lecture 3 shah radiology in foot and ankle
TRANSCRIPT
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Imaging in foot & ankle
Dr.Rajiv ShahFoot & Ankle Surgeon
‘Foot & Ankle Orthopaedics’Vadodara, Surat, Gujarat
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Ankle series X-rays
AP MortiseLateral
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AP view Tibiofibular clear
space Tibiofibular
overlap Talar tilt angle Lateral talar shift Shenton’s line Arcuate line
Mortise viewMedial clear
spaceTalocrural
angleAnkle
instability sign
Ankle X-rays: 9 radiological signs!
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Increased Tibio-fibular clear space Tibio- fibular overlap Talar Tilt angle
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Shenton line of ankle Arcuate Line/Dime sign
Increased medial Clear Space Disturbed Talocrural angle
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Lateral talar shift sign Insignificant sign!
Ankle instability sign
Larger medial clear space than superior clear (ankle joint) space
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LAT X-rays
Position of talus at ankle mortisePosition of posterior malleolus
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Ankle: Lateral View
Dome of the talus: centered under and congruous with tibial plafond
Posterior malleolus fractures & direction of fibular injuries can be identified
Avulsion fractures of the talus by the anterior capsule can be identified
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Neutral triangle Bone quality
Bohler’s Angle 20-40 degrees Can be depressed
in both intra and extra articular fx
Limited usefulness
Ankle: Lateral View
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Crucial angle of Gissane Dense cortical
bone margins of the STJ
Reconstitution is a must for calcaneal fractures
Ankle: Lateral View
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• Haglund’s deformity• Parallel pitch lines of
Pavlov
Ankle: Lateral View
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Lateral View: Posterior heel pathologies
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BRODEN’S VIEW
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Broden’s View
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Broden’s view:Subtalar joint assessmentfracture of calcaneus/fusions
40 deg20-30 deg10 deg
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Broden’s View: subtalar fusion assessment
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Broden’s View: subtalar fusion assessment
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Harris axial view
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Foot is plantar flexed, 15 degree pronated and the beam is angled 15 degree toward the head
It shows the medial column along the talar head and neck
Canale & Kelly’s View
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AP
Oblique
Lateral
Foot series X-rays
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Foot series: AP
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Talo-First MT line (Normal = 0 degrees)
Hallux valgus Talonavicular
Coverage Angle (Normal = 0-7
degrees)Useful for planning of
treatment for AAFD
Foot series: AP
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Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform
Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate) cuneiform
Normal Foot X-ray
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Medial border of 4th metatarsal aligned with medial border of cuboid
Medial and lateral borders of the 3rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal
Lateral margin of the 5th metatarsal can project lateral to cuboid by up to 3mm on oblique view
Normal Foot X-ray
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Diagnosis of Lisfranc injury
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IM space between 1st and 2nd metatarsals is equal to space between the medial and middle cuneiforms
Diagnosis of Lisfranc injury
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• The medial cuneiform-second MT space should be evaluated for the "fleck sign" indicating avulsion of the Lisfranc ligament.
Fleck sign: Lisfranc
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Foot series: Lateral
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Talo-First MT line(a.k.a Meary’s
line) Normal = 0
degrees Useful for
analysis for treatment of AAFD
Foot series: Lateral
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Lateral View Superior border
of second metatarsal is continuous with superior border second cuneiform
No dorsal nor plantar displacement of metatarsal bases
Foot series: Lateral
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SIGNS OF HINDFOOT VARUS
Increased Calcaneal pitch angle
“posterior” fibula “double talar-dome” sign “see-through” sign
Foot series: Lateral
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Routine view Anterior process
calcaneus Cuboid -5th
metatrsal
Foot series: Internal oblique
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To delineate medial column abnormalities &
injuries
Foot series: External oblique
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AP Foot
Lateral Foot
Foot series: Weight bearing views
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How to take weight bearing views?
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Non-weight bearing
Weight bearing
Weight bearing/standing views provide stress & will demonstrate subtle lisfranc injury
Lisfranc diagnosis: Weight bearing views
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1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
Weight bearing relationship: AP
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Weight bearing relationship: AP
1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
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Weight bearing relationship: AP
1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
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Weight bearing relationship: AP
1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
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Weight bearing relationship: AP
1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
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Weight bearing relationship: AP
1. Hallux-interphalangeal angle- nml: 6-24 deg
2. Distal metatarsal articular angle (DMAA)- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle (HV)- nml: 0-20 deg
4. First intertarsal angle (IMA)- nml: < 9 deg
5. Metatarsal break angle- nml: 140 deg
6. Talocalcaneal angle- nml: 30-50 deg (child)- 15-30 deg (>5 yo)
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Foot Series: AAFDWeight bearing vs. Non-weight-bearing
Weight-Bearing
Non Weight-Bearing
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Disruption of angles on weight bearing xrays suggest AAFD
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1. Lateral talocalcaneal angle- nml: 25-30 deg
2. 5th metatarsal base height- nml: 2.3-3.8 cm
3. Calcaneal pitch angle- nml: 10-30 deg
4. Bohler’s angle- nml: 22-48 deg
Weight bearing relationship: LAT
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Weight bearing relationship: LAT
1. Lateral talocalcaneal angle- nml: 25-30 deg
2. 5th metatarsal base height- nml: 2.3-3.8 cm
3. Calcaneal pitch angle- nml: 10-30 deg
4. Bohler’s angle- nml: 22-48 deg
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Weight bearing relationship: LAT
1. Lateral talocalcaneal angle- nml: 25-30 deg
2. 5th metatarsal base height- nml: 2.3-3.8 cm
3. Calcaneal pitch angle- nml: 10-30 deg
4. Bohler’s angle- nml: 22-48 deg
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Weight bearing relationship: LAT
1. Lateral talocalcaneal angle- nml: 25-30 deg
2. 5th metatarsal base height- nml: 2.3-3.8 cm
3. Calcaneal pitch angle- nml: 10-30 deg
4. Bohler’s angle- nml: 22-48 deg
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Midfoot projection views
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Seasmoid views
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Limitations of radiology
• Inter observer variations• Magnification variations• Patient to patient variations
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Stress radiography is gold standard for detection of ankle instability
Anterior drawer test
Talar tilt test
Stress views
Performed by tilting the hindfoot and looking for a suction sign or asymmetric movement.
Positive stress test : talar tilt > 15 degrees side to side diff of 10.
Ankle in 20 degree of plantar flexion The tibia is pushed posteriorly against the fixed foot positive test - >0.5 to1 cm or side to side diff of 3 mm
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Ankle off the edge of table
Rotated externally
Let it fallCross table viewDeltoid
incompetence
Gravity Stress views
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Midfoot Stress views
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Assess Fractures, stress
fractures, growth plate fractures
Neoplasms & infections
Foreign bodies Osteochondral lesions AVN Arthritis Congenital
abnormalities 3-D
reconstructions
CT Scan
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CT Scan axial, sagittal, semi coronal
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Calcaneus Fracture
Lisfrancs Dislocation
Fracture Lower Tibia
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CT Scan
Axial cuts across tibiofibular interval
Axial cuts at ankle mortise
Reduction Widening Rotation Fibular clear
space
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Axial cut 1 cm above joint
Line from flat anterolateral surface of fibula to anterior tubercle of tibia
Must be within 2mm from anterior surface of tibia
Most reliable CT sign!
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USG: Advantages
Most effective for superficial structures like tendons & ligaments
Dynamic Allows for direct palpation of painful
areas during imaging Comparison with opposite side Easy & cheap User dependent Inadequate joint visualization Poor osseous visualization
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USG: Normal tendon
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Tendinosis
Partial Tear
Complete Tear
USG: Tendon pathologies
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Achilles tendon tear
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Ultrasound v/s MRI Magical effect Subluxating
tendon Presence of
implants/metals
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STRENGTH OF US: Dynamic Evaluation of the Achilles tendon
Plantarflexion: gap in Achilles tendon narrows to less than 1 cm
Dorsiflexion: gapwidens to more than 2 cm
Achilles longitudinal
Achilles longitudinal
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Peroneal tendon dislocation
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--Anterior tibial tendon (yellow arrowhead) impinged by screw head (lg. white arrow) with fluid/synovitis (sm. arrows)-
STRENGTH OF US: tendon evaluation with metallic implant
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Excellent soft tissue visualization
Anatomical detailsAssessment of
TraumaNeoplasms/massesArthritis, InflammationAVNTarsal coalitionRSD
MRI
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Tissue T1 T2
Cortex Low Low
Ligaments Low Low
Articular cart Intermed Intermed
Red marrow Intermed Intermed
Old blood High High
Osteomyelitis Low High
Sarcoma Low High
Marrow edema Low High
Fat High Intermed
Pus Intermed High
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Strength of MRI: osteochondral lesion
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Axial T2 FS Coronal PD FS Treated with screw
Strength of MRI: occult fracture
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Os Trigonum Syndrome Tarsal Tunnel Syndrome Haglund’s Syndrome Os Peroneum Syndrome Anterolateral Gutter
Syndrome Sinus Tarsi Syndrome
Ankle disorders:MRI + USG
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Areas of increased metabolic activities 99mTc methylene diphosphonate (MDP) Assess
Tumors & -like conditions Metabolic disorders Trauma AVN Arthritis Infection RSD
Nuclear medicine
SLIDE COURTESY: DR.SELENE PAREKH
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That’s allThank you…