ANKLE & FOOT by hF1I2g1


									ANKLE & FOOT

      Done By:
      Rawan Jaradat
 There are 26 bones
  in the foot
 7 tarsals , 5
  metatarsals, 14
 The tarsals are :

  ,naviculum and the
  three cuniforms
 The ankle joint is a
  synovial hinge joint .
 Articulation : The lateral
  malleolus of the fibula
  and the medial malleolus
  of the tibia along with
  the inferior surface of the
  distal tibia articulate
  with three facets of the
  talus. These surfaces are
  covered by cartilage.
 Movements at the ankle
  joint are mainly
  dorsiflexion and
The anterior talus is wider
  than the posterior talus.
  When the foot is
  dorsiflexed, the wider part
  of the superior talus moves
  into the articulating
  surfaces of the tibia and
  fibula, creating a more
  stable joint than when the
  foot is plantar flexed.
 The foot externaly rotates
  with dorsiflexion and
  internally rotates with
Other joints in the foot :
1- the sub-talar joint.
  This joint lies between the calcaneum and the
  talus .
2-the mid-tarsal joint.
  This joint is really two joints - the joint between
  the talus and the navicular bone as well as the
  joint between the calcaneum and the cuboid bone.
  There is only one muscle on the dorsum of the foot (
  digitorum brevis).
 The muscles on the planter aspect of the foot are divided
  into four layers:
first layer:abductor hallucis,flexor digitorum
  brevis,abductor digiti minimi.
second layer:quadratus plantae,lumbricalis,flexor
  digitorum longus tendon,flexor hallucis longus tendon.
third layer: flexor hallucis brevis,adductor hallucis,flexor
  digiti minimi brevis.
 Forth layer: interossei , peroneus longus tendon,tibialis
  posterior tendon
The planter fascia is a very
important structure that takes
its origin from the heel
(calcaneum) and inserts into
the bases of the proximal
phalanges of the toes.
 Blood supply of the foot is from :
1-anterior tibial artery which gives dorsalis pedis
2-posterior tibial which gives the medial and lateral
  plantar arteries.
3- peroneal arteries.
 Nerve supply of the foot is from( saphenous, sural,
  superficial & deep peroneal)
               Blood supply

Nerve supply
1- Club foot
2- Flat foot
 A true clubfoot is a malformation. The bones,
 joints, muscles, and blood vessels of the limb are
 abnormal. The medical term for this is “talipes
 equinovarus” -- relating the shape of the foot to a horses
- Relatively common; the incidence is 1 or 2 /1000
-Boys are affected twice as often as girls.
-The condition is bilateral in one-third of cases.
- Similar deformities are seen in neurological
  disorders, e.g. myelomeningocele, and in
-It’s mostly a problem passed from
  parents to children (genetic), and it
  may run in families
 If you have one baby with clubfoot,
  the chance of having a second child
  with the condition are about one in
-Clubfoot does not have anything to
  do with the baby’s position during
 Clubfoot can be recognized in the infant by
  examination. The foot is inturned (twisted
  inward), stiff with the soles face posteromedially
 The heel is usually small and high retracted to
  the leg , and deep creases appear posteriorly and
 it cannot be brought to a normal position(
  plantigrade position, meaning flat on the floor.)
 The infant must always be examined for
  associated disorders such as congenital hip
  dislocation and spina bifida
In fact, doctors can see it on ultrasound images taken
  after about four months of pregnancy
X- rays : the tarsal bones are incompletely
 ossified at this age. However, the shape and
 position of the tarsal ossific centers are helpful
 in assessing progress after treatment
If the condition is not corrected early, secondary growth
 changes occur in the bones and these are permanent.
Relapse is common, specially in babies with
 associated neuromuscular disorders.
1-Conservative treatment:
Should begin early, preferably within a day or two of birth.
It consists of repeated manipulation and adhesive
  strapping or application of plaster of Paris casts, which
  will maintain the correction.
2- Operative treatment :
The objectives are:
A-The complete release of joint tethers (capsular and
     ligamentous contractures and fibrotic bands)
B-Lengthening of tendons, so that the foot can be
     positioned normally without undue tension.
 After operative correction, the foot is immobilized in
  its corrected position in a plaster cast.
 Kirschner wires are sometimes inserted across the
  intertarsal and ankle joints to augment the hold. The
  wires and cast are removed at 6-8 weeks.
 After that, hobble boots (Dennis Browne) or
  customized orthosis are used to maintain the
Infantile Flat Foot (Congenital
 Vertical Talus)
Flat Foot in Children and
Flat Foot in adults
   It’s a rare neonatal condition usually affects both
   In appearance it is the very opposite of a club-foot;
    the foot is turned outwards (valgus) and the medial arch
    is not only flat, it actually curves the opposite way from
    the normal, producing the appearance of a “rocker-
    bottom” foot.
 Passive correction is impossible
 The only effective treatment is by operation, ideally
  before the age of 2 years.
X-ray features are characteristic:
The calcaneum is in equinus and the talus points into
 the sole of the foot, with the navicular dislocated
 dorsally onto the neck of the talus.
When weight-bearing, the foot is turned outwards and
   the medial border of the foot is in contact with the
   ground; the heel becomes valgus.
Two forms of the condition are recognized:
1- Flexible flat-foot
2-Stiff (rigid) flat-foot
 Which  appears in toddlers as a normal
  stage in development.
 It usually disappears after a few years
  when medial arch development is
  complete. The arch can be restored by
  simply dorsiflexing the great toe.
 Many of the children with flexible flat-foot
  have ligamentous laxity and there may be
  a family history of both flat-feet, and joint
 Occur in older children and adolescents
 cannot be corrected passively, and should alter the
  examiner to an underlying abnormality.
 conditions to be considered are:
1-Tarsal coalition (often a bar of bone connecting the
  calcaneum to the talus or the naviculum)
2-Inflammatory joint condition
3-Neurological disorder.
1-flexible flat-foot: no symptoms, but the parents
 notice that the feet are flat or the shoes wear
 badly, the deformity becomes noticeable when
 the child stands.
On examination :ask the patient to go up on
 tiptoes: if the heels invert, it is a flexible
Then examine the foot with the child sitting or
 lying. Feel for localized tenderness and test the
 range of movement in the ankle, the subtalar
 and midtarsal joints.
A tight Achilles tendon may induce a
 compensatory flat-foot deformity.
2-rigid flat-foot Teenagers and young adults
 sometimes present with pain.
On examination, the peroneal and extensor tendons
 appear to be in spasm,sometimes its called
 “Spasmodic flat-foot”.
The spine, hips, and knees should always be examined
 as well as, joint hypermobility and neuromuscular

In some cases a definite cause may be found, but in
 many no    specific cause is identified.
- X-rays are unnecessary for asymptomatic, flexible flat-
-For Pathological flat-feet (usually painful, and stiff)
  standing AP, lateral and oblique views may help to
  identify underlying disorders.
-CT   scanning is the most reliable way of
 demonstrating tarsal    coalitions.
flexible flat-feet require no treatment. Parents need
to be reassured.
If the condition is obviously due to an underlying
disorder such as poliomyelitis .Splintage or operative
correction and muscle rebalancing may be needed.
Spasmodic flat-foot is relieved by rest in a cast or a
splint. If there is an abnormal tarsal bar or other
bony irregularity, this may have to be removed.
In late cases, if pain is intolerable, a triple
arthrodesis may be necessary.
   When adults present with symptomatic flat-feet the
    first thing to ask is whether they always had flat-feet
    or whether it is of recent onset.
   More recent deformities may be due to an underlying
    disorder such as rheumatoid arthritis or generalized
    muscular weakness

   Unilateral flat-foot should make one think of tibialis
    posterior synovitis or rupture.

 Treatment :
-Patients with painful rigid flat-feet may require more
  robust splintage.
-Those with tibialis posterior rupture can be helped by
  operative repair or replacement of the defective tendon

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