PowerPoint Presentation

Step-By-Step Ultrasound Assessment of the Ankle

Caitlin Gardiner

Presentation25 year old maleReferral: US assessment of the RIGHT ankle ?ATAF rupturePatient indicates falling off a skateboard 3 weeks agoLateral ankle pain and swellingReduction in symptomsReserved movement

Ultrasound ExaminationExplained examination to the patient to gain informed consentPatient was positioned supine on the bed with right knee bentA 5-13MHz linear array transducerMSK General preset

Anterior Ankle

Lateral Ankle

Findings

Rupture of the ATAF ligamentAnterior Joint EffusionA 12*7*3mm ganglion cyst arising from the medial talo-navicular joint Mild tenosynovitis of the peroneal tendonsStrain of the calcaneo-fibular ligament

The Anterior Talo-Fibular LigamentMost commonly injurered ligament of the ankleTypically occurs in individuals under 35 years of age, mostly 15-19 years and is sports-related in around 50% of cases (van den Bekerom et al, 2012)Important role in limiting anterior diaplacement of the talus and plantar flexion of the ankleTypically damaged by an inversion injury (Golano et al, 2010)Clinical PresentationAnkle diabilityPain and swellingGiving way or instability (Golano et al, 2010)The anterior talofibular ligament is composed of two bands, separated by vascular branches of the perforating peroneal artery and lateral malleolar arteryThe upper band is taut on plantar flexionThe inferior band is taut on dorsiflexionOriginates at the anterior malleolus and attaches around 10mm proximal to the fibulaOverall width of 6-10mm (Golano et al, 2010)The Anterior Talo-Fibular LigamentUltrasound FindingsDistruption/discontinuation of ligament pattern/hyperechoic bundles- TornHypechoic lesion- strainCan be classified as Attachment to fibulaMid-substanceAttachment to the talusRelevant as a 5mm margin of remnant from the attachment is required to suture the ligament (Oae et al, 2010). Around 60% of acute ATAF rupture cases showing a tibiotalar effusion (McCarthy et al, 2008)

The Anterior Talo-Fibular LigamentTreatment is typically conservative measureRest, Ice, Non-steroidal anti-inflammatoriesSupport bandages and immobilisationPhysical therapyInterventional is typically only required in profession sports players (van den Bekerom et al, 2012)Imaging ModalitiesArthroscopy- Gold Standard MR (93% when compared with Arthoscpy in the ATAF injury)US- easily available, economical and portable. Less reliable (63% when compared to Arthroscopy) (Oae et al, 2010).

The Anterior Talo-Fibular LigamentReflectionAlso use a hockey-stick probeUnfortunately only one hockey-stick probe at the practice and was unavailable at the time of examination Comparison picture of the calcaneo-fibular ligamentTo highlight the strain of the ligament Assess the type of tear of the ATAFPrior to this assignment I was unaware this is something that can and should be assessed

References Galano P, Vega J, de Leeuw PAJ et al, 2010. Anatomy of the Ankle Ligaments: A pictorial essay. Knee Surg Sports Traumatol Arthesc; 18: 557-569McCarthy CL, Wilson DJ, Coltman TP, 2008. Anterolateral ankle inmpingement; findings and diagnostic accuracy with ultrasound imaging; 37(209-216). Oae K, Takao M, Uchio Y and Ochi M, 2010. Evaluation of Anterior Talofibular Ligament with stress radiography, ultrasonography and MR imaging. Skeletal Radiol; 39:41-47. Van den Bekerom MPJ, Kerkhoffs GM, McCullum GA et al, 2012. Management of Acute Lateral Ankle Injury in the Atheltete. Knee Surg Sports Traumatol Arthosc; 21(6): 1390-1395