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50
2 Anatomy oftheHand andFoot
a
b
Fig. 2.57 Blood vessels of toe. (a) Dorsal blood vessels of toe (the ap
turned from tibia to bular). (b) Plantar blood vessels of toe. (1) Dorsal
artery of foot. (2) First dorsal metatarsal artery. (3) Dorsal artery of great
metatarsal space and gives off dorsal lateral nerve of great
toe and dorsal lateral nerve of second toe, which innervate
the skin adjacent to great toe and second toe, as well as the
rst dorsal interossei, intertarsal joint and metatarsophalangeal joint.
Deep Structures
Tendons ofToe
Dorsal aponeurosis of toe or extensor device is similar to that
of nger, located on dorsum of toe. Dorsal aponeurosis of toe
is less functionally important than aponeurosis dorsalis digiti
and unlike hand, lacks sagittal band, tendinous cap, and support band system.
Extensor pollicis longus of great toe passes along the dorsal side of rst metatarsal bone and terminates at aponeurosis
of great toe. Extensor longus of toe goes forward along dorsum of foot and terminates at aponeurosis of second to fth
toe. (4) Plantar deep arc. (5) First plantar metatarsal artery. (6) Common
plantar digitorum artery. (7) Tibia common plantar digitorum artery of
great toe. (8) Fibular common plantar digitorum artery of great toe
toe. Extensor pollicis brevis of toe and extensor digitorum
brevis run laterally to the deep surface of extensor longus,
and fuse with extensor longus to form dorsal aponeurosis of
toe on the dorsal side of proximal phalanx. First dorsal interossei originate from the opposite plane of rst and second
metatarsal bodies, passing through deep transverse ligament
that reaches the medial side of the base of proximal phalanges of second toe and dorsal aponeurosis of toe.
Arteries ofToe
Each toe is supplied by four arteries: tibial and bular dorsal
digitorum arteries, and tibial and bular plantar digitorum
arteries (Fig. 2.57). They are the continuation of dorsal
metatarsal artery and plantar metatarsal artery, respectively,
and become terminal branches.
First dorsal metatarsal artery: It originates from dorsal
artery of foot before that penetrates plantar pedis, and moves
forward along the surface of rst dorsal interossei, and
a
2.3 Applied Anatomy oftheFoot
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51
divides into three dorsal arteries of toe at the proximal phalangeal bone. The medial one is distributed on the medial
margin of great toe through the deep surface of extensor pol-
second dorsal metatarsal artery or second plantar metatarsal
artery should be considered as the supplying artery, rather
than rst dorsal metatarsal artery.
licis longus of great toe, while the lateral two are distributed
on the adjacent sides of rst and second toes.
The distal end of rst dorsal metatarsal artery can be con-
nected to bular common plantar digitorum artery of great
Bones ofFoot
Bones of foot include tarsals, metatarsals, and phalanges
(Fig.2.58).
toe (49%), to the bifurcation of tibial common plantar digitorum artery of second toe, and bular common plantar digitorum artery of great toe (23%), or the blood supply of the
great toe is mainly supplied by the branch of rst dorsal
metatarsal artery (38%). Therefore, in second toe transfer,
Fig. 2.58 Bones of foot. (a)
Dorsal side. (b) Plantar side.
(1) Talus. (2) Calcaneus. (3)
Navicular bone. (4)
Tuberositas ossis navicularis.
(5) Cuboid bone. (6) First
cuneiform bone. (7) Second
cuneiform bone (8) Third
cuneiform bone. (9) First
metatarsal bone. (10) Second
metatarsal bone. (11) Third
metatarsal bone. (12) Fourth
metatarsal bone. (13) Fifth
metatarsal bone. (14)
Tuberosity of fth metatarsal
bone. (15) Base of metatarsal
bone. (16) Shaft of metatarsal
bone. (17) Metatarsal bone
head. (18) Base of phalanges.
(19) Shaft of phalanges. (20)
Trochlear of phalanges. (21)
Proximal phalanges. (22)
Middle phalanges. (23) Distal
phalanges. (24) Sesamoid
bone
Tarsal Bone
There are seven tarsal bones, which are equivalent to carpal
bones of hand, but tarsal bones not only bear weight but also
transmit strong jumping force, so their shape, size, and
b
52
2 Anatomy oftheHand andFoot
arrangement are different from carpal bones. Tarsal bones
are large and tightly assembled, forming the posterior half of
bones of foot.
Talus
Above the other tarsal bones, it has three parts: head, neck,
and body. The front end is the round head, the back of the
head is the neck, and then it is the larger body. The upper part
of the body is called trochlea of talus, and the upper part is
connected with the inferior tibial articular surface. The
medial half-moon articular surface is related to the medial
malleolus, and the lateral triangle articular surface is related
to the lateral malleolus. There are three articular surfaces
below the body, namely, anterior, middle, and posterior,
respectively, corresponding with articular surface above calcaneus. There is an oblique and outward sulci tali between
the middle and posterior articular surfaces.
Calcaneus
The largest, approximately oblong, is located below talus,
with the anterior two-third supporting talus and the posterior one-third forming bulge of calcaneus. There are also
three articular surfaces on calcaneus, the posterior articular
surface corresponds to the posterior articular surface of
talus and forms talocalcaneal joint, and the anterior and
middle articular surfaces, together with talus and navicular
bone, form talocalcaneonavicular joint. There is also a bone
groove between middle and posterior articular surface
which is conformed with sulci tali and forms tarsal sinus.
The medial side of the calcaneus has sustentaculum talus,
which supports talus. The posterior end forms calcaneal
tubercle, and the anterior articular surface connects with
cuboid bone.
Navicular Bone
It is located between the head of talus and the three cuneiform bones and is articulated with cuneiform bones on anterior side, the posteriorly adjacent to talus, the medial
eminence is tuberositas ossis navicularis, which is easily palpable invivo.
Cuboid Bone
It is an irregular cube between calcaneus and fourth and fth
metatarsals. The posterior part is involved in forming calcaneocuboid joint. The anterior part, fourth and fth metatarsals
form tarsometatarsal joint. The middle part of medial surface
may be articulated with third cuneiform bone.
Cuneiform Bones
There are three, wedge-shaped, wide at the top and narrow at
the bottom, laid between navicular bone and the rst, second,
and third metatarsal bones. The rst and third metatarsal
bones are longer, while the second metatarsal bone is the
shortest. Therefore, the second metatarsal bone is relatively
xed between the three metatarsal bones.
Metatarsal Bones
Metatarsal bones, roughly similar to metacarpal bones, are
short, tubular bones located between the tarsal bones and
phalanges of toe and forms the middle part of foot. There are
ve pieces, whose shape and arrangement are roughly similar to metacarpal bones but longer and wider. The lateral side
of the bottom of fth metatarsal bone is particularly enlarged,
forming tuberosity of the fth metatarsal bone, which is easily palpable invivo.
Phalanges ofToe
The phalanges of toe are roughly similar to phalanges of nger, with a total of 14. Except for phalanges of great toe,
which are strong and have two segments, the other phalanges
of toe are far smaller than the phalanges of nger, all of
which are three segments.
Joints andLigaments ofFoot
The joints of foot include talocrural (ankle) joint, intertarsal
joint, tarsometatarsal joint, intermetatarsal joint, metatarsophalangeal joint, and interphalangeal joint of foot (Fig.2.59).
Ankle (Talocrural)Joint
The bony component of ankle joint is composed of the inferior tibial articular surface, the ankle articular surface and the
ankle articular surface of bula and the upper, medial and
lateral ankle articular surface of talus. The lateral malleolus
is at and long, 0.5cm longer than the medial malleolus, and
it moves backward about 1cm. The articular surface of lower
tibia is concave and the medial malleolus is blunt and conical. The joint capsule starts from the inferior articular surface
of tibia and the periphery of tibial and bular anklebone and
ends down at the edge of trochlea of talus and above talus
neck. The synovial membrane of joint capsule not only covers the inner surface of brous membrane, but also reaches
interosseous ligament along tibia and bula. The anterior and
posterior walls of the capsule are thin and loose, the lateral
walls are tense, and strengthened by tough collateral ligaments, including: (1) Tibial collateral ligament, also known
as triangular ligament, is a strong triangular bundle of bers
located on the medial side of the joint and is closely attached
to the joint capsule. It starts from the anterior and posterior
margin and tip of medial malleolus and fanning down to tarsal bones. According to the different attachment sites of the
bers in each part of the ligament, the ligament can be
divided into four parts: posterior tibial part, heel tibial part,
navicular tibial part, and anterior tibial part (Fig. 2.59,
Table 2.4). (2) Lateral collateral ligament: It is connected
between lateral malleolus, talus, and calcaneus, and consisted of three independent ligaments.
2.3 Applied Anatomy oftheFoot
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53
a
c
b
Fig. 2.59 Ligaments of foot. (a) Medial side view. (b) Lateral side
view. (c) Plantar side view. (1) Calcaneotibial ligament. (2)
Tibionavicular ligament. (3) Posterior talotibial ligament. (4) Anterior
talotibial ligament. (5) Plantar calcaneonavicular ligament. (6)
Calcaneocuboid ligament. (7) Plantar ligament longus. (8) Medial talo-
Table 2.4 ligaments of talocrural joint and intertarsal joint
Name Origin Course Insertion
Tibial collateral
ligament
Lateral collateral
ligament
Posterior talotibial
ligament
Calcaneotibial
ligament
Tibionavicular
ligament
Anterior talotibial
ligament
Anterior talobular
ligament
Calcaneobular
ligament
Posterior talobular
ligament
Posterior margin of
medial malleolus
Tip of medial malleolus Down Parentalus process of calcaneus
Anterior margin of
medial malleolus
Anterior margin of
medial malleolus
Anterior margin of lateral
malleolus
Slightly anterior of tip of
lateral malleolus
Posterior margin of
lateral malleolus
calcaneal ligament. (9) Posterior talocalcaneal ligament. (10) Peroneus
longus. (11) Plantar calcaneocuboid ligament. (12) Plantar calcaneonavicular ligament. (13) Tibialis anterior. (14) Tibialis posterior. (15)
Peroneus longus. (16) Plantar metatarsal ligament. (17) Plantar metatarsal ligament
Oblique backward
and down
Oblique forward and
down
Oblique forward Anterior margin of the medial malleolus articular
Forward and inside Anterior to lateral malleolus articular surface of
Oblique backward
and down
Transverse backward
and inside
Medial side of the talus, small nodules on
posterior process of talus
Tuberositas ossis navicularis, medial margin of
plantar calcaneonavicular ligament
surface of talus
talus, lateral side of talus neck
Small tubercle on the lateral surface of calcaneus
Process of posterior side of talus
54
2 Anatomy oftheHand andFoot
Intertarsal Joints
There are many intertarsal joints, including subtalar (talocalcaneal) joint, talocalcaneonavicular joint, calcaneocuboid
joint, transverse tarsal joint, intercuneiform joints, cuneonavicular joint, and cuneocuboid joint.
Subtalar (Talo-Calcaneal) Joint
The bony composition consists of the posterior articular surface of talus and the posterior articular surface of calcaneus.
The joint capsule is thin and abby, attached to the periphery
of the joint surface. The synovial layer is independent and
does not communicate with other joints. There are four
ligaments around the capsule. (1) Anterior talocalcaneal ligament: Posterior to the entrance of tarsal sinus, starting from
the neck of talus and ending above calcaneus; (2) posterior
talocalcaneal ligament: It starts from posterior process of
talus and the groove of lower edge of exor longus of great
toe, and stops at the posterior articular surface of calcaneus.
(3) medial talocalcaneal ligament: It is thin and strong, starting from the medial side of posterior process of talus (tibial
tubercle), oblique forward and below, ending at the posterior
part of calcaneal parientalis; (4) lateral talocalcaneal ligament: It is oblate and short, located anteriorly above calcaneobular ligament, starting from external process of talus,
extending posteriorly and terminating on the lateral surface
of calcaneus which has the effect that prevents backward
dislocation.
Talocalcaneonavicular Joint
The articular head is the navicular articular surface of
talus, and the articular fossa consists of the posterior articular surface of navicular bone, the anterior articular surface and the middle articular surface of calcaneus, and the
upper part of plantar calcaneonavicular ligament. The capsule attaches to the periphery of the articular cartilage and
is thinner at the front and thicker at the back. There are the
following ligaments around the joint. (1) Talocalcaneal
ligament is made up of a number of strong brous bundles.
Starting from the top of tarsal sinus, oblique outward and
downward, ending in front of the posterior articular surface of calcaneus and migrating with the anterior wall of
talocalcaneal capsule. Prevent backward dislocation of
foot; (2) plantar calcaneonavicular ligament: It is strong
and hypertrophic and consists of brous cartilage. Starting
from the anterior margin of calcaneal parentalus process
and ending below and medial to navicular bone. (3)
Bifurcate ligament: It is a strong ligament, divided into
two parts, medial and lateral. The medial part is called calcaneonavicular ligament, which is obliquely forward
medially and terminates at the lateral side of navicular
bone. The upper and lower parts of this ligament fuse with
dorsal and plantar calcaneonavicular ligament, respectively. The lateral part is called calcanocuboid ligament
and attaches forwards to the upper part of cuboid bone; (4)
Dorsal talonavicular ligament: It is broad and thin, starting
from the upper and lateral sides of the neck of talus and
above navicular bone.
Calcaneocuboid Joint
Calcaneocuboid joint is consisted of the cuboid articular surface of calcaneus and the posterior articular surface of cuboid
bone. The capsule is attached to the periphery of the articular
cartilage. The articular cavity is sometimes communicated
with talocalcaneonavicular joint. The peripheral ligaments
include: (1) calcaneocuboid part of bifurcate ligament; (2)
dorsal calcanocuboid ligament; (3) long plantar ligament,
and; (4) plantar calcanocuboid ligament.
Slight sliding and rotation of calcaneocuboid joint may
occur when the foot is varus or valgus. Calcaneocuboid joint
and talocalcaneonavicular joint form transverse tarsal joint,
and the joint line is “S” shaped across the middle division of
the tarsal bone group. The two joint cavities are not communicated with each other, so they are actually two independent
joints anatomically. Clinically, amputation is often performed along this joint line.
Cuneonavicular Joint
It is usually syndesmosis, located between the lateral margin
of navicular bone and the medial margin of cuboid bone, but
the joint formation is not uncommon. There are three ligaments around the joint: (1) dorsal cuneonavicular ligament;
(2) plantar cuneonavicular ligament, and; (3) inter cuneonavicular ligament.
Cuneocuboid Joint andIntercuneiform Joints
Cuneocuboid joint is located between the outer side of lateral cuneiform bone and the inner side of cuboid bone, and
intercuneiform joints are located among the three cuneiform
bones. They have a joint capsule and joint cavity in common, and communicate with cuneonavicular joint. The following ligaments around them: (1) Dorsal cuneocuboid
ligament; (2) plantar cuneocuboid ligament; (3) dorsal intercuneiform ligaments; (4) inter cuneocuboid ligament; (5)
plantar intercuneiform ligament, and; (6) intercuneiform
ligaments.
Intercuneiform joints, cuneonavicular joint, cuneocuboid
joint, and cuneonavicular joint only slide slightly at the start
of a run or jump.
Tarsometatarsal Joint
The structural characteristics of tarsometatarsal joint.
Tarsometatarsal joints are located in front of medial cuneiform bone and rst metatarsal base, in front of medial and
lateral cuneiform bones, and second and third metatarsal
base, in front of cuboid bone and fourth and fth metatarsal
base. The rst has a separate joint capsule and joint cavity.
2.4 Anatomy ofFinger Reconstruction by Transplantation ofFoot Flaps
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55
The joint capsule and joint cavity of the second and third
parts are communicated with intercuneiform joint and cuneonavicular joint. The following ligaments are around the joint:
(1) Dorsal tarsometatarsal ligament; (2) Plantar tarsometatarsoal ligament, and; (3) Inter tarsometatarsal ligaments.
Tarsometatarsal are plane joints, that can make slight sliding and exion and extension movement, rely on medial and
lateral tarsometatarsal joints can also make slight adduction
and abduction movement.
Intermetatarsal Joints
There are three intermetatarsal joints, located between the
base of second to fth metatarsal bones. There is no
independent joint capsule and joint cavity, often connected
with tarsometatarsal joints. There is no joint between rst
and second metatarsals. The following ligaments are around
the joints: (1) Dorsal metatarsal ligament; (2) Plantar metatarsal ligament; (3) Inter metatarsal ligament.
Only slight sliding of intermetatarsal joints can be done.
Metatarsophalangeal Joints
The bony portion of metatarsophalangeal joint consists of
the head of metatarsal bone and the proximal phalangeal
base. The joint capsule is loose, which is thinner on the dorsal side and thicker on the plantar side, attached to the
periphery of the joint surface. The following ligaments are
around the joints: (1) Collateral ligaments; (2) Plantar deep
transverse ligament; (3) Plantar ligament.
Slight exion, extension, adduction, and abduction of
metatarsophalangeal joint can be made.
Interphalangeal Joint ofFoot
There are nine interphalangeal joints, consisting of distal,
middle, and proximal phalanges except great toe which consisted of distal phalanx base and proximal phalanx trochlea.
The capsule is attached to the edges of the articular surfaces
of the two bones. The following ligaments are around the
joints: (1) Collateral ligaments; (2) Dorsal ligament; (3)
Plantar ligament.
2.4 Anatomy ofFinger Reconstruction by
Transplantation ofFoot Flaps
The skin of foot and hand is similar in color and texture, with
obvious anatomical signs, constant blood supply, abundant
tissue, and sensory nerves inside. Foot (muscle) ap is the
most commonly used (muscle) ap in clinic, especially for
repairing tissue defects of hand and nger reconstruction. It
has the advantage that other parts (muscle) ap cannot be
replaced. This section mainly introduces dorsal perforator
aps of foot, dorsal medial and lateral perforator aps of
foot, toe (perforator) aps, and plantar aps.
2.4.1 Perforator Flap withDorsalis Pedis
Artery
Proximal transposition of this ap can repair soft tissue
defects of heel, ankle, and posterior tibia, distal pedicled ap
can repair soft tissue defect in distal foot, free ap transplantation can be used to repair soft tissue defects in hand and for
nger reconstruction.
Applied Anatomy
Dorsalis pedis artery is divided into two terminal branches:
rst dorsal metatarsal artery and deep plantar artery at the
proximal side of rst and second metatarsal space on the
deep surface of extensor hallucis brevis, after passing
between extensor digitorum longus tendon and extensor hallucis longus tendon, crossing dorsum of talus, navicular
bone, and second cunieform bone. The main cutaneous
branches of dorsalis pedis are concentrated in the proximal
segment (2 cm below the origin) and the distal segment
(2cm before the initiation of rst dorsal metatarsal artery).
The main branches of dorsalis pedis artery are medial tarsal
artery and lateral tarsal artery. The former originates medially from the artery at the talus plane and runs through the
deep surface of extensor hallucis longus tendon to the medial
margin of foot. The latter originates laterally from the artery
and runs forward and outward on the deep surface of extensor digitalis brevis to the lateral margin of foot. Dorsalis
pedis artery has two accompanying veins, great saphenous
vein, and small saphenous vein, which form a dorsal venous
arch on the distal dorsal side of foot (Fig.2.60). The dorsal
cutaneous nerves are medial dorsal cutaneous nerve and lateral dorsal cutaneous nerve of supercial peroneal nerve.
Dissociation oftheFlap
With the direction of dorsalis pedis artery as the axis, the ap
should be designed according to the needs of the recipient
site. The pedicle and the outer edge of the ap should be cut
rst, and the subcutaneous tissue should be lifted from the
deep surface of the deep fascia from the outside to the inside
of the ap to preserve the integrity of the periapendoneum of
tendon. The dermis and deep fascial tissue of the ap should
be xed with several stitches to protect the blood supply of
the ap. The small supercial dorsal veins at the edge of the
ap should be ligated and cut off. The ap should be separated to the rst metatarsal space, the fascia should be cut
longitudinally on the lateral side of the space, and the extensor hallucis longus tendon and extensor digitorum longus
tendon could be retracted to both sides to expose the trunk of
dorsal blood vessels. Two small branches of dorsal blood
vessels could be seen to be given off and enter the ap. Pay
attention to protect the fascia tissue around the perforators
between the pedicle and the ap. Then, to cut open the skin
and subcutaneous tissue fascia at the lateral edge of the ap,
56
2 Anatomy oftheHand andFoot
a
Fig. 2.60 Dorsalis pedis artery and branches. (a) Course of dorsalis
pedis artery and branches. (b) Cutaneous perforator of dorsalis pedis
artery. (1) Dorsalis pedis artery. (2) Anterior lateral malleolus artery. (3)
Descending perforating branch of bular artery. (4) Lateral tarsal artery.
and lift the ap inward to the vascular pedicle area. Further
dissociation of the ap would show that a thick supercial
dorsal foot vein enters the ap, which should be sharply separated proximally and carried in the ap. The rst dorsal
metatarsal artery and the deep plantar artery at the distal end
of the ap should be ligated. The ap should be lifted distally
to proximally, the extensor retinaculum should be cut open,
and the proximal retrograde separation should be performed
and branches along the way should be ligated and severed,
and long sections of dorsal vessels can be separated.
Key Points forApplication
The following points should be noted in the clinic: (1) The
direction of the dorsalis pedis artery is located at the midpoint of the line between the medial malleolus and lateral
malleolus and the midpoint of the space between rst and
second toe web. The proximal pedicle of the vessel can
extend to the proximal side as needed. The rotation axis of
the distal pedicle is proximal to rst and second metatarsal
spaces. The region of the ap can be cut is as follows: upper
to the interankle line, lower to the toe web edge, both sides to
the inner and lateral edges of dorsum of foot; (2) Allen test
must be performed preoperatively to conrm that dorsalis
pedis artery and posterior tibial artery, which supply the
blood supply to the foot, are normal. Otherwise, this operation is disabled; (3) When repairing the wound of heel, dorsal cutaneous nerve from supercial peroneal nerve should
be included in the ap, so as to make the ap have a good
sensory function after transfer; (4) Dorsal foot ap donor
area is very similar to that of dorsal hand, which can be
designed as donor ap containing extensor digitorum tendon
for the repair of complex dorsal hand defect.
b
(5) Medial tarsal artery. (6) Distal medial tarsal artery. (7) First dorsal
metatarsal artery. (8) Deep plantar artery
2.4.2 Perforator Flap withDorsal Metatarsal
Artery
The ap with dorsal metatarsal artery is a ap supplied by
dorsal metatarsal artery and its perforator branches. There
are four dorsal metatarsal arteries, and theoretically, all of
them can form vascular pedicles independently for perforator aps. However, in general, except rst dorsal metatarsal
artery, which is constant, and the extension of dorsalis pedis
artery, the other three dorsal metatarsal arteries have great
variation, so their clinical application is limited. The most
commonly used clinical perforator ap of rst dorsal metatarsal artery is located at rst toe web. Distal transfer can
repair the distal end of foot and tibial side of plantar pedis
wounds. Free transplantation can be used to repair small skin
and soft tissue defects of hand.
Applied Anatomy
First dorsal metatarsal artery is one of terminal branches of
dorsalis pedis artery, originated before dorsalis pedis artery
penetrates plantar pedis, it moves forward along the surface
of rst dorsal interossei and divides into three branches at the
shaft of proximal phalangeal bone of foot which are: Dorsal
artery of great toe, through the deep surface of extensor hallucis longus tendon, distributes to the medial margin of great
toe. Tibial dorsal artery of second toe, distributes to the tibial
side of second toe. The main trunk is turned to plantar at toe
web and can be continued into bular artery of great toe and
tibial common plantar artery second toe, either anastomosed
with rst plantar metatarsal artery or anastomosed with a
proper plantar phalangeal artery on one side (Fig.2.61). It is
varied in origin, insertion, and course of this artery, and its
2.4 Anatomy ofFinger Reconstruction by Transplantation ofFoot Flaps
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57
a
b
Fig. 2.61 The rst dorsal metatarsal artery. (a) The course, branch, and
distribution of the rst dorsal metatarsal artery. (b) Origin and distribution of perforators. (1) The rst dorsal metatarsal artery. (2) Fibular
dorsal digital artery of the great toe. (3) Tibial dorsal digital artery of
perforator is mainly given off at the origin of toe web. The
ap area is generally 10–12cm×5–7cm. The venous return
of rst dorsal metatarsal artery ap is mainly through the
supercial dorsal vein system, followed by the accompanying vein of rst dorsal metatarsal artery. The sensory nerve of
the ap comes from cutaneous branch of deep peroneal
nerve.
Dissociation oftheFlap
According to the shape and size of the wound defect, the ap
can be designed on dorsum of rst and second metatarsal
Spaces with the rst metatarsal space as the axis, generally
smaller than 4cm×4cm. If necessary, the ap could also be
lengthwise expanded, or even removed together with dorsal
foot ap or dorsal toe ap. Cut the lateral edge of the ap
according to the design line, cut the subcutaneous tissue and
the supercial layer of deep fascia, and dissociate medially
on the periapendoneum of extensor digitorum tendon and the
the second toe. (4) Anastomotic branches. (5) Deep bular nerve. (6)
The proximal perforator of the rst dorsal metatarsal artery. (7) The
distal perforator of the rst dorsal metatarsal artery. (8) Cutaneous
branch of dorsal digital artery
saroneum of dorsal interossei. Carefully identify dorsal
artery and vein of foot, dissociate the anastomosis point of
rst dorsal metatarsal artery and plantar metatarsal artery at
toe web, protect the perforator from this point, and observe
the type of rst dorsal metatarsal artery. Dissociate the
medial margin of the ap outwards to meet the contralateral
side. Local ap transplantation and free ap transplantation
can be selected according to the recipient site.
Key Points forApplication
The following points should be noted in clinic: (1)
Preoperative ultrasonographic Doppler should be used to
detect the type of the rst dorsal metatarsal artery to determine the surgical method. If the rst dorsal metatarsal artery
is missing, or the terminal artery does not enter the ap but
goes directly into plantar pedis and anastomoses with plantar
metatarsal artery, the surgical method should be changed.
The rst choice of second blood supply system is second
58
2 Anatomy oftheHand andFoot
dorsal metatarsal artery. The plantar artery and its branch
that proper plantar phalangeal artery of foot, can also be cut
to supply the ap; (2) Be familiar with the anatomical variation of rst dorsal metatarsal artery to avoid surgical failure.
One is that rst dorsal metatarsal artery starts and runs
supercial and is thin, which can easily be mistaken for
supercial dorsal vein of foot. In the other case, rst dorsal
metatarsal artery is deep but turns supercial at the head of
metatarsal bone. (3) Maintain the integrity of dorsal metatarsal artery and its terminal branch, otherwise, the blood supply to the distal end of the ap will be affected; (4) Sharply
dissociate the ap and the dissociation of rst dorsal metatarsal artery should be careful, so as not to damage the main
trunk and the small cutaneous branches. (5) Paying attention
to the protection of aponeurosis which is conducive to the
survival of skin grafts. The size of the ap should not be too
large.
a
2.4.3 Antemalleolar Flap
This perforator ap is suitable in thickness and the subcutaneous tissue is loose which can not only be used for local
transfer and repair of foot and lower leg wound, but also for
free transplantation to repair wound around dorsal hand and
wrist joint. The ap can carry some ligaments to repair extensor retinaculum while repairing the wound surface.
Applied Anatomy
The axial vessels of antemallelar perforator ap are the antemallelar perforator vessels originating from proximal dorsal
artery of foot (Fig.2.62, Table2.5). There are usually two to
four branches, among which two branches are more common, accounting for 50.00%. Three branches followed,
accounting for 40.00%; four branches accounting for
10.00%. Because of extensor retinaculum and extensor ten-
b
c
Fig. 2.62 Origin and branches of antemalleolar perforator. (a) Two
branches type (lift the ap from inward to outward). (b) Three branches
type (lift the ap from outward to inward). (c) Four branch type (lift the
ap from outward to inward). (d) Perforator anastomosis. (1) Inferior
extensor retinaculum. (2) Extensor hallucis longus tendon. (3) Extensor
d
digitorum longus tendon. (4) First perforator. (5) Second perforator. (6)
Third perforator. (7) Fourth perforator. (8) Dorsalis pedis artery. (9)
Anterior tibial artery interossei perforator. (10) Ascending perforating
branch of bular artery. (11) Supercial peroneal nerve
χ
±
2.4 Anatomy ofFinger Reconstruction by Transplantation ofFoot Flaps
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59
Table 2.5 Measurement data of perforator of antemalleolar artery
(
s )
Initial
Occurrence
Name
First
perforator
Second
perforator
Third
perforator
Fourth
perforator
Note: a Show the distance between the puncture point and the interankle
line
rate (%) Initial vessel
70.00 Dorsalis pedis
artery
100.00 Dorsalis pedis
artery
60.00 Dorsalis pedis
artery/lateral
tarsal artery
10.00 Dorsalis pedis
artery
diameter
(mm)
0.4±0.3 0.1±0.1
0.7±0.3 1.4±0.6
0.6±0.4 2.9±0.5
0.3±0.6 3.2±0.4
Puncture
pointa (cm)
don occlusions, antemalleolar perforators are difcult to
directly pass through, relatively concentrated the ber insulation among inferior extensor retinaculum, extensor hallucis
longus tendon, and extensor digitorum longus tendon to subcutaneous, and give off numerous small branches that form
three types of anastomosion: (1) The antemalleolar perforator branches anastomose with each other on the surface of
inferior extensor retinaculum and inside deep fascia to form
a fascial vascular network; (2) Anastomosed with the nutrient vessels of the upper and lower segments of supercial
peroneal nerve and supply it; (3) Anastomosed with distal
interossei perforator of anterior tibial artery descending perforator of peroneal artery, supercial peroneal artery, and
other branches. There are two groups of venous reux: the
deep group is accompanying vein, and the supercial group
is great saphenous vein. The sensory nerve is supercial
peroneal nerve.
Dissociation oftheFlap
Preoperative routine Doppler examination should be performed in the range of 0–3cm on the distal side of the midpoint of the interankle line, and select the thick perforator as
the axial point of the ap, and the longitudinal line passing
the midpoint of the interankle line should be selected as the
axis of the ap. To draw a ap line 1cm larger than the soft
tissue defect according to its preoperative size and shape.
First, make a deep to subfascial incision on the medial edge
of the ap, and then lift the ap from the inside to the outside
along the surface of extensor retinaculum. The perforator can
be found between extensor hallucis longus tendon and extensor digitorum longus tendon and nearby of the midpoint of
interankle line and the ap design should be adjusted at any
moment. Then cut open the other edges of the ap, and dissociate to puncture point until the entire pedicle of the ap is
completely dissociated. Deate tourniquet to conrm blood
supply to the ap and transfer the ap to the defect.
Key Points forApplication
The following points should be noted in clinic: (1) Because
the donor site is located in front of the ankle joint and on the
surface of extensor retinaculum and dorsal extensor tendon
of foot, the indication should be strictly grasped; (2)
Preoperative Doppler detection should be routine to determine the position and size of the perforator, select the thick
perforator to design ap pedicle; (3) During free transplantation, the great saphenous vein should be removed to repair
the defect of anterior tibial artery (dorsal artery of foot), and
the aponeurosis of inferior extensor retinaculum and dorsal
extensor tendon of foot should be kept intact as far as possible. If injured, it should be repaired smooth as far as possible.
(4) When the donor site cannot be sutured (less than 3cm,
which can usually be directly sutured), skin graft should be
performed to prevent affecting the function of ankle joint.
When the ap is large, the donor site could be covered by
medial supramalleolar ap, lateral supramalleolar ap,
supercial peroneal vessel ap, and other lower leg aps. (5)
The tension of the pedicle of the ap should be closely
observed after the operation, and extrusion or distortion
should be avoided as much as possible. The affected limb
should be immobilized and raised if necessary.
2.4.4 Medial Pedis Flap
Medial pedis ap is a non-weight-bearing area between the
medial part of plantar pedis and the medial part of dorsum of
foot. The location is concealed, the skin texture is good, and
the blood supply is multi-source. Free transplantation can
repair soft tissue defects in hand and wrist. Proximal transfer
can repair soft tissue defects of the medial malleolus and
Achilles tendon, and distal transfer can repair forefoot
wounds.
Applied Anatomy
The blood supply of medial foot is multi-source, which is
supplied by supercial branch of medial plantar artery, anterior medial malleolar artery, medial tarsal artery, and perforating branches of rst plantar metatarsal artery (Fig.2.63,
Table2.6).
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