Lateral Ankle Sprain Anatomy – Can the Bifurcate Ligament be Consistently

Identified with Ultrasound on CadaversLyman 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

1/3

2/3

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 surfaceanatomy 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 StudentBrion Benninger, MD MSc

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