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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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mm

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 !

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