foot ankle trauma 2013

Foot & Ankle Trauma

Radiology

1

Dr W J Rennie

Musculoskeletal Radiologist

Leicester Royal Infirmary

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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3

Man who stand on street corner with hands in pockets, not feeling crazy, feeling nuts.

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!

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!

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

Isolated Posterior high ankle

sprain- Case series

1Botchu R, 2Allen P, 1Rennie WJ

Leicester Royal Infirmary,

Leicester, UK

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

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

Aim

• We present a case series of isolated PITFL

injury

Normal PITFL

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

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

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

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

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

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

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.

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

Management

• Symptomatic

• Orthotics

• Analgesics

• US guided injection of corticosteroids.

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

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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.

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syndesmosis ligaments. Surg Radiol Anat. 2006; 28(2):142-9.

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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

Thank You

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