foot ankle trauma 2013
TRANSCRIPT
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Foot & Ankle Trauma
Radiology
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Dr W J Rennie
Musculoskeletal Radiologist
Leicester Royal Infirmary
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Structure
• Some difficult Radiographs
• Important often missed fractures
• High Resolution High Quality MRI
• Tendon/Ligament Anatomy
• The Car Principle in MR Imaging!
• Foot Imaging
• The PITFL injury! The Leicester Theory!
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Man who stand on street corner with hands in pockets, not feeling crazy, feeling nuts.
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Modalities
• Radiographs
• Cross sectional Imaging• CT
• MRI
• Ultrasound
• Unclear Medicine
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Stress Fractures
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Stress Fractures
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Occult Fractures
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Occult Ankle Fractures
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Occult Fractures
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Coalition
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Man who eat
many prunes get
good run for his
money!
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Tendon Injuries
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Tendon Injuries
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Ankle- Lateral Ligaments
• Syndesmotic
Ligaments-
AITFL/PITFL
• ATFL
• CFL
• PTFL
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Ankle PITFL
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Lateral Ligaments- CFL
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Lateral Ligaments-PTFL
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Lateral ligaments-ATFL
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Axial- Syndesmotic ligaments
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Syndesmotic injuries
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Medial Tendons
• Tibialis Posterior
• Flexor Digitorum
Longus
• A
• V
• N
• Flexor Hallucis Longus
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Medial Structures
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Lateral Tendons
• Peroneus
Longus
• Peroneus
Brevis
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Peroneii Pathology
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Coronal Plane
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Courtesy of Prof H Umans
Lennox Hill Imaging centre NY
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Courtesy of Prof H Umans
Lennox Hill Imaging centre NY
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Ultrasound
• Extension of
Physical
examination
• Sonographic
Mulder’s Sign
• Forefoot
squeeze
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MRI
• Remember!
• Not ALL are
EQUAL!!
• Animal Farm
Rules apply!
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MRI
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• Remember!
• Not ALL are
EQUAL!!
• Animal Farm
Rules apply!
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Avoid the Ford!
• Open Low field
Strength 0.3T
MRI
• Non Diagnostic
for the
indications!
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Courtesy of Prof H Umans
Albert Einstein Medical School NY
USA
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Isolated Posterior high ankle
sprain- Case series
1Botchu R, 2Allen P, 1Rennie WJ
Leicester Royal Infirmary,
Leicester, UK
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Introduction
• Ligament injuries of the ankle are a
common injury
• The daily incidence in USA is 23000, 5600
in UK and 1600 in Netherlands
• Syndesmostic injuries form a subset
• Early diagnosis allows appropriate
management decreasing morbidity and
enabling quick return to sport
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Introduction
• AITFL is ruptured in almost all cases of
high ankle sprain
• PITFL is the strongest of the syndesmotic
ligaments and hence is always associated
with other ligamentous injuries
• Isolated PITFL injury has not previously
been reported
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Aim
• We present a case series of isolated PITFL
injury
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Normal PITFL
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Case 1
• 36 year old male presented with 8 month history of dull posterior and postero-lateral right ankle pain.
• No specific trauma
• Pain during push off phase of gait cycle
• Good Range of movement
• Tender posterior joint line
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Case 1
• MRI- Oedema within PITFL and tibial enthesis with thickening of fibres
• Physiotherapy and orthotics did not help
• US guided corticosteroid injection with symptomatic relief
• No recurrence at 8months follow up.
• X ray normal
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Case 2
• 42 year old female with 3 months of ankle
pain
• No specific trauma
• Good Range of movement
• Tenderness at inferior syndesmosis
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Case 2
• MRI- Oedema within PITFL and tibial enthesis
with thickening of fibres
• US guided corticosteroid injection with good
symptomatic relief
• No recurrence at 8 months follow up.
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Case 3
• 44 year old female with 2 years dull ankle pain
• Pain exaggerated while walking on uneven surface
• Clinical tenderness along posteromedial ankle
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Case 3
• MRI- edema within PITFL
• Physiotherapy and orthotics- no relief
• US guided corticosteroid injection with good symptomatic relief
• No recurrence at 1 year follow up.
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Discussion
• Ankle sprain is common and correlates to a
quarter of all musculoskeletal injuries, accounting
for 10 % of the workload in A&E
• 800 ankle sprains and 110 severe ankle sprains
per day in AE in UK
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Discussion
• 25% of foot ball injuries and 50% of basket ball
injuries.
• Associated with chronic ankle pain and instability
• Incidence higher among adolescent females
especially athletes
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Distal tibiofibular syndesmosis-
parts
• Interosseous membrane
• AITFL
• PITFL
• Inferior transverse ligament
• Interosseous ligament
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PITFL
• Triangular multifascicular ligament
• Spans - Lateral malleolus to distal tibial
posterior margin
• Wide tibial attachment and compact fibular
attachment.
• Superficial PITFL- minor contribution to
ankle instability(9%)
• Deep PITFL and AITFL- Major stabilisers
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Mechanism of injury
• External rotation and abduction of
dorsiflexed ankle- AITFL injury
• External rotation and abduction of
hyperdorsiflexed ankle- AITFL and PITFL
injury
• Adduction of hyperdorsiflexed ankle-
Isolated PITFL injury.
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Isolated PITFL Injury
• Supra-malleolar pain
• Clinical tenderness – posterior distal tibio-fibular syndemsosis (over PITFL)
• High index of suspicion
• MRI- Thickening and edema of PITFL
• Sprain- grade 1 or grade 2
• MRI- Good sensitivity(100%) and specificity (94-100%)
• Chronic injury may result in calcification
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Management
• Symptomatic
• Orthotics
• Analgesics
• US guided injection of corticosteroids.
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Management
• PITFL injuries require relatively longer
duration of treatment and rehabilitation
due to altered biomechanics in comparison
to standard ankle sprains.
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Message
• Isolated PITFL injuries are rare.
• Prompt diagnosis and appropriate
management helps to decrease morbidity
and enable quick return to sport.
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management of acute lateral ligament sprains of the ankle joint. Clinical Rehabilitation 1999 13:16-22
• Bridgman SA, Clement D, Downing A, Walley G, Phair I, Maffulli N. Population based epidemiology of ankle sprains
attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe
ankle sprains. Emerg Med J 2003;20:508–510.
• Williams G, Jones M, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007; 35(7):1197-207.
• Ebraheim NA, Taser F, Shafiq Q, Yeasting RA. Anatomical evaluation and clinical importance of the tibiofibular
syndesmosis ligaments. Surg Radiol Anat. 2006; 28(2):142-9.
• Norkus SA, Floyd, RT. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Journal of Athletic
Training 2001; 36(1):68-73.
• Boonthathip M, Chen L, Trudell DJ, Resnick DL. Tibiofibular syndesmotic ligaments: MR arthrography in cadavers
with anatomic correlation. Radiology. 2010; 254(3):827-36.
• Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, Ranstam J, Swierstra BA. Effects of ligament sectioning on
the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on
presumed trauma mechanisms with suggestions for treatment. Acta Orthop. 2006; 77(3):531-40.
• Press C, Gupta A, Hutchinson M. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep.
2009; 8(5):228-33.
• Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, Ochi M. Injury of the tibiofibular syndesmosis: value of MR
imaging for diagnosis. Radiology. 2003;227(1):155-61.
• Brown K, Morrison W, Schweitzer M, Parellada J, Nothnagel H. MRI findings associated with distal tibiofibular
syndesmosis injury. AJR Am J Roentgenol. 2004; 182(1):131-6.
• Amendola A, Williams G, Foster D. Evidence-based approach to treatment of acute traumatic syndesmosis (high
ankle) sprains. Sports Med Arthrosc Rev 2006 ;( 14):232-236.
• Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. 2007;
455:173-5.
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Structure
• Some difficult Radiographs
• Important often missed fractures
• High Resolution High Quality MRI
• Tendon/Ligament Anatomy
• The Car Principle in MR Imaging!
• Foot Imaging
• The PITFL injury! The Leicester Theory!
3
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Thank You
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