GEMC- Injuries of the Lower Extremity: Knee, Ankle and Foot- Resident Training
Lower extremity - Ankle and footbonepit.com/lectures/Ankle Nick Panchal.pdf · Lower extremity -...
Transcript of Lower extremity - Ankle and footbonepit.com/lectures/Ankle Nick Panchal.pdf · Lower extremity -...
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Lower extremity
- Ankle and foot
Department of RadiologyUCSD
SDUC
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Foot and Ankle - Anatomy
- Pathology
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Ref: sika.ecolad.com
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OBJECTIVES
Review the osseous anatomy, major normal
variants, and clinically important contours of
the calcaneus and talus
Review traumatic pathology of the calcaneus
and talus with an emphasis on
pathomechanics and accurate description
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Sonography-Embryonic hindfoot
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Anatomy- Calcaneal articular surfaces
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Anatomy- Lateral Contours Calcaneus
Saute et al. Radiology 242(2):509-517 Feb.
2007
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Normal anatomy- Talus
From above From below
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Radiographs
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Normal Variation
Calcaneal apophysis- fuses at age 12-15 in both sexes
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Transient Calcaneal Spur
Disappears by age 1!
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Normal Variant- Pseudocyst
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Prominent Vascular Remnant
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Os Supratalare- ?Normal Variant
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Pathology
of
the foot and ankleTrauma
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Calcaneus Fractures
Most common tarsal fracture
Accounts for 2% of all fractures
70-75% Intraarticular
20-25% Extrarticular
Historically poor prognosis
No consensus on management due to lack of standard, unified classification system and understanding of fracture pathoanatomy
High variability in fracture pattern based on magnitude and direction of impacting force, foot position, muscle tone, and bone mineralization
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Intraarticular Fx-Pathomechanics
Axial loading mechanism results in typical pattern of the primary shear (sagittal ) and secondary compression (coronal) type fracture lines
Sagittal fracture (parallel to long axis of the calcaneus) - occurs due to wedge force of the talus on calcaneus
If energy of impact is not expended completely, compression or secondary fracture lines may occur and may result in a “tongue” type or “joint depression” type fracture
Shear
Jt.
Depression
Tongue
Comp.
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Pathoanatomy
Diverging axis of the calcaneus and talus results in shear separation of the sustenatacular and tuberosity portions
Hindfoot varus- medial fx line
Hindfoot valgus-lateral fx line
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Calcaneus Fracture- Shear Force
Shear- Typical Split Shear- Unusual
Double Split
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Calcaneus Fractures
Marked rotation of
mobile posterolateral
tuberosity fragment
resulting in marked
widening of the
calcaneuss
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Calcaneus Fractures- Compression
Tongue Type FractureIntraarticular depressed
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CT Appearance
Tongue type Intraarticular Depressed
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Classification
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Classification
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SANDERS CLASSIFICATION (CT)
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Sanders Classification
Most useful system for intraarticular fracture classification
Improved interobserver variability
Has both clinical and prognostic implications
Type 1: Excellent results with conservative management
Type 2 and 3: Excellent results with surgical management
Type 4: Poor results with surgical managment
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Intraarticular Fractures: Typical
Osseous Features
Loss of Height due to impaction and/or rotation of the more mobile tuberosity fragment
Widening due to displacement of tuberosity fragment
Posterior subtalar joint disruption
Axial loading associated with TL burst fractures
Superior peroneal retinacular avulsions
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Intraarticular Calcaneus Fractures-
Extraosseous Associations
Peroneal
tendon
entrapment
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Entrapment Complication
Fibrosing tenosynovitis related
to untreated peroneal tendon
entrapment
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Associated injury- SPR Avulsion
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Intraarticular calcaneus fractures-
Extraosseous Findings
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MR Imaging
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MR Imaging
Diagnosis: Calcific Myonecrosis related to a
remote compartment syndrome
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Calcific myonecrosis
Relatively rare, late sequela of trauma
Plate/Sheet-like calcifications are characteristic
Only 1 case reported in the foot in the English
literature
May erode adjacent bone
Spontaneous draining sinus-tracts and culture
positive infections may develop
Appropriate treatment: compartmental excision or
debridement
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Miscellaneous Calcaneus fx
Axial loading with
extreme hindfoot varus
or inversion
May be intra or extra
articular depending on if
the fracture line involves
the calcaneal facet
Conservative treatment
Isolated sustentacular
fracture
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Miscellaneos fx
Isolated medial tubercle fx- axial load
In extreme hindfoot valgus
Extraarticular, conserative treatment
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Miscellaneous- Anterior Process
Calcaneus FractureType 1: Forced plantar flexion and inversion resulting in Bifurcate ligament injury and avulsion. Clinically mimics ankle sprain
Type 2: Eversion and dorsiflexion with shear injury to anterior process
Both susceptible to nonunion/AVN with recurrent pain
Early detection can prompt surgical management- displaced fractures involving more than 25% of the calaneocuboid are treated surgically
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Beak Fracture
Treated
surgically
Greater displacement =
greater functional loss of the
the Achilles tendon
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Stress fracture
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How can we make the report sound
sweet and help with management?
Intraarticular/extrarticular?
Think about the mechanism and why the fracture appears the way it does
Describe the displacement and comminution of the various named fragments (tuberosity, sustenacular, middle)
Describe the position of the IA fracture line with respect to the posterior calcaneal facet (Sanders)
Bohler’s and Gissane’s angle
Soft tissue entrapment
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Talus Fractures
Fractures divided into head, neck and body
fractures
Approximately 50 % of talar fractures involve
the neck
Most common body fractures are
osteochondral, less common involve the
lateral or posterior process
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Talar Neck Fractures
Hawkins Classificationof Talar Neck Fractures
Radiographic findings Risk of
AVN
Type I Nondisplaced fracture line 0-13%
Type
II
Displaced fracture, plus subluxation or
dislocation of subtalar joint
20-50%
Type
III
Displaced fracture, dislocation subtalar
AND tibiotalar joints
69-100%
Type
IV
Displaced fracture and disruption of
talonavicular joint
high
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Talar Neck Fractures(Aviator’s
Astragalus)
Most common mechanism: Dorsally directed force on a braced foot (MVA)
Complication - Since most of the blood supply to the talar body comes via the talar neck, fractures of the neck place the patient at risk for AVN
Hawkins Type III
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Talar Neck Fractures
Hawkins
Type II
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Talar Neck Fractures
Hawkins Type I
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Postoperative Talar Neck-
Complication
Partial Hawkins Sign- Indicates Intact
Vascularity on side and ischemia on the
other
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Complication- AVN
Peree et al. Radiographics 25: 399-410. 2005
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Lateral Process of the Talus-
Radiography
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Lateral Process Talus Fracture
PURE DORSIFLEXION, INVERSION AND AXIAL LOADING
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CEDELL FRACTURE
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Osteochondral Fractures
Inversion Injuries
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Radiographs MRI T2WI * Arthroscopy
1 NormalDiffuse high-signal
intensity
Normal, or softening of
cartilage
2Semicircular
lucent line
Semicircular low-signal
line
Break in cartilage, fragment
not displacement
2a
Subcortical
round
lucency(cysts)
High-signal fluid within
fragmentNone
3 Same as 2High-signal fluid
surrounds fragmentDisplaceable fragment
4 Loose bodyDefect talar dome,
possibly loose bodyDefect plus loose body
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35 yo s/p MCA
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35 yo s/p MCA
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Conclusion
Osseous anatomy of the talus and calcaneus
can seem complex
Using a systematic approach
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Distal
fibular
fracture
Weber A
Syndesmosis
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Bi-
malleolar
fracture
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Maisonneuve
fracture
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Weber Classification
Determine level of fracture with respect to the
syndesmosis.
Correlates with prognosis and treatment.
Type A= transverse fracture of lateral
malleolus below syndesmosis.
Type B= oblique fracture at the level of the
ankle joint; partial disruption of syndesmosis.
Type C= fibular fracture proximal to the ankle
joint with tear of tibiofibular ligaments and
syndesmosis.
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Metatarsal fractures
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Stress
fracture
foot
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Stress fracture
medial malleolus
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fracture 5th proximal phalanx -
renal osteodystrophy
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fracture sesamoid
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Avulsion tib.post. tendon
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Tibialis anterior tendon
tear
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Tear of the anterior
Syndesmosis ligament
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Achilles tendon tear
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Tear ant. talofibular lig
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Fracture of the
calcaneus
and talus
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Osteochondritis dissecans
Repeated microtrauma causes injury
Occurs in typical locations at the knee and
ankle.
In the ankle the talar dome is typical location.
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STIR
Fs T1-w Gd
T1-w
Bone marrow infarction
and stress fracture
in 50 yo patient with
chemotherapy
for lymphoma
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Pathology
of
the foot and ankleInflammation
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Osteomyelitis / Arthritis
foot
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Osteomyelitis ankle
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Tuberculous
dactilitis
- frequent in children
- multiple foci in 25-
30%
- Soft tissue swelling
- Periostitis
- May be cystic =
spina ventosa
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Rheumatoid arthritis
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Gout
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T1 T1fs-Gd
Reactive arthritis - Reiter‘s
syndrome
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Pathology
of
the foot and ankleTumor
![Page 91: Lower extremity - Ankle and footbonepit.com/lectures/Ankle Nick Panchal.pdf · Lower extremity - Ankle and foot Department of Radiology UCSD SD UC. Foot and Ankle - Anatomy - Pathology.](https://reader035.fdocuments.net/reader035/viewer/2022080720/5f79a0d72a3c8f0e3a635e5e/html5/thumbnails/91.jpg)
Plantar fibromatosis
fs-T2
fs-T1+Gd
STIR
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Metastatic Prostate Cancer
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Chondrosarcoma
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Pathology
of
the foot and ankleVarious
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Calcaneonavicular coalition
Fusion of tarsal bones
Talocalcaneal and calcaneonavicular are most
common types
Fibrous, cartilaginous or osseous.
Result in limited motion at these joints and
over time pain, arthritis, tendonopathy
develop.
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Club foot
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Clubfoot
1 in 1000 births.
Unclear etiology.
Hindfoot equinus, hindfoot varus, and forefoot
varus.
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Osteogenesis
imperfecta
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Chronic venous
stasis
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Necrosis/bone
bruise of the
navicular bone?
Follow-up 6 months
later
Bone marrow edema
Transient migratory osteoporosis
Fs T2-w
STIR
T1-w
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Summary and
Discussion
I. Anatomy
II. Pathologies
III. What pathologies are important at your level?