SECTION 9 : INFERIOR EXTREMITY Ankle Sree: CHAPTER 47 The ankle consists of the ankle joint (the tibia and the fibula proximally, and the talus round it (Fig. 714). The 2 malleoli can be distally) and those (structures which sur- felt distinctly, the lateral being less promi= nent, descending lower and lying farther back : Ect digitorar ieee Lat malleohas Ext retro: ‘ ea ‘ mallcclar Tendo VE q sulci eaneus 1 ills) nk rateo ee malleo! “Caleaneal fund peroneus rertias tuberosity lexor digi- tora. tibiell sand n acimate lig Abductor hatllu Fig. 714, The structures surrounding the right ankle: (A) seen from behind: 4B) the lateral structures: (C) the medial structures. 817818 than the medial. The tip of the lateral mal- Ieolus is about #4 inch below and behind the tip of its corresponding bony prominence Anterior to the lateral malleolus and lateral to the tendon of the peroneus tertius is a shallow depression which indicates the level of the ankle joint. A similar depression lies between the medial malleolus and the tibialis anterior tendon. At these two points the ankle joint is very superficial, and, when Muid is present, these areas become filled and form soft projections. If the foot is forcibly plantar- fiexed, the talus (astragalus) glides forward out of its socket and produces a prominence which is most apparent in front of the lateral malleolus, The medial or internal malleolus is large, flat and prominent. The ankle joint INFERIOR EXTREMITY: Ankle the extensor muscles stand out in bold re lief, especially when the joint is flexed. From within outward, they are (Figs. 714 and 715); the tendon of the anterior tibial mus~ cle, the extensor hallugis longus, the extensor digitorum longus and the peroneus tertius, ‘Above and behind the medial malleolus, the tendons of the posterior tibial and the ficxor digitorum muscles are noted; the for- mer liés closer to the bone. Behind the lateral malleolus, the long and the short peroneal tendons can be felt lying close to the edge of ihe fibula, the tendon of the smaller muscle being the closer to it. The interval between the medial malleolus and the calcancus is crossed by the laciniate (internal annular) ligament, Which also forms an osteo-aponcu lies approximately 14 inch above the tip of are found the tendons ‘ the internal malleolus. of the flexor digitorum longus, the flexor ‘The tendo. calcaneus (achillis) stands out _hallucis longus and the posterior tibial mus- prominently at the back af the ankle; between cles (Fig. 714 C). it and the malleoli are 2 hollowed grooves. The tendon of the tibialis posterior muscle Over the front of the ankle, the tendons of lies immediately behind the back of the me- Flexdigi.long 5) $ ae of: ate ‘continugus wit Te: nee tibialis flex.netinaculum post Gaciniate lig) Med.mallech Fost. tibial n. Long poe _rand vessels Rate epee! lid of j Antanklelig } i joint Tendon antaris — Sursea ane I gndocaleaneus petinaculum) fl ptal layer deep fase. long ort hall-lang 5 Fatty areolar tissue ee tibi j Sup peroncal Deep per concal'ng retinaculum Extdis i long 3’ ome ‘Tendon per: | oneus tertius : Short saphenous wv \\ \ andsurain. Peroneus brevis eroncus long zroneala. Synovial fold Flo. 715. The relations around the right ankle joint. The deep fascia and the lig ments are shown in bluedial malleolus and is sueceeded by the ten= dons of the flexor digitorum longus and the flexor hallucis longus. The posterior tibial Js and nerves lie between the last two named tendons. The tendons lie im close re- lation to the ankle joint, but the calcaneal tendon is separated from it by a considerable interval. A fairly wide space which is filled E with fatty areolar tissue also exists between the flexor hallucis longus tendon and the pos- terior tbial vessels, so that there is little chance of damage when operating om this tendon. Calcangal tendon “; Flex.digi. long Tibialls post: ; Flaxdigi. tong ” Deep Fascia 819 The skin about the ankle is thin and loosely attached to the subjacent parts. Owing to its proximity to the underlying malleoli, it may be damaged by the pressure of a cast or a bed rest, The subcutaneous tissue varies both in quantity and character. Over the front of the ankle it is lax and free from fat; there- fore, if edema is present, the skin will pit on pressure. DEEP FASCIA The deep fascia is strong and is directly continuous with the fascia which invests the Flexhall.long, = One medial band P x T-Laciniateligament _ 4 andy Exc digi long -} B 1 Twoanterior bands \W 11 nse crural lig (supextretinaculuns \if Supert an @ligs (int mn). | i peronealn, _--Peroneus brew 3 4-Peroneus long. -Lat, malleolus Tibialis \. Calcanaus it + 2) Two lateral bands 1-Sup peroneal retinaculum Zink peroneal retinaculum bh Fig. 716, The 5 binding bands around the ankle. i i i i820 leg and the foot, It forms 5 definite bands (in front of and at each side of the ankle) which maintain the tendons in contact with the bones, and it assists in forming osteo-aponcu- rotic tunnels through which the tendons and their synovial sheaths pass, ‘The § binding bands are (Fig. 716): the 2 anterior bands, the transverse crural and the cruciate ligaments; 1 medial band, the Inciniate ligaments 2 lateral bands, the pero- ‘The anterior thickening of the deep fascia has 2. divisions: an upper and a lower, The upper division, or the éresverse crural lig- ameni, stretches between the anterior borders of the tibia and the fibula immediately above the ankle joint. Beneath this ligament are the stcuctures which pass from the from of the leg to the dorsum of the foot. With the execp= jon of the tibialis anterior, which lies sep rately, they Tig in one compartment, ‘The “Tibtatis ant Trongccurt renner) Couciate Fic. 17, The 3 tendon sheaths of the anterior aspect of the ankle, INFERIOR EXTREMITY: Ankle structures from medial to lateral are: the anterior tibial muscle, the extensor halluci longus, the anterior tibial vessels, the deep peroneal nerve, the extensor digitorum longus and the peroneus tertius (Figs. 715 and 716 B). The structures which pass aver the su- perficial surface of this ligament are: the long saphenous vein, the saphenous nerve and the superficial peroneal nerve. The eruciate ligament is the lower dixie sion of the anterior thickening of deep fascia: it has been referred to as the inferior exten sor retinaculum, It is the more important of the two, Tis shape resembles the letter “Y," the stem of the letter being the lateral part of the ligament (Figs, 714, 715 and 716 B). The ¥ is placed on its side and lies across the dorsum of the foot close ta the ankle join Itis firmly attached to the anterior part of the upper surface of the calcaneum. The upper limb of the Y attaches to the medial malleo- Jus; the lower part uses with the deep fascia along the medial margin of the foot, and with the plantar fascia. The structures which pass beneath this ligament are identical with those passing under the transverse ligament. It splits to form 2 compartments. The medial of these is occupied by the tendon of the ex- tensor hallueis longus; the lateral compart- ment, by the peroneus tertius and the exten- sor cece longus. Each compartment is lined with a synovial sheath. The vessels and the nerves pass deeply to the ligament. The ligament usually docs not form a compart- ment for the ialis anterior tendon, because the tendon runs either above or below the ligament “The laciniate ligament (internal [aterai) bridges the hollow between the medial mal- Icolus and the calcaneus, to both of which itis attached (Fig. 716 A)_ Lt has 4 borders and 2 surfaces. Of its borders, the upper is continuous with 2 layers of fascia—the deep fascia of the Ieg and the strong faseia which extends between the superficial and the deep muscles of the ealf, The lower border is con~ tinuous with the medial part of the plantar aponeurosis. ‘The lateral border is attached 10 the tuberosity of the calcaneus; and the medial, to the medial malleolus. OF its sur- faces, the superficial is related to the medial alcaneal vessels and nerves, which first pierce it and then cross it; the deep surface is re-lated to the tendons, the vessels und the nerves passing in back of the leg to the sole of the foot, Theye lic in Compartment, in the following order from before backward (Fig. 715): the posterior tibial tendon, the flexor digitorum longus, the posterior bial artery with its companion veins, the posterior tibial nerve and the Mexor hallucis longus. Each tendon is supplied with a syno sheath of ils own. Under the lower part of this ligament the artery and the nerve both di- vide into medial and lateral plantar branches. The peroneal refinacula are 2 lateral thick. ened parts of the deep fascia: they also have been referred to as the external annular li aments. They bridge the groove between the lateral malleolus and the cale: 716 C). The superior perones! re Post tibial a. Med. ant maleolara Med.post: -+ malleglara Med plantara. Latplantara’, Tendon Sheaths 821 extends from the calcaneus to the lateral mal- Icolus and binds the 2 peronei, the longus and the brevis, to the back of the lateral malleolus. The brevis lies closer to the bone, The infe- rior peroneal retinaculum is attached to the outer surfaces of the calcaneus. It is divided into 2 compartments by a septum which is attached to the peroneal tubercle, The su- perior retinaculum forms a common com- partment for the peronei, unlike the inferior retinaculum, which forms 2 compartments. TENDON SHEATHS ‘The tendon sheaths around the ankle joint are mucous sheaths which are placed ante- riorly, medially, laterally and posteriorly The anterior sheaths ‘appear as 3 separate structures (Fig 717). They are: the sheath tibiala. crongala. Ant.pr Lat ant, -malleolar a. Lat post: miaileclara. . Communi- cating brs. Fis, 718, The arteries around the ankle, as seen from behind.822 INFERIOR EXTREMITY: Ankle of the tibialis anterior, which extends from the upper brder of the transverse ligament to just below the ankle joint; the sheaths of the extensor hallucis longus and of the exten- sor digitorum longus, which extend from the malleoli to the base of the metatarsal bones. The medial mucous sheaths are also 3 in number (Fig. 714 C): the sheath of the tibi- alis posterior, which extends from about 2 inches above the medial malleolus to the in- sertion of the tendon at the navicular tuber- osity; the sheaths of the flexor hallucis longus and the flexor digitorum longus, which ¢x- tend from the medial malleolus to the middle of the sole of the foot. Near the head of the metatarsal bones these tendons acquire new sheaths, resembling the arrangements seen in the fingers. Laterally, the peroneus longus and brevis are enclosed in a sheath which extends 2 inches above the tip of the malleolus and 2 inches below it (Fig. 714 B). Above the malleolus the tendons lie together in a single sheath, but where they diverge, the sheath provides cach with a separate investment, Posteriorly, the tendo achillis has a sheath which extends about 3 inches upward from the insertion of the tendon to the calcaneus. VESSELS The arteries around the ankle are mainly 3 in number (Fig. 718); the anterior tibial, the posterior tibial and the peroneal, ‘The anterior tibial artery is continued be- yond the line of the ankle joint as the dorsalis pedis (Fig. 722). Proximal to the joint line, the vessel is crossed by the tendon of the extensor hallucis longus. At a lower level it lies between the tendon of this muscle and the extensor digitorum longus. In the region of the ankle, it provides malleolar branches. The posterior tibial artery corresponds to the center of a line which connects the in- ternal malleolus and the most prominent part of the heel. The artery terminates opposite the lower margin of the laciniate ligament, where it divides into medial and lateral plantar arteries. The calcancal branches sup- ply the tissues at the medial side of the heel. The anterior branch of the peroneal artery crosses the ankle joint in front of the interos- seous ligament between the lower ends of the tiba and the fibula, The anterior and the pos terior tibial arteries and the peroneal artery form an anastomotic network about the ankle and the heel regions. ANKLE JOINT (TALOCRURAL) The ankle joint is a synovial joint of the ‘hinge variety which unites the foot to the Jeg. Its great strength and stability are en- sured by surrounding powerful ligaments and tendons, as well as by a close interlogking of its articulating surfaces. Because of its hinge action, the to-and-fro movements of walking are possible. When one walks, the triceps sural (both heads of the gastrocnemius and the soleus) raises the heel from the ground and produces plantar flexion of the ankle joint. The 4 anterior crural muscles cause the foot to clear the ground, and thus produce dorsiflexion of this joint. The malleoli grasp the sides of the talus, the latter transmitting the weight of the body to the tibia. The sharp. tip of the lateral (fibular) malleolus can be felt a little less than 1 inch below the level of the blunt ending medial (tibial) malleolus. Since there are no muscles at the sides of the ankle, the malleoli are subcutaneous and may ‘be palpated readily. With the exception of the tendo calcaneus, all tendons that cross the ankle joint (4 in frontand 5 behind) pass for- ward and become inserted into the foot an- terior to the midtarsal joint, Bones The bones that enter into the formation of the ankle joint are the talus and the distal ends of the tibia and the fibula. ‘The talus articulates with the bones of the leg by 3 of its surfaces: the upper, the medial and ‘the lateral. ‘The bones form a deep socket which receives the upper part of the talus. Tibia and Fibula, The roof of the joint is formed entirely by the tibia, As the 2 malleoli project downward, they grasp the talus firmly at each side, thus permitting only a slight degree of lateral or medial movement, The bones just mentioned are so intimately re- lated with the tarsal bones and joints in the mechanics and the alignment of the ankle joint that it is impossible to isolate the ankle joint from the rest of the foot in either clini- cal or anatomic discussions (sce Joints of the Foot, p. 838).Ankle Joint (Talocrural) 823 Ligaments (Fig. 719). (See also diagram at bottom of Capsular Ligament, The bones that form page 824.) the ankle joint are held together by a cap- ‘The capsule is loose in front and behind sular ligament which is subdivided into ante- and tight at the sides. Proximally, it is at- rior, posterior, lateral and medial ligaments tached to the margins of the articular surfaces Second layer at deepfascla “Calcaneus B Post: talo- calcane Tibialis pos! Flax. digtlong sy Anting tibiofibu. lig Dorsal tubercle taiotibel fant is of = talonavicular 4 ere Tigt lat-malleolus) N an ® Dorsal sal " -navicularlig of Plantaréaleane cadove for a - DE ia Flo hall long: pi eaeeees ag). | eral caleanc. Sustentdculum — engonperonedsy CGBSia Tig ; Ant talo: caleane. lig Fic. 719, The ligaments around the ankle joint824 INFERIOR EXTREMITY: Ankle of the tibial and the fibular epiphyses and distally to the margins of the superior articu- lar surface of the talus except at the anterior aspect of the joint, where it extends forward to the neck of the bone, The medial part of this capsule is greatly thickened and is named the delfoid ligament. It is triangular in shape, with its apex attached above 16 the tip of the medial malleolus. Its base has a more extensive attachment, extending from the tubercle of the navicular, the plantar cal- caneonavicular (spring) ligament, the neck of the talus and the sustentaculum tali to the body of the talus, [ts medial surface is crossed by the tendons of the tibialis posterior and the flexor digitorum longus (Fig. 719 B). If the foot is everted to an extreme degree, the delioid ligament usually tears away from the medial malleolus rather than rupturing itself. It braces the spring ligament and helps to support the head of the talus and to preserve the arch of the foot ‘The lateral ligament is weaker and less complete. Most authors divide it into 3 parts (Figs. 719 B and D), 1. The calcaneofibular ligament extends downward and backward from in front of the apex of the lateral malleolus to the lateral surface of the cileaneus. These fibers are separated from the other fibers of the lateral ligament by some fatty and areolar tissues The ligament is crossed by the peronei 2. The anterior talofibular ligament passes horizontally forward and inward from the an~ terior aspect of the lateral malleolus to the lateral side of the neck of the talus 3. The posterior talofibular ligament ¢x- tends inward behind the joint, from the inner surface of the lateral malleolus to the poste- rior process of the talus. It is the strongest of the 3 bands and binds the fibula to the talus in a rigid manner. The anterior ligament of the ankle joint is a thin wide membrane is composed chiefly of transverse fibers. It extends from the anterior margin of the distal surface of the tibia to the dorsal surface of the neck of the talus (Fig, 719 A). A cut across the foot immediately in front of the tibia will open the ankle joint at this point The posterior ligament is the weakest of all the ankle ligaments. It is thin, sometimes de- fective and difficult to define. It extends from the posterior border of the distal end of the tibia to the posterior surface of the talus. The tendon of the flexor hallucis longus acts as a strong posterior support for the joint. SYNOVIAL MEMBRANE. ‘The synovial membrane lines the capsular ligament and covers the intracapsular portion of the neck of the talus (Fig. 715). It passes up between the tibia and the fibula for about ¥4 inch and extends weil forward onto the neck Of the talus, A puneture wound or su- perficial incision made in front of the joint may enter the joint cavity. The membrane is Tax in front and behind where it is covered by the anterior and the posterior ligaments, at which points the capsular ligament is thin and loose. It is continuous with the synovial embrane of the distal tibiofibular joint. A effusion bulges the synovial membrane and the weak capsule anteriorly and pos- teriorly. Vessets anp NERVES ‘The nerves to the ankle joint are d from the anterior and the posterior tibial nerves. Relations (Figs. 715 and 720): Anterior, From the medial to the lateral side lie the tibialis anterior, the extensor hal- lucis longus, the anterior tibial vessels, the anterior tibial nerves, the extensor digitorum Medial (Deltoid) Ligament a (1. Caleancofibular Ligament 2. Anterior Talofibular Ligament Lateral Ligament 3. Posterior Talofibular Ligament Capsular Ligament) amerior Ligament Posterior Ligament -longus and the peroneus tertius. The perfo- Fating branch of the peroneal vessels is found on the lateral malleolus. The inferior exten- sor retinaculum crosses the joint obliquely. ‘The superficial structures which are found in this region are the branches of the musculo- cutaneous nerve, the superficial vessels, the long saphenous vein and the saphenous nerve on the medial malleolus. Posterior. The tendo caleaneus is separated from the posterior ligament by an interval Deep peronealn. Ln. peas = Lart: mallechas \, Ant telofibular lig, Penoneus a. eal tertiusm. inne ys Tendon post tibial m. Med. marginal Fendon a ‘pial mi. BSE Soag Talus’ Dorsalis pedisa, Deeppereneal ri. Tendon ext: digi long. a . Tendon peroneus tertingm Ext hallucis brevis mi. Lat.talocalcancal lig! | Tendon flex. digit. long » {Post-tibial a. & v: Ankle Joint (Talocrural) 825 of fatty areolar tissue which contains small vessels, Between the joint and the tendon are found the flexor hallucis longus, the pos- terior tibial nerves and vessels, and the flexor digitorum longus, the latter structures being named. in a lateromedial order. The vessels and the nerves are more superficial than the 2 fiexors and overlap them. All of these struc- tures are maintained in position by the flexor retinaculum. Medial, The tibialis posterior lies on the / Med.matieclus & talus Tendon flex hallucis long. _ Achillas tendon. ’ post, talofibular lig. Tendon P-- Hex. dig jong ma" Abducton f- haliucis m -Med. plantar a. 6. Lat: plantar a.éni. Quadratus *plantaem. Tendon. flex hall. Long tn. “ B Caldaneus ‘Tendon peroneus longus m. “Ipochlear process Tendon peroneushrevis mn. Ext digi. brevis m. Fic. 720. Cross sections through the ankle and the foot: (A) section taken through the malleoli; (B) section taken through the calcaneus and the talus.826 INFERIOR EXTREMITY: Ankle dehoid ligament above the sustentaculum and the flexor digitorum longus lies on the attachment of that ligament to the sus- tentaculum. The flexor retinaculum overlies the tendon. Lateral, The peroneus brevis lies on the posterior talofibular ligament and separates the peroneus longus from it, Its tendons are held down by a retinaculum of deep fascia; they have a common synovial sheath. The termination of the peroneal artery anasto- moses with its perforating branch on this side of the joint. More superficially are the short saphenous vein and the sural nerve. MovEMENTS ‘The movements of the ankle joints involve the joints of the foot as well. Inversion and eversion of the foot are effected by plantar fiexion (true flexion) and dorsiflexion (ex- tension). Plantar flexion and dorsiflexion are effected mainly at the ankle joint between the talus, the tibia and the fibula, Dorsifiexion is limited by the lengthening of the calf mus- cles; if the knee is flexed, the range of move- ment is greater. Plantar flexion is produced the gastrocnemius, the soleus and the flexor hallucis longus; it also is produced to a minor degree by the tibialis posterior, the peroneus longus and the plantaris muscles ‘When the foot is moved so that the sole faces medially, the movement is described as in- version; the contrary movement is eversion. Inversion of the foot is brought about by the action of the tibialis anterior and the tibialis posterior; eversion is accomplished by the peronci longus, the brevis and the tertius. A greater range of inversion may be produced when the ankle joint is plantar flexed; is due apparently to an increased range of metatarsal movement. The 5 tendons which pass behind the ankle are situated too close to the axis of the joint to act on it; therefore, if the tendo caleaneus is cut, the power to plantar flex is lost. SURGICAL CONSIDERATIONS Symz’s AMPUTATION THROUGH THE ANKLE JOINT This is a disarticulation with removal of both malleoli and the articular surface of the tibia, The incision passes under the heel, from the tip of the lateral malleolus to a cor- responding point on the medial malleclus (Fig. 721). The distal ends of the tibia and the fibula are exposed, and these bones are sectioned about 1 em. proximal to their artic~ ular surfaces. The terminal branches of the peroneal vessels and the posterior tibials should be preserved. The anterior tendons are united to the caleaneus tendon or to the periosteum of the tibia. This amputation pro- vides a good end-bearing stump, but it is dif- ficult to fit with a prosthesis without produc- ing a wide and ugly-looking ankle. In the Pirogojf amputation, the posterior portion of the calcaneus is sawed off and ap- ‘Fic. 721, Amputation through the ankle joint (Syme).proximated to the sawed end of the tibia and the fibula. Therefore, it is a modified Syme’s amputation, the only differenee being that part of the calcaneus is retained and brought into contact with the divided lower ends of the tibia and the fibula, DISLecATIONs OF THE ANKLE Jom Dislocations of the ankle joint (between the talus and the tibia and the fibula) are classified according to the direction in which the foot passes: namely, backward, forward, medial, lateral or upward. Lateral and medial displacements occur in association with Pott’s fracture or fractures of the malleoli In forward (anterior) dislocation, the lig- aments or malleoli are torn, the heel is short- ened and the distance from the malleoli to the heel is diminished: the distance from the Surgical Considerations 827 malleoli to the toes, however, is increases The foot appears to be lengthened, the noi mal hallows at the sides of the tendo achillis are obliterated, and the talus may be felt in front of the tibia. The malleoli appear to lie nearer the sole. Backward dislocation is the most frequent type; this may be associated with a Pot's fracture, It results from extreme plantar fiexion of the foot which tears the ligaments. Involvement of the malleoli and the posterior articular edge of the tibia is usually present. ‘The foot appears to be shortened, and the heel is prominent, The malleoli appear some- what anteriorly. The distance from the mal- leoli to the heel is increased, while that from the malleoli to the toc is diminished. Reduction is easy if the knee is bent to relax the tendo achillis and if proper traction and counter traction are applied.