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StatPearls . Sweetheart Island (FL): StatPearls Publishing; 2021 Jan-.


Anatomy, Bony Pelvis and Lower Limb, fish eye Joint

Daniel Manganaro; Khalid Alsayouri.

Author Information


The ankle joint is a hinged synovial joint that is formed by the articulation of the talus, tibia, and fibula bones. The articular facet of the lateral malleolus (bony prestige on the reduced fibula) develops the lateral border that the ankle joint while the articular page of the medial malleolus (bony prominence on the lower tibia) forms the medial border that the joint. The superior part of the fish eye joint develops from the inferior articular surface of the tibia and also the remarkable margin of the talus. Together, these three borders form the fishing eye mortise.

The talus articulates inferiorly with the calcaneus and anteriorly with the navicular. The top surface, dubbed the trochlear surface, is rather cylindrical and permits for dorsiflexion and plantarflexion of the ankle. The talus is more comprehensive anteriorly and much more narrow posteriorly. It develops a wedge the fits in between the medial and lateral malleoli make dorsiflexion the many stable position for the ankle.

The fishing eye is stabilized by strong collateral ligaments medially and laterally. The main stabilizing ligament medially is the deltoid ligament, and also laterally the ankle has actually stabilization native three separate ligaments, the anterior and also posterior talofibular ligaments, and the calcaneofibular ligament. The anterior and posterior talofibular ligaments attach the talus come the fibula, and the calcaneofibular ligament connects the fibula come the calcaneus inferiorly. The anterior talofibular ligament (ATFL) is the weakest that the three lateral ligaments and thus the most commonly injured. The deltoid ligament actually consists of four ligaments that type a triangle connecting the tibia to the navicular, the calcaneus, and also the talus. The anterior and also posterior tibiotalar ligaments connect the tibia come the talus. The last two ligaments the the triangle space the tibionavicular ligament i m sorry attaches to the navicular anteriorly and also the tibiocalcaneal ligament i m sorry attaches come the calcaneus inferiorly.<1>

Structure and Function

The ankle share is important during ambulation due to the fact that it adapts to the surface ar on i beg your pardon one walks. The movements that take place at the ankle joint are plantarflexion, dorsiflexion, inversion, and also eversion. The muscles of the foot divide into anterior, posterior, and also lateral compartments. The leg"s posterior compartment the the foot divides into the superficial posterior compartment and also the deep posterior compartment. The superficial posterior compartment consists of the gastrocnemius and also the soleus muscles, which room the major muscles involved in ankle plantarflexion. The deep compartment includes the tibialis posterior, the flexor digitorum longus, and also the flexor hallucis longus muscles. The flexor digitorum longus and the flexor hallucis longus have roles in ankle plantarflexion, and also the tibialis posterior muscle theatre a role in ankle joint inversion. The tibialis anterior muscle, discovered in the anterior compartment of the leg, is the primary muscle the facilitates dorsiflexion of the fishing eye joint. The peroneus longus and also peroneus brevis muscles, found in the lateral compartment of the leg, duty to facilitate eversion that the ankle joint.<2>

Ligament Testing

The anterior drawer check is supplied to research the verity of the anterior talofibular ligament (ATFL) and utilizes the anterior translation of the talus under the tibia. The check is perform by stabilizing the distal tibia (and fibula) through one hand while the other hand hold the calcaneus and puts the ankle in slight dorsiflexion. The calcaneus is then translated anteriorly while at the same time translating the foot (distal tibia and also fibula) posteriorly. Too much talar anterior translate in on the injured side compared to the uninjured side is indicative that a optimistic test.

The talar tilt test, additionally known as the inversion stress test, is provided to test the truth of calcaneofibular ligament. The examiner performs this check by stabilizing the distal tibia (and fibula) through one hand and inverting the fish eye while that is in the neutral position. Pains elicited at the area that the ligament suggests a confident test.

The eversion tension test is supplied to assess for a deltoid ligament injury. It is carry out by everting and also abducting the heel while stability the tibia (and fibula). Boosted laxity or pain shows a optimistic test.<3>

Blood Supply and also Lymphatics

The key blood it is provided to the ankle originates from the anterior tibial artery, the posterior tibial artery, and the peroneal artery.

The anterior tibial artery subdivides right into the anterior medial malleolar artery (supplies the medial malleoli), anterior lateral malleolar artery (supplies the lateral malleoli) and also the dorsalis pedis artery (supplies the dorsum of the foot).

The posterior tibial artery subdivides into the posterior medial malleolar artery (supplies the medial malleolus) and the medial calcaneal artery (supplies the heel). The terminal branches of the posterior tibial artery are the lateral plantar artery and medial plantar arteries. The larger of the terminal branches is the lateral plantar artery, i m sorry completes the deep plantar arch. The deep plantar arch is one arterial anastomosis uncovered on the single of the foot the is consisted of of the deep plantar artery (branch that dorsalis pedis) and the lateral plantar artery. The medial plantar artery runs in the medial foot and also terminates together the superficial plantar arch (an inconstant anastomosis in between the medial and lateral plantar arteries).

The peroneal artery subdivides right into the perforating artery, the posterior lateral malleolar artery, and the lateral calcaneal artery. The perforating artery joins through the anterior lateral malleolus artery and supplies the posterior talus. The posterior lateral malleolar artery supplies the lateral malleolus, and also the lateral calcaneal artery provides the heel.<4>


Innervation come the reduced leg originates from the lumbar plexus and the sacral plexus.

The lumbar plexus provides rise to the femoral nerve, which becomes the saphenous nerve as soon as it will the medial side of the knee. The saphenous nerve descends along the medial leg and then divides into two branches (a branch the ends in ~ the ankle and also a branch the passes in front of the ankle to the medial next of the foot) and provides sensory innervation come the medial fish eye joint and also the medial arch that the foot. 

The sciatic nerve creates from the sacral plexus, which further branches into the tibial and common fibular nerve.

The tibial nerve travel posterior to the medial malleolus and also branches into the medial calcaneal nerve (provides sensory innervation to the heel), medial plantar nerve (provides sensory innervation come the medial two-thirds of the plantar surface of the foot and motor innervation to the muscle on the medial sole), and lateral plantar nerve (provides sensory innervation to the lateral sole and lateral one-third the the plantar surface of the foot and also motor innervation to the deep muscles of the foot).

The common fibular nerve travels approximately the fibular head and subdivides right into the superficial and also deep peroneal nerves.

The superficial peroneal nerve travels in the lateral compartment the the leg down to supply sensory innervation to the lateral malleolus where it divides right into the intermediate dorsal cutaneous nerve (sensory innervation to the dorsal foot) and also the medial dorsal cutaneous nerve (sensory innervation to the medial hallux).

The deep peroneal nerve runs in the anterior compartment that the leg together with the anterior tibial artery and overcome under the inferior and also superior extensor retinaculum. The medial branch provides sensory innervation to the interdigital room between the an initial and second toes. The lateral branch gives motor innervation to the extensor hallucis brevis and also the extensor digitorum brevis. The tibial and common fibular nerves likewise give rise to a medial and also lateral sural nerve, respectively, which provides sensory innervation come the lateral heel and foot.<5><6>

Clinical Significance

Ankle Fracture

Ankle fractures are common in all periods with the involvement of one or both malleoli. The fracture sample determines the stability of the fracture. Patients commonly present through pain, swelling, and inability to bear load on the fishing eye joint. Monitoring of steady fractures contains a quick leg cast for 4 to 6 weeks. Rough fractures call for an open reduction and also internal fixation (ORIF) to reclaim a congruent mortise and fibular length.

The Lauge-Hansen and also AO classifications room tools provided to help determine the prognosis and treatment of fishing eye fractures. The Lauge-Hansen classification has its basis on the foot position and also the device of injury. Fractures classify into four various groups: supination-adduction, supination-external rotation, pronation-abduction, pronation-external rotation. The an initial term defines the place of the foot throughout an injury when the second refers come the direction that force applied to the ankle.

The Danis-Weber group of describing ankle fractures has actually its basis on the location of the fibular fracture. This category divides right into three groups: fracture listed below the syndesmosis (type A), at the syndesmosis (type B), and over the syndesmosis (type C).<7><8>

Talus Fracture

This injury usually occurs indigenous a high power injury prefer a motor car accident or a fall from a height. The talus has actually a tenuous blood supply and is in ~ high danger of avascular necrosis (AVN) in displaced fractures. The Hawkins category helps come predict the possibility that AVN will certainly occur. Over there are 4 different species of talus fractures, with kind I having the finest prognosis and kind IV predicting a hundreds percent opportunity of emerging AVN. Form I is a nondisplaced fracture that the talar neck, type II is a subtalar dislocation. Form III is similar to type II, yet with tibiotalar dislocation, type IV is similar to kind III however with a talonavicular dislocation. Identify the type of fracture is no only vital for predicting the chance of AVN, yet it is also important for determining the form of treatment needed. Form I fractures room usually treated through percutaneous pins while varieties II-IV are treated with open reduction and internal continuous (ORIF).

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Ottawa fish eye Rules:

Simple indict to identify patients through ankle or midfoot injury who do not require X-ray. Fish eye X-ray is important if any kind of of the following are present.<10>

Bone tenderness along the posterior facet of the distal 6 cm of either the medial or lateral malleolus