Ankle And Foot Anatomy

Front 1

How many bones are in the foot?

Back 1

26 bones: 7 tarsal, 5 metatarsals, and 14 phalanges

Front 2

What defines the hindfoot, midfoot, and forefoot?

Back 2

Hindfoot: Calcaneus, Talus
Midfoot: Navicular, Cuboid, 3 Cuneiforms
Forefoot: Phalanges and Metatarsals

Front 3

What defines the "tarsals" in the foot?

Back 3

This network of bones includes the talus, calcaneus, cuboid, navicular, and three cuneiforms...essentially everything except the metatarsals and phalanges

Front 4

Is the talus wider anteriorly or posteriorly? How many articular surfaces does the talus have? What is the posterior process for?

Back 4

Wider Anteriorly

3 articular surfaces: The trochlea (which includes surfaces for the malleoli articulations), and the posterior and middle calcaneal facets

The posterior process is for the posterior talofibular ligament

Front 5

In a trimal fracture or just a posterior malleolus fracture, what do you know about the integrity of the posterior talofibular ligament?

Back 5

You know that it is intact, it is attached to the fractured piece of the posterior malleolus

Front 6

How many muscular attachments does the talus have?

Back 6

The talus has no muscular attachments but has a groove posteriorly for the tendon of the FHL

Front 7

How much of the talus is covered with cartilage?

Back 7

2/3

Front 8

What is the primary blood supply to the talar body? (bold)

Back 8

The primary blood supply to the talar body is from the artery of the tarsal canal (posterior tibial artery).

Other blood supply is from the superior neck vessels (anterior tibial artery) and the artery of the tarsal sinus (dorsalis pedis)

Front 9

What are the surfaces of the calcaneus that articulate with the talus?

Back 9

The calcaneus has three surfaces that articulate with the talus: a large posterior facet, an anterior facet, and a middle facet

Front 10

The sustentaculum tali is an overhanging horizontal eminence on the anteromedial surface of the calcaneus. What is its purpose?

Back 10

The sustentaculum tali supports the middle articular surface above it and has an inferior groove for the FHL tendon

Front 11

What tendon grooves the cuboid on its plantar surface?

Back 11

Peroneus Longus

Front 12

The cuboid has 4 facets for articulations with what bones?

Back 12

Lying on the lateral aspect of the foot, the cuboid has four facets for articulation with the calcaneus, the lateral cuneiform, and the fourth and fifth metatarsals

Front 13

What is the shape of the navicular proximally and distally?

Back 13

Proximally, the surface is oval and concave for its articulation with the head of the talus.

Distally, the navicular has three articular surfaces, one for each of the cuneiforms

Front 14

What tendon inserts on the navicular?

Back 14

The medial plantar projection serves as the insertion for the posterior tibial tendon

Front 15

What hallmark of the intermediate cuneiform lets the second metatarsal "key in" to place? (bold)

Back 15

The intermediate cuneiform does not extend as far distally as the medial cuneiform, which allows the second metatarsal to “key” into place

Front 16

What is the only tarsal bone with ossification centers?

Back 16

The calcaneus has a second center posteriorly

Front 17

When do the tarsal bones ossify?

Back 17

The calcaneus and talus are present at birth but the calcaneus's posterior cetner appears during the eighth year

Lateral cuneiform - 1st year
Medial cuneiform - 2nd year
Intermediate cuneiform and navicular - 3rd year

Front 18

What are the ossification centers for the metatarsals?

Back 18

The second through fifth metatarsals have two ossification centers:
□ A primary center in the shaft
□ A secondary center for the head, which appears at ages 5 to 8 years

Front 19

What are the secondary ossification centers for the first metatarsal and the phalanges of the foot and when do these ossify?

Back 19

The phalanges and first metatarsal have secondary centers at their bases that appear proximally during the third or fourth year and distally during the sixth or seventh year

Front 20

What are the ligaments that support the inferior tibiofibular joint?

Back 20

Supported by four ligaments: the anterior and posterior inferior tibiofibular ligaments, a transverse tibiofibular ligament, and an interosseous ligament

Front 21

Avulsion of which ligament of the ankle may lead to a Tillaux fracture? (bold)

Back 21

The anteroinferior tibiofibular ligament is an oblique band that connects the bones anteriorly. Avulsion of this ligament may result in a Tillaux fracture

Front 22

What ligaments make up the 2 layers of the deltoid ligament complex of the ankle?

Back 22

The superficial layer: tibionavicular and tibiocalcaneal

The deep layer: anterior and posterior tibiotalar

Front 23

What are the lateral fibular ligaments?

Back 23

The lateral fibular ligaments are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament

Front 24

Which ligament of the ankle is the weakest?

Back 24

The anterior talofibular ligament is the weakest and is intracapsular (intracapsular thickening)

Front 25

The position of the ankle is critical when the lateral ligament complex is tested. What positions tighten the anterior talofibular ligament and calcaneofibular ligament? (bold)

Back 25

Plantar flexion tightens the anterior talofibular ligament, and inversion with neutral flexion tightens the calcaneofibular ligament.

Front 26

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Interosseous talocalcaneal

Back 26

Common Name: Cervical
Origin: Talus
Insertion: Calcaneus

Front 27

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Calcaneocuboid/calcaneonavicular

Back 27

Common Name: Bifurcate
Origin: Calcaneus
Insertion: Cuboid and navicular

Front 28

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Calcaneocuboid-metatarsal

Back 28

Common Name: Long plantar
Origin: Calcaneus
Insertion: Cuboid and first to fifth metatarsals

Front 29

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Plantar calcaneocuboid

Back 29

Common Name: Short plantar
Origin: Calcaneus
Insertion: Cuboid

Front 30

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Plantar calcaneonavicular

Back 30

Common Name: Spring
Origin: Sustentaculum tali
Insertion: Navicular

Front 31

What is the common name, origin, and insertion of the following ligament of the intertarsal joint?
Tarsometatarsal

Back 31

Common Name: Lisfranc
Origin: Medial cuneiform
Insertion: Second metatarsal base

Front 32

What is the ligamentous connection of the base of the first and second metatarsals?

Back 32

There isn't one. The base of the first metatarsal is not ligamentously connected to the second metatarsal.

Front 33

What connects the medial cuneiform to the second metatarsal?

Back 33

The Lisfranc ligament connects the medial (shortest) cuneiform to the second (longest) metatarsal

Front 34

The ligament interconnects the metatarsal heads and what relationship does this ligament have to the digital nerve?

Back 34

The deep transverse metatarsal ligaments interconnect the metatarsal heads. The digital nerve courses in a plantar direction under the transverse metatarsal ligament and is the spot where interdigital neuritis (Morton's neuroma, usually the second or third interdigital space) occurs

Front 35

What attaches the 2nd MT head to the fibular sesamoid?

Back 35

The transverse metatarsal ligament attaches the second metatarsal head to the fibular sesamoid

Front 36

This ligament holds the hallucal sesamoids in place and gives the appearance of sesamoid subluxation when the first metatarsal moves medially in hallux valgus

Back 36

The deep transverse metatarsal ligaments

Front 37

What is the primary stabilizing structure of the MTP joints?

Back 37

The plantar plate

Front 38

What is the maximum AP dimension of the achilles tendon on MRI?

Back 38

8mm

Front 39

What are the muscles of the dorsal layer of the foot?

Back 39

Extensor digitorum brevis

Front 40

What are the muscles of the 1st plantar layer of the foot?

Back 40

Abductor Hallucis (MPN)
Flexor digitorum brevis (MPN)
Abductor digiti minimi (LPN)

Front 41

What are the muscles of the 2nd plantar layer of the foot?

Back 41

Quadratus plantae (LPN)
Lumbricals (1=MPN, 1-4 LPN)

Front 42

What are the muscles of the 3rd plantar layer of the foot?

Back 42

Flexor hallucis brevis (MPN)
Adductor hallucis (LPN)
flexor digiti minimi brevis (LPN)

Front 43

What are the muscles of the 4th plantar layer of the foot?

Back 43

Plantar interossei (LPN)
Dorsal interossei (LPN)

Front 44

What is the origin, insertion, action, innervation, blood supply, and layer of the following muscle of the foot?
Extensor digitorum brevis

Back 44

Origin: Dorsal surface of calcaneus
Insertion: Base of PP of 2nd, 3rd, 4th toes
Action: Extends toes
Innervation: Deep peroneal nerve (L5)
Layer: Dorsal
Arterial Supply Dorsalis pedis artery

Front 45

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Abductor hallucis

Back 45

Origin: Calcaneal tuberosity
Insertion: Base of great toe, proximal phalanx
Action: Abduct great toe
Innervation: Medial plantar nerve
Layer: 1st Plantar

Front 46

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Flexor digitorum brevis

Back 46

Origin: Calcaneal tuberosity
Insertion: Distal phalanx of second to fifth toes
Action: Flexes toes
Innervation: Medial plantar nerve
Layer: 1st Plantar

Front 47

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Abductor digiti minimi

Back 47

Origin: Calcaneal tuberosity
Insertion: Base of fifth toes
Action: Abduct small toe
Innervation: Lateral plantar nerve
Layer: 1st Plantar

Front 48

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Quadratus plantae

Back 48

Origin: Medial and lateral calcaneus
Insertion: FDL tendon
Action: Helps flex distal phalanges
Innervation: Lateral plantar nerve
Layer: 2nd Plantar

Front 49

What is the origin, insertion, action, innervation, blood supply, and layer of the following muscle of the foot?
Lumbricals

Back 49

Origin: FDL tendon
Insertion: EDL tendon
Action: Flex metatarsophalangeal, extends interphalangeal
Innervation: Medial (1) and Lateral (1-4) plantar nerve
Layer: 2nd Plantar

Front 50

What is the origin, insertion, action, innervation, blood supply, and layer of the following muscle of the foot?
Flexor hallucis brevis

Back 50

Origin: Cuboid / lateral cuneiform
Insertion: Proximal phalanx of great toe
Action: Flexes great toe
Innervation: Medial plantar nerve
Layer: 3rd Plantar

Front 51

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Adductor hallucis

Back 51

Origin
Oblique: second to fourth metatarsal
Insertion: Proximal phalanx of great toe (lateral side)
Action: Adduct great toe
Innervation: Lateral plantar nerve
Layer: 3rd Plantar

Front 52

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Flexor digiti minimi brevis

Back 52

Origin: Base of fifth metatarsal head
Insertion: Proximal phalanx of small toe
Action: Flexes small toe
Innervation: Lateral plantar nerve
Layer: 3rd Plantar

Front 53

What is the origin, insertion, action, innervation, blood supply, and layer of the following muscle of the foot?
Plantar interossei

Back 53

Origin: Third to fifth metatarsals
Insertion: Proximal phalanges medially
Action: Adducts toes
Innervation: Lateral plantar nerve
Layer: 4th Plantar

Front 54

What is the origin, insertion, action, innervation, and layer of the following muscle of the foot?
Dorsal interossei

Back 54

Origin: Two heads from the proximal half of the of the sides of adjacent metatarsal bones
Insertion The two heads of each muscle form a central tendon that insert on the bases of the second, third, and fourth proximal phalanges and into the aponeurosis of the tendons of EDL. The first is inserted into the medial side of the second toe; the other three are inserted into the lateral sides of the 2nd, 3rd, and 4th toes.
Action: Abduct MTP joint
Innervation: Lateral plantar nerve
Layer: 4th Plantar

Front 55

What is the origin and insertion of the following ankle joint ligament?
Capsule

Back 55

Origin: Tibia
Insertion: Talus

Front 56

What is the origin and insertion of the following ankle joint ligament?
Deltoid

Back 56

Origin: Medial Malleolus
Insertion: Medial Malleolus

Front 57

What is the origin and insertion of the following ankle joint ligament?
Tibionavicular

Back 57

Origin: Medial Malleolus
Insertion: Navicular tuberosity

Front 58

What is the origin and insertion of the following ankle joint ligament?
Tibiocalcaneal

Back 58

Origin: Medial Malleolus
Insertion: Sustentaculum tali

Front 59

What is the origin and insertion of the following ankle joint ligament?
Posterior Tibiotalar

Back 59

Origin: Medial Malleolus
Insertion: Inner side of talus

Front 60

What is the origin and insertion of the following ankle joint ligament?
Anterior Tibiotalar

Back 60

Origin: Medial Malleolus
Insertion: Medial surface of talus

Front 61

What is the origin and insertion of the following ankle joint ligament?
Anterior Tibiofibular

Back 61

Origin: Lateral Malleolus
Insertion: Transversely to talus anteriorly

Front 62

What is the origin and insertion of the following ankle joint ligament?
Posterior Tibiofibular

Back 62

Origin: Lateral Malleolus
Insertion: Transversely to talus posteriorly

Front 63

What is the origin and insertion of the following ankle joint ligament?
Calcaneofibular

Back 63

Origin: Lateral Malleolus
Insertion: Obliquely to calcaneus posteriorly

Front 64

Back 64

Front 65

Back 65

Front 66

Back 66

Front 67

What layer of the foot are the extrinsic tendons more important?

Back 67

2nd and 4th plantar layers

Front 68

Where do plantar heels spurs originate from? (bold)

Back 68

In the flexor digitorum brevis

Front 69

Are the lumbrical muscles plantar or dorsal to the transverse metatarsal ligament?
What about the interosseous tendons?

Back 69

The lumbrical muscles are located plantar to the transverse metatarsal ligament, and interosseous tendons are dorsal

Front 70

A person has an intact and normal achilles tendon and is unable to perform a single-stance toe rise, why is this?

Back 70

The posterior tibial tendon is the initiator of hindfoot inversion during gait

Front 71

What nerve supplies the intrinsic muscles of the foot save for the extensor digitorum brevis?

Back 71

Tibial nerve. EDB is innervated by the deep peroneal

Front 72

Which nerve splits into the medial and lateral plantar nerves and where does this occur? (bold)

Back 72

The tibial nerve splits into two branches (the medial and lateral plantar nerves) under the flexor retinaculum

Front 73

What layer does the medial and lateral plantar nerves run in? (bold)

Back 73

The second plantar layer

Front 74

The medial plantar nerve runs deep to the _____________, and the lateral plantar nerve runs obliquely under the cover of _______________ (bold)

Back 74

The medial plantar nerve runs deep to the ABDUCTOR HALLUCIS, and the lateral plantar nerve runs obliquely under the cover of THE QUADRATUS PLANTAE

Front 75

What is the most proximal branch of the lateral plantar nerve? (bold)

Back 75

The most proximal branch of the lateral plantar nerve is the nerve to the abductor digit quinti (Baxter's nerve)

Front 76

The distribution of the sensory and motor branches of the plantar nerves is similar to that in the hand.
▪ The medial plantar nerve (like the median nerve of the hand) supplies plantar sensation to the medial three and a half digits and motor sensation to only a few plantar muscles (flexor hallucis brevis, abductor hallucis, flexor digitorum brevis, and the first lumbrical muscle).
▪ The lateral plantar nerve (like the ulnar nerve in the hand) supplies plantar sensation to the lateral one and a half digits and the remaining intrinsic muscles of the foot

Back 76

The distribution of the sensory and motor branches of the plantar nerves is similar to that in the hand.
▪ The medial plantar nerve (like the median nerve of the hand) supplies plantar sensation to the medial three and a half digits and motor sensation to only a few plantar muscles (flexor hallucis brevis, abductor hallucis, flexor digitorum brevis, and the first lumbrical muscle).
▪ The lateral plantar nerve (like the ulnar nerve in the hand) supplies plantar sensation to the lateral one and a half digits and the remaining intrinsic muscles of the foot

Front 77

The lateral terminal branch of the deep peroneal nerve ends in the proximal dorsal foot by supplying the_____________________

Back 77

The lateral terminal branch of the deep peroneal nerve ends in the proximal dorsal foot by supplying the EDB MUSCLE

Front 78

The medial terminal branch of the deep peroneal nerve supplies sensation where?

Back 78

To the first web space

Front 79

The medial and intermediate dorsal cutaneous nerves of the superficial peroneal nerve supply the bulk of the sensation to what?

Back 79

The dorsal aspect of the foot

Front 80

What nerve supplies sensation to the dorsomedial aspect of the great toe?

Back 80

The dorsal medial cutaneous nerve (a branch of the superficial peroneal nerve) crosses the EHL in a lateral-to-medial direction and supplies sensation to the dorsomedial aspect of the great toe

Front 81

The dorsalis pedis artery is a continuation of what artery? What are the branches of the dorsalis pedis artery

Back 81

Dorsalis pedis is a continuation of the anterior tibial artery of the leg. Provides the blood supply to the dorsum of the foot via its lateral tarsal, medial tarsal, arcuate, and first dorsal metatarsal branches. Its largest branch, the deep plantar artery, runs between the first and second metatarsals and contributes to the plantar arch

Front 82

What are the 2 branches of the posterior tibial artery in the foot and where do they divide?

Back 82

Divides into the medial and lateral plantar branches under the abductor hallucis muscle

Front 83

What is the largest branch of the posterior tibial artery and what does it form and where?

Back 83

The larger lateral branch receives the deep plantar artery and forms the plantar arch in the fourth layer of the plantar foot.

Front 84

Back 84

Front 85

What is the interval and risks associated with the following approach?
Anterior approach to the ankle

Back 85

Interval: between the EHL and extensor digitorum longus (both deep peroneal nerve)

Risks: The deep peroneal nerve and anterior tibial artery, which lie directly in this interval, must be retracted medially along with the EHL.

Dissection: Before incising the extensor retinaculum, carefully protect the superficial peroneal nerve.

Front 86

What is the interval and risks associated with the following approach?
Approach to the medial malleolus

Back 86

Dissection: Because it is superficial, use an anterior or posterior approach. Use a posteromedial approach behind the medial malleolus through the tendon sheath of the posterior tibialis.

Risk: The anterior approach jeopardizes the saphenous nerve and the long saphenous vein; the posterior approach jeopardizes the structures running behind the medial malleolus in the following order: posterior tibial tendon, FDL, posterior tibial vein, posterior tibial artery, posterior tibial nerve, and FHL
(mnemonic: “Tom, Dick, and very angry nervous Harry”).

Front 87

What is the interval and risks associated with the following approach?
Posteromedial approach to the ankle and foot used for release of clubfoot in children

Back 87

Dissection: Begin this approach medial to the Achilles tendon, and follow the curve distally along the medial border of the foot.
□ Use the posterior tibialis tendon as a landmark for the location of the subluxated navicular in the clubfoot.

Risk: Care must be taken to protect the posterior tibial nerve and artery and their branches

Front 88

What is the interval and risks associated with the following approach?
Lateral approach to the ankle

Back 88

Dissection: Use a subcutaneous approach for ORIF of distal fibula fractures.

Risks: The sural nerve (posterolateral) and the superficial peroneal nerve (anterior) must be avoided.

Front 89

What is the interval and risks associated with the following approach?
Lateral approach to the hindfoot used for triple arthrodesis

Back 89

Interval: between the peroneus tertius (deep peroneal nerve) and peroneal tendons (superficial peroneal nerve)

Risks:
□ The lateral branch of the deep peroneal nerve (which supplies the EDB) must be protected in this approach.
□ Deep penetration with an instrument used in this approach can injure the FH

Dissection: Remove the fat pad covering the sinus tarsi, and reflect the EDB from its origin to expose the joints.

Front 90

What is the interval and risks associated with the following approach?
Anterolateral approach to the midfoot

Back 90

Dissection: In this approach, which is commonly used for excision of a calcaneonavicular bar, release the EDB.

Risk: The calcaneal navicular (spring) ligament may be injured