Lateral Ankle Sprain Anatomy ¢â‚¬â€œ Can the Bifurcate Ligament ... Lateral Ankle Sprain Anatomy ¢â‚¬â€œCan

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  • Lateral Ankle Sprain Anatomy – Can the Bifurcate Ligament be Consistently

    Identified with Ultrasound on Cadavers Lyman Wood, 1st Year Medical Student

  • Overview • Objective

    • Bifurcate ligament anatomy

    • Understanding lateral ankle injury

    • Methods & Materials

    • Results and clinical significance

    • Conclusion

  • Objective

    • Investigate whether the bifurcate ligament could be identified using ultrasound on cadavers as a training exercise for anatomy education, clinical training, and assessment

  • Introduction • The bifurcate ligament (BFL) is under

    appreciated regarding lateral ankle injuries

    • Similar orientation to the anterior talofibular ligament (ATFL)

    • The BFL supports the joints between the calcaneous, cuboid and naviculus bones

  • Understanding Lateral Ankle Sprians • Typical Mechanism

    – Plantar flexion

    – Inversion

    • High Recurrence – A survey of 380 athletes

    revealed 73.5% of 563 ankle sprains had been previously injured

    • Variable Recovery Time – Average non-surgical complete

    rehabilitation 36-72 days

    Fallat, Grimm, Saracco, 1998

  • Methods • Literature Search – current imaging text and

    online journals

    • Dissection – 58 cadavers to identify BFL

    – 55 (n=110 sides; 55R:55L) Carolina solution

    – 3 (n=6; 3R:3L) Freedom Art solution

  • Methods • Evaluate Structural Relationships – Digital caliper

    measurements between:

    – Apex distal fibula (ADF), 5th metatarsal tuberosity (5MT)

    – ADF, Proximal aspect of BFL ligament (PBFL)

  • Methods

    • Surface Anatomy Template - developed using palpable bony landmarks for proper probe placement

    • Ultrasound – 31 donor cadaver patients (n=61 30R:31L) utilizing surface anatomy template

  • Materials

    • Ultrasound systems used

    – Sonosite M-Turbo – Classic probe

    – Fukuda-Denshi AG760 machines - SonicEye finger probe

    Sonosite M-Turbo Fukuda-Denshi AG760

  • Results

    • Literature Search – Revealed no studies of ultrasound (US) identification of BFL on cadavers

    – Study of 19 patients revealed 95% positive I.D. by US of ATFL damage (confirmation by Arthroscopy)

    • Dissection & Measurements

    – ADF – 5MT 60.22mm ± 0.43

    – ADF – PBFL 42.18mm ± 0.51

    Ratio ADF-PBFL:ADF-5MT = 1/3 from ADF



  • Results

    • Surface Anatomy Template

    – Revealed 76.27% positive BFL I.D. with 1st probe placement

    – Modified 2nd attempt revealed 92.86% positive I.D. with slight transducer adjustment

    Ultrasound Probe Placement Accuracy

    Accuracy of 61 US probe placements utilizing surface anatomy template and palpable landmarks

  • Results

    Caveric tissue

    In vivo

  • Results

    Caveric tissue

    In Vivo

  • Conclusion & Discussion

    • The bifurcate ligament can be positively identified using ultrasound on cadavers

    • Utilizing the surface anatomy template provides accurate and efficient I.D. with multiple different ultrasound systems and transducers

    • Ultrasound provides cost effective, quality imaging of affected anatomy regarding lateral ankle injuries

    • Accurate identification of ALL injured structures can reduce recurrence, recovery time, and improve overall patient care

  • Acknowledgements

    Bryan Beall 4th Year Medical Student Brion Benninger, MD MSc

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