of quadriceps femoris
muscle which leads to loss of
extension of the knee.
Sensory changes :
1- loss of skin sensation over
anterior & medial sides of thigh.
( intermediate + medial cutaneous N.
of the thigh injury).
2- loss of sensation over medial side
of leg + medial border of foot as far
as the metatarso-phalangeal joint or
root of big toe. (saphenous N. injury)
Sciatic nerve injury
(L4,5/S1,2,3) Causes :
1-penetrating wounds.
2-fractures of pelvis or dislocation of hip
joint.
3-wrong injections into gluteus maximus
or medius ( upper outer quadrant of the
buttock is the best site).
In 90% of cases, common peroneal part
of the sciatic N. is the most affected
because its fibres lie most superficial in
sciatic N.
Motor changes :
1-paralysis of hamstring ms., but weak
flexion of knee is possible by the action
of sartorius (Femoral N.) + gracilis
(obturator N.).
2-paralysis of extensors of the leg
(supplied by deep peroneal N.), leading to
‘’foot drop’’.
Sciatic nerve injury
(L4,5/S1,2,3)
Sensory changes :
1-Loss of sensation below knee
at the lateral side of leg and
back of leg (supplied by lateral
cutaneous N. of calf & sural
communicating branch of
common peroneal N. / and
sural N. of tibial N. ), EXCEPT
along medial side of lef + along
medial border of foot as fare as
the ball of big toe, (supplied by
saphenous N. from femoral N.).
Sciatica
it is a condition in which the
patients have pain along the
sensory distribution of sciatic
N., in the posterior aspect of
thigh, posterior & lateral sides
of leg and lateral side of foot.
-causes :
1-intervertebral disc prolapse
with pressure on roots of lower
lumbar + sacral spinal Ns.
2-intrapelvic tumor, presses on
sacral plexus or sciatic N.
3-inflammation of sciatic N. or
its terminal branches.
Common peroneal N. injury
 It has an exposed position as it leaves
popliteal fossa and winds around neck
of fibula to enter peroneus longus ms.
 Commonly injured in fractures of neck
of fibula and by pressure from casts or
splints.
 Motor changes : paralysis of ms. Of
anterior compartment of leg (supplied
by deep peroneal N.) + ms. Of lateral
compartment (supplied by superficial
peroneal N.), so the opposing ms.
Plantar flexor of ankle + invertors of
subtalar and transverse tarsal joints,
cause : planter flexion of foot (foot
drop) and inversion, referred to as
‘’equino-varus’’.
Common peroneal N. injury
Sensory changes :
 Loss of sensation on the anterior &
lateral sides of leg + intermediate
part of dorsum of foot & all toes (by
superficial peroneal N.), except the
lateral side of little toe. But :
 Lateral border of foot + lateral side
of little toe are virtually unaffected
(sural N. mainly from tibial N.).
 Medial border of foot as far as the
ball of big toe is completely
unaffected (saphenous N. from
femoral N.).
Tibial N. injury
 It leaves popliteal fossa deep to gastrocnemius
& soleus ms.
 Because of its deep position, it is rarely injured.
 Motor changes :
-paralysis of plantar flexor ms. Of back of leg +
of sole of foot, so the opposing ms. (extensors)
dorsiflex the foot at ankle + evert foot at
subtalar & transverse tarsal joints, it is reffered
to as calcaneo-valgus.
 Sensory changes :
-loss of sensation on sole of foot, Later trophic
ulcers develop.
Obturator N. injury
It enters thigh as anterior & posterior
divisions through upper part of obturator
foramen. / anterior division descends
infront of adductor brevis, and
posterior division descends behind
adductor brevis and in front of adductor
magnus.
It is rarely injured as in case of
penetrating wounds.
Motor changes : paralysis of all
adductor ms. Except ischial (hamstring)
part of adductor magnus (by sciatic N.).
Sensory changes : is minimal on the
medial aspect of the thigh.
Great Saphenous Vein Cut Down
A & B at the ankle.
Great saphenous vein is constantly
found in front of medial malleolus of tibia.
C & D at the groin.
Great saphenous vein drains into
femoral vein 2 fingerbreadths below &
lateral to pubic tubercle.
Exposure of the vein through a skin
incision (a ‘cut down’) is usually
performed at ankle, but this site has
disadvantages of phlebitis (inflammation
of the vein wall) as a complication.
In the groin, phlebitis is rare because
the larger diameter of the vein at this site
allows the use of large-diameter
catheters and rapid infusion of large
volumes of fluids.
Great Saphenous Vein in
Coronary Bypass surgery
 In occlusive coronary disease, the diseased
arterial segment can be bypassed by inserting a
graft from great saphenous vein.
 At the donor sit, the superficial venous blood
ascends the lower limb against gravity by
passing through perforating veins into the deep
veins.
 Great saphenous vein can also be used to
bypass obstructions of brachial or femoral
arteries.
Femoral Vein Catheterization
The femoral vein lies medial to femoral
artery just about 2 fingerbreadths below
inguinal ligament and is easily
cannulated.
Because of high incidence of
thrombosis and fatal pulmonary
embolism, the catheter should be
removed once the patient is stabilized.
Superficial inguinal Lymph Nodes
They are arranged into Horizontal &
Vertical groups.
Horizontal group :
-lies below and parallel to inguinal
ligament.
-The medial members of this group
receive afferent vessels from :
1-superficial lymph vessels from anterior
abdominal wall below umbilicus.
2-lymph vessels from perineum, + urethra
+ external genitalia (except lymph
drainage of testes ends in lumbar
(para-aortic) L.Ns. at level of L1 vertebra
+ lower ½ of anal canal.
-The lateral members of this group
receive afferent superficial lymph
vessels from back below level of iliac
crest (skin of gluteal region)
Superficial inguinal Lymph Nodes
Vertical group :
-Lies along terminal part of great
saphenous vein.
-They receive most of afferent superficial
lymph vessels of the lower limb
(except lateral sides of foot & leg
drained into popliteal L.Ns. +
gluteal region drained by horizontal group
of inguinal L.Ns.).
Efferent lymph vessels from vertical
& horizontal groups of superficial
inguinal L.Ns. : pass through
saphenous opening in the deep fascia to
end in deep inguinal L.Ns. (lying along
medial side of femoral vein).
Popliteal Lymph Nodes :
They are lying in popliteal fossa.
Their afferent lymph vessels from :
1-superficial lymph from skin of lateral
side of foot & leg.
2-lymph from knee joint.
3-Deep lymph vessels accompaning
anterior & posterior tibial arteries.
Their efferent lymph vessels pass
into : deep inguinal lymph nodes
(lying along medial side of femoral vein).
Deep Inguinal Lymph Nodes
They are located beneath the
deep fascia along medial side of
femoral vein.
They receive afferent lymph
vessels from :
-superficial inguinal L.Ns.
-popliteal L.Ns.
-deep structures of thigh.
Their efferent lymph vessels
pass through femoral canal to end
into external iliac lymph nodes.