LOWER LIMB RECONSTRUCTION—ANATOMY
Anatomy
Sural nerve
Only cutaneous branch of tibial nerve
Exits popliteal fossa and lies between heads of gastroc
Then pierces fascia (mid calf) and descends behind lat malleolus
Distally joins peroneal communicating nerve—at level of gastroc tendon
Short Saphenous Vein
Runs with sural nerve
Pierces deep fascia over popliteal fossa and drains into popliteal vein
Communications with Great Saphenous vein
Layers of sole of foot
Popliteal artery last pg173
LEG
4 Compartments
Anterior tib ant
EHL
EDL
PT
Lateral PL
PB
Posterior Gastroc
Soleus
Plantaris
Popliteus
+Deep Pos FHL
FDL
Tib post
Tib ant type IV muscle from ant tib
Deep peroneal n L4
Into med cuneiform and 1st MT
EHL type IV muscle form ant tib
Deep peroneal n L4,5
From mid fibula then becomes superficial between tib ant & EDL
EDL type IV muscle from ant tib
Deep peroneal L4,5
From upper ¾ fibula and i/m septum
Splits into central slip and lateral bands (joined by lumbricals and interossei)
Peroneus tertius
Type IV muscle from ant tib
Deep peroneal n L5
From distal fibula into base 5th MT
Deep peroneal n arises in PL and then passes to lie on interosseous membrane (Lat to vessels)
Artery---initially lies on I/M between tib ant and EDL, then crossed by EHL so at ankle 2 muscles
on each side
Peroneus Longus
Type IV muscle from peroneal—perforators through FHL (drains into short saphenous)
Sup peroneal n L5, S1
From fibula behind PB, into base 1st MT
Peroneus Brevis
Type IV from peroneal
Sup peroneal n L5, S1
In front of PL and into base 5th MT
Blood supply via peroneal artery via perforators running through FHL and Interosseous membrane
Gastroc type I via sural arteries from popliteal
Tibial n S1,2
From femoral condyles, medial is longer at each end
Plantaris arises above gastroc (lat head)
Runs between gastroc and soleus
Soleus type II muscle peroneal to lat soleus and post tibial to medial
Tibial n S1,2 2 branches one in pop fossa and one deep
From tibia and fibula + fibrous arch
Venous pump
Popliteus unlocks tibia in extension
FDL $$ branches of pos tib
Tibial n S1,2
From both bones, crosses tib post in leg, crosses FHL in sole and divides into 4
Receives slips from flex accessorius , gives origin to lumbricals, perforates FDB—P3
FHL $$$$ branches of peroneal
Tibial n S1,2
Powerful, from fibula into base P3, most impt in maintaining med longitudinal arch
Tib Post $$$$$ mainly via peroneal perforators (through FDL) and also post tib
Tibial n L4
From both bones, unipenate, tuberosity of navicular
Both tibial vessels lie medial to respective nerves
Pos tibial artery under fibrous arch of Soleus, between FDL & FHL, lies on fibular aponeurosis
of FDL
Nutrient artery passes through fibular aponeurosis of FDL and enter between
origins of FDL and tib post
pass behind med malleolus as TDAVNH
Peroneal artery at ankle communicates with—
Lat ant malleolar br of ant tib via perforating br that pierces interosseous m
5cm above ankle—pos tib via calcaneal branches
Septocutaneous perforators from
Peroneal pass between soleus and lat compartment
Pos tibial pass between FDL and soleus
Ant tibial pass between tib ant and EDL and EDL and lat compartment
Pos tibial artery has 3 terminal branches
Medial and lateral plantar + calcaneal
Calcaneal branch (supplies heel) pierces flexor retinaculum and then connects with branches
of peroneal artery
FOOT
Dorsum of foot
Dorsal venous network drains into long and short saphenous veins
EDB arises from calcaneus and gives 4 tendons to medial 4 toes
The tendon to great toe is EHB
Tendons pass deep to EDL and insert into ext expansions
Deep peroneal n
Dorsalis pedis is lateral to EHL and crossed by EHB
Runs down 1st MT space as 1st dorsal MT artery to join lateral plantar artery
Branches are
Lateral tarsal—runs deep to EDB
Arcuate—runs laterally beneath tendons of EDB giving branches to MT spaces
Each has 2 branches—1 dorsal and 1 connects with plantar arch
Plantar Aponeurosis
From calcaneus via 5 slips into each toe
Septum passes deeply from each side to separate FDB from abductors of 1st and 5th toes
4 layers N/V structures pass between 1st and 2nd layers
generally type II muscles
1st Layer
3 short muscles
FDB from calcaneus and splits to base P2
Medial plantar n
Abd H from calcaneus to P1
Medial plantar n
ADM from calcaneus to P1
Lateral plantar n
2nd Layer
long flexors and their connections
FHL crossed by tendon of FDL and gives of slips to 2 medial tendons
FDL crosses superficial to FHL, receives flexor accessorius, gives off lumbricals, to P3
Flexor accessorius / Quadratus Plantae
From calcaneus to FDL, flexes toes in full ankle plantarflexion
Lateral plantar n
Lumbricals
Pass on medial side, plantar to deep transverse ligament into extensor expansions
Medial plantar n—unicipital muscle—1st lumbrical to 2nd toe
Lateral plantar n—bicipital muscles—2nd to 4th
3rd Layer
3 muscles
FHB cuboid and cuneiforms to P1
Medial plantar n
Adductor Hallicus
Oblique and transverse heads to base P1
Lateral plantar n
FDMB from base 5th MT to base P1
Lateral plantar n
4th Layer
longitudinal axis of foot is 2nd MT
Plantar Interossei—3
Tendons pass deep to deep transverse ligament to bases P1 and ext expansion
Dorsal Interossei—4
Insert into P1 mainly and to ext expansion
All by lateral plantar n
1st MT space has 1 muscle, rest have 2
PL
Tib post
Posterior tibial nerve
3 branches
Calcaneal medial heel pad
Med plantar n supplies Abd Hal, FDB, FHB and 1 lumbrical
Medial 3½ toes
Lateral plantar n rest
Posterior tibial artery
3 branches
Calcaneal anastomoses with branches from peroneal artery
Medial plantar artery smaller of the 2, on medial side of nerve, under 1st layer
Perforating branches run between Abd Hal and FDB
No arch
Lateral plantar artery perforators to sole travel between FDB and ADM
Main trunk forms plantar arch—level of bases of MTs
and joins DP through 1st interMT space