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by the removal of the talus. It fills up the angular gap
between the sustentaculum tali and the navicular bone, and
enters into the formation of the socket for the head of the
talus (Fig. 198). Its upper surface is smooth and covered
with a synovial layer ; its plantar surface is supported
by the tendon of the tibialis posterior. This ligament
has an important part to play in maintaining the integrity
of the longitudinal arch of the foot. Posteriorly it is
attached to the anterior border of the sustentaculum tali,
whilst anteriorly it is fixed to the plantar surface of the
navicular bone.

The calcaneo-navicular part of the bifurcate ligament (O.T.



JOINTS OF THE FOOT



43 1



external calcaneo-scaphoid ligament] also forms a part of the
socket for the head of the talus. It is placed deeply in
the anterior part of the depression between the calcaneus
and the head of the talus, and is the medial part of the
V-shaped ligamentum bifurcatum, which springs from the

Tendon of insertion of
peronaeus longus muscle

Base of metatarsal bone
of hallux



Plantar inter-meta-
tarsal ligaments



Ridge on cuboid bone

Plantar cubo-cunei-
form ligament

Plantar calcaneo-
cuboid ligament

Tendon of peronaeus
longus muscle



Long plantar ligament




'j Tendon of insertion
} of tibialis anterior
) muscle



First cuneiform bone
Plantar naviculo-cunei-
form ligament



N Tendon of tibialis

posterior muscle
Groove for tendon of
tibialis posterior muscle

Plantar calcaneo-
navicular ligament



/ \Deltoid ligament
/ of ankle

Medial malleolus
Groove for tendon of flexor
hallucis longus muscle



Calcaneus



FIG. 199. Plantar Aspect of Tarsal and Tarso-metatarsal Joints.



anterior part of the upper surface of the calcaneus and
immediately divides into a medial or navicular part and
a lateral or cuboid portion. The calcaneo-navicular part
is continuous below and medially with the plantar calcaneo-
navicular ligament, and dorsally with the talo- navicular
ligament.



432 THE INFERIOR EXTREMITY

Calcaneo- cuboid Articulation. In the calcaneo- cuboid
joint the concavo-convex surface on the anterior aspect of
the calcaneus articulates with the corresponding surface on
the posterior aspect of the os cuboideum. It is a distinct
joint, that is, its cavity does not communicate with the cavities
of neighbouring joints. The ligaments which bind the two
bones together are :

1. Capsula articularis.

2. Ligamentum calcaneo-cuboideum plantare.

3. Ligamentum plantare longum.

The capsule completely surrounds the joint and its dorsal
and medial parts, which are somewhat thickened, are some-
times called the dorsal and medial ligaments of the joint.
The medial ligament is the calcaneo cuboid part of the lig.
bifurcatum mentioned above.

The long plantar ligament springs from the plantar surface
of the calcaneus, immediately anterior to the tuber calcanei.
It extends forwards to the plantar surface of the cuboid bone
where it broadens out and is, for the most part, attached
to the tuberosity of that bone. Numerous strong fibres,
however, are prolonged forwards, across the tendon of
the peronaeus longus, to gain attachment to the bases of
the second, third, and fourth metatarsal bones. The long
plantar ligament, therefore, extends over the greater part of the
plantar aspect of the lateral portion of the tarsus, and is the
longest of the tarsal ligaments. Further, it forms the greater
part of the sheath of the tendon of the peronaeus longus.

The plantar calcaneo-cuboid ligament (O.T. short plantar
ligament} is placed under cover of the long plantar ligament.
Slip the knife between them and carry the cutting edge back-
wards so as to detach the long plantar ligament from the
plantar surface of the calcaneus. When the detached band is
thrown forwards the plantar calcaneo-cuboid ligament comes
into view, and little dissection is required to make its connec-
tions apparent. It is composed of short, strong fibres, not
more than an inch in length. They spring from the small
tubercle on the anterior part of the plantar surface of the
calcaneus, and are attached, anteriorly, to the plantar surface
of the cuboid, posterior to its tuberosity. The ligament is
broader than the long plantar ligament and could be seen
at the medial border of the latter before it was reflected.

In the maintenance of the longitudinal arch of the foot,



JOINTS OF THE FOOT 433

the long plantar ligament and the plantar calcaneo-cuboid
ligament have an importance which is surpassed only by that
of the plantar calcaneo-navicular ligament.

The joint between the talus and the navicular and that between the
calcaneus and the cuboid are frequently referred to together as the trans-
verse tarsal joint. It is there that some parts of the movements of eversion
and inversion of the foot take place. It should be noted that all the
ligaments which connect together the anterior and the posterior segments
of the tarsus at this joint, except one, are attached posteriorly to the
calcaneus. They are :



Plantar calcaneo-navicular,

Bifurcate,

Long plantar,

Plantar calcaneo-cuboid,

Calcaneo-cuboid capsule,

Dorsal talo-navicular,



Attached to the calcaneus.



Attached to the talus.



Inter - cuneiform Articulations. The three cuneiform
bones are held together so firmly that very little individual
movement is permitted. The chief uniting structures are
two strong interosseous ligaments which pass between the non-
articular portions of their opposed surfaces. These can be
seen only when the bones are separated from each other.
Dorsal inter-cuneiform ligaments also are present. These are
short, flat, transversely-placed bands.

Cuneo - navicular Articulation. - - The three cuneiform
bones articulate with the anterior surface of the navicular.
They are held in position by dorsal ligaments, which pass from
the dorsal surface of the navicular to the dorsal surface of each
of the cuneiform bones, and by plantar ligaments, which are
similarly disposed. The strength of the plantar ligaments is
greater than that of the dorsal ligaments, and they are
reinforced very largely by slips from the tendon of the tibialis
posterior.

Dissection. The dissector may now divide freely all the
dorsal and the most medial of the plantar cuneo-navicular liga-
ments. The navicular bone can then be drawn backwards so
as to expose the interior of the joint. The knife may also be
carried round the lateral side of the lateral calcaneo-navicular
ligament. A much better view of this ligament is thus obtained,
although this dissection entails the division of the dorsal cubo-
navicular ligament.

The convex anterior articular surface of the navicular fits
into a transversely concave socket, which is formed for it by
the posterior surfaces of the three cuneiform bones, "and, often,

VOL, i 28



434 THE INFERIOR EXTREMITY

by a small facet on the medial surface of the cuboid as
well. The articular surface of the navicular is divided by
prominent ridges into areas or facets corresponding with the
different parts of the socket in which it lies. The synovial
stratum, which lines this joint, is prolonged forwards into the
intercuneiform joints.

Cubo-navicular and Cubo-cuneiform Articulations. It has
been noted that the anterior pillar of the longitudinal arch of
the foot consists of a lateral and a medial column. The
tarsal portions of these are connected together by the cubo-
navicular and the cubo-cuneiform articulations.

It is only occasionally that the navicular touches and
articulates directly with the medial surface of the cuboid.
When it does so, the facet on the cuboid lies in series
with the articular surfaces on the posterior ends of the cunei-
form bones, and forms with them the socket for the anterior
surface of the navicular. The ligaments which bind the
navicular to the cuboid are disposed transversely, and
consist of (i) a series of short strong interosseous fibres
which bind the opposed surfaces together ; (2) a dorsal band ;
and (3) a plantar band.

The dorsal band has previously .been divided in exposing
the interior of the cuneo-navicular joint and in defining the
lateral calcaneo-navicular ligament, but the interosseous and
plantar ligaments may be readily displayed.

The cuboid, by an oval facet on its medial surface,
articulates with the third cuneiform bone, forming thereby
the cubo-cuneiform joint. The two bones are bound together
by interosseous, dorsal, and plantar ligaments. By dividing
the dorsal ligament and insinuating the knife between the
two bones the interosseous ligament may be detected. It is
the strongest of the three ligaments.

The synovial layer which lines the cuneo-navicular articula-
tion is prolonged into the cubo-cuneiform joint and also
into the naviculo-cuboid joint, when that exists.

Tarso-metatarsal Articulations. The bases of the five
metatarsal bones articulate with the three cuneiform bones
and the cuboid bone, and are very firmly attached to them
by dorsal, plantar, and interosseous ligaments. It is particu-
larly important to note that the line of articulation is irregular,
and that the base of the second metatarsal bone is wedged
between the first and third cuneiform bones.



JOINTS OF THE FOOT 435

The dorsal ligaments are flat, distinct bands which can
readily be defined by the careful dissector. One such liga-
ment passes to the base of the first metatarsal from the
first cuneiform ; three, one from each of the cuneiform bones,
proceed to the base of the second metatarsal ; one extends
from the third cuneiform to the base of the third metatarsal ;
two, of which one proceeds from the third cuneiform and the
other from the cuboid, go to the base of the fourth meta-
tarsal; and one passes from the cuboid to the base of the
fifth metatarsal.

The plantar ligaments are not so regularly disposed. Those
in connection with the first and second metatarsal bones are
very strong. Some of the bands have an oblique direction,
and those which go to the bases of the second, third, and
fourth metatarsal bones are more or less connected with the
sheath of the tendon of the peronaeus longus, and therefore
with the long plantar ligament.

To bring the interosseous ligaments into view, divide freely
the dorsal ligaments, and then forcibly bend the metatarsus
plantarwards upon the tarsus. The interosseous ligaments
will resist this proceeding, and on looking into the joints the
dissector will see them stretched and tense. If the force is
continued they will rupture. The interosseous ligaments are
three in number, viz., a medial, an intermediate, and a lateral.

The medial interosseous ligament is an exceedingly strong
band, which passes laterally from the anterior part of the
lateral surface of the first cuneiform bone to the adjacent
surface of the base of the second metatarsal bone. The
intermediate interosseous ligament is small. It passes between
the anterior part of the medial surface of the third
cuneiform and the adjacent surface of the base of the
second metatarsal. The lateral interosseous ligament passes
from the lateral surface of the third cuneiform bone to the
medial side of the base of the fourth metatarsal. One inter-
osseous ligament, therefore, passes from the first cuneiform
bone and two from the third cuneiform ; and of these, two
are attached to the base of the second, and the third to the
base of the fourth metatarsal bone.

Tarso- metatarsal Articular Surfaces. The manner in

which the metatarsus is implanted upon the tarsus should

now be examined. The first metatarsal rests against the

first cuneiform, and this joint possesses a separate synovial

T 28 a



436 THE INFERIOR EXTREMITY

cavity. The second metatarsal rests against the second cunei-
form, but its base is grasped by the projecting anterior
ends of the first and third cuneiform bones, with both of
which it articulates, and with both of which it is connected
by interosseous ligaments. It is not surprising, therefore,
that this metatarsal should possess so little power of inde-
pendent movement, and present a difficulty to the surgeon
when he is called upon to amputate the anterior part of the
foot through the tarso- metatarsal articulation. The third
metatarsal rests against the third cuneiform. The synovial
layer which lines the joints between the tarsus and the second
and third metatarsal bones is continuous with that which is
present between the first and second cuneiform bones, and
through that with the synovial layer of the cuneo-navicular
articulation. The bases of the fourth and fifth metatarsal
bones are supported by the cuboid, but that of the fourth,
by its medial margin, articulates also with the third cunei-
form. The joint formed between the lateral two metatarsal
bones and the tarsus has a capsule and a cavity separate from
that of the adjacent joints.

Intermetatarsal Joints. The bases of adjacent metatarsal
bones, with the exception of the first, articulate with each
other, and are very firmly bound together.

The ligaments which connect the bases of the four lateral
metatarsal bones are dorsal, plantar, and interosseous. They
are strong bands which pass between the non-articular por-
tions of the basal parts of the bones, and they constitute the
chief bonds of union.

Dissection. To bring the interosseous ligaments into view
divide the dorsal ligaments and then forcibly separate the bases
of the bones from one another.

In addition to the ligaments which connect the basal ends
of the metatarsal bones, the strong transverse metatarsal liga-
ment of the heads of the metatarsal bones unites the distal
extremities of the bones together. That ligament has been
previously described (p. 399).

Joint Cavities of the Foot. There are six separate
joint cavities in connection with the tarsal, tarso-meta-
tarsal, and intermetatarsal articulations, viz. (i) The cavity
between the posterior facets of the talus and calcaneus.
(2) The calcaneo-cuboid joint cavity. (3) The cavity of the



. e





1 2



PLATE XLVI



Distai epiphysis
of tibia



Distal epiphyseal
line of tibia



Tibia



Fibula



Navicula



Cuboi




FIG. 202. Radiograph of the Foot of a Child 6 years old.
Note ( i ) % That the ossification of the epiphysis of the calcaneus
has just commenced and that there is no indication
of the os trigonum (see Fig. 201).

(2) That the distal epiphyseal line of the fibula runs
parallel with the upper border of the talus.



PLATE XL VI I



Tibia



Fibula



Talus



Os supra -
navicular
spur in m

Naviculare



Calcaneus



|



FIG. 203. Radiograph of the Foot of an Adult showing an
occasional variation.

(Major A. W. Pirie.)



JOINTS OF THE FOOT 437

joint formed by the head of the talus, the navicular, the sus-
tentaculum tali, the plantar calcaneo-navicular ligament, the
navicular part of the bifurcate ligament and talo-navicular
ligament. (4) The cavity of the naviculo-cuneiform articula-
tion, which is prolonged forwards between the cuneiforms,
and also between the cuboid and third cuneiform bones;
that cavity extends beyond the tarsus, and is continuous
with the cavity between the second and third metatarsal
bones and the tarsus, as well as with the cavities of the
joints between the bases of the second, third, and fourth
metatarsal bones. 1 (5) A separate cavity lies between the
first metatarsal and the first cuneiform. (6) A distinct
cavity for the articulations between the cuboid and the
lateral two metatarsal bones ; this is prolonged distally into
the joint between the bases of these two metatarsals.

Metatarso-phalangeal and Interphalangeal Joints. The
metatarso-phalangeal and interphalangeal joints of the foot
are constructed on a plan which is practically identical with
that met with in the cases of the corresponding joints of the
hand. In the cases of the metatarso-phalangeal joints the
slightly cupped bases of the first phalanges articulate with the
rounded heads of the metatarsal bones. The joints so formed
are of the condyloid variety and allow flexion, extension,
abduction, adduction, and circumduction. The interphalan-
geal joints, on the other hand, are hinge joints, which permit
only flexion and extension. In them there are two cup-
shaped depressions at the proximal end of the distal bone,
which fit against the condyles of the trochlear surface of the
distal end of the proximal bone. In both the metatarso-
phalangeal joints and the interphalangeal joints the articular
surfaces on the distal bones of the joints are limited, strictly,
to the proximal ends of the bones, but the articular surfaces
on the distal ends of the proximal bones are more extensive
and are prolonged for a considerable distance on the plantar
surface of the distal end of each bone. The result of this
arrangement is that when the joints are extended a consider-
able part of the convex articular surface of the proximal bone
rests upon the plantar accessory ligament of the joint capsule,

1 The lateral interosseous tarso-metatarsal ligament, which passes from
the third cuneiform bone (frequently from the cuboid bone) to the base of
the fourth metatarsal bone, separates the cavity between the fourth and fifth
metatarsal bones and the cuboid from the general tarsal articular cavity.



438 THE INFERIOR EXTREMITY

or, in the cases of the metatarso-phalangeal joint of the great
toe, and occasionally of some of the other toes also, upon the
sesamoid bones developed in the plantar accessory ligament
(Fig. 197). When the joints are flexed the proximal end of
the distal bone moves to the plantar aspect of the distal end
of the proximal bone, and the extremities of the distal bones
are then covered only by the extensor tendons and the skin.
When the joints are flexed, therefore, they are easily opened
from the dorsal aspects by cutting transversely directly against
the heads of the proximal bones. The dissector should open
one or more joints in that manner.

Each joint possesses the following ligaments :

Capsula articularis,
Ligamenta collateralia,
Ligamentum accessorium plantare.

Capsula Articularis. The fibrous stratum of the articular
capsule is deficient dorsally, and there the extensor tendons
lie in direct relation with the synovial stratum which lines the
interior of the fibrous stratum. At the sides the fibrous
stratum is blended with the collateral ligaments, and on the
plantar aspect with the plantar accessory ligament.

Ligamenta Accessoria Plantaria. Each plantar accessory
ligament is a dense fibrous plate which is firmly attached to
the plantar aspect of the base of the distal bone of the joint,
whilst it is loosely attached to the plantar aspect of the neck
of the proximal bone of the joint. The collateral ligaments
and the flexor sheath are fixed to its margins, and the trans-
verse ligament of the heads of the metatarsal bones is attached
to the plantar accessory ligaments of the metacarpo-phalangeal
joints. The plantar accessory ligaments always move with the
distal bones.

Ligamenta Collateralia. The collateral ligaments are
strong, thick triangular bands placed one on each side of each
joint. The apex of the band is attached to the tubercle and
the depression on the corresponding side of the head of the
proximal bone of the joint, and the expanded base is attached
to the side of the base of the distal bone and to the corre-
sponding margin of the plantar accessory ligament.

Movements. It has already been pointed out that at the
interphalangeal joints, which are hinge joints, only the move-
ments of flexion and extension are permitted, whilst the



JOINTS OF THE FOOT 439

metatarso-phalangeal joints, which are condyloid joints, permit
also abduction, adduction, and circumduction. At all the
joints the movements of extension are produced by the
extensors of the toes, but extension of the interphalangeal
joints of the lateral four toes is produced also by the action
of the lumbrical and interossei muscles, which act by means
of their attachments to the extensor expansions. Flexion of
the terminal interphalangeal joints of the lateral four is
produced by the flexor digitorum longus ; flexion of the first
interphalangeal joint by the short flexor of the toes, aided
by the long flexor of the toes. In flexion of the metatarso-
phalangeal joints the long and short flexors play a part, but
they are aided by the lumbrical and interossei muscles, and
in the case of the little toe by the flexor digiti quinti brevis.

Flexion and extension of the interphalangeal joint of the
great toe are produced by the long flexor and extensor respec-
tively, and flexion and extension of the metatarso-phalangeal
joint by the short flexor and extensor, aided by the long flexor
and extensor. The dissector should remember that the
lumbrical and interossei are flexors of the metatarso-phalan-
geal joints and extensors of the interphalangeal joints.

Abduction and adduction of the toes at the metatarso-
phalangeal joints are produced by the interossei and the
special abductors and adductors. The movements take place
from and towards a line drawn longitudinally along the middle
of the second toe. The lateral three toes are adducted by
the plantar interossei, the great toe by the oblique and trans-
verse adductors. The great toe and the little have each a
special abductor muscle. The second toe is alternately
abducted and adducted away from or towards its own middle
line by the first and second dorsal interosseous muscles. The
third toe is abducted by the third, and the fourth toe by the
fourth dorsal interosseous muscle.



INDEX.



Acromion, 2, 8, 49
Anastomosis around ankle, 380,
419

of back of thigh, 324

crucial, 296, 301

around elbow, 188

around knee, 403

around scapula, 90
Antibrachium, i
Aponeurosis, palmar, 70, 73, 152,

154

plantar, 383, 428
Arch, carpal, dorsal, 192

volar, 132
coraco-acromial, 84
femoral, deep, 239

superficial, 239
of foot, 428, 432, 434
plantar arterial, 386, 397
pubic, 214

venous, dorsal digital, 63
dorsal, of foot, 335, 336

of hand, 63
volar, deep, 167, 171
superficial, 155, 171
Areola mammae, 15

in male, 17

Armpit, I, 3, 7, 8, 16, 21
Arteries-
arcuate, 350

axillary, 25, 26, 31, 65, 94
brachial, 94, 100, 101, no
calcanean, lateral, 373

medial, 375, 383, 389
carotid, common, 39
carpal, radial, dorsal, 192

volar, 132
ulnar, dorsal, 144

volar, 144
cervical, transverse, 41, 58



Arteries (contd.}

cervical, transverse, ascending

branch of, 58, 85
descending branch of, 58, 60,

61, 90
circumflex, femoral, lateral, 246,

260, 268, 402
medial, 246, 247, 268, 271,

293. 295, 300
humeral, anterior, 28, 36, 78,

82

posterior, 28, 36, 77, 82
iliac, superficial, 225, 227
scapular, 28, 36, 91
coccygeal, 288, 296
collateral, ulnar, inferior, 101,

105, 188

superior, 101, 104, 188
comitans nervi ischiadici, 296
communicating, volar, 144
digital, of foot, 350, 388, 398

of hand, 70, 156
dorsalis indicis, 192
pedis, 344, 349, 397
pollicis, 192

epigastric, superficial, 225, 227
femoral, 246, 247, 253, 272

branches of, 272
genicular, 311, 317, 357, 402
genu suprema, 250, 251, 255, 402
gluteal, inferior, 287, 292, 295,

296

superior, 287, 292, 295, 302
of hip-joint, 250, 260, 272, 277,

303, 328, 331
iliac, circumflex, superficial, 225,

227

infrascapular, 91
inguinal, superficial, 227
innominate, 39



441



442



INDEX



Arteries (contd.)
intercostal, 17
interosseous, common, 142, 143

dorsal, 143, 185

recurrent, 185, 188

volar, 144, 148, 182, 188, 191
malleolar, 348, 419
mammary, external, 17, 35

internal, 12, 14, 17
median, 144, 147
metacarpal, dorsal, 192

volar. 67
metatarsal, dorsal, 350

plantar, 397, 398
musculo-articular, 255
nutrient, of femur, 269

of fibula, 373

ofhumerus, 101, 104

of radius, 144

of scapula, 90

of tibia, 375

of ulna, 144
obturator, 277

abnormal, 244
perforating, of foot, 397, 398

of hand, 167, 192

of internal mammary, 13, 14,

17

of peroneal, 344, 350, 373, 419
of profunda femoris, 267, 268,

2 93> 2 95. 323
peroneal, 371, 373, 419
plantar, lateral, 385, 388

medial, 385, 388
popliteal, 305, 307, 311, 315,

371, 372

princeps pollicis, 70, 170, 171
profunda brachii, 98, 101, 104,

ill, 117, 188
femoris, 246, 247, 267
pudendal, external, deep, 246,

248

superficial, 225, 227
internal, 293, 295, 298
to quadratus femoris, 296
radial, no, 130, 170, 191

recurrent, 131, 188
radialis indicis volaris, 70, 170,

171

recurrent, of elbow, in
interosseous, 185, 188
radial, 131, 188
tibial, anterior, 348, 403



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