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The Leg Dr. Fadel Naim Orthopedic Surgeon Faculty of Medicine IUG DR FADEL NAIM IUG Fascial Compartments of the Leg The deep fascia surrounds the leg Continuous above with the deep fascia of the thigh Below the tibial condyles: Attached to the anterior and medial borders of the tibia It is fused with the periosteum Two intermuscular septa pass from its deep aspect to be attached to the fibula. Together with the interosseous membrane, divide the leg into three compartments 1. 2. 3. DR FADEL NAIM IUG Anterior Lateral Posterior DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG INTEROSSEOUS MEMBRANE A thin but strong membrane connecting the interosseous borders of the tibia and fibula Most fibers run obliquely downward and laterally Binds the tibia and fibula together and provides attachment for neighboring muscles Is continuous below with the interosseous ligament of the inferior tibiofibular joint. DR FADEL NAIM IUG INTEROSSEOUS MEMBRANE A large opening exists in the upper part of the membrane Permit the anterior tibial vessels to enter the anterior fascial compartment of the leg A small opening is present in the lower part of the membrane For the perforating branch of the peroneal artery to enter the anterior fascial compartment. DR FADEL NAIM IUG RETINACULA OF THE ANKLE In the region of the ankle joint, the deep fascia is thickened to form a series of retinacula Keep the long tendons in position and act as modified pulleys. DR FADEL NAIM IUG RETINACULA OF THE ANKLE The superior extensor retinaculum A thickened band of deep fascia that is attached to the distal ends of the anterior borders of the fibula and tibia Near its medial end, it splits to enclose the tendon of the tibialis anterior muscle. DR FADEL NAIM IUG DR FADEL NAIM IUG Inferior Extensor Retinaculum A v-shaped band of deep fascia Attached by its stem to the upper surface of the anterior part of the calcaneum The upper limb of the Y is attached to the medial malleolus The lower limb is continuous with the plantar fascia on the medial border of the foot. The tendons of: The The The The DR FADEL NAIM IUG tibialis anterior extensor hallucis longus extensor digitorum longus peroneus tertius Split the upper limb of the retinaculum into superficial and deep layers. Fibrous bands separate the tendons into compartments each of which is lined by a synovial sheath. DR FADEL NAIM IUG DR FADEL NAIM IUG Flexor Retinaculum A thickened band of deep fascia Extends from the medial malleolus downward and backward Attached to the medial surface of the calcaneum It binds the tendons of the deep muscles to the medial side of the ankle as they pass forward from behind the medial malleolus to enter the sole of the foot. The tendons lie in compartments each of which is lined by a synovial sheath. DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG The Superior Peroneal Retinaculum A thickened band of deep fascia Extends from the lateral malleolus downward and backward Attached to the lateral surface of the calcaneum It binds the tendons of the peroneus longus and brevis to the lateral side of the ankle. The tendons are provided with a common synovial sheath. DR FADEL NAIM IUG The inferior peroneal retinaculum A thickened band of deep fascia Attached to the peroneal tubercle and to the calcaneum The tendons of peroneus longus and brevis each possess a synovial sheath, which is continuous above with the common sheath. DR FADEL NAIM IUG DR FADEL NAIM IUG Superficial Veins Numerous small veins curve around the medial aspect of the leg and ultimately drain into the great saphenous vein DR FADEL NAIM IUG Lymph Vessels The greater part of the lymph from the skin and superficial facsia on the front of the leg drains upward and medially in vessels that follow the great saphenous vein, to end in the vertical group of superficial inguinal lymph nodes DR FADEL NAIM IUG Lymph Vessels A small amount of lymph from the upper lateral part of the front of the leg may pass via vessels that accompany the small saphenous vein and drain into the popliteal nodes DR FADEL NAIM IUG CONTENTS OFTHE ANTERIOR FASCIAL COMPARTMENT Muscles: Blood supply: The tibialis anterior Extensor digitorum longus Peroneus tertius Extensor hallucis longus. Anterior tibial artery. Nerve supply: Deep peroneal nerve. DR FADEL NAIM IUG Tibialis Anterior Origin: From the upper half of the lateral surface of the tibia From the interosseous membrane Insertion: The tendon passes through both extensor retinacula Attached to Nerve supply: The medial cuneiform bone Adjoining base of the first metatarsal bone. Deep peroneal nerve. Action: Dorsiflexes the foot at the ankle joint Inverts the foot at the subtalar and transverse tarsal joints Assists in holding up the medial longitudinal arch of the foot. DR FADEL NAIM IUG DR FADEL NAIM IUG Extensor Digitorum Longus Origin: Insertion: The tendons pass behind the superior and through the inferior extensor retinacula. The four tendons then diverge and pass to the lateral four toes. Nerve supply: From the upper two thirds of the anterior surface of the fibula from the interosseous membrane Deep peroneal nerve. Action: Extends the toes Extends the foot at the ankle joint. DR FADEL NAIM IUG Extensor Expansion Of The Foot On the dorsal surface of each toe, the extensor tendon becomes incorporated into a fascial expansion called the extensor expansion. The central part of the expansion is inserted into the base of the middle phalanx The two lateral parts converge to be inserted into the base of the distal phalanx DR FADEL NAIM IUG Peroneus Tertius Origin: Insertion: follows the tendons of extensor digitorum longus behind the superior and through the inferior extensor retinacula and shares their synovial sheath. into the medial side of the dorsal aspect of the base of the fifth metatarsal bone Nerve supply: part of the extensor digitorum longus. arises from the lower third of the anterior surface of the fibula and the interosseous membrane. Deep peroneal nerve Action: Extends the foot at the ankle joint Everts the foot at the subtalar and transverse tarsal joints. DR FADEL NAIM IUG Extensor Hallucis Longus Origin: Insertion: The tendon passes behind the superior and through the inferior extensor retinacula Into the base of the distal phalanx of the great toe Nerve supply: From the middle half of the anterior surface of the fibula From the interosseous membrane Deep peroneal nerve. Action: Extends Big toe Foot at the ankle joint Assists in inversion of the foot at the subtalar and transverse tarsal joints DR FADEL NAIM IUG Artery Of The Anterior Fascial Compartment Of The Leg Anterior Tibial Artery The smaller of the terminal branches of the popliteal artery. It arises at the level of the lower border of the popliteus muscle Passes forward into the anterior compartment of the leg through an opening in the upper part of the interosseous membrane It descends on the anterior surface the interosseous membrane, accompanied by the deep peroneal nerve In the upper part of its course, it lies deep beneath the muscles of the compartment. DR FADEL NAIM IUG Anterior Tibial Artery In the lower part of its course, it lies superficial in front of the lower end of the tibia In front of the ankle joint, the artery becomes the dorsalis pedis artery passes behind the superior extensor retinaculum the tendon of the extensor hallucis longus on its medial side the deep peroneal nerve and the tendons of extensor digitorum longus on its lateral side. pulsations can easily be felt in the living subject DR FADEL NAIM IUG DR FADEL NAIM IUG Branches Anterior Tibial Artery Muscular branches to neighboring muscles. Anastomotic branches with branches of other arteries around the knee and ankle joints. DR FADEL NAIM IUG Venae comitantes of the anterior tibial artery join those of the posterior tibial artery in the popliteal fossa to form the popliteal vein. DR FADEL NAIM IUG Compartment Syndrome When the pressure within a compartment exceeds the perfusion pressure of the capillaries within that compartment compromising venous blood flow, and limiting capillary perfusion. Leads to muscle ischemia and necrosis. TRUE ORTHOPEDIC EMERGENCY DR FADEL NAIM IUG ANTERIOR COMPARTMENT OF THE LEG SYNDROME Soft tissue injury associated with bone fractures is a common cause Early diagnosis is critical. The deep, aching pain in the anterior compartment of the leg that is characteristic of this syndrome Dorsiflexion of the foot at the ankle joint increases the severity of the pain. Stretching of the muscles that pass through the compartment by passive plantar flexion of the ankle also increases the pain. DR FADEL NAIM IUG ANTERIOR COMPARTMENT OF THE LEG SYNDROME In sever cases, the arterial supply is eventually cut off by compression the dorsalis pedis arterial pulse disappears. Paralysis of: Loss of sensation in area supplied by the deep peroneal nerve The tibialis anterior the extensor digitorurum longus the extensor hallucis longus the skin cleft between the first and second toes. Decompression by fasciotomy of the anterior compartment of the leg. DR FADEL NAIM IUG Review those “P’s” DR FADEL NAIM IUG Pain? Paresthesias? Paralysis? Pallor? Pulselessness? poikilothermia (cool limb)? DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG CONTENTS OF THE LATERAL FASCIAL COMPARTMENT OF THE LEG Muscles: Blood supply: Peroneus longus peroneus brevis. Branches from the peroneal artery. Nerve supply: Superficial peroneal nerve DR FADEL NAIM IUG Peroneus Longus Origin: Nerve supply: From the upper two thirds of the lateral surface of the fibula Superficial peroneal nerve. Action: Plantar flexes the foot at the ankle joint Everts the foot at the subtalar and transverse tarsal joints. It plays an important part in holding up the lateral longitudinal arch in the foot serves as a tie to the transverse arch of the foot. DR FADEL NAIM IUG Peroneus Longus Insertion: The tendon runs downward behind the lateral malleolus and is held in position by the superior peroneal retinaculum. The tendon then runs forward on the lateral surface of the calcaneum below the peroneal tubercle. Here, it is held in place by the inferior peroneal retinaculum. On reaching the lateral aspect of the cuboid, it winds around the lateral margin and enters a groove on its inferior aspect. It is inserted into the medial cuneiform and the base of the first metatarsal. DR FADEL NAIM IUG Peroneus Brevis Origin: Insertion: The tendon passes downward behind and directly in contact with the lateral malleolus held in position by the superior peroneal retinaculum. The tendon runs forward above the peroneal tubercle of the calcaneum and is held in place by the inferior peroneal retinaculum. It is inserted into the tubercle on the base of the fifth metatarsal bone. Nerve supply: From the lower two thirds of the lateral surface of the fibula Superficial peroneal nerve. Action: Plantar flexes the foot at the ankle joint Everts the foot at the subtalar and transverse tarsal joints. It assists in holding up the lateral longitudinal arch of the foot. DR FADEL NAIM IUG TENOSYNOVITIS AND DISLOCATION OF THE PERONEUS LONGUS AND BREVIS TENDONS Tenosynovitis Can affect the tendon sheaths of the peroneus longus and brevis muscles as they pass posterior to the lateral malleolus. Treatment consists of Immobilization Heat Physiotherapy. Tendon dislocation The tendons of peroneus longus and brevis dislocate forward from behind the lateral malleolus. The superior peroneal retinaculum must be torn It usually occurs in older children and is caused by trauma. DR FADEL NAIM IUG Artery of the lateral Fascial Compartment of the leg Numerous branches from the peroneal artery which lies in the posterior compartment of the leg, pierce the posterior fascial septum and supply the peroneal muscles. DR FADEL NAIM IUG Superficial Veins The small saphenous vein Arises from the lateral part of the dorsal venous arch of the foot It ascends behind the lateral malleolus in company with the sural nerve. It follows the lateral border of the tendo calcaneus and then runs up the middle of the back of the leg. The vein pierces the deep fascia and passes between the two heads of the gastrocnemius muscle in the lower part of the popliteal fossa Numerous valves along its course. DR FADEL NAIM IUG Superficial Veins Tributaries Numerous small veins from the back of the leg. Communicating veins with the deep veins of the foot. Important anastomotic branches that run upward and medially and join the great saphenous vein The mode of termination of the small saphenous vein: DR FADEL NAIM IUG It may join the popliteal vein It may join the great saphenous vein It may split in two One division joining the popliteal The other joining the great saphenous vein. Lymph Vessels Lymph vessels from the skin and superficial fascia on the back of the leg drain upward and either pass forward around the medial side of the leg to End in the vertical group of superficial inguinal nodes Drain into the popliteal nodes DR FADEL NAIM IUG CONTENTS OF THE POSTERIOR FASCIAL COMPARTMENT OF THE LEG The deep transverse fascia of the leg: A septum that divides the muscles of the posterior compartment into superficial and deep groups Superficial group of muscles: Deep group of muscles: Popliteus Flexor digitorum longus Flexor hallucis longus Tibialis posterior. Blood supply: Gastrocnemius Plantaris Soleus. Posterior tibial artery. Nerve supply: Tibial nerve. DR FADEL NAIM IUG Gastrocnemius The gastrocnemius is the most superficial of the calf muscles. Origin: Lateral head medial head The two large and powerful fleshy bellies join the posterior part of the common tendon called the tendo calcaneus attached to the posterior surface of the calcaneum. Nerve supply: from the popliteal surface of the femur above the medial condyle. Insertion: from the lateral aspect of the lateral condyle of the femur Tibial nerve. Action: Plantar flexes the foot at the ankle joint flexes the knee joint DR FADEL NAIM IUG A small bursa separates the tendon from the upper part of the posterior surface of the bone. DR FADEL NAIM IUG Plantaris The plantaris muscle has a small fusiform belly. sometimes double or it may be absent. Origin: Insertion: From the lateral supracondylar ridge of the femur. It has a small fleshy belly and a long narrow tendon. The tendon is commonly used in reconstructive surgery of the tendons of the hand The long tendon descends obliquely in the interval between the gastrocnemius and soleus then along the medial border of the tendo calcaneus attached to the posterior surface of the calcaneum on the medial side of the tendon. Nerve supply: Tibial nerve. Action: It assists in plantar flexing the foot at the ankle joint flexing the knee joint DR FADEL NAIM IUG Soleus The soleus is a broad, flat muscle that lies anterior to the gastrocnemius. Origin: An inverted V-shaped origin Insertion: from the soleal line on the posterior surface of the tibia from the upper one quarter of the posterior surface of the shaft of the fibula from a fibrous arch between these bones. The tendon joins the anterior part of the common tendon, the tendo calcaneus attached to the posterior surface of the calcaneum. • Nerve supply: Tibial nerve. DR FADEL NAIM IUG Soleus • Action: Together, the soleus, gastrocnemius, and plantaris act as powerful plantar flexors of the ankle joint. They provide the main forward propulsive force in walking and running by using the foot as a lever and raising the heel off the ground DR FADEL NAIM IUG GASTROCNEMIUS AND SOLEUS MUSCLE TEARS produce severe localized pain over the damaged muscle Swelling may be present DR FADEL NAIM IUG RUPTURED TENDO CALCANEUS Common in middle aged men and frequently occurs in tennis players. The rupture occurs at its narrowest part, about 2 in. (5 cm) above its insertion. A sudden, sharp pain is felt, with immediate disability. The gastrocnemius and soleus muscles retract proximally Leaving a palpable gap in the tendon. It is impossible for the patient to actively plantar flex the foot. The tendon should be sutured as soon as possible The leg immobilized with the ankle joint plantar flexed and the knee joint flexed. DR FADEL NAIM IUG DR FADEL NAIM IUG RUPTURE OF THE PLANTARIS TENDON Rupture of the plantaris tendon is rare Tearing of the fibers of the soleus or partial tearing of the tendo calcaneus is frequently diagnosed as such a rupture. DR FADEL NAIM IUG PLANTARIS TENDON AND AUTO GRAFTS The plantaris muscle, which is often missing Can be used for tendon autografts in repairing severed flexor tendons to the fingers; The tendon of the palmaris longus muscle can also be used for this purpose. DR FADEL NAIM IUG Flexor Digitorum Longus Origin: From the medial part of the posterior surface of the tibia, below the solealline Insertion: The tendon passes behind the medial malleolus, deep to the flexor retinaculum enters the sole of the foot. It receives a strong slip from the tendon of the flexor hallucis longus. The main tendon now divides into four tendons pass to the lateral four toes, where they are inserted into the bases of the distal phalanges. Each tendon passes through an opening in the corresponding tendon of flexor digitorum brevis DR FADEL NAIM IUG Flexor Digitorum Longus Nerve supply: Tibial nerve. Action: Flexes the distal phalanges of the lateral four toes assists in plantar flexing the foot at the ankle joint. It plays an important part in maintaining the medial and lateral longitudinal arches in the foot. DR FADEL NAIM IUG Flexor Hallucis Longus Origin: Insertion: The tendon passes behind the medial malleolus, deep to the flexor retinaculum. It grooves the posterior surface of the talus and passes forward on the sole of the foot beneath the sustentaculum tali. It gives off a strong slip to the tendon of flexor digitorum longus. It is inserted into the base of the distal phalanx of the big toe. Nerve supply: From the lower two thirds of the posterior surface of the shaft of the fibula Tibial nerve. Action: Flexes the distal phalanx of the big toe Assists in plantar flexing the foot at the ankle joint. It plays an important part in maintaining the medial longitudinal arch in the foot. DR FADEL NAIM IUG Tibialis Posterior Origin: From the lateral part of the posterior surface of the tibia the interosseous membrane upper half of the posterior surface of the fibula Insertion: The tendon passes behind the medial malleolus deep to the flexor retinaculum. It runs forward into the sole of the foot above the sustentaculum tali and is inserted mainly into the tuberosity of the navicular bone. Small tendinous slips pass to Nerve supply: the cuboid the cuneiforms the bases of the 2nd , 3rd, and 4th metatarsals. Tibial nerve. Action: Plantar flexes the foot at the ankle joint Inverts the foot at the subtalar and transverse tarsal joints. It plays an important part in holding up the medial longitudinal arch in the foot. The small tendinous slips of insertion assist in holding the bones of the foot together. DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG Posterior Tibial Artery one of the terminal branches of the popliteal artery It begins at the level of the lower border of the popliteus muscle passes downward deep to the gastrocnemius and soleus and the deep transverse fascia of the leg It lies on the posterior surface of the tibialis posterior muscle above on the posterior surface of the tibia below. In the lower part of the leg the artery is covered only by skin and fascia. The artery passes behind the medial malleolus deep to the flexor retinaculum and terminates by dividing into medial and lateral plantar arteries DR FADEL NAIM IUG Branches Peroneal artery, a large artery that arises close to the origin of the posterior tibial artery It descends behind the fibula, either within the substance of the flexor hallucis longus muscle or posterior to it. The peroneal artery gives off Muscular branches distributed to muscles in the posterior compartment of the leg. Nutrient artery to the tibia. Anastomotic branches, numerous muscular branches a nutrient artery to the fibula ends by taking part in the anastomosis around the ankle joint. A perforating branch pierces the interosseous membrane to reach the lower part of the front of the leg . join other arteries around the ankle joint. Medial and lateral plantar arteries DR FADEL NAIM IUG DEEP VEIN THROMBOSIS AND LONG-DISTANCE AIR TRAVEL Passengers, who sit immobile for hours on long-distance flights are very prone to deep vein thrombosis in the legs. Thrombosis of the veins of the soleus muscle give rise to mild pain or tightness in the calf and calf muscle tenderness. deep vein thrombosis can also occur with no signs or symptoms. Should the thrombus become dislodged, it passes rapidly to the heart and lungs, causing pulmonary embolism, which is often fatal. Preventative measures include stretching of the legs every hour to improve the venous circulation. 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