Ankle X Rays
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Transcript of Ankle X Rays
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X-Ray Rounds:
(Plain) Radiographic Evaluation
of the Ankle
Garry W. K. Ho, M.D.VCU / Fairfax Family Practice
Sports Medicine Fellow
September 2006
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Anatomy
Complex hinge joint
Articulations among:
Fibula
Tibia
Talus
Tibial plafond
Distal tibial articularsurface
Complex ligamentoussystem
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Anatomy
Medial malleolus
Distal tibia
Medial support
Lateral malleolus Distal fibula
Lateral support
Talus
Trapezoid-shaped
Mortise (tibial plafond, medial & lateral malleoli)
- Constrained articulation with the talar dome
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Anatomy
Syndesmotic ligamentcomplex
Axial, rotational, &translational stability
Four ligaments:Anterior tibiofibularligament
Posterior tibiofibularligament
Transverse tibiofibularligament
Interosseous ligament
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Anatomy
Deltoid (medial)ligament complex
Superficial (contributes
little to stability)Tibionavicular ligament
Tibiocalcaneal ligament
Superficial Tibiotalarligament
Deep (primary medialstabilizer)
Intraarticular:
Deep tibiotalarligament
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Anatomy
Lateral (fibularcollateral) ligamentcomplex
Anterior talofibular
ligament (weakest) Posterior talofibular
ligament (strongest)
Calcaneofibularligament
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Indications for Ankle Radiographs
Ottawa Ankle Rules Age 55 years or older
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Indications for Ankle Radiographs
How good are the Ottawa Rules? When originally published:
100% sensitivity & 40% specificity for detectingmalleolar fractures
Subsequent studies:
Lower sensitivity (93% to 95%) and specificity (6%to 11%) than originally thoughtNot perfect, but still a good tool
Other indications The patient cannot communicate (altered
mental status, alcohol intoxication, or other) Pain and swelling do not resolve within 7-10
days after injury Anytime your history and physical dont give
you enough information
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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
DE: Talar Tilt: < 2 degrees of angulation is Nl
D
E
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AP View of the Ankle
Talar Tilt: > 2 degrees angulation mayindicate medial or lateral disruption
Tib-fib Clear Space > 5mm orTib-fib Overlap < 10mm
may indicate syndesmotic injury
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Lateral View of the Ankle
Dome of the talus:centered underand congruouswith tibial plafond
Posterior tibialtuberosityfractures &direction offibular injuries
can be identified
Avulsionfractures of thetalus by theanterior
capsule can beidentified
Anydeformity tothe talus,calcaneusor subtalar
joint
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Calcaneal Fractures
Bohlers Angle
30-35 degreesis normal
Others:
Critical Angleof Gissane
BrodensViews
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Mortise View of the AnkleAP view taken with the footin 15-20 degrees of internal
rotation to offset theintermalleolar axis
Medial clear space > 4mm may indicate
lateral talar shift
Talar tilt, Tib-fib Overlap,Tib-fib clearspace (see APview)
Talocrural angle (angle b/wplafond parallel andintermalleolar line) Normal is 8-15 degrees
(where the lines intersect) Smaller angle may indicate
fibular shortening
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Mortise 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:
Open mortise(decreased tib-fiboverlap)
= Syndesmotic
injury
= Surgical referral
(needs a screw)
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28 y/o M whotwisted his leftankle while playingbasketball 1 day
ago
Danis-Weber Type B fibularankle fracture
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Ankle Fracture Classification
Danis-Weber Classification Defined by location of the
fracture line
Type A: below the
tibiotalar jointType B: at the level of thetibiotalar joint
Type C: above thetibiotalar joint
Syndesmotic ligamentcompromise
Lauge-HansenClassification Infrequently used,
clinically; 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 wrongon the right foot,
hurting the ankle
Exam with positivetalar tilt
Lateralligamenttears
-ATFL
-CFL
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Radiographic Stress Tests of the Ankle
Talar Tilt Stress Test
Stabilize the leg with onehand while inverting plantarflexed heel with the other
Contralateral ankle used forcomparisonLine is drawn across thetalar dome and tibial vault
Degree of lateral openingangle is measured Normal tilt is less than 5
deg
Standing Talar Tilt StressTest:
may be more sensitivePatient stands on aninversion stress platformwith the foot and ankle in40 deg of plantar flexionand 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 Ankle
Anterior Drawer Test Abnormal anterior
translation is between 5to 10 mm, or 3 mmmore 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 clearspace
Decreased tib-fib overlap
= Medial &syndesmoticligamentcompromise
= surgicalreferral
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mmNormal AP &lateral views
Open mortise
= needs a screw
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mm
Weber Type Alateral malleolar
fracture
Treat conservatively
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mm
Open mortisewith high fibularfracture
Name?
Maissoneurve
fracture
= surgicalreferral
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mm
Salter-Harrisfracture, type II
= Refer for ORIF
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S A L T ERStraightAbovebeLowThroughCERush1 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 malleolaravulsion fracture
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mm
AbnormalBohlers 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
Open mortise:syndesmotic injury
Maissoneurve Fx
= Surgery
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mm
Bimalleolar fractures
Osteopenic appearingbone
Surgical referral
Tx osteoporosis prn
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mm
Diagnosis?
Charcots foot
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mm
Anterolateral
tibial epiphysealfracture
aka: Tillauxfracture
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Tillaux Fracture
Fracture of theanterolateral tibialepiphysis
Mechanism
Avulsion of epiphysealfragment due to thestrong anteriortibiofibular ligament
External rotational forceacross the ankle
Commonly seen inadolescents
Treatment: ORIF
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mm
Calcanealosteomyelitis
= IV Abx
= Surgical I & Dif chronic
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mm
Calcanealfracture
= ORIF
M ti i
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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
/ F ll hil k li bi
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s/p Fall while rockclimbing Treatment ?
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Conclusion
Plain radiographicanatomy of theankle
Indications forplain radiographsof the ankle
Direct and indirectsigns of injury onplain radiographs
h d
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The End