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Lower Limb T&O (2nd session) Joachim Ho Vetted by: Mr. TanThanks to our partners!Anatomy of lower limb (2) Continuation from the sehip, and thigh2024 that covered theKnee joint • Muscles covered in earlier teaching session. • Bones involved: femur, tibia and patella • Patella is formed and resides in the quadriceps femoris tendon. It functions as a fulcrum to increase power of knee extension. • Soft tissues: menisci, ligaments • Others: bursaeMovement • Extension: from quadriceps femoris • Flexion: from hamstrings, gracilis, sartorius and popliteus • Lateral rotation: from biceps femoris • gracilis, sartorius and popliteus.semimembranosus, semitendinosus, • “locked”)nd medial rotation can only occur when knee is flexed (not • femur (while tibia is fixed) medially rotates about 10 degrees in full extension due to inequality of articular surfaces of femur condyles. • This tightens the cruciate and collateral ligaments, increasing the stability of the knee.Meniscus • Functions • Deepens articular surface of tibia • Acts as shock absorbers • Medial meniscus is more fixed to the medial collateral ligament and hence get injured together more often • Lateral meniscus is more mobile Bursae Synovial fluid contained in them to decrease friction between tendons, bone and skin during movement • 4 bursae • Suprapatellar: between quadriceps femoris and femur • Prepatellar: between patella and skin • Infrapatellar: split into deep and superficial. Deep is between tibia and patella ligament; superficial between patella ligament and skin • muscle and medial head of gastrocnemiust, between semimembranosusLigaments • Patellar ligament: continuation of quadriceps femoris tendon distal to patella. Attaches to tibial tuberosity • Collateral ligaments: (2): • Medial collateral ligament (wider) attaches medial epicondyle of femur to medial condyle of tibia • attaches lateral epicondyle of femur) to depression on lateral surface of fibular headCruciate ligaments • Anterior cruciate ligament attaches anterior intercondylar region of tibia to femur in the intercondylar fossa • Prevents anterior dislocation of tibia onto femur • Posterior cruciate ligament attaches posterior intercondylar region of tibia to anteromedial femoral condyle • Prevents posterior dislocation of tibia onto femurThe leg, foot And the ankleThe bones and muscles Bones Muscles • Tibia • The leg • Anterior compartment • Fibula • Bones of the foot • Lateral compartment • Tarsals • Posterior compartment • The foot (intrinsic muscles) • Metatarsals • Dorsal • Phalanges • PlantarThe tibia (shin bone) • Divided into 3 parts: • Proximal • The flat surface forms the tibial plateau • Intercondylar eminences are attachments for ligaments and menisci.The tibia (shin bone) • Divided into 3 parts: • Shaft has anterior border (palpable as the shin), posterior surface, lateral border • Patella tendon, attachment site for patella ligament • Soleal line – attachment for soleus muscle • Lateral border gives rise to interosseous membrane binding tibia and fibula together.The tibia (shin bone) • Divided into 3 parts: • Distal • Widened area of the tibia to increase surface area of contact with the bones of the feet (talus), increasing stability. • Medially, the projection is the medial malleolus, also articulating with the tarsal bones to form the ankle. • Laterally, a fibular notch is present, where the fibular meets the tibia, forming the tibiofibular joint.Fibular • Similarly, 3 parts: proximal, shaft and distal • Proximal part articulates with lateral condyle of the tibia. • Shaft has 3 surfaces: anterior, lateral and posterior, each corresponds to a compartment in the leg • Distal part has the lateral malleolus, which is more prominent than the medial malleolus.Talofibular articulation and ankle • 2 talofibular articulation (proximal and distal), and the ankle where the malleoli meet the talar bones.Proximal talofibular joint • Ligaments at the proximal talofibular joint: anterior and posterior superior tibiofibular ligaments • Lateral collateral ligament • Biceps femoris (runs from ischial tuberosity all the way to fibular head)Distal talofibular joint • Ligaments: anterior and posterior inferior tibiofibular ligaments (and a continuation: inferior transverse tibiofibular ligamentInterosseous membrane • Runs spanning the length of tibia and fibula • Supporting structure of both talofibular joints. • Opening superiorly for anterior tibial vessels and inferiorly for perforating branch of fibular arteryMuscles around the tibia and fibula • Anterior compartment • Tibialis anterior • Originates from Lateral surface of tibia and attaches to medial cuneiform and base of metatarsal I. • Acts to dorsiflex and inverse the foot. • Innervated by the deep fibular nerve. • Extensor digitorum longus • Originates from lateral condyle of tibia and medial surface of fibula and splits into 4 tendons each inserting into toes forming extensor hoods • Acts to extend the lateral 4 toes, and dorsiflex the foot • Innervated by deep fibular nerve.Anterior compartment continued • Extensor Hallucis Longus • Originates from medial surface of the fibular shaft and attaches into base of distal phalanx of great toe • Acts to extend the great toe and dorsiflex the foot • Innervated by deep fibular nerve • Fibularis tertius • Originates with the extensor digitorum longus from the medial surface of fibula and attaches to the 5 metatarsal. • Acts to evert and dorsiflex the foot • Innervated by deep fibular nerveAnterior compartment summaryAnterior compartment summaryAnterior compartment summaryAnterior compartment summaryPosterior compartment • 3 muscles within superficial compartment, 4 muscles in deep compartment • 2 bursae in the calcaneal tendon (of which all 3 muscle of the superficial compartment attach to the calcaneus through) • Subcutaneous calcaneal bursa • Deep bursa of the calcaneal tendon • All muscles will have an origin, attachment, action and innervationSuperficial compartment • Gastrocnemius • Soleus • 2 heads, • Soleal line, Converges with gastric • Lateral femoral condyle into calcaneal tendon (calcaneus) • Medial femoral condyle • Plantarflexion (ankle), flexion (knee) • Singular muscle belly converges • Tibial nerve with soleus forming calcaneal tendon, attaching to calcaneus • Plantaris • Plantarflexes ankle joint, flexion at • Lateral supracondylar line of femur, knee joint into calcaneal tendon (calcaneus) • Plantar flexion (ankle), flexion (knee) • Tibial nerve • TibialDeep compartment • Popliteus (behind knee joint) • Flexor hallucis longus • From Lateral condyle of femur and • From posterior fibula surface to lateral meniscus (knee). Inserts onto plantar surface of great toe phalanx proximal tibia, above soleal line. • Flexes great toe • Laterally rotates femur relative to • Tibial nerve tibia*. • Tibial nerve • Tibialis posterior • From posterior surface and • Flexor digitorum longus interosseous membrane of tibia and • From medial tibia to plantar surface fibula to plantar surfaces of medial of lateral four digits. tarsal bones • Flexes the lateral 4 toes • Inverses and plantarflexes foot* • Tibial nerve • Tibial nerveSummarySummarySummarySummarySummarySummarySummarySummarySummaryLateral compartment • Fibularis longus • Superior and lateral surfaces of fibula and lateral tibial condyle into medial cuneiform and base of metatarsal I. • Everts and plantarflexes foot* • Superficial fibular (peroneal) nerve. • Fibularis brevis • From inferolateral surface of fibular shaft into 5 metatarsal tubercle (base) • Everts the foot • Superficial fibular nerve.SummaryVessels and nerves • Popliteal artery moves down the popliteus, divides into the anterior of tibial artery and tibioperoneal trunk (which then divides into posterior tibial and fibular arteries) • Posterior tibial artery follows tibialis posterior and enters the sole of the foot through tarsal tunnel. • Fibular artery descends posteriorly to rise to perforating branches (supplying lateral compartment muscles) • Anterior tibial artery follows down anteriorly, forming the dorsalis pedis artery.Vessels and nerves • Tibial nerve (L4-S3) • Common fibular nerve (L4-S2)Vessels and nerves • Superficial fibular (L4-S1) • Deep fibular (L4-S2)Bones of the foot • Tarsals • Metatarsals • PhalangesT arsals • 7 bones: • Talus (the most superior and transmit weight of entire body to foot) • Calcaneus (largest tarsal bone; constitutes heel) • Navicular • Cuboid (furthest lateral) • 3 Cuneiforms (lateral, intermediate and medial)Metatarsals and phalanges • 5 metatarsals (labelled I-V medial to lateral) • Phalanges – bones of the toes • Second to fifth toes have proximal, middle and distal phalanges • Great toe only has 2: proximal and distal phalangesMuscles of the foot • Extrinsic muscles (from anterior, posterior and lateral compartments of the leg; have been covered earlier) • Responsible for eversion, inversion, plantarflexion and dorsiflexion of the foot. • Intrinsic muscles are located within the foot; responsible for fine motor actions of the foot.Intrinsic muscles (dorsal aspect) • Extensor digitorum brevis • Calcaneus and inferior extensor retinaculum to extensor tendons of medial 4 toes • Extends the lateral 4 toes • Deep fibular nerve • Extensor Hallucis Brevis • Calcaneus and inferior extensor retinaculum to base of proximal phalanx of great toe • Extends great toe • Deep fibular nervePlantar aspect (first layer – most superficial) • Abductor Hallucis • Medial tubercle of calcaneus, flexor retinaculum and plantar aponeurosis to medial base of proximal phalanx of great toe • Abducts and flexes great toe • Medial plantar nerve • Flexor digitorum brevis • Medial tubercle of calcaneus and plantar aponeurosis to middle phalanges of lateral four digits • Flexes lateral 4 toes at PIP* • Medial plantar nerve • Abductor digiti minimi (similar to hand’s) • Medial and lateral tubercles of calcaneus and plantar aponeurosis to lateral base ofp proximal phalanx of 5 digit • Abducts and flexes little toe • Lateral plantar nervePlantar aspect (second layer) • Quadratus Plantae • Medial and lateral plantar surface of calcaneus to tendons of flexor digitorum longus • Assists flexor digitorum longus in flexing lateral 4 toes • Lateral plantar nerve • Lumbricals (4 of them) • Tendons of flexor digitorum longus to extensor hoods of lateral 4 digits • Flexes MTP joints and extension at IP joints. • Medial lumbrical – medial plantar nerve, lateral 3 lumbricals – lateral plantar nervePlantar aspect (third layer) • Flexor hallucis brevis • Plantar surfaces of cuboid and lateral cuneiforms (lateral), and tendon of posterior tibialis tendon (medial) to base of proximal phalanx of great toe • Flexes great toe at MTP • Medial plantar nerve • Adductor hallucis • Bases of 2nd, 3 and 4 metatarsals (oblique), and plantar ligaments of MTPJ (transverse) to lateral aspect of base of proximal phalanx of great toe • Adducts great toe and supports transverse foot arch • Deep branch of lateral plantar nerve • Flexor digiti Minimi brevis th th • Bdigitf 5 metatarsal to base of proximal phalanx of 5 • Flexes little toe at MTPJ • Superficial branch of lateral plantar nervePlantar aspect (fourth layer) • Plantar interossei (unipennate) • Medial side of metatarsals 3 to 5, to medial sides of phalanges of digits 3 to 5. • Adducts lateral 3 digits and flexes at MTPJ • Lateral plantar nerve • Dorsal interossei (bipennate) • Lateral aspect of metatarsals. First muscle attacnds to medial sidthof proximal phalanx of 2 digit. 2nd to 4 interossei attach to lateral sides of proximal phalanxes of digits 2 to 4. • Abducts lateral 4 digits and flexes MTPJ • Lateral plantar nerve • Venous drainage* Nerves and vessels • Great saphenous vein (into femoral vein inferior to inguinal • 2 main arterial supply: ligament) • Dorsalis pedis (from anterior tibial) • Small saphenous Vein (into popliteal vein) • Posterior tibialArchitecture of the foot • Ankle joint, talocrural joint is a hinge joint (distal tibia and fibula meets talus). Dorsiflexion and plantar flexion • Supported by ligaments, 2 main groups, deltoid (medial collateral ligament) and lateral collateral ligamentOther joints around the ankle • Inferior tibiofibular (syndesmosis) • Talocalcaneal (inversion and eversion) • Talocalcaneonavicular (similar to talocalcaneal) • Calcaneocuboid (saddle joint; gliding and rotation) • Naviculocuneiform (gliding and rotation) • Cuboideonavicular (syndesmosis)Movements • 4 main movements.Architecture of the foot (continued) • Arches • 2 longitudinal (medial and lateral) • Medial • Plantar ligaments, medial ligament of ankle joint • Plantar aponeurosis • Lateralape of bones of arch • Plantar ligaments • Shape of bones of arch • Plantar aponeurosis • 1 anterior transverse • Plantar ligaments and deep transverse metatarsal ligaments • Plantar aponeurosis • Wedged shape of bone archesThe ”windlass” mechanism • Describes manner in which plantar fascia supports foot during weight- bearing activities • Provides a more rigid base from which we can push-off • The windlass test (checking for tenderness) checks for plantar fasciitis. • Plantar fascia/aponeurosis helps maintain the arch shape of the foot despite ground reactive forces/high standing, staying balanced anduseful for absorbing shock.Clinical ConditionsTibial shaft fracturesTibia • The tibia is a long bone, and hence prone to fractures. • More prone to trauma • Injuries in this area may lead to compartment syndrome and open fractures.Clinical features • Signs and symptoms • Severe pain (?Compartment syndrome) • Inability to weight bear • There may be clear deformity (?open fracture) • Usual fracture signs and symptomsCommon signs and symptoms of fractures (closed) • Bruising or discoloured skin • Swelling • Pain, and it worsens with movement/pressure • Numbness or tingling • Deformity • Loss of functionRisk factors • Advanced age • Chronic corticosteroid use Mainly, a reduction in bone density overall can • Excessive alcohol consumption • Chronic smoking be a risk factor for • Menopause fractures! • History/FHx of osteoporosis • Low calcium ± vitamin D • Sedentary lifestyle • Low BMIDifferential diagnosis • Soft tissue injury • Ankle fractures • Fibular fractures • Tibial plateau fracturesInvestigations • Need to carry out a neurovascular examination on lower limbs • A to E assessment, especially if major trauma • Usual bloods, including coagulation screen and group and save • ImagingInvestigations • Need to carry out a neurovascular examination on lower limbs • A to E assessment, especially if major trauma • Usual bloods, including coagulation screen and group and save • Imaging • Full length antero-posterior • Lateral plain film radiographs • CT may be necessary for ex/including intra-articular fracturesEarly management • Realign as soon as possible (best done under anaesthetic). • Above knee backslab to control rotation and elevated quickly. • This is done with knees slightly flexed, to allow for preservation of knee extension function, but not fully extended to avoid straining soft tissue surrounding it. • Usual painkiller ladder for managing symptoms.Management • Largely surgical • Intramedullary nailing • allows for full weight bearing immediately post-op. • Proximal or distal fractures may need open reduction internal fixation (ORIF) • External fixation may be indicated first if patient is unstable • Conservative management • Sarmiento cast – only in stable fractures in distal half of tibia • usually follows application of a long leg cast after 4-6 weeks post injuryComplications • Compartment syndrome • Ischaemic limb (because of prolonged compartment syndrome) • Open fractures • Malunion (especially if non-operative) Tibial plateau fracture Significant injury, in whichthe tibial plateau. the femoral condyle ontoTibial plateau fractures • Fractures here most commonly occur after high- energy trauma. • They can less commonly occur in elderly patients following a fall. • Typical forces affecting it come from the side (laterally), causing the lateral tibial plateau to be more frequently fractured than the other side. • If left untreated, this injury can lead to degenerative changes within the knee.Clinical features • History of trauma, with the classic scenario being a “bumper fracture” (car striking a pedestrian’s fixed knee) • Occurs with axial loading or weight bearing on the knee. • Sudden onset of pain, unable to weight-bear, and swelling of the knee (classical fracture signs and symptoms) • Tenderness alongside medial or lateral aspects of the knee joint.Differential Diagnosis • Knee dislocations • Soft tissue injury (meniscal/ligamentous injuries) • Patella dislocation • Knee fractures (patella or even distal femur) • Patella/quadriceps tendon ruptureInvestigations • Must carry out neurovascular examination • Vascular injuries are common in Type IV (medial) tibial plateau fractures*. • Some nervous injury (neuropraxia) • X-rays to include: anterior-posterior, lateral and intercondylar notch views. • CT scans. A lipohemarthrosis is an indication of intra-articular fracture present. • MRI scan would be used to evaluate meniscal and ligamentous pathology. (not so much on fractures)Classification (Schatzker Classification) • Type 1: Lateral split fracture • Type 2: Lateral split – depressed fracture • Type 3: Lateral pure depression fracture • Type 4: Medial plateau fracture • Type 5: Bicondylar fracture • Type 6: Metaphyseal – diaphyseal disassociationManagement • Non-operative • Indicated in minimally displaced fractures: hinge brace, immediate passive range of motion started and non-weight bearing for 6-8 weeks slowly progressing to full weight-bearing as tolerated after another 6 weeks. • Physiotherapy and analgesia • Operative • Indicated in complicated fractures • Open reduction and internal fixation (ORIF) • Postoperatively a hinged knee brace and 8-12 weeks after, non-weight bearing. • If extensive soft tissue injury, External fixation with delayed ORIFComplications • Long-term complication: Post-traumatic osteoarthritis • of the knee: due to axial malalignment, septic arthritis, ligamentous instability. • Abnormal gait if improper healing which leads also to post-traumatic osteoarthritis of the ankle • Chronic pain. Lisfranc injury* *could sometimes be called a “Lfracturefracture”, though not a realBrief anatomy • Not an actual fracture, but severe injuries to the tarsometatarsal (Lisfranc) joint between medial cuneiform and the base of 2 nd metatarsal. • Usually missed due to subtle radiological features, hence understanding of anatomy and how it a normal foot presents is important. • Multiple interosseous ligaments support the joint, of which the Lisfranc ligament (from medial cuneiform to base of 2 metatarsal) is the largest and strongest.More imagesClinical features • Most commonly occur after torsional or translational forces on a plantar flexed foot. • Commonly seen in road traffic accidents and athletic injuries. • Signs and symptoms • Swelling and tenderness over midfoot • Plantar bruising • Pain over midfoot and inability to bear weight if very serious. • Pain on “push-off” phase of runningDifferential diagnosis • Ankle fractures • Tarsal fractures (?Snowboarders fracture) • Proximal metatarsal fracture • Cuboid fracture • Midfoot sprainInvestigations • Diagnosis based on high level of suspicion -> imaging to confirm • X-ray: anterior posterior, lateral and 30-degree internal oblique projections. • Weight bearing films can be obtained to help diagnose if still uncertain • Palpation of the foot. • Look out for “piano key sign” • Abduction and pronation of forefoot with hindfoot fixed. • In severe dislocation, blood flow may be disrupted -> palpate dorsalis pedis pulse and capillary refill. • If inadequate imaging, CT scans may be used.Management • Non-operative • Immobilise for 6-12 weeks with Air-cast boot or cast (non-weight-bearing) • Operative (more severe) • Open reduction and internal fixation (ORIF) • Done through screw fixation mainly, to allow tissues to heal correctly • Primary arthrodesis can be used for severely comminuted or displaced fracture- dislocations. • Then immobilise for 8-12 weeks. • Physiotherapy and pain managementComplications • Post-traumatic arthritis occurs up to 25%. • More common if management is delayed • May require arthrodesis • Midfoot compartment syndrome • Chronic painReferences • Malik S, Herron T, Mabrouk A, et al. Tibial Plateau Fractures. [Updated 2023 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan- . Available from: https://www.ncbi.nlm.nih.gov/books/NBK470593/ • https://teachmesurgery.com/orthopaedic/knee/tibial-shaft-fracture/ • https://teachmesurgery.com/orthopaedic/knee/tibial-plateau-fracture/ • https://www.physio-pedia.com/Lisfranc_Injuries • https://teachmesurgery.com/orthopaedic/ankle-and-foot/lisfranc- injury/#:~:text=Introduction,“fracture%2Ddislocation”).See future sessions and watch recordings at: SUPTA.UK