j. ben hafdhallah, s. bourkhis, f. snene, m.a.ghodhbani, h. rajhi, n. mnif. charle nicolle’s...
TRANSCRIPT
POSTERIOR IMPINGEMENT SYNDROME : A CASE REPORT
J. BEN HAFDHALLAH, S. BOURKHIS, F. SNENE, M.A.GHODHBANI, H. RAJHI, N. MNIF. CHARLE NICOLLE’S
HOSPITAL, TUNIS, TUNISIA.
MK6
OBJECTIVES
Evaluate the role of imaging modalities in
the diagnosis and management of the
posterior tibio talian syndrome. It includes
clinical situations secondary to entrapment
of bony elements or soft tissue between the
posterior edge of the tibia and calcaneus
during plantar flexion of the ankle.
A CASE REPORT
This is a 27-year-old male who usually
complains of posterior ankle pain
exacerbated by plantar flexion or
dorsiflexion . An Achille tendinopathy was
firstly suspected.
RESULTS
AN ULTRASOUND EXAM OF ACHILLE TENDON
Tibio talian intra articular liquid
Right anlke / axial plane
Lateral ankle radiographs
RESULTS
Lateral ankle radiograph shows a prominent posterior process of the tibia and a long posterior talian process .
MR imaging RESULTS
Sagittal (T2 / T1-weighted) and axial (T1-weighted) MR image shows focal thickening of posterior pericapsular tissue ( ) but normal bone marrow signal intensity in the postérior process. Note the tibio talian intra articular liquid ( ).
TREATMENT RESULTS
A posterior tibio talian syndrome was diagnosed. The patient had an arthroscopic treatement with supression of prominent posterior process. Clinical evolution marked by an improvement.
Lateral ankle radiograph before and after surgery shows a disappearance of prominent posterior process ( ).
DISCUSSION
Posterior impingement has been described under a variety of different names, including os trigonum syndrome and posterior tibiotalar compression syndrome.
The condition arises from compression of the soft tissues between the posterior process of the talus and the posterior tibia on plantar flexion of the ankle.
CAUSES
The syndrome can develop after
a significant acute injury: avulsion of the posterior talo-fibular ligament. talar fracture. disruption of an os trigonum.
A chronic injury: a repetitive forced plantar flexion of the foot(ballet
dancers).
DISCUSSION
CLINICAL FEATURES
The syndrome usually manifests clinically when a significant soft-tissue component forms.
Clinical symptoms usually consist of posterior ankle pain exacerbated by plantar flexion or dorsiflexion.
Clinical examination shows: Posterior tenderness anterior to and not involving
the Achilles tendon. Occasionally, palpable soft-tissue thickening
DISCUSSION
CONVENTIONAL RADIOGRAPHS
Conventional radiographs may show a prominent lateral talar process or os trigonum.
IMAGING FEATURES
DISCUSSION
US exam
Ultrasound is a useful technique for accurate real-time guidance of therapeutic injection.
IMAGING FEATURES
DISCUSSION
MR imaging
MR imaging shows: Bone marrow edema. A fracture line. fluid in the synchondrosis. Posterior capsular or ligament thickening with
intermediate to low signal intensity on T2-weighted images.
IMAGING FEATURES DISCUSSION
The integrity of the ligaments. Possible associated flexor hallucis longus abnormality
or other internal derangement, which can alter any planned surgical approach.
Enhancement after intravenous administration of gadolinium contrast material can highlight small focal areas of synovitis.
MR imaging
IMAGING FEATURES DISCUSSION
Management
Imaging-guided injection (a steroid or local anesthetic):
Most cases of posterior impingement of the ankle respond to conservative treatment (physiotherapy).
Surgery: in resistant cases.
IMAGING FEATURES DISCUSSION
CONCLUSION
Impingement syndromes of the ankle are usually
a clinical diagnosis.
Conventional radiograph plays an important role in the initial assessment of these conditions.
MR imaging is most useful in posterior impingement, where it can identify the relative contributions of the osseous and soft-tissu components.