Foot & Ankle Trauma

Radiology

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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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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.

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.

• 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.

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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.

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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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