1. Anatomy of the Foot Long Nguyen

2. Exam q’s With which bones does the first (medial) cuneiform articulate? How does the 1st cuneiform appear in a lateral radiograph of the tarsal region? (Oct 99) With which bones does the first (medial) cuneiform articulate? How does the 1st cuneiform appear in a lateral radiograph of the tarsal region? (Oct 99) Give an account of the ossification centres of the foot. State their time of appearance and fusion. (?) Give an account of the ossification centres of the foot. State their time of appearance and fusion. (?) What joints does the talus contribute to? (?) What joints does the talus contribute to? (?)

3. Foot Bones Tarsus Tarsus Proximal Proximal Talus Talus Calcaneus Calcaneus Medial Medial Navicular Navicular Distal Distal Medial, intermediate and lateral cuneiforms Medial, intermediate and lateral cuneiforms Cuboid Cuboid Metatarsals Metatarsals Phalanges Phalanges

4. Talus Only bone articulating with leg bones Only bone articulating with leg bones No muscle attachments No muscle attachments Head articulates with navicular Head articulates with navicular Inferiorly a has 3 facets Inferiorly a has 3 facets Anterior talocalcaneal articular surface Anterior talocalcaneal articular surface Middle talocalcaneal articular surface Middle talocalcaneal articular surface Facet for plantar calcaneonavicular (spring) ligament Facet for plantar calcaneonavicular (spring) ligament Neck Neck Directed inferiomedially making angle of 150º with body Directed inferiomedially making angle of 150º with body Sulcus tali: deep groove which separates middle and posterior talocalcaneal articular surface Sulcus tali: deep groove which separates middle and posterior talocalcaneal articular surface Body Body Superior convex articular surface (trochlea) with shallow central groove (saddle shaped) Superior convex articular surface (trochlea) with shallow central groove (saddle shaped) Posteriorly Posteriorly Lateral tubercle: attachment for posterior talofibular ligament Lateral tubercle: attachment for posterior talofibular ligament Medial tubercle: posterior fibres of deltoid ligament Medial tubercle: posterior fibres of deltoid ligament Inferiorly Inferiorly Anterior talocalcaneal articular surface Anterior talocalcaneal articular surface Anastamotic blood supply running from anterior to posterior. Fractures of talar neck can cause AVN of body Anastamotic blood supply running from anterior to posterior. Fractures of talar neck can cause AVN of body

6. Calcaneus Superior surface Superior surface Roughened posterior 1/3 Roughened posterior 1/3 Middle 1/3: Posterior articular surface for body of talus Middle 1/3: Posterior articular surface for body of talus Anterior 1/3: medial shelf-like projection, sustentaculum tali which has middle articular surface for talus. Anteriolaterlly is the anterior articular surface with talus. Anterior 1/3: medial shelf-like projection, sustentaculum tali which has middle articular surface for talus. Anteriolaterlly is the anterior articular surface with talus. Anterior surface articulates with cuboid Anterior surface articulates with cuboid Posterior surface Posterior surface Smooth upper surface for attachment of tendo calcaneus Smooth upper surface for attachment of tendo calcaneus Calcaneal tuberosity with lateral and medial processes Calcaneal tuberosity with lateral and medial processes

7. Calcaneus Inferior surface Inferior surface Anterior tubercle provides attachment to short plantar ligament Anterior tubercle provides attachment to short plantar ligament Medial surface Medial surface Sustentaculum tali projects from anterior part of superior border. Plantar calcaneonavicular ligament attaches in front and superficial part of deltoid ligament behind. Sustentaculum tali projects from anterior part of superior border. Plantar calcaneonavicular ligament attaches in front and superficial part of deltoid ligament behind. Lateral surface Lateral surface Flat except for peroneal trochlea/tubercle Flat except for peroneal trochlea/tubercle

8. Calcaneus Superior surface Superior surface Roughened posterior 1/3 Roughened posterior 1/3 Middle 1/3: Posterior articular surface for body of talus Middle 1/3: Posterior articular surface for body of talus Anterior 1/3: medial shelf-like projection, sustentaculum tali which has middle articular surface for talus. Anteriolaterlly is the anterior articular surface Anterior 1/3: medial shelf-like projection, sustentaculum tali which has middle articular surface for talus. Anteriolaterlly is the anterior articular surface Anterior surface articulates with cuboid Anterior surface articulates with cuboid Posterior surface Posterior surface Smooth upper surface for attachment of tendo calcaneus Smooth upper surface for attachment of tendo calcaneus Calcaneal tuberosity with lateral and medial processes Calcaneal tuberosity with lateral and medial processes Inferior surface Inferior surface Anterior tubercle provides attachment to short plantar ligament Anterior tubercle provides attachment to short plantar ligament Medial surface Medial surface Sustentaculum tali projects from anterior part of superior border. Plantar calcaneonavicular ligament attaches in front and superficial part of deltoid ligament behind. Sustentaculum tali projects from anterior part of superior border. Plantar calcaneonavicular ligament attaches in front and superficial part of deltoid ligament behind. Lateral surface Lateral surface Peroneal trochlea/tubercle Peroneal trochlea/tubercle

9. Calcaneus Subtle compression fractures can be suspected by assessing Bohler’s angle Subtle compression fractures can be suspected by assessing Bohler’s angle If decreased below 25–40º, a fracture should be suspected If decreased below 25–40º, a fracture should be suspected

10. Navicular and Cuboid Navicular Navicular Proximal: talus; plantar spring ligament medially Proximal: talus; plantar spring ligament medially Distal: 3 facets for cuneiforms Distal: 3 facets for cuneiforms Lateral: cuboid Lateral: cuboid Medial: tuberosity for insertion of tibialis posterior Medial: tuberosity for insertion of tibialis posterior Cuboid Cuboid Proximal: calcaneus Proximal: calcaneus Distal: base of 4 th and 5 th MTs Distal: base of 4 th and 5 th MTs Medial: lateral cuneform +/- navicular Medial: lateral cuneform +/- navicular Lateral & plantar surface: grooved by tendon of peroneus longus Lateral & plantar surface: grooved by tendon of peroneus longus InferiorLateral ProximalDistal

11. Cuneiforms Wedge shaped Wedge shaped Medial cuneiform (largest) broader at plantar surface Medial cuneiform (largest) broader at plantar surface Intermediate & lateral cuneiform broader at dorsal surface Intermediate & lateral cuneiform broader at dorsal surface

12. Metatarsals and phalanges MTs MTs Base, shaft, head Base, shaft, head Articulates with distal row of tarsus and with each other Articulates with distal row of tarsus and with each other 1 st MT shortest and thickest 1 st MT shortest and thickest 1 st MT head has 2 articular facets on plantar surface for two sesamoid bones in tendon of flexor hallicus brevis 1 st MT head has 2 articular facets on plantar surface for two sesamoid bones in tendon of flexor hallicus brevis 5 th MT base has tuberosity on lateral aspect providing attachment for peroneus brevis tendon. Tuberosity may be avulsed by acute inversion injury 5 th MT base has tuberosity on lateral aspect providing attachment for peroneus brevis tendon. Tuberosity may be avulsed by acute inversion injury Phalanges Phalanges 14 phalanges (2 in 1 st digit) 14 phalanges (2 in 1 st digit)

13. Lisfranc injury Lisfranc’s joint is made up of the tarsometatarsal joints and a dislocation or fracture- dislocation of this region is termed a Lisfranc injury. Lisfranc’s joint is made up of the tarsometatarsal joints and a dislocation or fracture- dislocation of this region is termed a Lisfranc injury. The second MT base is held by the strong plantar oblique ligament between the medial cuneiform and the second MT base (Lisfranc ligament). This is ruptured in a Lisfranc injury. The second MT base is held by the strong plantar oblique ligament between the medial cuneiform and the second MT base (Lisfranc ligament). This is ruptured in a Lisfranc injury.

14. Ossification AppearanceUnion Calcaneus - posterior surface - posterior surface 5 month fetus - 6-8 years - 6-8 years 14-16 years Talus 6 month fetus Cuboid 9 month fetus Lateral cuneiform 1 year Intermediate 2 years Medial 3 years Navicular (several os centres) 3 years

15. Ossification AppearanceUnion MT shafts - epiphysis of 2-5 MT head, 1 st MT base - epiphysis of 2-5 MT head, 1 st MT base 9-10 week fetus - 3-4 years - 3-4 years 18 years Distal phalanges - epiphysis at base - epiphysis at base 9-12 week fetus - 6 th year - 6 th year Prox phalanges - epiphysis at base - epiphysis at base 11-15 week fetus - 2-8 years - 2-8 years Middle phalanges - epiphysis at base - epiphysis at base 15+ week fetus - 3-6 years - 3-6 years MT & phalanges ossification centres appear by 2 nd trimester of pregnancy Epiphyses appear by 6-8 years and fuse by 18 years

16. Sesamoid and accessory ossicles (6) Os peroneum in tendon of peroneus longus (20%) (7) Os vesalianum in tendon of peroneus brevis (1) Os tibiale externum: separate ossification centre for tuberosity of navicular (5%) (12) Os trigonum: separate ossification centre for the posterior surface of the talus which does not unite

17. (6) (7) (1) (12)

18. Tarsal coalition Congenital fusion of tarsal bones Congenital fusion of tarsal bones Can be fibrous, cartilaginous or osseous Can be fibrous, cartilaginous or osseous Most common: Most common: Calcaneonavicular Calcaneonavicular Talocalcaneal Talocalcaneal

19. Joints of the hindfoot - Subtalar joint Articulation between posterior facet on the inferior surface of the talus and the corresponding surface of the calcaneus Articulation between posterior facet on the inferior surface of the talus and the corresponding surface of the calcaneus Reinforced by medial and lateral talocalcaneal ligaments and by interosseus talocalcaneal ligament joining the sulcus tali to sulcus calcanei Reinforced by medial and lateral talocalcaneal ligaments and by interosseus talocalcaneal ligament joining the sulcus tali to sulcus calcanei Fibrous capsule lined by synovium Fibrous capsule lined by synovium Inversion and eversion of foot Inversion and eversion of foot

20. Talocalcaneonavicular joint Articulation between head of tarsus, posterior surface of navicular anteriorly, the anterior two facets on the superior surface of the calcaneum and the plantar calcaneonavicular ligament Articulation between head of tarsus, posterior surface of navicular anteriorly, the anterior two facets on the superior surface of the calcaneum and the plantar calcaneonavicular ligament Ball and socket type joint Ball and socket type joint Ball: head of talus Ball: head of talus Socket: two bones & two ligaments Socket: two bones & two ligaments Dorsal talonavicular ligament (neck of talus to dorsal navicular bone) Dorsal talonavicular ligament (neck of talus to dorsal navicular bone) Plantar calcaneonavicular (spring) ligament (sustentaculum tali to posteroinferior surface of navicular) Plantar calcaneonavicular (spring) ligament (sustentaculum tali to posteroinferior surface of navicular)

21. Calcaneocuboid joint Articulation between anterior surface of calcaneum and posterior surface of cuboid Articulation between anterior surface of calcaneum and posterior surface of cuboid Ligaments Ligaments Dorsal calcaneocuboid ligament Dorsal calcaneocuboid ligament Long plantar ligament (plantar surface of calcaneus to cuboid tuberosity) Long plantar ligament (plantar surface of calcaneus to cuboid tuberosity) Short plantar ligament (anterior tubercle of calcaneus to adj plantar surface of cuboid) Short plantar ligament (anterior tubercle of calcaneus to adj plantar surface of cuboid) Transverse Tarsal (Midtarsal) Joint = talocalcaneonavicular + calcaneocuboid joint Transverse Tarsal (Midtarsal) Joint = talocalcaneonavicular + calcaneocuboid joint

22. Arches of the foot

23. Dorsum of foot

24. Sole of foot 4 muscular layers 4 muscular layers Maintain arches Maintain arches Muscles have gross functionality and are of little importance individually Muscles have gross functionality and are of little importance individually Two neurovascular planes Two neurovascular planes Superficial between 1 st and 2 nd layers Superficial between 1 st and 2 nd layers Deep between 3 rd and 4 th layers Deep between 3 rd and 4 th layers

25. Sole of foot – Layers 1 & 2

26. Sole of foot – Layers 3 & 4

27. Arterial supply