Radiological Examination of the High Ankle Sprain

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Radiological Exam of the High Ankle Sprain:

Radiological Exam of the High Ankle Sprain Lindsay Allen, Maddy Bosek, Stephanie Cadro, Jamonika Gaines, Jenny Iskat, Richard Thom, & Courtney Wallace

What is a “high ankle sprain?”:

What is a “high ankle sprain?” “Syndesmosis s prain” of the tibiofibular syndesmotic structures superior to the talocural “ankle” joint “Bowing” of the fibula that results in partial tearing or stretching of the ligaments may occur with S evere axial loading Incorrect foot planting during an athletic maneuver Falling forward of the body while the foot is still planted E xcessive external rotation of the ankle with abduction or adduction of the foot E nd -range extremes of dorsiflexion Combination of extreme dorsiflexion in association with adduction or abduction of the foot

Ligaments Involved:

Ligaments Involved To inhibit and resist rotational and translational biomechanical forces on the lower extremity and support the anatomical relationship between the distal fibula and the distal tibia, contributing to the overall stability of the ankle joint. The syndesmotic ligaments consist of: A nterior inferior tibiofibular ligament D istal posterior tibiofibular ligament Interosseous ligament I nterosseous membrane

Degree of Sprain:

Degree of Sprain Excessive separating of the distal tibia and fibula represents the degree of syndesmotic sprain, referred to as diastasis. Grade 1 Grade 2 Grade 3 Radiograph showing widening of the tibiofibular “clear space” (arrows) as a result of disruption of the syndesmosis . The clear space is normally less than 5 mm wide.

Incidence of High Ankle Sprains :

Incidence of High Ankle Sprains Medial and lateral ankle sprains are more common HAS occur in up to 15% of all ankle injuries HAS account for approximately 11% of ankle injuries in athletic injuries Male > female

Risk Factors for High Ankle Sprains:

Risk Factors for High Ankle Sprains Male athletes in high intensity, high impact sport Higher body mass index Improper muscle conditioning, stretching, strength training Poor proprioception or fatigue while playing high impact sports Sports that require cleats or skates Older athletes Wearing inappropriate or improper footwear for sport

Maisonneuve fracture :

Maisonneuve fracture Fracture at the site of injury as well as extending proximally fracturing the fibular head Complete rupture of the interosseous membrane proximally may lead to fractures of the proximal one-third of the fibula The most common fracture is seen in the distal third of the fibula

Osteochondral fracture :

Osteochondral fracture Fracture of the talus, distal fibula, and proximal fibula Usually significantly unstable O pen reduction internal fixation (ORIF ) Osteochondral fracture of the talar dome

Diagnostic Imaging :

Diagnostic Imaging Determine extent of damage Imaging serves to supplement manual diagnostic techniques to assess tenderness and joint mobility or laxity after trauma. Radiography is effective in gaining insight regarding the amount of joint stability and overall alignment of the joint.

Imaging Views:

Imaging Views Radiograph Lateral -view stress radiograph For more severe or high ankle sprains, anteroposterior and lateral radiographs R esearch suggests that MRI has a higher sensitivity (74%) and specificity (100%) in detecting complete lateral ankle tears as compared to conventional radiography MRI: Axial T1-weighted MR images are able to demonstrate tears of the anterior talofibular ligament and the calcaneofibular ligament As this condition is treated with physical therapy interventions, progress may be monitored with these imaging options.

Role of Imaging for the Physical Therapist :

Role of Imaging for the Physical Therapist Assist physician in diagnosis of ankle sprain prior to attending physical therapy Ottawa Ankles Rules will assist the therapist in helping to determine if imaging studies are necessary Patient should receive radiographic images prior to MRI studies

Role of Imaging MRI :

Role of Imaging MRI MRI is indicated if: There is an increased amount of space between the lateral aspect of the medial malleolus and the talus shown on radiograph. MRI will confirm suspected ligamentous damage Syndesmotic injuries are easily identified using MRI

Role of Imaging MRI:

Role of Imaging MRI The following images are usually taken to evaluate the ankle: Coronal and axial views are completed for the T2 weighted fast spin echo images with fat suppression Axial-Proton density weighted images Sagittal fast spin echo inversion recovery images Sagittal and axial T1 weighted spin echo images

PowerPoint Presentation:

Healthy High Ankle Sprain

PowerPoint Presentation:

AP and lateral views of syndesmotic ankle sprain

PowerPoint Presentation:

MR Image of High Ankle Sprain/ Syndesmotic injury T1 Axial Slice T2 Axial Slice

References:

References Bennett, J. M. (2011). High ankle sprain (syndesmotic sprain). Retrieved August 6, 2012 from http://www. sportsmed.com /articles/id/40.aspx Boyles RE, Gorman I, Pinto D, Ross MD. Physical therapist practice and the role of diagnostic imaging. J Orthop Sports Phys Ther . 2011;41(11):829-837. doi : 10.2519/jospt.2011.3556. Breitenseher MJ, Trattnig S, Kukla C, et al. MRI versus lateral stress radiography in acute lateral ankle ligament injuries. J Comput Assist Tomogr . 1997;21(2):280-285. Childs SG. Syndesmotic ankle sprain. Orthop Nurs . 2012;31(3):177-184. doi : 10.1097/NOR.0b013e318257a974. Evans JM, Schucany WG. Radiological evaluation of a high ankle sprain. Proc ( Bayl Univ Med Cent). 2006;19(4):402-405. Frey, C. (2004). Persistent pain and instability following ankle sprain: Honing in on the diagnosis. Journal of Musculoskeletal Medicine, 2(8), 435–443. Hermans , J. J., Beumer , A., de Jong, T. A., & Kleinrensink , G. T. (2010). Anatomy of the distal tibiofibular syndes - mosis in adults: A pictorial essay with a multimodality approach. Journal of Anatomy, 217(6), 633–645. Kirchner, J. S., Musgrave, A. L., & Musgrave, D. S. (2005). Managing chronic pain after ankle sprain. Journal of Musculoskeletal Medicine, 22(8), 407–416. Silvestri , P. G., Uhl , T. L., Madaleno , J. A., Johnson, D. L., & Blackport , R. M. (2002). Management of syndesmotic ankle sprains. Athletic Therapy Today, 7(5), 2–3. Veenema , K. R. (2000). Ankle sprain: Primary care evaluation and rehabilitation. Journal of Musculoskeletal Medicine, 17(9), 563–576. Wilson , F. C. (1984). Fractures and dislocations of the ankle. In C. Rockwood & D. Green (Eds.), Fractures in adults (2nd ed., Vol. 2, pp. 1665–1701). Philadelphia, PA: Lippincott. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. (2001) Management of Ankle Sprains. Retrieved August 6, 2012 from http://www.aafp.org/afp/2001/0101/p93.html Bruce J. (2010). The Elusive High Ankle Sprain. Retrieved August 6, 2012 from http://physical-therapy.advanceweb.com/Archives/Article-Archives/The-Elusive-High-Ankle-Sprain.aspx MacIntyer , I. Syndesmotic Injury. Retrieved August 6, 2012 from http://www.sportsperformancecentres.com/articles/scientific/Syndesmotic_Injury_or_High_Ankle_Sprain.pdf High Ankle Sprain Syndesmotic Injury. Retrieved August 5, 2012 from http://morphopedics.wikidot.com/high-ankle-sprain-syndesmotic-injury Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport. 2011;12(2):57-69. doi : 10.1016/j.ptsp.2011.03.001.