Vous êtes sur la page 1sur 12

Foot Ankle Clin N Am 10 (2005) 413 424

The Anatomy of the Calcaneus and Surrounding Structures


Brian J. Keener, MD, Joseph A. Sizensky, MD*
Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, MSHMC-UPC, Hershey, PA 17033-0850, USA

Appreciation of the normal anatomy of the calcaneus is significant for various reasons. Restoration of normal anatomy has been of particular interest for fracture care. In addition, knowledge of surrounding structures is important when planning surgical approaches and vital when performing percutaneous procedures. Understanding of anatomic relationships allows discernment of the pathophysiology that is related to chronic conditions. The biomechanics of normal structures provides a theoretic basis for reconstruction and rehabilitation, and individual variations in calcaneal anatomy can be a predisposition for pathology.

Topographic anatomy The medial aspect of the calcaneus is difficult to palpate because of the intervening soft tissue structures. The posterosuperior calcaneal tuberosity typically can be distinguished as well as the sustentaculum, which lies approximately one finger breadth below the tip of the medial malleolus. The plantar surface of the calcaneus is obscured largely by the heel pad; however, the larger and broader medial process of the calcaneal tuberosity frequently is palpable compared with the small lateral process. Dorsiflexion of the toes can bring the plantar fascia into tension and allow palpation of its insertion into the distal aspect of the medial tuberosity. The proximal plantar skin covers the rounded posterior inferior border of the calcaneus. Posteriorly, the skin thins and allows

* Corresponding author. E-mail address: jsizensky@psu.edu (J.A. Sizensky). 1083-7515/05/$ see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.fcl.2005.04.003

foot.theclinics.com

414

keener

&

sizensky

palpation of the Achilles tendon as it inserts into the posterior surface of the calcaneus. The medial and lateral borders are well-defined here. From the prominent superolateral corner of the tuberosity moving inferiorly, the lateral tubercle can be palpated through the glabrous skin. The abductor digiti minimi defines the posteroinferior lateral border of the foot. Dorsal to the lateral malleolus, the peroneal tubercle can be palpated. The sinus tarsi can be identified by noticing the soft tissue depression just anterior to the lateral malleolus. Further distal and more inferior, approximately two thirds the distance from the lateral malleolus to the base of the easily palpated fifth metatarsal, is the calcaneocuboid joint. The anterior process of the calcaneus can be identified here if the forefoot is adducted.

Bone morphology The calcaneus is the largest of the seven tarsal bones, transmits body weight, and provides a strong lever. There are four articular surfaces to the calcaneus (Fig. 1). The superior surface of the calcaneus is divided into an anterior portion that contains three articular facets for articulation with the talus, and a posterior portion that is smooth and terminates as the calcaneal tuberosity. The posterior facet is the largest of these, and is oval and convex along its longitudinal axis, which runs distal and lateral 458 to the sagittal plane. Because only the central portion of the facet is visible on axial (Harris-Beath) views, Brodens views that are taken with the beam directed at multiple angles allow evaluation of the entire facet [1]. The sulcus calcaneus, which separates the middle facet from the posterior facet, is the floor of the tarsal canal. The tarsal canal empties laterally and distally into the sinus tarsi, and within it are five ligamentsthe three portions of the inferior extensor retinaculum, the oblique talocalcaneal (cervical) ligament, and the ligament of the tarsal canal [2]. The middle facet, located on the upper surface of the sustentaculum tali, is concave and oval. The anterior facet is anterolateral to the middle facet and supported by the beak of the cal-

Fig. 1. The calcaneal facets are pictured from a superior view. A, anterior facet; C, calcanealcuboid facet; M, middle facet; P, posterior facet.

anatomy of the calcaneus

415

caneus. The middle and anterior facets have a variable anatomy [3]. Viladot and colleagues [3] described three variations: a combined facet, two separate facets, or congruent facets in a bean shape. The anterior and middle facets, the posterior articular surface of the navicular, and the plantar calcaneonavicular (spring) ligaments combine to form the acetabulum pedis, which contains the head of the talus [4]. The cuboid articular surface makes up the entire anterior surface of the calcaneus. It is convex horizontally and concave vertically which results in a saddle shape [5]. The bulk of the calcaneus is composed of cancellous bones contained by a thin cortical shell. Laterally, the anterior process aids in supporting the lateral process of the talus. Posterior and lateral to the anterior process is the eminentia trochlearis, or peroneal tubercle, which is the site of insertion for the peroneal retinaculum (Fig. 2). The peroneal trochlea is just posterior to this and separates the peroneal tendons. The superior groove transmits the peroneus brevis tendon, whereas the inferior groove transmits the peroneus longus tendon. Posteroinferiorly, there are two tuberosities that transmit the force of the body weight (Fig. 3) [6]. The medial tuberosity is the larger of the two. The medial surface of the calcaneus is dominated by the sustentaculum tali (Fig. 4). The inferior surface of the sustentaculum tali is grooved for the flexor hallucis longus tendon. The talocalcaneal component of the deltoid ligament and the superomedial calcaneonavicular ligament also attach to this area of strong cortical bone. On a Harris-Beath axial radiograph, sustentaculum tali is identified as the prominent medial projection and on the lateral radiograph, it is distinct secondary to its being denser than the surrounding bone. The sustentaculum also forms the lateral boundary of the tarsal tunnel with the talus. A triangle is formed by the trabeculae of the calcaneus when viewed laterally. The apex of the triangle has been termed the thalamic portion of the calcaneus and is where the pressure trabeculae converge to support the anterior and posterior facets. The base of the triangle is made up of the traction trabeculae that

Fig. 2. Lateral view of the calcaneus. B, Bohlers angle; G, crucial angle of Gissane; P, peroneal tubercle.

416

keener

&

sizensky

Fig. 3. Posterior view of the calcaneus. L, lateral process of calcaneal tuberosity; M, medial process of calcaneal tuberosity; S, sustentaculum tali.

radiate from the inferior cortex. The blood supply to the medullary cavity is believed to enter at the center of the triangle [7,8]. The crucial angle of Gissane also can be viewed on the lateral radiograph. Typically 1208 to 1458, it is formed by a line from the anterior process to the sulcus calcaneus and a line along the posterior facet. The lateral process of the talus sits within the strong cortical struts that make up the angle of Gissane, and typically is the site of the primary fracture line in joint depression-type calcaneal fractures [5,911]. Bohlers angle is formed by a line from the highest point on the calcaneal tuberosity to the highest point on the posterior articular surface and a line that extends from the highest point on the anterior process through the highest point on the posterior articular surface. Normal angles typically are reported as being between 258 and 408 and a decrease in this angle helps to quantify the degree of compression and deformity in joint depression fractures (see Fig. 2) [9,12,13].

Fig. 4. Medial view of the calcaneus. S, sustentaculum tali; T, calcaneal tuberosity.

anatomy of the calcaneus

417

Nerves and vessels The cutaneous blood supply to the skin surrounding the calcaneus is from the peroneal and posterior tibial arteries and its two branches, the medial and lateral plantar arteries. The lateral incision to the calcaneus is at risk for necrosis because of its location in the watershed between the peroneal, posterior tibial, and lateral plantar arteries [14]. The calcaneus itself is more vascular. Andermahr and colleagues [15] found that 10% of the blood supply is from the sinus tarsi artery, and the remainder is divided equally between the lateral and plantar arteries. The medial supply is from two or three arteries, generally branches of the posterior tibial artery or lateral plantar artery that penetrate the bone inferior to the sustentaculum. The lateral supply typically is from the lateral calcaneal artery off the posterior tibial artery, but occasionally is from the peroneal artery. The sinus tarsi artery is formed from branches of the lateral tarsal and lateral malleolar branches of the anterior tibial artery [2]. Laterally, the cutaneous innervation is from the lateral sural cutaneous nerve and the sural nerve and its lateral calcaneal branch. Innervation is provided by the saphenous nerve posteromedially, the superficial peroneal nerve anteriorly, and the medial calcaneal branch of the tibial nerve inferomedially [16]. The calcaneocuboid joint receives innervation from the lateral plantar, deep peroneal, and lateral dorsal cutaneous nerves. The talonavicular joint receives innervation from the medial plantar and deep peroneal nerves. The subtalar joint is innervated by the medial plantar and lateral dorsal cutaneous nerves. Occasionally, the superficial peroneal nerve continues into the accessory deep peroneal nerve and provides additional branches to the subtalar and calcaneocuboid joints [17].

Joints and ligaments The calcaneus has three articulations: subtalar, talocalcaneonavicular, and calcaneocuboid (Fig. 5). Anatomically, the subtalar joint is composed of the posterior facet of the calcaneus and the posterior articular surface of the talar body. Clinically, the subtalar joint also includes an anterior articulation, although they have two separate capsules. The posterior articulation is separated from the subtalar portion of the talocalcaneonavicular joint by the inferior extensor retinaculum and by the talocalcaneal interosseous ligament (Fig. 6). Cahill [18] described two parts of the inferior extensor retinaculum: the cruciate ligament in the tarsal canal and the oblique talocalcaneal band. Smith [19] identified two parts to the talocalcaneal interosseous ligament: the ligament of the tarsal canal and the cervical ligament. Additional support medially comes from the tibiocalcaneal portion of the deltoid ligament and the medial talocalcaneal ligament that is located posteriorly to it. Laterally, there is the calcaneofibular ligament and anterior to it is the lateral talocalcaneal ligament (Fig. 7) [16].

418

keener

&

sizensky

Fig. 5. Three views of the calcaneus. (A ) Lateral view. (B ) Medial view. (C ) Posterior view. L, lateral process of calcaneal tuberosity; M, medial process of calcaneal tuberosity; S, sustentaculum tali.

The talocalcaneonavicular joint is one continuous joint cavity and functions with the subtalar joint. The talonavicular section is part of the transverse tarsal joint and the dorsolateral portion of the capsule is made up of the calcaneonavicular portion of the bifurcate ligament. The bifurcate ligament is composed of a calcaneonavicular limb that extends from the anteromedial angle of the sinus tarsi

Fig. 6. Inferior view of talus and superior view of calcaneus illustrating the subtalar joint and its facets. A, anterior facet of the calcaneus; M, middle facet of the calcaneus; P, posterior facet of the calcaneus; T, posterior facet of the talus.

anatomy of the calcaneus

419

Fig. 7. (A ) Inferior medial view of the calcaneus and surrounding structures. (B ) Lateral view of calcaneus and bifurcate ligament composed of the calcaneonavicular (Cn) and calcaneocuboid (Cc) ligaments. F, calcaneal tuberosity; H, talar head; L, plantar calcaneonavicular (spring) ligament.

to the lateral aspect of the navicular, and a calcaneocuboid limb that extends from the intermediary tubercle of the calcaneus to the dorsal aspect of the cuboid and arranged in a Y or V configuration (Fig. 8) [20]. As in most of the foot, the plantar ligaments are the strongest and most important. The plantar calcaneonavicular ligament (spring ligament) complex is composed of a quadrangular superomedial band (the superomedial calcaneonavicular ligament) which runs from the anterior and medial margins of the sustentaculum tali to the medial one third of the navicular, a trapezoidal inferior band (the inferior calcaneonavicular ligament) which runs from the coronoid fossa of the calcaneus below the anterior and medial facets to the plantar aspect of the navicular in addition to the tibioligamentous portion of the superficial deltoid ligament (see Fig. 8) [21,22]. It helps to support the head of talus, and when disrupted, allows the talus to interpose between the calcaneus and navicular which flattens the arch and abducts the foot [16]. The calcaneocuboid joint is at the high point of the lateral longitudinal arch. Dorsally, it is supported by the bifurcate ligament and plantarly it is supported by the short and long plantar ligaments. The short plantar (plantar calcaneocuboid) ligament is deep to the long plantar ligament and separated by loose connective tissue. It runs from the anteroinferior surface of the calcaneus to the tuberosity of the cuboid. The long plantar ligament is the main support for the lateral part of the arch. Its calcaneal attachment is the entire inferior surface of the calcaneus distal to the tuberosities. The deep fibers attach to the posterior aspect of the groove for the peroneus longus tendon on the tuberosity of the cuboid. The superficial fibers envelop the tendon and insert on the lateral metatarsal bases [16].

Muscles and tendons The calcaneus serves as the origin and insertion of several muscles; additional muscles also have a close anatomic relationship (Figs. 9 and 10). Plantarly, the

420

keener

&

sizensky

Fig. 8. Ligaments of the ankle joint. The medial view shows the medial ligament, which forms a dense, almost continuous ligament. The ligaments on the lateral side, however, are usually separated from one another. From Gardner ED, Muller F, et al. Gardner-Gray-ORahilly anatomy: a regional study of human structure. Philadelphia: Saunders; 1986.

most superficial layer is the plantar aponeurosis; it runs from the medial tuberosity distally to the middle of the foot where it sends slips to each of the five digits. The most superficial muscle layer consists of the abductor hallucis and flexor digitorum brevisboth arise from the medial tuberosityand the abductor digiti minimi that arises from the lateral tuberosity and plantar surface of the calcaneus. There also are some fibers from the medial tuberosity deep to the flexor digitorum brevis. All of these muscles insert onto the proximal phalanges and help to maintain the longitudinal arch. The medial and lateral plantar nerves pass deep to the abductor hallucis. The medial plantar nerve comes medial to the flexor digitorum brevis muscle and sends motor branches to the abductor hallucis, flexor digitorum brevis, and the first lumbrical. The lateral plantar nerve courses between the flexor digitorum brevis and the quadratus and innervates the abductor digiti minimi; quadratus plantae; the lateral three lumbricals; the second, third, and fourth interossei; and the transverse head of the adductor hallucis [16]. The deeper layer is made up of the quadratus plantae and tendons of the flexor hallucis longus and flexor digitorum longus. The tendon of the flexor digitorum

anatomy of the calcaneus

421

Fig. 9. The right calcaneus, upper aspect, showing muscular and ligamentous attachments in the floor of the sinus tarsi and tarsal canal. From Gardner ED, Muller F, et al. Gardner-Gray-ORahilly anatomy: a regional study of human structure. Philadelphia: Saunders; 1986.

longus passes superficial to the quadratus plantae and flexor hallucis longus tendon and deep to the medial plantar nerve in its course to the lesser toes. The quadratus plantae takes its insertion from the calcaneus in two heads that are located medial and lateral to the long plantar ligament. The lateral headthe more tendinous of the twois variable and occasionally is missing or takes its origin from the fibula [23]. It joins with the medial head to insert on the deep surface of the flexor digitorum longus, typically at the level of its division into

Fig. 10. Schematic section (approximately coronal) or right calcaneus and talus. This is a composite representation, not all of the structures being present in any one section. From Gardner ED, Muller F, et al. Gardner-Gray-ORahilly anatomy: a regional study of human structure. Philadelphia: Saunders; 1986.

422

keener

&

sizensky

four separate tendons. It is innervated by the lateral plantar nerve that runs superficial to it [16]. Dorsally, the calcaneus gives rise to the extensor brevis muscles. It is unique in that there is no counterpart to the hand, and although it inserts on four toes, they are the medial four rather than the lateral four. Generally, the most medial belly is defined as the extensor hallucis brevis, and the lateral three make up the extensor digitorum brevis. They arise from the superior surface of the calcaneus just proximal to the calcaneocuboid joint. Their deep surface receives the terminal muscular branch from the deep peroneal nerve, and occasionally, they receive a contribution from the superficial peroneal nerve [16]. Posteriorly, the calcaneus serves as the insertion of the Achilles and plantaris tendons. The tendo Achilles comprises the tendons of the soleus and gastrocnemius. The soleus muscle is anterior to the gastrocnemius; however, as it descends to insert into the calcaneus, it rotates approximately 908 so that the soleus fibers insert mostly medially and the gastrocnemius fibers insert mostly laterally [24,25]. The insertion is on the inferior posterior surface, more medial than lateral, but does not extend to either wall [26]. Superior to its insertion is the retrocalcaneal bursa between the posterior calcaneus and the tendon (Fig. 11). A continuous heavy layer of collagen fibers continues from the Achilles tendon into the plantar fascia in neonates [27]. With age, these fibers decrease in number such that by late adulthood, these fibers seem to be absent. The plantaris inserts just medial to the tendo Achilles. Medially, the posterior tibial tendon, flexor digitorum longus tendon, posterior tibial artery and vein, tibial nerve, and flexor hallucis longus tendon pass deep to the flexor retinaculum and superficial to the deltoid ligament on their course into the foot. Their location is important to consider, especially when inserting percutaneous anteromedial transcalcaneal pins. Mekhail and colleagues [28] found that when placing a pin into the sustentaculum tali 2.5 cm distal to the medial malleolus, the neurovascular bundle is 1 cm posteroinferior. In their cadaver study, the flexor tendons were transfixed 4 out of 14 times. They found a

Fig. 11. The retrocalcaneal bursa lies between the retracted Achilles tendon (T) and the calcaneal tuberosity (C).

anatomy of the calcaneus

423

Fig. 12. Superficial lateral view of calcaneus illustrating relationship to the peroneal tendons. The instrument tip is on the peroneal tubercle.

safer alternative to be the posteromedial transcalcaneal pin site, which is located three fourths of the distance between the medial malleolus and the medial calcaneal tubercle; although the medial calcaneal artery and nerve are still at risk, injury may be avoided with blunt dissection [28]. Laterally, the peroneus longus tendon passes posteroinferior to the peroneus brevis tendon, which runs in a groove in the posterior fibula under the superior and inferior peroneal retinaculum (Fig. 12). The inferior peroneal retinaculum divides the two tendons into separate sheaths. The calcaneus contains a groove for the peroneus longus, and occasionally, is an insertion for an accessory peroneal muscle [29].

References
[1] Shereff MJ, Johnson KA. Radiographic anatomy of the hindfoot. Clin Orthop 1983;(177): 16 22. [2] Schwarzenbach B, Dora C, Lang A, et al. Blood vessels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat 1997;10(3):173 82. [3] Viladot A, Lorenzo JC, Salazar J, et al. The subtalar joint: embryology and morphology. Foot Ankle 1984;5(2):54 66. [4] Pisani G. La coxa pedis ed i movimenti torsionali astragalici [The coxa pedis and the torsional movement of the talus]. Chir Piede 1988;12:357 [in Italian]. [5] Mann RA, DuVries HL, Inman VT. Surgery of the foot: in memory of Henri L. DuVries and Verne T. Inman. 5th edition. St. Louis (MO)7 Mosby; 1986. [6] Scurran BL. Foot and ankle trauma. New York7 Churchill Livingstone; 1989. [7] Harty M. Anatomic considerations in injuries of the calcaneus. Orthop Clin North Am 1973; 4(1):179 83. [8] Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975;57(4):413 21. [9] Hall RL, Shereff MJ. Anatomy of the calcaneus. Clin Orthop 1993;(290):27 35. [10] Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg 1952;39(157):395 419. [11] Stephenson JR. Displaced fractures of the os calcis involving the subtalar joint: the key role of the superomedial fragment. Foot Ankle 1983;4(2):91 101.

424

keener

&

sizensky

[12] Mann RW. Calcaneus secundarius: description and frequency in six skeletal samples. Am J Phys Anthropol 1990;81(1):17 25. [13] Bohler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg 1931;13:7581. [14] Salmon M, Taylor GI, Tempest MN. Arteries of the skin. 1st English edition. London7 Churchill Livingstone; 1988. [15] Andermahr J, Helling HJ, Rehm KE, et al. The vascularization of the os calcaneum and the clinical consequences. Clin Orthop 1999;(363):212 8. [16] Hollinshead WH. Anatomy for surgeons. 3rd edition. Philadelphia7 Harper & Row; 1982. [17] Gardner E, Gray DJ. The innervation of the joints of the foot. Anat Rec 1968;161(2):141 8. [18] Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965;153(1):1 17. [19] Smith JW. The ligamentous structures in the canalis and sinus tarsi. J Anat 1958;92(4):616 20. [20] Golano P, Farinas O, Saenz I. The anatomy of the navicular and periarticular structures. Foot Ankle Clin 2004;9(1):1 23. [21] Davis WH, Sobel M, DiCarlo EF, et al. Gross, histological, and microvascular anatomy and biomechanical testing of the spring ligament complex. Foot Ankle Int 1996;17(2):95 102. [22] Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographic, functional. Philadelphia7 Lippincott; 1983. [23] Lewis OJ. The comparative morphology of M. flexor accessorius and the associated long flexor tendons. J Anat 1962;96:321 33. [24] White J. Torsion of Achilles tendon: its surgical significance. Arch Surg 1943;46:7847. [25] Cummins EJ, Carr BW, Wright RR. The structure of the calcaneal tendon (of Achilles) in relation to orthopedic surgery. Surg Gynecol Obstet 1946;83:107 16. [26] Chao W, Deland JT, Bates JE, et al. Achilles tendon insertion: an in vitro anatomic study. Foot Ankle Int 1997;18(2):81 4. [27] Snow SW, Bohne WH, DiCarlo E, et al. Anatomy of the Achilles tendon and plantar fascia in relation to the calcaneus in various age groups. Foot Ankle Int 1995;16(7):418 21. [28] Mekhail AO, Ebraheim NA, Heck BE, et al. Anatomic considerations for safe placement of calcaneal pins. Clin Orthop 1996;(332):254 9. [29] Hecker P. Study on the peroneus of the tarsus: preliminary notes. Anat Rec 1923;26:7982.

Vous aimerez peut-être aussi