Foot ankle trauma 2013
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Transcript of 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!
2
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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11
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13
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Man who eat
many prunes get
good run for his
money!
Tendon Injuries
16
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!
36
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
44
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.
50
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.
58
Message
• Isolated PITFL injuries are rare.
• Prompt diagnosis and appropriate
management helps to decrease morbidity
and enable quick return to sport.
References• Nyanzi CS, Langridge J, Heyworth JRC, Mani R. Randomized controlled study of ultrasound therapy in the
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.
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with anatomic correlation. Radiology. 2010; 254(3):827-36.
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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.
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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.
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syndesmosis injury. AJR Am J Roentgenol. 2004; 182(1):131-6.
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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.
61
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
62