SURGICAL SURGICAL ANATOMY OF ANATOMY OF
DIABETIC FOOTDIABETIC FOOT
DR.ARUN BALDR.ARUN BALMUMBAIMUMBAI
Leonardo da Vinci described the foot as
“A masterpiece of engineering and a work of art”
Dr.bal
HUMAN FOOT IN HUMAN FOOT IN EVOLUTIONEVOLUTION
HUMAN FOOT HAS CULTURAL HUMAN FOOT HAS CULTURAL VARIATIONSVARIATIONS
INDIAN FEET HAVE SHALLOW INDIAN FEET HAVE SHALLOW MEDIAL ARCHMEDIAL ARCH
SHALLOW MEDIAL ARCH SHALLOW MEDIAL ARCH INCREASES MEDIAL MOBILITY AT INCREASES MEDIAL MOBILITY AT MIDTARSAL JOINTSMIDTARSAL JOINTS
HUMAN FOOT IN EVOLUTION
QUADRUPEDAL REQUIRES FOR GRIPPING ABILITY ORTHOGRADE/BIPEDAL REQUIRES FOR ABILITY TO SUPPORT
Dr.bal
SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE DIABETIC FOOT THE DIABETIC FOOT
FOOTFOOTTHE FOOT CONSISTS OF:THE FOOT CONSISTS OF:29 JOINTS (8 MAJOR & 29 JOINTS (8 MAJOR & 21 MINOR)21 MINOR)
26 BONES26 BONES42 MUSCLES42 MUSCLES
PLANTAR PLANTAR ARCHESARCHES
ARCHES OF FOOTARCHES OF FOOTLONGITUDINALLONGITUDINALTRANSVERSETRANSVERSE
LONGITUDINAL ARCHESLONGITUDINAL ARCHESMEDIAL: MEDIAL: HIGHERHIGHER MORE MOBILEMORE MOBILE RESILIENTRESILIENTLATERAL:LATERAL:LOWLOW LIMITED MOBILITYLIMITED MOBILITY BUILT TO BEAR WT.BUILT TO BEAR WT.
MEDIAL LONGITUDINAL MEDIAL LONGITUDINAL ARCHARCH
CAL-TAL-NAV-CUN-THREE MED MTCAL-TAL-NAV-CUN-THREE MED MT ENDEND:HEADS OF MEDIAL THREE MT:HEADS OF MEDIAL THREE MT SUMMITSUMMIT:SUP.ART.SURFACE - TALUS:SUP.ART.SURFACE - TALUS ANT.PILLAR:ANT.PILLAR:TALUS-NAV-THREE MTTALUS-NAV-THREE MT POST PILLAR:POST PILLAR:MEDIAL HALF OF CALMEDIAL HALF OF CAL
LATERAL LONGITUDINAL LATERAL LONGITUDINAL ARCHARCH
CALCANEUM-CUBOID-TWO LAT MTCALCANEUM-CUBOID-TWO LAT MT ENDEND:HEADS OF 4TH&5TH MT:HEADS OF 4TH&5TH MT SUMMIT:SUMMIT:SUP.SURFACE OF CALSUP.SURFACE OF CAL ANT.PILLAR:ANT.PILLAR:CUBOID-TWO LAT MTCUBOID-TWO LAT MT POST.PILLAR:POST.PILLAR:LAT.HALF OF CALLAT.HALF OF CAL
TRANSVERSE ARCHES
MEDIAL:MEDIAL: PLANTAR APONEUROSISPLANTAR APONEUROSIS FLEX.DIG.BREVISFLEX.DIG.BREVIS ABDUCTOR HALLUSISABDUCTOR HALLUSIS TIBIALIS ANTERIORTIBIALIS ANTERIOR TIBIALIS POSTERIORTIBIALIS POSTERIOR FLEX.HAL.LONGUS FLEX.HAL.LONGUS
MAINTENANCE OF FOOT MAINTENANCE OF FOOT ARCHESARCHES
MAINTENANCE OF FOOT MAINTENANCE OF FOOT ARCHESARCHES
LATERALLATERAL:: LATERAL PLANTAR LATERAL PLANTAR APONEUROSOS .APONEUROSOS . ABD.DIG.MINIMIABD.DIG.MINIMI PERONEUS LONGUSPERONEUS LONGUS PERONEUS BREVIS PERONEUS BREVIS
FUNCTIONS OF FOOT FUNCTIONS OF FOOT ARCHESARCHES
DISTRIBUTION OF BODY WEIGHTDISTRIBUTION OF BODY WEIGHT ELASTICITY HELPS IN WALKINGELASTICITY HELPS IN WALKING SHOCK ABSORBERSHOCK ABSORBER CONCAVITY PROTECTS SOFT CONCAVITY PROTECTS SOFT
TISSUES AND BLOOD VESSELSTISSUES AND BLOOD VESSELS
LIGAMENTS OF LIGAMENTS OF FOOTFOOT
LIGAMENTS OF FOOTLIGAMENTS OF FOOTDELTOID LIGAMENTDELTOID LIGAMENTLATERAL LIGAMENTLATERAL LIGAMENTSPRING LIGAMENTSPRING LIGAMENTLONG PLANTAR LIGAMENTLONG PLANTAR LIGAMENTSHORT PLANTAR LIGAMENTSHORT PLANTAR LIGAMENT
LATERAL LIGAMENT
DELTOID LIGAMENT
PLANTAR(FASCIALPLANTAR(FASCIAL) SPACES) SPACES
MEDIAL PLANTAR SPACEMEDIAL PLANTAR SPACE DORSAL:DORSAL:INF SURFACE OF 1STMTINF SURFACE OF 1STMT MEDIAL:MEDIAL:PLANTAR FASCIA EXTENSIONPLANTAR FASCIA EXTENSION LATERALLATERAL::INTERMUSCULAR SEPTUMINTERMUSCULAR SEPTUM
CONTENTS:CONTENTS: ADD.HALLUSISADD.HALLUSIS FLEXOR H.LONGUSFLEXOR H.LONGUS TIB.POSTERIORTIB.POSTERIOR FLEXOR H.BREVIS FLEXOR H.BREVIS PERONEAL LONGUS PERONEAL LONGUS
CENTRAL PLANTAR CENTRAL PLANTAR SPACESPACE
INFERIOR:INFERIOR:PLANTAR FASCIAPLANTAR FASCIA LATERAL:LATERAL:INTERMUSCULAR SEPTUMINTERMUSCULAR SEPTUM DORSAL:DORSAL:TARSOMETATARSAL JTSTARSOMETATARSAL JTS
CONTENTS: CONTENTS: FLEXOR DIG LONGUSFLEXOR DIG LONGUS FLEXOR DIG BREVISFLEXOR DIG BREVIS LUMBRICALSLUMBRICALS PERONEAL&POST TIB.PERONEAL&POST TIB. ADD.HAL.MUSCLEADD.HAL.MUSCLE
LATERAL PLANTAR LATERAL PLANTAR SPACESPACE
DORSAL:DORSAL: 5TH METATARSAL5TH METATARSAL MEDIAL:MEDIAL:INTERMUSCUALR SEPTUMINTERMUSCUALR SEPTUM LATERAL:LATERAL:PLANTAR FASCIAPLANTAR FASCIA
CONTANTSCONTANTS::ABDUCTOR DIG.ABDUCTOR DIG. FLEXOR DIG QUINTIFLEXOR DIG QUINTI SMALL MUSCLES OF SMALL MUSCLES OF 5TH TOE5TH TOE
CONCEPT OF PLANTAR SPACES
PLANTAR SPACES
SURGICAL TREATMENT SURGICAL TREATMENT OF DIABETIC FOOTOF DIABETIC FOOT
MID FOOT MID FOOT ABCESS WITH ABCESS WITH TOE GANGRENETOE GANGRENE
Dr.bal
SURGICAL TREATMENT SURGICAL TREATMENT OF DIABETIC FOOTOF DIABETIC FOOT
DRAINAGE DRAINAGE OF MID FOOT OF MID FOOT ABCESS-ABCESS-POST POST OPERATIVEOPERATIVE
Dr.bal
PLANTAR PLANTAR FASCIAFASCIA
SUP.TRAN.MT.
LIGAMENTS
TRANS.
FASCIC.
ROLE OF PLANTAR FASCIA IN LJM
ROLE OF PLANTAR ROLE OF PLANTAR FASCIA IN FOOT FASCIA IN FOOT
ULCERATIONULCERATION RUPTURE OF PLANTAR FASCIARUPTURE OF PLANTAR FASCIA ATTACHMENT OF PLANTAR FASCIA ATTACHMENT OF PLANTAR FASCIA
TO SKIN UNDER 1ST MT TO SKIN UNDER 1ST MT GLYCATION OF FASCIA CHANGES THE GLYCATION OF FASCIA CHANGES THE
LOADING PATTERN OF THE FOOTLOADING PATTERN OF THE FOOT
ARTERIES OF THE ARTERIES OF THE FOOTFOOT
ARTERIES OF THE ARTERIES OF THE FOOTFOOT
POST.TIBIAL IS DOMINANT VESSELPOST.TIBIAL IS DOMINANT VESSEL POST.TIBIAL IS CLOSELY RELATED TO POST.TIBIAL IS CLOSELY RELATED TO
THE TENDON OF F.H.L.THE TENDON OF F.H.L. LAT.PLANTAR ARTERY IS MAJOR LAT.PLANTAR ARTERY IS MAJOR
BRANCH OF POST.TIBIALBRANCH OF POST.TIBIAL ANT.TIBIAL CONTRIBUTES TO THE ANT.TIBIAL CONTRIBUTES TO THE
BLOOD SUPPLY TO 1,2 DIGITSBLOOD SUPPLY TO 1,2 DIGITS
POPLITEAL
ARTERY
TIBIOPERONEAL
TRUNK
POST TIBIAL
PERONEAL
ANT.TIBIAL
SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE FOOTTHE FOOT
ARTERIES OF ARTERIES OF THE FOOTTHE FOOT
CAUSE OF NEUROPATHIC ODEMA
CROWDING OF TOES CAUSING ARTERIAL THROMBOSIS
ANATOMY OF THE HEEL
NERVES OF THE FOOTNERVES OF THE FOOT
PERONEAL N.TIBIAL NERVE
TIBIAL N
LATERALPLANTARNERVE
MEDIAL
PLANTAR
NERVE
FOOT FOOT MOVEMENTSMOVEMENTS
AXIS OF ANKLE MOVEMENT
FOOT FOOT BIOMECHANICSBIOMECHANICS
NORMAL WALKING CYCLENORMAL WALKING CYCLE
Initial contact Forefoot contact
Heel lift Toe-off
Dr.bal
HEEL STRIKEHEEL STRIKE
Initial contact Start midstace Start foot flat
Dr.bal
MIDSTANCE PHASEMIDSTANCE PHASE
Start mischance Start foot flat Heel lift
Dr.bal
PROPULSION PHASEPROPULSION PHASE
Heel lift Toe-off
Dr.bal
Neutral Neutral PositionPosition
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal
Rear-Rear-foot foot
pronatiopronationn
(Valgus)(Valgus)
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal
Rear-foot supinatio
n(varus)
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal
IMPULSE LOADING IMPULSE LOADING IS MORE IS MORE
RELEVENT THAN RELEVENT THAN ONLY HIGH ONLY HIGH PRESSUREPRESSURE
IMPULSE LOADING IMPULSE LOADING IS PRODUCT OF IS PRODUCT OF PRESSURE AND PRESSURE AND
GROUND CONTACT GROUND CONTACT TIMETIME
Excessive pronation (cont.)
DISORDERS OF THE FOOT
Dr.bal
MAJORITY OF DIABETIC FOOT ULCERS ARE IN THE REGION OF 1ST MTP JOINT
FOOT FOOT PATHOBIOMECHANIPATHOBIOMECHANI
CSCS
HALLAUX RIGIDUS
HALLAUX RIGIDUS
MECHANISM OF DIABETIC MECHANISM OF DIABETIC FOOT ULCERFOOT ULCER
ROLE OF ROLE OF HALLAUX HALLAUX RIGIDUS AND RIGIDUS AND SUBCUT.PAD SUBCUT.PAD OF FATOF FAT
PATHO BIOMECHANICS PATHO BIOMECHANICS OF DIABETIC FOOT OF DIABETIC FOOT
ULCERULCER
MECHANISM MECHANISM OF DIABETIC OF DIABETIC FOOT ULCERFOOT ULCER
Dr.bal
HAMMER TOE
MALLET TOE
CLAW TOE
HAWAI(WEB & HAWAI(WEB & TOE STRAP) TOE STRAP) SLIPPERS SLIPPERS
ACCENTUATE TOE ACCENTUATE TOE DEFORMITIESDEFORMITIES
HAWAI SLIPPERS /STANDING
HAWAI SLIPPERS /WALKING
TOE PRESSURE
PATHO- BIOMECHANICS PATHO- BIOMECHANICS OF DIABETIC FOOT OF DIABETIC FOOT
ULCCEERULCCEER
BIOMECHANICBIOMECHANICS OF FORE S OF FORE FOOT FOOT AMPUTATIONAMPUTATION
Dr.bal
PATH -BIOMECHANICS OF PATH -BIOMECHANICS OF DIABETIC FOOT ULCERDIABETIC FOOT ULCER
BIOMECHANICBIOMECHANICS OF S OF FOREFOOT FOREFOOT AMPUTATIONAMPUTATION
Dr.bal
NORMAL AXIS OF MTP JTS
CAUSE OF 2ND MT ULCER
SEPARATION 1ST AND 2ND CUNEIFORM IN CHARCOT`S FOOT
SEPARATION OF 1ST AND 2ND CUNEIFORM IN CHARCOT`S FOOT
ANGLE OF ADDUCTUSPRIMUS
LISFRANC`S JOINT
CHARCOT`S FOOTCHARCOT`S FOOT
EARLIEST EARLIEST RADIOLOGICAL RADIOLOGICAL SIGNSIGN
Dr.bal
LISFRANC`S JOINT
LOAD TRAINGLE
AXISOF
WEIGHTTRANSMISSION
BILATERAL CHARCOT FOOT
SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE DIABETIC FOOTTHE DIABETIC FOOT
NEURO ARTHROPATHY NEURO ARTHROPATHY OCCURS:OCCURS:
60% IN TARSAL &TARSO MT 60% IN TARSAL &TARSO MT JOINTSJOINTS
30% META TARSO 30% META TARSO PHALANGEAL JOINTSPHALANGEAL JOINTS
10% ANKLE JOINTS10% ANKLE JOINTS
SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE FOOTTHE FOOT
FOOT SIZE FOOT SIZE
DOES NOT DOES NOT CHANGE WITH CHANGE WITH AGE BUT AGE BUT SHAPE SHAPE CHANGESCHANGES
MECHANISM OF PES CAVUS
ANATOMICAL BASIS OF ANATOMICAL BASIS OF SPREADING FOOT SPREADING FOOT
INFECTIONINFECTION
FOOT IS MOST FOOT IS MOST ENERGY EFFICIENT ENERGY EFFICIENT
MACINE.THIS MACINE.THIS ENERGY EFFECIENCY ENERGY EFFECIENCY
IS LOST IN IS LOST IN DIABETES DUE TO DIABETES DUE TO
NEUROPATHYNEUROPATHYDr.bal
HUMAN FOOT CAN NOT HUMAN FOOT CAN NOT BE STUDIED IN BE STUDIED IN
EXPERIMENTAL ANIMAL EXPERIMENTAL ANIMAL MODELSMODELS
FUNDAMENTAL PRINCIPLE FUNDAMENTAL PRINCIPLE OF DIABETIC FOOTWEAROF DIABETIC FOOTWEAR
FOOTWEAR FOOTWEAR SHOULD DO WHAT SHOULD DO WHAT FOOT CAN NOT DOFOOT CAN NOT DO
TAKE HOME MESSAGETAKE HOME MESSAGE
KNOWLEDGE OF FOOT KNOWLEDGE OF FOOT ANATOMY & BIOMECHANICS ANATOMY & BIOMECHANICS IS ESSENTIAL FOR IS ESSENTIAL FOR PREVENTION OF HIGHER PREVENTION OF HIGHER LEVEL AMPUTATION IN LEVEL AMPUTATION IN DIABETESDIABETES
An ancient Sanskrit saying.“The one who walks, his good fortune also
marches ahead.”
PRESERVE & PROTECT THEM
THANK THANK YOUYOU
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