ankle

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RADIOLOGICAL ANATOMY ANKLE Dr. Rohit Madhurkar PG, Dept. of Radiology YENEPOYA UNIVERSITY Part I

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Articulations among: Fibula Tibia Talus Tibial “plafond” Distal tibial articular surface Bones

Bones: 

Bones Medial malleolus Distal tibia Medial support Lateral malleolus Distal fibula Lateral support Talus Trapezoid-shaped Mortise (tibial plafond, medial & lateral malleoli) - Constrained articulation with the talar dome

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3 Primary Joints Medial malleolus w/medial talus Tibial plafond w/ talar dome Lat malleolus w/ lat talus 3 sets of Ligaments: Lateral collaterals Syndesmotic Ligaments Medial collaterals (Deltoid)

Ligaments: 

Ligaments Anterior talofibular ligament ( weakest ) from the anterior margin of the LM to the neck of the talus. Posterior talofibular ligament (strongest ) from the lower part of the malleolar fossa of the fibula to the lateral tubercle of the talus . Calcaneofibular ligament from the notch of the lower border of the LM to the tubercle on the lateral surface of the calcaneum Lateral (fibular collateral) ligament complex

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Ligaments Lateral (fibular collateral) ligament complex

Ligaments: 

Four ligaments: Anterior tibiofibular ligament Posterior tibiofibular ligament Transverse tibiofibular ligament Interosseous ligament Ligaments Axial, rotational, & translational stability Syndesmotic ligament complex

Ligaments: 

Deltoid (medial) ligament complex Superficial (contributes little to stability) Tibionavicular ligament attached to the tuberosity of the navicular bone and to the medial margin of the spring ligament. Tibiocalcaneal ligament attached to the whole length of the sustenticulum tali . Superficial Tibiotalar ligament attached to the medial tubercle and to the adjoining part of the medial surface of the talus. Deep (primary medial stabilizer) Intraarticular : Deep tibiotalar ligament Ligaments

Ligaments: 

Ligaments

Medial Ligaments: 

Medial Ligaments

PowerPoint Presentation: 

It surrounds the joint and is attached all around the articular margins with two exceptions : Posterosuperiorly it is attached to the inferior transverse tibiofibular ligament and Anteroinferiorly , it is attached to the dorsum of the neck of the talus at some distance from the trochlear surface. The anterior and posterior parts of the capsule are loose and thin to allow the hinge movements. On each sides however it is supported by strong collateral ligaments. The synovial membrane lines the capsule. Fibrous capsule :

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Fibula Inf surface of tibia Lat. & Med. Malleolus Sup surface of trochlea Body of talus Lat. & Med. Surface Neck Head

Retinacula : 

Flexor retinaculum: Extends inferiorly and posteriorly from medial malleolus to medial calcaneal surface. Retinacula

Retinacula : 

Extensor retinacula: Superior: Attaches to distal anterior tibia & fibula ;invests tibialis anterior tendon. Inferior: Y shaped.From anterolateral part of calcaneus to medial malleolus & medial plantar fascia. Retinacula

Retinacula : 

Retinacula Peroneal retinacula: Superior: Lateral malleolus to lateral calcaneal surface. Inferior: Peroneal trochlea & calcaneus above to peroneal tendons below.

Indications for Ankle Radiographs: 

Indications for Ankle Radiographs Ottawa Ankle Rules c. or inability to talk four steps bearing body weight

Indications for Ankle Radiographs: 

How good are the Ottawa Rules? When originally published: 100% sensitivity & 40% specificity for detecting malleolar fractures Subsequent studies: Lower sensitivity (93% to 95%) and specificity (6% to 11%) than originally thought Not perfect, but still a good tool Other indications The patient cannot communicate (altered mental status, alcohol intoxication, or other) Pain and swelling do not resolve within 7-10 days after injury Anytime your history and physical don’t give you enough information Indications for Ankle Radiographs

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Normal ankle (AP view) Normal ankle (Mortise view) Normal ankle (Lateral view)

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Normal ankle (AP view) Tibia Ankle joint Medial malleous Lateral malleous Malleolar fossa Trochlear surface (dome) of the talus Tibiofibular synchondrosis Fibula

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Normal ankle (Mortise view) Tibia Ankle joint Medial Malleous Lateral Malleous Malleolar fossa Trochlear surface (dome) of the talus Tibiofibular synchondrosis fibula

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Normal ankle (lateral view) Ankle joint Trochlear surface of talus Navicular Medial cuneiform Head of 1 st metetarsal Calcaneum Posterior talo -calcaneal joint Posterior tubercle of talus Lateral malleous Tibia Fibula Promontory of tibia

AP View of the Ankle: 

AP View of the Ankle DE: Talar Tilt: < 2 degrees of angulation is Nl D E

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Talar tilt, Tib -fib Overlap, Tib -fib clearspace AP View of the Ankle

AP View of the Ankle: 

AP View of the Ankle Talar Tilt: > 2 degrees angulation may indicate medial or lateral disruption Tib -fib Clear Space > 5mm or Tib -fib Overlap < 10mm may indicate syndesmotic injury

Mortise View Of The Ankle: 

Mortise View Of The Ankle AP view taken with the foot in 15-20 degrees of internal rotation to offset the internalleolar axis Medial clear space > 4mm may indicate lateral talar shift

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Mortise View Of The Ankle Talocrural angle (angle b/w plafond parallel and intermalleolar line) Normal is 8-15 degrees (where the lines intersect) Smaller angle may indicate fibular shortening

Mortise view of the ankle: 

Mortise view of the ankle

Lateral View of the Ankle: 

Lateral View of the Ankle Dome of the talus: centered under and congruous with tibial plafond Posterior tibial tuberosity fractures & direction of fibular injuries can be identified Avulsion fractures of the talus by the anterior capsule can be identified Any deformity to the talus, calcaneus or subtalar joint

Calcaneal Fractures: 

Calcaneal Fractures Bohler’s Angle 30-35 degrees is normal (28-40) Others: Critical Angle of Gissane

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Calcaneal Fractures

Anteroposterior View: 

Anteroposterior View Tibiofibular overlap <10mm implies syndesmotic injury Tibiofibular clear space >5mm implies syndesmotic injury Talar tilt >2mm is considered abnormal

Mortise x-ray: AP view of ankle with foot internally rotated(15 degree) : 

Mortise x-ray: AP view of ankle with foot internally rotated(15 degree) Medial clear space Between lateral border of medial malleous and medial talus <4mm is normal >4mm suggests lateral shift of talus

Mortise x-ray:: 

Mortise x-ray: Talar tilt Normal = -1.5 to +1.5 degrees ( ie . Parallel) Can go up to 5 degrees in stress views <2mm difference between medial and lateral talar /plafond distances

PowerPoint Presentation: 

RADIOLOGICAL ANATOMY ANKLE Dr. Rohit Madhurkar PG, Dept. of Radiology YENEPOYA UNIVERSITY Part II

Anterior : 

Anterior Tibialis Anterior tendon Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Longus Peroneus Brevis

Medial view : 

Medial view Tibialis posterior Flexor digitorum longus Flexor hallucis longus Achilles Tendon

Lateral : 

Lateral Achilles Tendon Peroneus Longus Peroneur Brevis

Structures Of Interest – Anterior : 

Structures Of Interest – Anterior Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Dorsal Pedis Artery Superfical Peroneal Nerve Anterior Tibiotalar Joint Recess

Anterior : 

Anterior Tibialis Anterior tendon Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Longus Peroneur Brevis

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USG– Anterior Ultrasonography

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Tibialis Anterior Extensor Hallucis Longus Dorsal Pedis Artery Tibialis Anterior* USG– Anterior Ultrasonography

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Extensor Digitorum Longus Extensor Digitorum Longus Extensor Hallucis Longus USG– Anterior Ultrasonography

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Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus USG– Anterior Ultrasonography

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USG– Anterior Ultrasonography

Structures Of Interest – Medial: 

Structures Of Interest – Medial Tibialis posterior Flexor digitorum longus Flexor hallucis longus Deltoid ligament Tibial nerve

Medial view : 

Medial view Tibialis posterior Flexor digitorum longus Flexor hallucis longus Achilles Tendon

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Tibialis posterior Flexor Digitorum Longus Angulation* anisotropy USG– Medial Ultrasonography

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Flexor Retinaculum Tibialis Posterior Tendon Flexor Digitorum Longus Tendon Tibial Artery Tibial Veins Tibail Nerve Flexor Hallucis Longus Tendon Flexor Hallucis Longus Muscle USG– Medial Ultrasonography

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Tibialis posterior tendon Flexor digitorum longus tendon Flexor hallucis longus tendon Angulation* anisotropy USG– Medial Ultrasonography

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USG– Medial Ultrasonography

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USG– Medial Ultrasonography

Structures Of Interest – Lateral: 

Structures Of Interest – Lateral Peroneus Longus Peroneur Brevis Anterior Talofibular Ligament Calcaneofibular Ligament Anterior Tibiofibular Ligament

Lateral : 

Lateral Achilles Tendon Peroneus Longus Peroneur Brevis

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Peroneus longs Peroneur Brevis Peroneur Brevis Peroneus longs USG– Lateral Ultrasonography

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Peroneus Longus tendon Peroneur Brevis muscle Peroneur Brevis tendon USG– Lateral Ultrasonography

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USG– Lateral Ultrasonography

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USG– Lateral Ultrasonography

Structures Of Interest – Posterior: 

Structures Of Interest – Posterior Achilles Tendon Bursae

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Achilles Tendon Flexor Hallucis Longus Muscle Kager’s fat pad Achilles Tendon Kager’s fat pad USG– Posterior Ultrasonography

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USG– Posterior Ultrasonography

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USG– Posterior Ultrasonography

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RADIOLOGICAL ANATOMY ANKLE Dr. Rohit Madhurkar PG, Dept. of Radiology YENEPOYA UNIVERSITY Part III

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MRI Link to DICOM SOFTWARE

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Thank You