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XX--Ray Rounds:Ray Rounds:
(Plain) Radiographic Evaluation(Plain) Radiographic Evaluationof the Ankleof the Ankle
Garry W. K. Ho, M.D.Garry W. K. Ho, M.D.VCU / Fairfax Family PracticeVCU / Fairfax Family Practice
Sports Medicine FellowSports Medicine Fellow
September 2006September 2006
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Anatomy Anatomy
Complex hinge jointComplex hinge jointArticulations among:Articulations among: FibulaFibula
TibiaTibia TalusTalus
Tibial plafond Tibial plafond Distal tibial articularDistal tibial articular
surfacesurface
Complex ligamentousComplex ligamentoussystemsystem
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Anatomy Anatomy
Medial malleolusMedial malleolus Distal tibiaDistal tibia Medial supportMedial support
Lateral malleolusLateral malleolus Distal fibulaDistal fibula Lateral supportLateral support
TalusTalus TrapezoidTrapezoid- -shapedshaped
Mortise (tibial plafond, medial & lateral malleoli)Mortise (tibial plafond, medial & lateral malleoli)-- Constrained articulation with the talar domeConstrained articulation with the talar dome
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Anatomy Anatomy
Syndesmotic ligamentSyndesmotic ligamentcomplexcomplex Axial, rotational, & Axial, rotational, &
translational stabilitytranslational stability Four ligaments:Four ligaments:
Anterior tibiofibularAnterior tibiofibularligamentligamentPosterior tibiofibularPosterior tibiofibularligamentligament
Transverse tibiofibularTransverse tibiofibularligamentligamentInterosseous ligamentInterosseous ligament
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Anatomy Anatomy
Lateral (fibularLateral (fibularcollateral) ligamentcollateral) ligamentcomplexcomplex Anterior talofibularAnterior talofibular
ligament (weakest)ligament (weakest) Posterior talofibularPosterior talofibular
ligament (strongest)ligament (strongest) CalcaneofibularCalcaneofibular
ligamentligament
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Indications for Ankle RadiographsIndications for Ankle RadiographsO ttawa Ankle RulesO ttawa Ankle Rules Age 55 years or olderAge 55 years or older
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Normal ankle(AP view)
Normal ankle(Mortise view)
Normal ankle(Lateral view)
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AP View of the Ankle AP View of the Ankle
DE: Talar Tilt: < 2 degrees of angulation is Nl
DE
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AP View of the Ankle AP View of the Ankle
Talar Tilt: > 2 degrees angulation mayindicate medial or lateral disruption
Tib-fib Clear Space > 5mm orTib-fib O verlap < 10mm
may indicate syndesmotic injury
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Lateral View of the AnkleLateral View of the AnkleDome of the talus:centered underand congruouswith tibial plafond
Posterior tibialtuberosityfractures & direction of fibular injuriescan be identified
Avulsionfractures of thetalus by theanterior
capsule can beidentified
Anydeformity tothe talus,calcaneusor subtalar
joint
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C alcaneal FracturesC alcaneal Fractures
B ohlers Angle30-35 degreesis normal
O thers:
Critical Angleof Gissane
B rodensViews
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M ortise View of the AnkleM ortise View of the AnkleAP view taken with the footAP view taken with the foot
in 15in 15- -20 degrees of internal20 degrees of internalrotation to offset therotation to offset theintermalleolar axisintermalleolar axis
Medial clear spaceMedial clear space > 4mm may indicate> 4mm may indicate
lateral talar shiftlateral talar shift
Talar tilt, TibTalar tilt, Tib- -fib O verlap,fib O verlap,TibTib--fib clearspace (see APfib clearspace (see APview)view)
Talocrural angle (angle b/wTalocrural angle (angle b/wplafond parallel andplafond parallel andintermalleolar line)intermalleolar line)
Normal is 8Normal is 8- -15 degrees15 degrees(where the lines intersect)(where the lines intersect)
Smaller angle may indicateSmaller angle may indicatefibular shorteningfibular shortening
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M ortise View of the AnkleM ortise View of the Ankle
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mm
Normal AP & lateral rightankle X Ray
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mm
AP View:
Widened medialclear space
Mortise View:
O pen mortise(decreased tib-fiboverlap)
= Syndesmoticinjury
= Surgical referral
(needs a screw)
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28 y/o M who twisted his leftankle while playing
basketball 1 dayago
Danis-Weber Type B fibularankle fracture
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Ankle Fracture C lassification Ankle Fracture C lassification
DanisDanis- -Weber ClassificationWeber Classification Defined by location of theDefined by location of the
fracture linefracture line
Type A : below thetibiotalar jointType B : at the level of thetibiotalar jointType C : above thetibiotalar joint
Syndesmotic ligamentcompromise
LaugeLauge- -HansenHansenClassificationClassification
Infrequently used,Infrequently used,clinically; mostly academicclinically; mostly academic
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mm
Mortise view:
Weber C fracturewith open mortiseand widenedmedial clear space
= deltoid & syndesmoticligament tears,with fracture
= surgical referral
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mm
25 y/o volleyballplayer landed wrong on the right foot,
hurting the ankle
Exam with positivetalar tilt
Lateralligamenttears
-ATFL
-CFL
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Radiographic Stress Tests of the AnkleRadiographic Stress Tests of the Ankle
Talar Tilt Stress Test Stabilize the leg with oneStabilize the leg with onehand while inverting plantarhand while inverting plantarflexed heel with the otherflexed heel with the other
Contralateral ankle used forContralateral ankle used forcomparisoncomparisonLine is drawn across theLine is drawn across thetalar dome and tibial vaulttalar dome and tibial vault
Degree of lateral openingDegree of lateral openingangle is measuredangle is measured
Normal tilt is less than 5Normal tilt is less than 5degdeg
Standing Talar Tilt StressStanding Talar Tilt StressTest:Test:
may be more sensitivemay be more sensitive
Patient stands on anPatient stands on aninversion stress platforminversion stress platformwith the foot and ankle inwith the foot and ankle in40 deg of plantar flexion40 deg of plantar flexionand 50 deg of inversionand 50 deg of inversion
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Grade IIIATFL anklesprain
25 y/o male tennisplayer torqued hisright ankle
Exam with positiveanterior drawer sign
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Radiographic Stress Tests of the AnkleRadiographic Stress Tests of the Ankle
Anterior Drawer Test Abnormal anterior
translation is between 5to 10 mm, or 3 mm
more than other side
External Rotation StressTest
Evaluates syndesmotic & deep Deltoid ligaments
Difference in width of superior clear spacebetween medial and lateralside of the joint should be< 2 mm
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mm
AP View:
Widenedmedial clear
space
Decreased tib-fib overlap
= Medial & syndesmoticligamentcompromise
= surgicalreferral
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mmNormal AP & lateral views
O pen mortise
= needs a screw
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mm
Weber Type Alateral malleolarfracture
Treat conservatively
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mm
O pen mortisewith high fibular
fracture
Name?
Maisson eurvefr act ure
= surgicalreferral
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mm
Salter-Harrisfracture, type II
= Refer for O RIF
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S A L T ERS traight Above be Low Through C ER ush1 2 3 4 5
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mm
Lateral ligamentousinjury
Medial malleolaravulsion fracture
Surgical referral
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mm
Nondisplacedspiral fibularfracture
= CR & immobilization
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mm
Posterior malleolar
avulsion fracture
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mm
AbnormalB ohlers angle
= Calcaneal Fx
Surgerize!
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mm
Medial malleolarfracture
= refer for screwfixation
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mm
Medial malleolar Fx
Widened medialclear space: talardislocation
O pen mortise:syndesmotic injury
Maisson eurve Fx
= Surgery
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mm
B imalleolar fractures
O steopenic appearing
bone
Surgical referral
Tx osteoporosis prn
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Diagnosis?
Charcots foot
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Tillaux FractureTillaux FractureFracture of theFracture of theanterolateral tibialanterolateral tibialepiphysisepiphysisMechanismMechanism
Avulsion of epiphysealAvulsion of epiphysealfragment due to thefragment due to thestrong anteriorstrong anteriortibiofibular ligamenttibiofibular ligamentExternal rotational forceExternal rotational forceacross the ankleacross the ankle
Commonly seen inCommonly seen inadolescentsadolescentsTreatment: O RIFTreatment: O RIF
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mm
Calcanealosteomyelitis
= IV Abx
= Surgical I & Dif chronic
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mm
Mortise view
AP view
Lateral view
Pilon fracture(Comminuted tibial
plafond compressionfracture)
Management?
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mm
Positive talar tiltstress test
Surgery
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s/p Fall while rockclimbing Treatment ?
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C onclusionC onclusion
Plain radiographicPlain radiographicanatomy of theanatomy of theankleankle
Indications forIndications forplain radiographsplain radiographsof the ankleof the ankle
Direct and indirectDirect and indirectsigns of injury onsigns of injury onplain radiographsplain radiographs
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The End
Th k !