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Functional Anatomy of Tendons and Ligaments in the Distal Limbs (Manus and Pes)

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TENDON AND LIGAMENT INJURIES: PART I 0749-0739/94 $0.00 + .20 FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS (MANUS AND PES) Jean-Marie Denoix, DVM, PhD Tendons and ligaments of the distal limbs of the horse have a prom­ inent anatomic, functional, and clinical importance. During phylogenesis, equine limbs developed special adaptation for moving at higher speed, including simplification of the distal extremity to a single and strong digit, reduction of the muscle components in the distal limbs and devel­ opment of accessory ligaments to reinforce the passive and automatic behavior of the limbs. Equine tendons and ligaments became very strong anatomic structures that sustain very high loads and strains, both while standing and moving; therefore, the function of this elastic and complex apparatus during weight bearing therefore is twofold-(l) to provide support to the fetlock and prevent hyperextension of the carpus, and (2) to restore the energy of impact and full weight bearing during propul­ sion and lift off. This functional importance is doubled by a great clinical interest because tendon and ligament injuries of the distal limbs are common problems and are detrimental to the horse industry. Further­ more, the development of new diagnostic methods, such as ultrasonog­ raphy, have increased the need for a more detailed knowledge of tendon and ligament anatomy.56 This paper was supported by the Institut National de Recherche Agronomique, De­ partment of Animal Pathology, and by the Service des Haras, des Courses et de l'Equita­ tion, Paris, France. From the Service d' Anatomie--Clinique Equine, Ecole Nationale Veterinaire d' Aifort, Cecex, France VETERINARY CLINICS OF NORTH AMERICA: EQUINE PRACTICE VOLUME 10 • NUMBER 2' AUGUST 1994 273 274 DENOIX DESCRIPTIVE ANATOMY The gross anatomy of the tendons and ligaments in the distal fore­ limb and hindlimb of the horse has been described and illustrated.1, 2, 5, 15, 16, 19, 27, 35, 37, 50, 51 All the anatomic terms used in this article conform with the international nomenclature,22 Tendon and ligament anatomy varies between the manus and the pes (distal thoracic and pelvic limbs), but is quite similar in the digit of the thoracic and pelvic limbs. In each limb (Figs. 1 and 2), three anatomofunctional entities can be described-the superficial digital flexor tendon (SOFT) and its accessory ligament (AL­ SOFT); the deep digital flexor tendor (OOFT) and its accessory ligament (AL-OOFT); and the suspensory apparatus composed by the third in­ terosseous muscle (TIOM), the proximal scutum, and the distal sesa­ moidean ligaments (OSLs). The attachment sites of tendons and liga- Figure 1. Medial aspect of the carpometacarpal area. 1, Radius; 2, third metacarpal bone; 3, second metacarpal bone; 4, extensor carpi radialis; 5, extensor carpi obliquus; 6, antebra­ chial fascia; 7, flexor retinaculum; 8, distal radial artery; 9, palmar annular ligament; 10, SDFT; 10a, manica flexoria; 11 , DDFT; 12, AL-DDFT; 13, TIOM; and 14, dorsal digital extensor tendon. FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS 275 Figure 2. Lateral aspect of the metacarpus. 1, Third metacarpal bone; 2, fourth metacarpal bone; 3, flexor retinaculum; 4, SDFT; 5, DDFT; 6, AL-DDFT; 7, TIOM; 7a, body; 7b, lateral branch; 7c, medial branch; 8, dorsal digital extensor tendon; 9, lateral digital extensor tendon; and 9a, carpal attachment. ments to bone (entheses) are of particular interesr9, 4o and require further studies in horses because, at least in human medicine, the enthesis is considered to be the weakest point of the bone-tendon or bone-ligament functional unit.41 Superficial Digital Flexor Tendon and its Accessory Ligament The body of the superficial digital flexor muscle is attached proxi­ mally to the medial epicondyle of the humerus, has strong tendinous intersections, and progressively continues to the SOFT in the distal fore­ arm. This tendon also originates from an AL-SOFT inserted on the cau­ domedial aspect of the radius (Fig. 3), 7 to 11 cm proximal to the ante­ brachiocarpal joint. This strong fan-shaped fibrous band, previously 276 DENOIX Figure 3. Palmaromedial aspect of the carpus. The carpal canal is opened. 1, Radius; 2, third metacarpal bone; 3, second metacarpal bone; 4, extensor carpi obliquus; 5, flexor carpi radialis; 6, tendon sheath of the flexor carpi radialis within the junction between the flexor retinaculum and the antebrachial fascia; 7, flexor carpi ulnaris; 8, SDFT; 9, AL-SDFT; 10, SDF muscle body; 11, DDFT; 12, AL-DDFT; 13, common palmar ligament of the carpus; and 14, TIOM. called radial, proximal, or superior check ligament,53 courses distocaudally and fuses with the tendon just proximal to the antebrachiocarpal joint (Fig. 3). Medially, it is in contact with the flexor carpi radialis tendon sheath. Knowledge of this relationship is important in view of the sur­ gical technique of desmotomy of the AL-SOFT as a treatment for meta­ carpophalangeal flexural deformities23 and SOFT injuries.6 The fused rounded-shaped tendon passes distally through the carpal canal (discussed subsequently). In the metacarpus, the SOFT becomes flattened, with a half-moon shape. Its lateral border is sharp and its medial border round. Histologically, the lateral sharp border is more cellular than the broader medial part.62 Behind the palmar (intersesa­ moidean) ligament of the fetlock, its shape becomes symmetric and the tendon widens greatly. Proximal to the proximal sesamoid bones, a FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS 277 fibrous ring called the manica flexoria (Figs. 1 and 4) is attached to its borders and encircles the DDFT, which passes through it. Distal to the proximal sesamoid bones, the SDFT becomes progressively thinner in the sagittal plane and thicker abaxially. At the distal end of the proximal phalanx, the SDFT distal branches separate and become thicker distally on each side of the pastern (Fig. 5). They end between the axial and abaxial palmar ligaments of the proximal interphalangeal joint. All these anatomic elements insert distally on the scutum medium. This thick fibrocartilaginous structure is attached to the proximopalmar as­ pect of the middle phalanx and is in contact with the palmar aspect of the distal condyles of the proximal phalanx dorsally, and to the DDFT palmarly. Figure 4. Dorsal aspect of the digital part of the isolated flexor tendons. 1, SDFT; 2, manica flexoria; 3, distal branches of the SDFT; 4, synovial fold between these branches; 5, DDFT; 5a, enlargement at the palmar aspect of the fetlock; 5b, size reduction at the mid-pastern; 5c, fibrocartilaginous pad palmar to the proximal part of the middle phalanx; 5d, widening at the palmar aspect of the distal sesamoid bone; and 6, distal attachment of the digital sheath synovial membrane. 278 DENorx Figure 5. Palmomedial aspect of the digit. 1, Ungular cartilage (sectioned); 2, digital cushion (partially removed); 3, pal­ mar annular ligament; 4, proximal digital annular ligament; 5, distal digital annular ligament; 6, SOFT distal branch; 7, OOFT; 8, mesotendon of the OOFT seen through the digital sheath wall; 9, proper palmar digital artery; 10, ramus tori ; and 11, distal branch for the OOFT. Deep Digital Flexor Tendon and its Accessory ligament The deep digital flexor muscle consists of three heads. The principal one, the humeral head, contains collagenous intersections and is pro­ vided with a strong tendon. This tendon appears about 8 to 10 cm proximal to the antebrachiocarpal joint (see Fig. 3), but muscle bundles remain within it until the level of that joint, where it is joined by the tendons of the two other (ulnar and radial) heads. The broad, conjoined OOFT has a triangular cross-sectional shape in the carpal canal and becomes progressively narrower and round in the proximal metacarpus. At about the middle of the metacarpus, it blends with its AL-OOFT, previously called the subcarpal, distal, or inferior check ligamenP3 (see Figs. 1-3). This strong fibrous band is the direct continuation of the common palmar ligament of the carpus. Proximally, it is broad and has a rectan­ gular shape; it becomes progressively narrower and thicker distally and then molded on the dorsal aspect of the OOFT. At the lateral and medial aspects of the OOFT, a member of fibrous bundles join the SOFT, predis­ posing to adhesions between the AL-OOFT and the SOFT in pathologic conditions. The corresponding ligament is thinner in the hindlimb.1, 53 The OOFT results from the union of a strong lateral digital flexor tendon and a thin medial digital flexor tendon. The lateral digital flexor tendon incorporates the caudal tibialis tendon and passes over the sustentacu­ lum tali within the plantar tarsal sheath. The medial digital flexor tendon FUNCTIONAL ANATOMY OF TENDONS AND LIGAMENTS IN THE DISTAL LIMBS 279 passes over the proximal tubercle of the talus, at the medial aspect of the tarsus in its own sheath. These two tendons fuse in the proximal meta­ tarsus. In the distal third of the metacarpus (metatarsus), the DDFT has incorporated all the fibers of its accessory ligament, becomes oval, and passes through the manica flexoria (see Figs. 1,3,4). Behind the proximal scutum, it becomes considerably wider, elliptic, and fibrocartilaginous. At the level of the proximal half of the proximal phalanx, the DDFT is divided into two round, symmetric parts in which its fibers adopt a spiral disposition. Its dorsopalmar thickness and its lateromedial width decrease distally (see Fig. 4). The narrowest cross­ sectional area is located in the middle of the proximal phalanx, where the DDFT passes between the two distal branches of the SOFT and becomes superficial (see Fig. 5). Palmar to the distal half of the proximal phalanx, the size of the DDFT increases in dorsopalmar and lateromedial directions. At the level of the proximal part of the middle phalanx, the dorsal half of the tendon becomes a distinct fibrocartilaginous pad prox­ imal to the distal sesamoid bone (see Fig.
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