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Ankle and Foot
This chapter is intended to serve as a practical approach to imaging the ankle and foot using computed tomography (CT) and magnetic resonance imaging (MRI). Rather than providing an exhaustive review of the literature, we illustrate the anatomic structures and common pathologic processes seen with CT and MRI scans. In addition, we have included discussions regarding the techniques for obtaining these scans, including the CT and MR protocol sheets we use daily in the Radiology Department of the University of Wisconsin in Madison (UW). The most up-to-date versions of these protocol sheets are available for free download at www.schreibman.info. Throughout this chapter, we have endeavored to include references to review articles for readers who wish to explore topics in more detail. The images and content of this chapter are based on Dr. Schreibman’s lecture series.
and head. The dome of the talus along with the distal ends of the tibia and fibula make up the ankle joint (Fig. 47-3). (Ankle joint is the preferred name of this joint in the radiology and orthopedic surgery literature, rather than “tibiotalar joint” or “crural joint.”)
The flat talar dome articulates with the flat surface at the distal end of the tibia known as the plafond. Plafond is an architectural term meaning “a ceiling formed by the underside of a floor.” In essence, the plafond is the ceiling of the ankle joint, formed by the floor of the tibia. The ankle joint is bounded on the sides by the inner articular surfaces of the medial and lateral malleoli. The plafond and malleoli together form a rectangular opening called the mortise into which the talar domes fit, analogous to a mortise-andtenon joint in woodworking. The ankle mortise is a remarkably sturdy joint. Like the hip and knee joints, the ankle must bear our entire body weight with every step. But although it is common for primary osteoarthritis to affect the hips and knees of many of us as we age, it is uncommon to have primary osteoarthritis of the ankle. The joint between the distal tibia and fibula is called the syndesmosis. Syndesmosis is a Greek term meaning “to bind together,” and in general a syndesmosis joint is held together by thick connective ligaments. (Most joints in the body, including the ankle and subtalar joints, are synovial joints in that they are enclosed by a synovium-lined capsule that creates synovial fluid.) The distal fibula, just above the lateral malleolus, fits into a shallow groove in the adjacent tibia, and this relationship is best visualized in the axial plane of a CT scan.
• Tarsal Bones • Gross Anatomy of the Tarsal Bones
Figures 47-1 through 47-4 are photographs of cadaveric bones arranged to illustrate the relationships of the major tarsal bones and joints. Figure 47-1 represents the bones we typically cover when scanning the distal tibia/ankle/ foot. Central to all this is the talus, labeled Ta. (The label abbreviations in Fig. 47-1 will be consistent throughout all figures.) Indeed, the word talus is Latin for “ankle,” indicating that early anatomists considered the talus the center of the ankle. Understanding the articulations between the talus and the surrounding bones is the key to understanding the anatomy of the ankle and foot. Two views of the talus are shown in Figure 47-2. The dome is the broad, curved articular surface on the top of the talus. (The specimen in Fig. 47-2 has an osteochondral lesion centrally in the medial edge of the talar dome. Osteochondral lesions are discussed later in the chapter.) The head is the rounded process at the anterior aspect of the talus, and it articulates with the navicular bone. The body of the talus comprises everything between the dome
The talus articulates with the tibia from above and with the navicular in front. It is at the undersurface of the talus where it articulates with the calcaneus that things get complicated. This joint below the talus is called the subtalar joint, which is preferred over “talocalcaneal joint.” Figure 47-4 illustrates the three facets that make up the subtalar joint. In Figure 47-4A to D, the talus and calcaneus were attached using colored modeling clay. In Figure 47-4E, the two bones have been disarticulated and the talus flipped
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2208 VII Imaging of the Musculoskeletal System
neal fractures we obliquely angle our coronally reformatted CT slices to be perpendicular to the posterior facet. The middle facet is defined by the sustentaculum tali, a shelflike projection from the anteromedial portion of the calcaneus that supports the middle of the talus. Sustentaculum in Latin means “a supporting structure.” The flexor hallucis longus tendon passes under the sustentaculum tali. The middle facet of the subtalar joint is a completely separate articulation from the posterior facet. When injecting contrast (often mixed with anesthetic) into the posterior facet of the subtalar joint, we do not expect it to communicate with the middle facet. Across the middle facet of the subtalar joint is one of the two most common locations for tarsal coalitions to occur, the other being between the anterior process of the calcaneus and the lateral pole of the navicular. Unlike the posterior and middle facets, the anterior facet is not well defined and may even be absent. When present, the anterior facet is a smooth continuation of the middle facet, extending under the head of the talus. Directly lateral to the anterior and middle facet is the sinus tarsi, an area devoid of bone and filled primarily with fat.
• Anatomic Divisions
Figure 47-5 is a three-dimensionally reformatted CT image showing the anatomic divisions between the tarsals and metatarsals. The hindfoot consists of the talus and the calcaneus and is separated from the midfoot by the Chopart* joint, a smooth continuation between the talonavicular and calcaneocuboid joints. The midfoot consists of the other five tarsal bones, the navicular, the cuboid, and the three cuneiforms. The forefoot consists of the metatarsals and phalanges and is separated from the midfoot by the tarsometatarsal joint, also known as the Lisfranc† joint. Along
Figure 47-1. Gross anatomy of the tarsals and surrounding bones. Ti, tibia; Fi; fibula; Ta, talus; Ca, calcaneus; ST, sustentaculum tali; N, navicular; Cu, cuboid; 1, 2, and 3, refer respectively to the first, second, and third cuneiforms (sometimes referred to as the medial, intermediate, and lateral cuneiforms, respectively); I, II, III, IV, and V refer to the first through fifth metatarsals, respectively.
*François Chopart (1743-1795), a pioneer in urology, was known for the particular attention he gave to recording his numerous clinical observations. Thus, it is somewhat surprising that he never wrote about the midtarsal amputation that bears his name almost three centuries later. He performed this surgery only once, on August 21, 1791, to resect a presumed liposarcoma of the foot. The approach was based on Chopart’s knowledge of the anatomy of the midfoot and was published by his student, Laffiteau, in 1792. † Jacques Lisfranc (1790-1847) was a very aggressive surgeon who wrote extensively and described many new procedures, including disarticulation of the shoulder, excision of the rectum, and amputation of the cervix. At age 23 he joined Napoleon’s army as a battlefront surgeon, a setting where amputations were the norm. Military surgeons (of the period) were not given the calm and unhurried atmosphere necessary for the task of laboriously picking out bone splinters and bits of clothing from gaping wounds. Locating the open ends of severed arteries and tying them off in the smoke of battle or by flickering candlelight was an enormous problem. Although some wounds did not themselves dictate amputation, it often had to be done because the patient could not otherwise survive the rigors of transport to the rear. The mind did not have time to reason. Experience and cold-bloodedness counted for more than talent. Everything had to be done with prompt and decisive action. In 1815, the final year of the war, Lisfranc wrote a 50page paper describing his technique for performing a partial amputation of the foot at the tarsometatarsal joint, with the sole being preserved to make the flap. The technique was used to treat forefoot gangrene from frostbite. Lisfranc was widely known for his ability to amputate a foot in less than a minute, an important skill in that preanesthesia era.
over, displaying the talar and calcaneal articular surfaces of the posterior, middle, and anterior facets of the subtalar joint in red, blue, and green, respectively. The posterior facet is the largest and is the primary weight-bearing portion of the subtalar joint. At the anterolateral corner of the posterior facet, the talus comes to an acutely angled corner, the lateral process of the talus. When the subtalar joint experiences an extreme axial load, such as when a person falls from a height or undergoes a deceleration injury in a motor vehicle collision, the pointy lateral process of the talus acts like a wedge, splitting and fracturing the calcaneus.13 Calcaneal fractures tend to extend into the posterior facet, and when imaging calca-
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47 Ankle and Foot
Figure 47-2. Gross anatomy of the talus as viewed from the top and medial sides. The green arrows show an osteochondral lesion of the talus (OLT) in the medial edge of the dome.
Figure 47-3. Gross anatomy of the ankle joint. A, The plafond (dotted line) is the transverse cortical articular surface at the distal end of the tibia. The mortise is the rectangular opening consisting of the plafond as well as the inner cortical articular surfaces (solid lines) of the medial malleolus (MM) and lateral malleolus (LM). B, The talar dome fits into the ankle mortise. The joint between the distal tibia and fibula is the syndesmosis (black bracket).
the Lisfranc joint is a common site for fracture-dislocations to occur, particularly in diabetic patients with peripheral neuropathy. Figure 47-5 illustrates how the base of the second metatarsal (II) sticks down like a keystone, disrupting the otherwise relatively smooth tarsometatarsal joint. For this reason dislocations along the Lisfranc joint are typically accompanied by fractures across the base of the second metatarsal.
• Cross-sectional Anatomy of the Tarsal Bones
Figure 47-6 is a series of straight axial images through the ankle and hindfoot, from proximal (see Fig. 47-6A) to distal (see Fig. 47-6F). The straight axial plane is well suited to examine the syndesmosis (see Fig. 47-6B, arrow). The two joints that make up the Chopart joint, the talonavicular joint (see Fig. 47-6D) and the calcaneocuboid joint (see Fig. 47-6F), are also well profiled in the axial plane. However, the ankle and subtalar joints are not well profiled
in the axial plane, and because examination of these two joints is usually the primary indication for requesting a CT of the ankle or hindfoot, other reformatted planes are required. Figure 47-7 is a series of straight sagittal images through the hindfoot, from lateral (see Fig. 47-7A) to medial (see Fig. 47-7C). Nearly all of the joints are profiled in the sagittal plane, including the ankle joint, the calcaneocuboid and talonavicular joints, and the posterior and middle facets of the subtalar joint. The only joint not well seen in the sagittal plane is the syndesmosis, but this is easily seen in the axial plane. The lateral sagittal images are also useful for visualizing the lateral process of the talus and the anterior process of the calcaneus (compare Fig. 47-7A with Fig. 47-4C). Figure 47-8 is a series of oblique coronal images through the hindfoot, from posterior (see Fig. 47-8A) to anterior (see Fig. 47-8D). This plane best profiles the subtalar joint, and the broad posterior facet can be followed
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2210 VII Imaging of the Musculoskeletal System
Figure 47-4. Various views of the gross anatomy of the subtalar joint. A, Medial view. ST, sustentaculum tali. B, Inferior medial view. ST, sustentaculum tali. C, Lateral view. LPT, lateral process of talus; APC, anterior process of calcaneus. D, Anterior lateral view looking into the sinus tarsi (asterisk). E, The subtalar joint has been disarticulated: left, talus (flipped over); right, calcaneus. The articular surfaces of the three facets of the subtalar joint are coated with colored modeling clay: posterior (red), middle (blue), anterior (yellow).
Figure 47-5. Three-dimensional CT scan illustrating anatomic divisions of the foot. The Chopart joint separates the hindfoot (talus [Ta] and calcaneus [Ca]) from the midfoot (navicular [N], cuboid [Cu], and the three cuneiforms [1, 2, 3]). The Lisfranc joint separates the midfoot from the forefoot (metatarsals and phalanges).
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47 Ankle and Foot
Figure 47-6. Straight axial images through the ankle and hindfoot, proximal (A) to distal (F). A, Proximal to syndesmosis. Fi, fibula; Ti, tibia. B, Through the syndesmosis (arrow). Fi, fibula; Ti, tibia. C, Through the top of the mortise. LM, lateral malleolus; MM, medial malleolus; Ta, talus. D, Through the sustentaculum tali (ST). Ca, calcaneus; N, navicular; Ta, talus; TNJ, talonavicular joint. E, Through the level where the calcaneus gets close to the navicular (arrowhead) but does not normally form a joint. If there were an articulation here, or osseous bridging, that would be tarsal coalition. Ca, calcaneus; Cu, cuboid. Numerals indicate cuneiforms. F, Through the calcaneocuboid joint (CCJ). Ca, calcaneus; Cu, cuboid. Roman numerals indicate metatarsals.
over several 3-mm slices (see Fig. 47-8A). As the posterior facet ends the middle facet begins, as defined by the sustentaculum tali (see Fig. 47-8B). When the oblique coronal slices are properly angled, the middle facet appears horizontally oriented (see Fig. 47-8C). The sinus tarsi is the cone of soft tissues directly lateral to the middle facet. Anterior to the subtalar joint, the round head of the talus is seen as a circle forming the talonavicular joint (see Fig. 47-8D). This demarcates the Chopart joint, the division between the hindfoot and midfoot.
• Ankle Tendons
There are 10 tendons that cross the ankle joint. For imaging purposes, these tendons can be clustered into four groups based on their anatomic locations, as illustrated by the colored curved lines drawn atop three-dimensional CT images in Figure 47-9. The anterior tendons are the anterior tibial, the extensor hallucis longus, and the extensor digitorum longus (see Fig. 47-9A). Posteriorly, there are the Achilles and plantaris tendons (see Fig. 47-9B). Laterally, the peroneus longus and peroneus brevis tendons pass under the lateral malleolus (see Fig. 47-9C). Medially, the posterior tibial and flexor digitorum longus tendons pass
under the medial malleolus, whereas the flexor hallucis longus passes under the sustentaculum tali (see Fig. 47-9D and E). On MRI, ankle tendons are best appreciated in cross section in the direct axial plane (Fig. 47-10). The oblique coronal plane (Fig. 47-11) is a good secondary plane to observe the medial and lateral tendons as they course under the malleoli. Normal tendons should appear uniformly black on all imaging sequences and have a sharply defined interface with adjacent fatty soft tissues. Any increased signal in a tendon on a T2-weighted image indicates the presence of pathology, typically an intrasubstance tear. In addition, more than a trace amount of fluid around an ankle tendon is abnormal, indicating inflammation or some other pathologic process. The exception to this is the flexor hallucis longus, which can normally contain some fluid in its tendon sheath.
• Anterior Tendons
The normal anterior tibial tendon serves as a useful internal standard with which to compare the size of the other ankle tendons. The anterior tibial is normally the largest
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2212 VII Imaging of the Musculoskeletal System
Figure 47-7. Straight sagittal images. Ca, calcaneus; Cu, cuboid; N, navicular; Ta, talus; Ti, tibia. A, Through the lateral hindfoot, profiling the calcaneocuboid joint (CCJ), the ankle joint (AJ), and the posterior facet of the subtalar joint (P-STJ). The brown arrow points to the lateral process of the talus (LPT), and the red arrow points to the anterior process of the calcaneus (APC). Fractures through these pointed bony projections are often difficult to see on radiographs and are typically worked up with CT. B, Through the middle of the hindfoot, profiling the talonavicular joint (TNJ), the ankle joint (AJ), and the posterior facet of the subtalar joint (P-STJ). The middle facet of the subtalar joint (M-STJ) can now be seen. C, Through the medial hindfoot, now profiling the middle facet, above the sustentaculum tali (ST). Straight alignment should normally be present between the talus, navicular, medial cuneiform (1), and first metatarsal (I).
Figure 47-8. Oblique coronal images through the hindfoot, posterior (A) to anterior (D). Ca, calcaneus; Fi, fibula; ST, sustentaculum tali; Ta, talus; Ti, tibia. A, This plane best profiles the posterior facet of the subtalar joint (red arrow). The ankle mortise (yellow line) can be appreciated in the oblique coronal plane but would be better profiled in the mortise coronal plane. B, This oblique slice is just anterior to the ankle joint, where the posterior facet of the subtalar joint is ending (red arrow) and the middle facet is beginning (blue arrow). C, The oblique coronal slices are angled correctly if the middle facet of the subtalar joint (blue arrow) has a horizontal orientation. The cone of soft tissues lateral to the middle facet is the sinus tarsi (asterisk). D, The junction of the hindfoot and midfoot is at the round head of the talus at the talonavicular joint (circle).
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inserting on the distal phalanx. light purple) wrapping under the cuboid.47 Ankle and Foot 2213 47 A B C D E Figure 47-9. At the level of the midfoot.21. red). the extensor digitorum longus fans out into four separate tendon slips. Posterolateral view of the lateral tendons: peroneus brevis (PB. Medial (D) and posterior (E) views of the medial tendons. blue). Ch047-A05375. dark purple) inserting into the base of the fifth metatarsal. The most lateral of the three anterior ankle tendons is the extensor digitorum longus. A. The anterior tibial is the most medial of the three anterior tendons. tendon in axial cross section. in turn. proceeding straight to its insertion at the dorsal base of the great toe distal phalanx. Posterior view of the posterior tendons: Achilles (Ach. and the flexor hallucis longus (FHL. uncrossed. C. extensor hallucis longus (EHL. red) wraps under the medial malleolus and inserts on the medial pole of the navicular (N). which. B.42 The anterior tendons extend. except the Achilles tendon. green). The 10 ankle tendons are illustrated as colored lines drawn over three-dimensional CT images. and Harry” mnemonic: the posterior tibial (PT. 47-9A). 47-10C).31 Whereas the anterior tibial and extensor digitorum longus tendons can be followed over a series of axial images (see Fig.7 It is important not to misinterpret this lack of visualization as a rupture of the extensor hallucis longus tendon. green) runs behind the talus.indd 2213 9/9/2008 5:33:31 PM . wraps under the sustentaculum tali (ST). and out to the second to fifth toes. the flexor digitorum longus (FDL. and peroneus longus (PL. This is in part due to “magic-angle” effects. Also labeled are the medial pole of the navicular (N) and the sustentaculum tali (ST). under N. illustrating the “Tom. The extensor hallucis longus is the middle of the three anterior tendons. over the ankle joint and foot (see Fig. a condition that is exceedingly rare. proceed along the forefoot to insert at the dorsal bases of the second through fifth middle and distal phalanges. Dick. crosses under the FDL at the master knot of Henry. blue) runs behind the PT. It extends along the medial aspect of the great toe tarsometatarsal joint to insert on the plantar aspect of the base of the first metatarsal and the adjacent medial cuneiform bone. 47-10). and passes between the two great toe sesamoids (white arrows). light blue) and plantaris (yellow). and extensor digitorum longus (EDL. it is common to lose visualization of the extensor hallucis longus tendon as it curves anterior to the midfoot (see Fig. Anterior view of the anterior tendons: anterior tibial (AT.
indd 2214 9/9/2008 5:33:33 PM . anterior tibial tendon. EDL. FHL. Through the tip of the medial malleolus. D. Image through the talonavicular joint demonstrates the PT tendon inserting on the navicular (N). PT. Just above the syndesmosis.2214 VII Imaging of the Musculoskeletal System A B C D Figure 47-10. Achilles tendon. extensor digitorum longus tendon. At this level. B. C. posterior tibial tendon. flexor hallucis longus tendon. Ach. peroneus brevis tendon. A. EHL. A&N (artery and nerve) points to the dotted circle surrounding the neurovascular bundle that includes the posterior tibial artery and nerve. AT. peroneus longus tendon. the EDL is dividing into separate tendon slips. PL. and the FHL tendon passing under the sustentaculum tali (ST). extensor hallucis longus tendon. MRI of normal ankle tendons in the straight axial plane. Ch047-A05375. One slice distal to B there is loss of the dark signal from the EHL tendon. FDL. PB. flexor digitorum longus tendon.
ST. At this level. the Achilles and plantaris tendons together make up the posterior group. PB. 47-12). The lack of edematous signal along the course of the extensor hallucis longus on T2-weighted images should reassure the radiologist there is no pathologic process. sustentaculum tali. it is prudent to search for other causes for pain. PL. medial. the PT tendon has divided into separate slips. including the anterior ankle tendons. such as an unsuspected stress fracture (Fig. and inserts onto the back of the calcaneal tuberosity. Injury Tears of the anterior ankle tendons are rare. PT. This patient has an os peroneum. flexor digitorum longus tendon. Ch047-A05375. posterior tibial tendon. Through the middle facet of the subtalar joint. The Achilles tendon is the largest tendon in the body. MRI of normal ankle tendons in the oblique coronal plane. and if the patient indicates that the point of maximal tenderness is directly over the anterior tendons. peroneus brevis tendon. The white line with the round end points to the portion of the PT that inserts onto the medial pole of the navicular (N). flexor hallucis longus tendon. FDL. C. A&N (artery and nerve) points to the dotted circle surrounding the neurovascular bundle that includes the posterior tibial artery and nerve. Ganglion cysts can arise from any synovium-lined structure. B.47 Ankle and Foot 2215 47 A B C Figure 47-11. Through the posterior facet of the subtalar joint. peroneus longus tendon. originating in the midcalf at the junction of the two heads of the gastrocnemius muscle and the soleus muscle. The white line with the square end points to the portion of the PT that passes under the navicular. Unlike the anterior. FHL. 47-13 shows a synovial cyst arising from and partially enveloping the anterior tibial tendon. A. which is why the PL tendon appears enlarged and gray at this level (dark gray arrow). Through the talonavicular joint. Figure • Posterior Tendons Normal Anatomy For anatomic purposes.indd 2215 9/9/2008 5:33:35 PM .
there should never be any fluid seen around a normal Achilles tendon. This paratenon is analogous to synovium in that it provides nutrients for the tendon. is not seen on this slice. Axial proton-density– weighted (A) and T2-weighted (B) images well demonstrate normal anterior tibial (AT) and extensor digitorum longus (EDL) tendons. there is no need for the lubrication func- tion of synovium.26 Kager’s fat pad is located in the retromalleolar region and is defined anteriorly by the posterior aspect of the tibia and posteriorly by the Achilles tendon. The answer is revealed on the sagittal T1weighted (C) and T2-weighted fat-suppressed (D) images: there is a navicular stress fracture (black arrow). but because the Achilles tendon does not change its axis of motion.indd 2216 9/9/2008 5:33:37 PM . the Achilles is surrounded by thin layers of filmy fibrous tissue with fine internal blood vessels. called the paratenon or paratendon.2216 VII Imaging of the Musculoskeletal System A B C D Figure 47-12. Thus. all of which are surrounded by synovial sheaths. and lateral ankle tendons. The normal Achilles tendon (Ach) is uniform in thickness and dark signal in both sagittal sequences and has a sharp interface with the adjacent Kager’s fat pad. The patient is a 45-year-old with pain over the dorsum of the midfoot. although it should be just below the marker. Could this be a rare EHL tear? The lack of edema in (B) argues against this diagnosis. A portion of the normal AT tendon is seen. indicated by the marker (m). as well as a normal amount of fluid in the retrocalcaneal bursa (white arrowhead in D). with the base being the Ch047-A05375. which was well seen and normal on more proximal slices. The extensor hallucis longus (EHL) tendon. Directly anterior to the Achilles tendon is a triangular fat pad described radiographically by Kager in 1939.
3 mm medial to lateral. The tendon itself is normal. Injury For practical purposes. imaging with MRI or ultrasonography is used to measure the tendinous gap between the retracted ends of a complete tear. A B proximal aspect of the calcaneus. the ventral margin of the tendon becomes concave. In these cases. Partial tears can also present as nearly complete ruptures.” By MRI. In the axial plane. often by the patients themselves. Patients can often recall the exact instant the Achilles ruptured. and the normally lucent fatty tissue space becomes obscured (see Fig.41 Any fluid behind the Achilles tendon. with its cross-sectional area greater than that of the normal anterior tibial tendon. in a retro-Achilles bursa. However. is abnormal. perhaps with younger players. Complete ruptures of the Achilles tendon typically occur at one of two locations. The Achilles tendon is easily evaluated by physical examination as well as by MRI or ultrasonography. between the underlying soleus and more superficial gastrocnemius muscles (Fig. the Achilles tendon should appear uniformly straight and black on T1-weighted images (Fig. without an adequate warm-up. On rupture of the Achilles tendon. The normal retrocalcaneal bursa should measure less than 6 mm superior to inferior. This is a relatively hypovascular watershed region. The other site is relatively high. abnormal fluid can be seen surrounding the intact fibers. the plantaris tendon is seldom clinically relevant in the ankle. 47-12D and 47-14C). Distally. producing a well-defined lucent triangle that can be seen on lateral radiographs of the ankle (Fig. 47-21A). Axial (A) and sagittal (B) T2-weighted images demonstrate the cystic outpouching (white arrow) of the synovial sheath surrounding the anterior tibial tendon (black arrow). and edema-sensitive images reveal increased signal in a swollen. The space contained within this triangle is filled with fatty tissue. 47-15). Figure 47-16 illustrates a chronically swollen and scarred posterior tibial tendon. 47-21). Ruptures of the Achilles tendon are usually diagnosed clinically. and 2 mm anterior to posterior. this space becomes poorly demarcated. with upturned corners resembling a smile (see Fig. 47-19). up at the musculotendinous junction (Fig. plantaris tears present as fluid tracking along the length of the calf. These more proximal tears may require that the imaging coil be repositioned around the lower calf rather than around the ankle to visualize the torn and retracted proximal end (Fig. with only a few remaining fibers intact (Fig. There should be a sharp interface between the Achilles tendon and Kager’s fat pad directly ventral to it. The classic patient is a middle-age “weekend warrior” who leads a sedentary life and attempts to participate in sports. confirmation with MRI is usually unnecessary. Figs. Imaging with MRI or ultrasonography is used to assess the extent of partial tears. at the plantaris musculotendinous junction. An Achilles tendon that has undergone internal healing and scar formation from a prior intrasubstance tear tends Ch047-A05375. describing the sensation “as if someone kicked me.47 Ankle and Foot 2217 47 Figure 47-13. A normal retrocalcaneal bursa may be present just in front of the Achilles tendon (white arrowhead. 47-21E). such as occurs in basketball or other jumping sports. 47-18). 47-20).” The classic Achilles tendon rupture occurs with forced dorsiflexion of the planted foot. 47-14B) as well as on fluid-sensitive images (Fig.23 In the sagittal plane. Synovial cyst of the anterior tibial tendon in a 23year-old. abnormally rounded tendon (Fig. 47-14A). the Achilles tendon should appear flattened in the anteroposterior direction. the Achilles is the only one for which disorders have a male predominance. within the distended paratenon (see Fig. and have been called “tennis leg. 47-17). 47-14C). 47-10D). When it is clinically apparent to all that the Achilles tendon is completely ruptured. Partial tears of the Achilles tendon are usually intrasubstance tears. Tears of the plantaris tendon tend to occur high in the calf. One site is low.indd 2217 9/9/2008 5:33:38 PM . Of all the tendons of the foot and ankle. 3 to 5 cm just proximal to the calcaneal insertion (Fig.
Normal Achilles tendon in a 14-year-old with a calcaneal stress fracture. There is bone marrow edema throughout the calcaneus as a response to the stress fracture in the tuberosity. C. B.indd 2218 9/9/2008 5:33:39 PM . bright Kager’s fat pad and the normal. which is uniform in thickness throughout its length. Midsagittal inversion recovery image reveals no abnormally increased signal in the uniformly dark Achilles tendon. Midsagittal T1-weighted image shows the sharp interface between the normal. A. Lateral radiograph shows the normal sharp interface between the lucent Kager’s fat pad and the semiradiopaque Achilles tendon (white arrows). A B C Ch047-A05375. straight and uniformly dark Achilles tendon (Ach). A normal amount of fluid is present in the retrocalcaneal bursa (white arrowhead). The dark line running perpendicular to the trabeculae in the calcaneal tuberosity is the stress fracture (black arrowheads). The sclerosis in the calcaneal tuberosity (black arrowheads) is more subtle radiographically.2218 VII Imaging of the Musculoskeletal System Figure 47-14.
C. obtained at the same level.47 Ankle and Foot 2219 47 A B Figure 47-15. B. Proton-density–weighted image shows that the chronically swollen and scarred PT is larger in axial cross section than the normal anterior tibial tendon (AT). Axial T2-weighted fat-suppressed images taken at the level of the dotted line in A show the edema tracking between the left soleus (S) and the gastrocnemius (G) muscles. These are straight axial images. B. Coronal T2-weighted fat-suppressed images through both calves reveal a band of edema tracking between the left calf muscles (white arrowheads). Plantaris tear in a 71-year-old who. A.indd 2219 9/9/2008 5:33:41 PM . while playing tennis. T2-weighted image shows that the tissue surrounding the PT is not fluid but the chronic fibrotic scarring of stenosing tenosynovitis. A B C Figure 47-16. heard a “snap” and experienced sudden onset of posterior calf pain. Ch047-A05375. Stenosing tenosynovitis of the posterior tibial tendon (PT) in a 57-year-old with chronic medial ankle pain. with different sequences. A. T1-weighted image shows loss of the normal sharp fat–tendon interface around the PT (arrowhead).
Midsagittal T1-weighted image shows that the tear occurred at the musculotendinous junction (white arrow). Sagittal T1-weighted (A) and T2-weighted fat-suppressed (B) images reveal the complete Achilles tendon tear at the critical zone. A B C Figure 47-18.2220 VII Imaging of the Musculoskeletal System Figure 47-17. 3 to 5 cm proximal to the calcaneal insertion. Complete Achilles tendon rupture in a 38-year-old who. C. The arrows show the torn ends of the retracted fibers. felt a sudden “pop” and pain “like getting hit in the back of the leg. Complete Achilles tendon rupture in a 41-year-old with history of renal transplantation and steroid use. while playing volleyball. B. A B Ch047-A05375. Incidentally noted is the intact plantaris tendon (arrow).” A. Midsagittal T2-weighted fatsuppressed image shows the torn ends of the retracted fibers (arrows). Axial T1weighted image through the tear reveals no intact Achilles tendon fibers (arrowhead). who experienced acute posterior ankle pain 5 days earlier when bending over while gardening. This Achilles tendon tear required surgical repair.indd 2220 9/9/2008 5:33:43 PM .
An incidental finding is an abnormal amount of fluid in the posterior tibial tendon sheath (white arrow in B).” with the AN standing for the posterior tibial artery and nerve. However. and inserts on the medial pole of the navicular (see Fig. A B to retain its thickened fusiform shape. it is easier to remember the neurovascular bundle that runs between the flexor digitorum longus and flexor hallucis longus tendons (see Figs. The coil was repositioned proximal to the ankle joint to include the musculotendinous junction. unlike the acute intrasubstance tear. ANd Harry.47 Ankle and Foot 2221 47 Figure 47-19. called the navicular tubercle. This crossover point has been called the master knot of Henry. and Harry” is useful for remembering the order of the medial ankle tendons. Ch047-A05375. The flexor digitorum longus tendon runs directly behind the posterior tibial tendon. D the flexor digitorum longus tendon.24 and the sheaths of these two flexor tendons communicate at this point. The bulk of the posterior tibial tendon inserts on the navicular tubercle. The flexor digitorum longus tendon extends plantar to the bones of the midfoot. Intrasubstance tear of the Achilles tendon in a 54-year-old with a history of rheumatoid arthritis and several months of persistent heel pain. An initial set of sagittal images was obtained with the extremity coil centered on the heel. proceeds medial to the talus. the flexor digitorum longus divides into separate tendon slips that insert on the plantar bases of the second through fifth distal phalanges. T represents the posterior tibial tendon. By changing the emphasis to “Tom. 47-10D). and H the flexor hallucis longus tendon.indd 2221 9/9/2008 5:33:45 PM . Dick. 47-22). B. A. The posterior tibial tendon runs directly behind and under the medial malleolus. The marker (m) is at the palpable defect. T2-weighted fat-suppressed images in the sagittal (A) and axial (B) planes reveal that the distal Achilles tendon is abnormally swollen with increased intrasubstance signal (black arrow). A B Figure 47-20. a healed Achilles tendon does not contain internal signal (Fig. 47-10 and 47-11). • Medial Tendons Normal Anatomy The classic mnemonic “Tom. Dick. although these two tendons maintain individual tendon sheaths. which was too low to include the proximal end of the tear. 47-11C) to insert on the plantar aspects of all three cuneiforms as well as the bases of the second through fourth metatarsals. At this insertion site there is a focal osseous prominence. Complete Achilles tendon rupture at the musculotendinous junction in a 52-year-old. although smaller slips of tendon pass under the navicular (see Fig. crossing superficially to the flexor hallucis longus tendon. Distally.
This Achilles tear ultimately required surgical repair. B. Lateral radiograph shows obscuration of the normally lucent Kager’s fat pad. Axial T1-weighted image through the level of the syndesmosis shows the markedly thinned intact Achilles tendon fibers (arrow). Near-complete Achilles tendon rupture in a 54-year-old who.indd 2222 9/9/2008 5:33:47 PM . while playing racquetball. C. Axial T2-weighted fat-suppressed image at the same level shows bright abnormal fluid in the abnormally thickened and distended paratenon (arrowheads). E. B C D E Ch047-A05375. Midsagittal T2weighted fat-suppressed image shows the retracted ends of the torn fibers (black arrows). D.” A. Midsagittal T1weighted image shows only a few remaining intact Achilles tendon fibers (arrow). White arrow shows the few remaining fibers. White arrow shows the thinned intact Achilles tendon fibers. felt a pain “like being kicked in the back of the heel.2222 VII Imaging of the Musculoskeletal System A Figure 47-21.
more commonly affecting C D E Figure 47-23. The posterior tibial tendon is relatively hypovascular in this region. This longitudinally split posterior tibial tendon.47 Ankle and Foot 2223 47 Figure 47-22. 47-9D and E). the posterior tibial is the most prone to tear. Perhaps because of these longitudinal frictional stresses. Ch047-A05375. Axial T1weighted (A). and sagittal T2-weighted (C) images reveal that the distal Achilles tendon is too round and thick but contains no increased signal. when grouped with the flexor digitorum and hallucis longus tendons.indd 2223 9/9/2008 5:33:49 PM . this frictional wear increases. This is often a chronic irritative process. The tendon is thickened and butterflied open. In C.39 This region of the tendon is also susceptible to mechanical wear as the tendon rubs against the medial malleolus (Fig. and passes between the two great toe sesamoids. axial T2-weighted (B). the wedges of tendinopathy have progressed to a longitudinal tear. A more anterior view of a partially torn PT as it might appear if it were laid flat. taken in the axial or oblique coronal plane through the longitudinal tear as it develops. 47-24). (The dashed line represents the location of cross sections C to E). blue). B. and the proximal end of the tendon passes through a groove along the posterior talus. with the gray region representing abnormal internal signal. tendinopathy (gray wedges) now involves the outer and inner surfaces of the PT. In E. a longitudinal split in the posterior tibial tendon resembles two individual tendons. giving the appearance in cross section that the PT is two tendons. Illustration of posterior tibial tendon mechanical wear becoming a longitudinal tear. C to E. characteristically along the portion that curves around the medial malleolus. Whereas the posterior tibial and flexor digitorum longus tendons pass under the medial malleolus. 47-23). The musculotendinous junction extends distally to the level of the ankle joint. there is a gray wedge of abnormally increased signal along the inner aspect of the flattened PT (black ellipse). MRI cross sections of the PT only (now shown as a black ellipse). The flexor hallucis longus then crosses deep to the flexor digitorum longus. has been called the four-tendon sign (Fig. A. The PT is susceptible to mechanical wear as it rubs back and forth (as indicated by the double-headed black arrow) between the underlying medial malleolus (gray lightning bolts) and the overlying FDL (white lightning bolts). Tenosynovitis refers to inflammation between the tendon and the surrounding synovial sheath. to insert on the plantar base of the distal phalanx (see Fig. rather than the transverse rupture seen in Achilles tendon tears. red) as it wraps over the medial malleolus and under the flexor digitorum longus tendon (FDL. If the surrounding tendon sheath does not provide adequate lubrication. A B C The flexor hallucis longus muscle is a posterior structure originating from the lower two thirds of the back of the fibula. Medial malleolus A B Injury Of the three medial ankle tendons. A 57-year-old with an Achilles tendon that has healed with chronic scarring. such as in stenosing tenosynovitis or rheumatoid pannus formation. In D. extends under the first metatarsal. When imaged in the axial plane. the flexor hallucis longus tendon passes under the sustentaculum tali. the posterior tibial tendon tends to tear with a longitudinal split. Medial view of the posterior tibial tendon (PT.
Active posterior tibial tenosynovitis in a 46-year-old with chronic pain in the distribution of the posterior tibial tendon (PT). B. Ch047-A05375. B. Proton-density–weighted image shows what appears to be four medial tendons. Shown are the same straight axial images obtained through the tip of the medial malleolus (MM). indicating active tenosynovitis. A. A B Figure 47-25. and 3 and 4 are the normal flexor digitorum longus (FDL) and flexor hallucis longus (FHL) tendons.2224 VII Imaging of the Musculoskeletal System A B C Figure 47-24. The PT is slightly larger in cross section than the normal anterior tibial tendon. Longitudinal split in the posterior tibial tendon (PT) in a 39-year-old. The fluid in the FHL sheath (white arrowhead) is within normal limits for this tendon only. the four-tendon sign.indd 2224 9/9/2008 5:33:51 PM . A. T2-weighted image demonstrates not bright fluid but gray scar (gray arrowhead) around the split PT. There is an abnormal amount of fluid in the FDL sheath (black arrowhead). Straight axial proton-density–weighted image demonstrates that the PT is intact and contains no abnormal internal signal. and there is loss of the normal fat signal around the tendon (gray arrowhead). suggesting that this is chronic stenosing tenosynovitis. T1-weighted image well demonstrates the anatomy of the tendons as well as the neurovascular bundle (dotted oval). where 1 and 2 are the two halves of the split PT. suggesting active tenosynovitis here. Straight axial T2-weighted image at the same level reveals an abnormal amount of fluid in the posterior tibial tendon sheath (black arrowhead). C.
40 • Lateral Tendons Laterally. aids in the diagnosis of pathology of the peroneal tendons. being the shortest. the peroneus brevis (PB) is closer to the distal fibula than is the peroneus longus (PL). The presence of increased signal in the substance of the tendon.indd 2225 9/9/2008 5:33:52 PM . 47-16. The peroneus longus tendon passes through a groove in the plantar surface of the cuboid. using several imaging planes and sequences (Fig. and extends medially to insert on the plantar aspect of the medial cuneiform and the base of the first metatarsal. Even when these tendons are intact. Ch047-A05375. (This is the same patient as in Fig. which are normally round or oval in axial cross section. running posterior and inferior to the peroneus brevis. Distal to the lateral malleolus. Unlike the medial ankle tendons. hugs the inside curve and is thus closest to the fibula. It has been suggested that these inflammatory conditions of the tendon sheath can be ameliorated by therapeutic tenography. can normally appear flattened as it passes around the lateral malleolus. Coronal MRI (left) and graphic representation in the sagittal plane (right) demonstrate the relationship of the peroneal tendons to the lateral malleolus (LM). An abnormal amount of fluid in the tendon sheath indicates active tenosynovitis (Fig. 47-25). the tendons are enveloped with individual sheaths. It is often helpful to examine the peroneal tendons over multiple slices. The peroneus longus follows the outside of the curve. 47-27). A trick for identifying the peroneal tendons is to think of the lateral malleolus as a race track (Fig. particularly workers who are on their feet all day. the peroneus brevis Figure 47-27. 47-55) and should enhance if intravenous contrast is administered. women than men. crosses under the midfoot deep to the master knot of Henry. their tendon sheaths and surrounding soft tissues should be carefully examined. tenosynovitis most frequently occurs in the posterior tibial tendon and in the two peroneal tendons. these straight axial images are two slices distal to those. 47-28). fibrous tissue around the tendon suggests chronic scarring or stenosing tenosynovitis (Fig.) T1-weighted (A). proton-density–weighted (B). Chronic posterior tibial stenosing tenosynovitis in a 57-year-old with chronic pain in the distribution of the posterior tibial tendon (PT). the peroneus brevis and longus tendons share a common sheath as they pass under the lateral malleolus. such as waitresses and sales clerks.47 Ankle and Foot 2225 47 A B C Figure 47-26. 47-26). or the presence of fluid in the surrounding sheath. and T2-weighted (C) images all show abnormally dark signal (gray arrowhead) around the PT. The peroneus brevis. In the ankle. Dark. just lateral to the anterior tibial tendon insertion site. Rheumatoid pannus can also be demonstrated by MRI (see Fig. The peroneus brevis tendon extends along the lateral aspect of the midfoot and inserts on the tuberosity at the lateral base of the fifth metatarsal.
indd 2226 9/9/2008 5:33:54 PM . and T2-weighted (F) images through the LM. and T2-weighted (I) images distal to the LM. best seen on the PD image (E). the T2-weighted image shows an abnormal amount of fluid in the common peroneal tendon sheath (white arrowhead). Straight axial T1weighted (A). D E F G H I Ch047-A05375. located between the lateral malleolus (LM) and the peroneus longus tendon (PL). At this level. The PB (black arrow) is well seen on T1 and PD weighting. Longitudinal split of the peroneus brevis tendon (PB) in a 62-year-old. the PB is abnormally flattened to such an extent that it is draped over the PL. However. the PB has a normal flattened appearance. PD-weighted (H). and T2-weighted images through the syndesmosis. proton-density (PD)– weighted (B). At this level. Straight axial T1weighted (G).2226 VII Imaging of the Musculoskeletal System A B C Figure 47-28. Straight axial T1-weighted (D). PDweighted (E).
the bright signal in the PB on the T2-weighted image represents a true intrasubstance tear.indd 2227 9/9/2008 5:33:56 PM . Ch047-A05375. through the pain marker (m). Oblique coronal T1-weighted (J). All three sequences show increased signal in the PB (black arrow) as opposed to the normal black signal in the PL (white arrow). the PB is split into two pieces (black arrows). separated by the intact PL (white arrow). cont’d The marker (m) indicates the site of maximal tenderness. At this level. and T2-weighted (L) images anterior to the LM. magic angle does not affect the long TE T2-weighted sequence. PD-weighted (K). M and N. Although the “magic angle” can artifactually increase the intratendinous signal on the short TE sequences (T1 and PD). Far lateral sagittal inversion recovery images demonstrate the abnormal fluid in the common peroneal tendon sheath (white dotted rectangle) as well as the edema in the swollen PB (black dotted rectangle).47 Ankle and Foot 2227 47 J K L M N Figure 47-28. The abnormal fluid in the common peroneal tendon sheath (white arrowhead) indicates active tenosynovitis. Thus.
both of which are transversely oriented and thus best seen in the straight axial plane (Fig. Of the lateral ankle ligaments. B. A B C D Figure 47-29. 47-29B). The lateral capsular ligaments consist of the thin anterior talofibular ligament and the broader posterior talofibular ligament. black arrowhead). 47-30). Axial image two slices distal to A. 47-29A). Coronal image through the back of the ankle joint shows the PTiFL (black arrow) running between the posterior malleolus of the talus and the fibula. 47-29D). in the same normal volunteer as in Figure 47-10. The normal lateral ankle ligaments. 47-29C). and the longitudinally oriented calcaneofibular ligament. shows two of the three lateral capsular ligaments: the anterior talofibular ligament (ATaFL.indd 2228 9/9/2008 5:33:57 PM . white arrow) and the posterior tibiofibular ligament (PTiFL. through the top of the talar dome. Laterally there are the syndesmotic ligaments and the lateral capsular ligaments. D. Ch047-A05375. white arrowhead) and the posterior talofibular ligament (PTaFL. It is these syndesmotic ligaments that are disrupted in a Weber type C ankle fracture (see Fig. the calcaneofibular ligament (CFL. although they may be seen in the coronal plane if a single image serendipitously cuts though one (Fig. best seen in the coronal plane (Fig. A. gray arrowhead). the anterior ones are more subject than the posterior ones to tearing from twisting injuries (Fig. Axial image through the bottom of the syndesmosis shows the two syndesmotic ligaments: the anterior tibiofibular ligament (ATiFL. C. These ligaments are typically best seen in the straight axial plane (Fig.2228 VII Imaging of the Musculoskeletal System • Ankle Ligaments 14 There are three sets of ligaments around the ankle joint. black arrow). The syndesmotic ligaments consist of the thin anterior tibiofibular ligament and the broader posterior tibiofibular ligament. 47-60C). Also seen is a portion of the third of the three lateral capsular ligaments. Coronal image two slices anterior to C shows the PTaFL (black arrowhead) running between the back of the talus and the fibula. These are all T1-weighted images obtained using a high-resolution 512 acquisition matrix.
one or two slices in a single imaging plane. often at the musculotendinous junction. the accessory navicular medial to the navicular bone. 47-32) or even avulsion fractures. and sometimes stress radiographs. When viewed in the coronal plane (Fig. Unlike the ankle tendons. to assess the functional integrity of the ankle ligaments.47 Ankle and Foot 2229 47 Figure 47-30. ordering MRI primarily for the bones and tendons. and these are well documented in the encyclopedic text by Keats. And when they are seen in a piecemeal fashion on two images. and the os peroneum plantar to the calcaneocuboid joint. Straight axial protondensity (PD)–weighted (A) and T2-weighted fatsuppressed (B) images through the syndesmosis show disruption of the anterior tibiofibular ligament (arrow). Although in the vast majority of people these are nothing more than asymptomatic inci- Ch047-A05375. and are caused by sudden and powerful contractions or from overuse. Injuries of the deltoid ligament tend to be sprains* rather than complete ruptures. Three of the most commonly found accessory ossicles in the feet are the os trigonum posterior to the talus. the ankle joint is stabilized by a group of ligaments that fan out from the distal tip of the medial malleolus in a triangular configuration and collectively are called the deltoid ligament. Certainly. it can be difficult to determine whether the two halves of the ligament are continuous. “Strains” are defined as stretching or tearing of muscles. although they may be accompanied by bone marrow edema (Fig. Straight axial PD-weighted (C) and T2-weighted fatsuppressed (D) images through the top of the ankle mortise show an interruption (arrowhead) of the anterior talofibular ligament. the deltoid ligament can be seen to consist of deep fibers that insert on the medial process of the talus and superficial fibers that insert on the calcaneus at the sustentaculum tali. There are many accessory ossicles that can be present throughout the skeleton. seeing fluid extending through or around the ankle ligament helps confirm the diagnosis of a tear. They rely on physical examination.27 Many of these normal variants can be found in the feet. the ankle ligaments are usually seen on only *”Sprains” are defined as stretching or tearing of ligaments and are due to twisting injuries. which when visualized by MRI can be followed over a series of sequential slices in several planes. 47-31). but at the UW our sports medicine clinicians and orthopedic surgeons do not use MRI to evaluate the ankle ligaments. A B C D Medially.indd 2229 9/9/2008 5:34:00 PM . Tears of the anterior lateral ankle ligaments in a 47-year-old.
indd 2230 9/9/2008 5:34:01 PM . and with these the posterior tibial tendon inserts onto the accessory navicular. • Os Trigonum Syndrome The os trigonum is a common accessory ossicle located directly behind the talus. adjacent to where the flexor hallucis longus wraps around the back of the talus. 47-35). conditions that can be difficult to diagnose and difficult to treat. 47-34). The normal medial ankle ligaments on a T1-weighted image obtained using a high-resolution 512 acquisition matrix. D. The broader deep fibers (black arrow) run from the medial malleolus (MM) to the medial process of the talus. 47-33). There are no radiographic findings in a patient with symptomatic os trigonum syndrome.” the medial pole of the navicular is the primary insertion site of the posterior tibial tendon (see Figs. As previously mentioned under “Medial Tendons. • Accessory Navicular Syndrome The accessory navicular bone (os tibiale externum) is a common normal variant found adjacent to the medial pole of the navicular in approximately 10% of the population. Larger accessory navicular bones are called type 2 (Fig. The posterior tibial tendon still inserts normally on the navicular. During growth this fuses to the talus in most people. flexor digitorum longus. Figure 47-31. flexor hallucis longus) and the posterior tibial neurovascular bundle (dotted oval). A B Ch047-A05375. The os trigonum develops as a separate ossification center. The more slender superficial fibers (white arrow) run from the MM to the calcaneus at the sustentaculum tali (ST). posterior tibial. in rare circumstances they are painful normal variants. 47-10D and 47-11C).2230 VII Imaging of the Musculoskeletal System dental findings. H. at the posterior end of the subtalar joint. Also shown is the flexor retinaculum (open arrowheads). 47-29D). Mortise coronal T1-weighted (A) and T2-weighted fat-suppressed (B) images show abnormally increased signal in the deep deltoid (black arrow). but in 5% to 15% of normal feet it remains nonunited and is variable in size and shape. forming the roof of the tarsal tunnel atop the three medial tendons (T. Small accessory navicular bones are called type 1 and are simply sesamoid bones in the substance of the posterior tibial tendon (Fig. rather than on the navicular Figure 47-32. Deltoid ligament sprain in an 18-yearold.44 although the diagnosis can be made with MRI by demonstrating marrow edema in the os trigonum and the adjacent talus (Fig. The superficial deltoid (white arrow) is intact. There is bone marrow edema at its insertion site on the medial talus (arrowhead). The magnified dashed box to the right shows the superficial and deep components of the deltoid ligament. This coronal image is located just behind the middle facet of the subtalar joint. (This image is seven slices anterior to Fig. and the type 1 accessory navicular bones are of no clinical significance.
a common normal variant. Corresponding sagittal inversion recovery image shows bone marrow edema in the os trigonum (arrow) as well as in the adjacent talus (arrowhead). Straight axial proton-density–weighted image shows the irregular cleft (arrowhead) between the os trigonum and the talus. neurovascular bundle (&). C D E F Ch047-A05375. Corresponding axial T2-weighted fat-suppressed image shows bone marrow edema in the os trigonum (arrow) and in the adjacent talus (arrowhead). E. Lateral view of the symptomatic left ankle (A) shows a small os trigonum. D. and flexor hallucis longus tendon (H). Well seen are the normal structures in the tarsal tunnel: the posterior tibial tendon (T). C. flexor digitorum longus tendon (D).47 Ankle and Foot 2231 47 A B Figure 47-33. Midsagittal T1weighted image shows the small os trigonum (arrow).indd 2231 9/9/2008 5:34:03 PM . F. Os trigonum syndrome in an 11-yearold competitive Irish dancer. The asymptomatic right side (B) is shown for comparison.
47-37). A more objective finding Ch047-A05375. Normally. Chronic inflammation can be suspected radiographically if the os peroneum is abnormally sclerotic. Incidentally seen is a normal os peroneum (black arrow). there should be a solid fibrous union between the type 2 accessory navicular and the navicular. although this finding is subjective. The presence of a line of fluid between these bones is abnormal and indicates a pseudarthrosis. Figure 47-35. this normal ossicle can become inflamed and painful. especially if this corresponds to the point of maximum pain (Fig. • Os Peroneum Syndrome The os peroneum is a common sesamoid bone located in the peroneus longus tendon as it passes under the cuboid. another MRI finding in accessory navicular syndrome (Fig. Normal type 1 (small) accessory navicular (arrow in dashed magnified box). bone itself. A painful accessory navicular syndrome can be diagnosed by MRI by the presence of marrow edema in the accessory navicular and the adjacent navicular bone. Patients with this normal variation are typically asymptomatic unless they have a fracture through the normal fibrous union between the navicular and accessory navicular. 47-36).2232 VII Imaging of the Musculoskeletal System Figure 47-34. Normal type 2 (large) accessory navicular (white arrow in dashed magnified box).indd 2232 9/9/2008 5:34:04 PM . In rare cases.
indd 2233 9/9/2008 5:34:06 PM . A. as well as the fibrous union (arrowhead) between it and the navicular bone (N). B. Far-medial sagittal T1-weighted image well shows the posterior tibial tendon (T) inserting onto the type 2 accessory navicular (A). G. This has been referred to as a cornuate navicular and as a type 3 accessory navicular. Corresponding axial T2-weighted fat-suppressed image shows subcortical edema (arrows) on both sides of this abnormal articulation. E. Oblique axial T1-weighted image shows that the marker (m) indicating the site of focal tenderness is directly over the abnormal articulation between the type 2 accessory navicular (A) and the navicular bone (N). D. C. H. Accessory navicular syndrome in a 20-year-old with focal pain directly over the left medial navicular. Standing anteroposterior radiograph of the asymptomatic right foot shows an elongated medial pole of an otherwise normal navicular (arrow). Standing anteroposterior radiograph of the symptomatic left foot barely reveals the type 2 accessory navicular (arrow in the magnified dashed box). Corresponding sagittal inversion recovery image shows subcortical edema (arrows) on both sides of this fibrous union. Oblique coronal T1-weighted image through the round head of the talus (Ta) shows the marker (m) indicating that the site of focal tenderness is directly over the abnormal articulation between the type 2 accessory navicular (A) and the navicular bone (N). F.A B C E D F Figure 47-36. Corresponding coronal T2-weighted fat-suppressed image shows subcortical edema (arrows) on both sides of this abnormal articulation. G H Ch047-A05375.
the accessory navicular can faintly be seen through the anterior calcaneus (open arrow in magnified white dashed box). It is discussed in more detail later. Imaging Protocol All imaging of the ankle and foot must begin with radiographs. the question often arises as to which imaging modality should be obtained next if radiographs do not sufficiently delineate the fracture or do not demonstrate the cause of symptoms. However. A. Axial (C) and far-medial sagittal (D) T2-weighted fat-suppressed images reveal a line of fluid (white arrowhead) indicating an abnormal joint where there should be a solid fibrous union between the navicular (N) and accessory navicular (A). B. and radiographs are the quickest and least expensive imaging modality for the detection and follow-up of these fractures. Traumatic fractures are the most common cause of ankle and foot pain. best shown with an edema-sensitive MRI sequence targeted to the lesion (Fig. • Os Calcaneus Secondarius Os calcaneus secondarius is an occasionally seen normal variant that resides between the anterior process of the calcaneus (APC) and the lateral pole of the navicular (Fig. The far-medial sagittal image shows the posterior tibial tendon (T) inserting on the type 2 accessory navicular. 47-38). Anteroposterior radiograph shows a type 2 accessory navicular (white arrow in magnified gray dashed box). Accessory navicular syndrome in a 38-year-old. On the lateral radiograph.indd 2234 9/9/2008 5:34:07 PM . of os peroneum syndrome is edema in and around the small ossicle.2234 VII Imaging of the Musculoskeletal System B A C D Figure 47-37. Ch047-A05375. 47-39).
Continued C D E Ch047-A05375. wrapping around the lateral malleolus (LM). Corresponding inversion recovery image of slice at D demonstrates bone marrow edema throughout the os peroneum (arrow). (Case courtesy of Edwin Rogers. D.indd 2235 9/9/2008 5:34:10 PM . a common normal variant. MD. the PL is passing under the calcaneus (Ca) and cuboid (Cu). Sagittal T1-weighted image one slice medial to C. Directly plantar to the calcaneocuboid joint is the os peroneum (black arrow).) Oblique (A) and lateral (B) radiographs reveal an os peroneum (white arrow) below the calcaneocuboid joint. C. toward the base of the fifth metatarsal (5). a sesamoid of the PL.) E. Here. Behind and below the PB is the peroneus longus tendon (PL). Os peroneum syndrome in a 58-yearold who developed chronic lateral foot pain after ballroom dancing.47 Ankle and Foot 2235 47 B A Figure 47-38. (The os peroneum is difficult to see on this T1-weighted image because its edematous bone marrow is dark. Far-lateral sagittal T1-weighted image shows the peroneus longus tendon (PB).
Axial T1-weighted image through the bottom of the foot shows the os peroneum (arrow). I K J L Ch047-A05375. This sequence is so fluid sensitive it shows marrow edema not only in the os peroneum (arrow) but also in the adjacent cuboid (arrowhead). shows increased activity in the os peroneum (arrow) of the left foot. To help with localization. corresponding coronal slice to (F). Coronal T1-weighted slice through the os peroneum (arrow) shows its marrow to be darker than that of the other bones.indd 2236 9/9/2008 5:34:12 PM . T2-weighted image without fat suppression. K. H. I. G. Bone scan. The normal right foot is included for comparison.2236 VII Imaging of the Musculoskeletal System F G H Figure 47-38. Corresponding coronal inversion recovery image of slice at F and G. Axial inversion recovery image corresponding to slice at I shows the bone marrow edema in the os peroneum (arrow). both-feet-on-detector view. cont’d F. This sequence is not particularly edema sensitive. also included is an axial scout MRI (L) showing the os peroneum (arrow). and the marrow signal of the os peroneum (arrow) is isointense to that of the other bones. J.
indd 2237 9/9/2008 5:34:13 PM . CT is also useful for showing fractures that are difficult to see radiographically. In patients who have undergone a surgical arthrodesis in an attempt to fuse a painful arthritic joint who remain symptomatic. CT Assess cortex • Fractures -Calcaneus -Distal tibia -Lateral process of talus • Arthritis • Fusions • Coalitions -Osseous -Nonosseous MRI Everything else • Tendons -Tears -Tenosynovitis • Masses -Soft tissue -Osseous • Bone pathology -Occult fracture -Osteochondral lesions -Infection US • Tendons -Achilles • Toes -Morton’s -Plantar plate • Masses -Vascularity -Cyst vs solid • Foreign bodies -Wood NM • Screening -Sesamoid • Charcot Figure 47-40 is a flow chart outlining which modalities we use to image various pathologic processes. It is the best way to evaluate masses arising from either the soft tissues or bones of the extremities. which images all of the ankle bones and tendons at once. This is particularly helpful to orthopedic surgeons as part of their presurgical planning. Ultrasonography (US) can be used to perform a focused examination of the soft tissues of the ankle or foot. Flow chart for imaging ankle and foot (see text). CT data can also be volume rendered into threedimensional projections to show the alignment of comminuted fractures. US is used when we wish to examine one specific tendon. such as the subtalar joint. CT can be used to show arthritic narrowing of joints that are difficult to visualize radiographically. especially complex fractures involving the distal tibia or calcaneus.47 Ankle and Foot 2237 47 Figure 47-39. both solid osseous and nonosseous coalitions. and as such is it useful for the detection of conditions that may be radiographically occult. Unlike MRI. CT is also the best modality to show the abnormal bone cortex in cases of tarsal coalition. MRI is essentially used for everything else. CT is used when we specifically need to assess bone cortex. such as the lateral process of the talus or the anterior process of the calcaneus. The ability to reformat CT data into twodimensional cross-sectional images in any plane desired makes it the ideal modality to assess the intra-articular extent of fractures. osteochondral lesions. The os calcaneus secondarius (OCS) is an occasionally seen normal variant that resides between the anterior process of the calcaneus (APC) and the lateral pole of the navicular (N). US is particularly useful when we wish to examine a torn Achilles tendon in a dynamic fashion to see how much the tendinous gap opens between plantar Ch047-A05375. CT can show the degree of bone fusion at the cortical level. MRI is extremely sensitive for the detection of bone marrow and soft tissue edema/inflammation. Radiographs Figure 47-40. MRI is the best way to evaluate all of the ankle tendons at once for tears or tenosynovitis. and infection. including stress fractures.
but rather a continuous volume of patient imaging information. It is important to closely scrutinize the alignment of the tarsometatarsal joints on both of these views when assessing for a Lisfranc fracturedislocation.indd 2238 9/9/2008 5:34:14 PM . In neuropathic feet in which radiographs show Charcot changes of collapse and bone fragmentation.) He subsequently identified this fracture on radiographs of two other patients and published his series of three in the Annals of Surgery in 1902. tangled power cables were eliminated and the gantry could spin in one direction continuously while the table moved continuously through it. Scans were relatively slow because time was lost stopping the gantry’s clockwise momentum to reverse its rotation. The raw data are then reconstructed into a series of axial slices that we refer to as Ch047-A05375. mortise. 1895).2238 VII Imaging of the Musculoskeletal System flexion and dorsiflexion. depending on the preference of the ordering clinician. then stop and spin counter-clockwise one rotation to prevent tangling of the power cables supplying the x-ray tube. Figure 47-44 is an example of differences that can be seen between standing and non–weight-bearing views. US is also extremely sensitive for the detection of subcutaneous foreign bodies in the extremities. rather it was “dancing in a circle round the tent pole” with his military colleagues. These were the days of true CAT. particularly to assess the degree of vascularity or to determine if the mass is cystic or solid.5 AP and oblique views (Fig. Jones first described this fracture after having sustained such an injury himself “whilst dancing. CT. 47-42A and B) can be obtained by placing the x-ray cassette on the floor and having the patient stand on the cassette while the x-ray beam is pointed downward. helical CT (also known as spiral CT. let us now briefly review how these should be obtained.) Nuclear medicine (NM) plays a limited role when it comes to imaging the ankle and foot. With early generations of single-slice CT scanners the gantry would spin clockwise one rotation. US is used to evaluate small superficial structures that are sometimes difficult to see on MRI. and the fourth and fifth metatarsals with the cuboid. This elevates the feet to a level where the x-ray beam can be oriented horizontally while the cassette is held between the feet. The table would move between gantry rotations and stop at each slice position. There was no mention as to whether alcohol was involved. 47-41). “Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Figure 47-41 is such a case. US can also be used to characterize soft tissue masses. An early proponent of x-rays. where the Jones* fracture can be seen at the edge of the lateral view. • Radiography Because radiographs are a necessary first step in the workup of the ankle or foot. analogous to a spiral-sliced ham) was born. Thus. 4743). or MRI. (A discussion of nuclear medicine is beyond the scope of this chapter. in which “A” stood for “axial. The standing lateral view of the foot (Fig. and this can cause the clinician to request radiographs of the ankle rather than of the foot. Normally. a CT gantry consists of a spinning ring on which is mounted an x-ray tube. Patients with fractures of the base of the fifth metatarsal clinically present complaining of lateral ankle pain. In the broadest terms. with the leg internally rotated 15 degrees to obtain a better profile of the ankle mortise. The mortise view is similar to the AP view. • Ankle Radiography Ankle radiographs can be either weight bearing or non– weight bearing. the second metatarsal with the middle cuneiform.) • Foot Radiography It is preferable to obtain radiographs of the foot with the patient standing to visualize the bones in their weightbearing alignment.” and scans consisted only of a series of axial slides. A standard radiographic ankle series consists of three projectional views: anteroposterior (AP). The patient lies on a padded table that moves through the spinning gantry. The patient table would be stationary during each of the scanning rotations while the gantry was spinning and the tube was emitting x-rays. Now the data stream coming out of the x-ray detectors no longer represents individual axial slices.” • Computed Tomography • Overview Bone CT protocols have evolved as scanner technology has progressed. especially when the both-feeton-detector view is used. although in certain circumstances a bone scan can be helpful. The tube emits a fan-shaped x-ray beam. aimed through the center of the ring to an array of x-ray detectors mounted on the other side. it is important that the technologist include the base of the fifth metatarsal on at least one view. Jones imaged the transverse extra-articular fracture across the proximal diaphysis of the fifth metatarsal just a few months after Röntgen published “On a New Kind of Rays” (December 28. Fractures of the sesamoid bones of the great toe tend to be less conspicuous on MRI than on bone scans. such as Morton’s neuromas or the plantar plate. With the innovation of slip-ring technology. *Sir Robert Jones (1857-1933) was the father of orthopedic surgery in England and revolutionized the care of wounded soldiers during World War I. the third metatarsal with the third cuneiform. the first metatarsal should line up perfectly with the first (medial) cuneiform. When obtaining radiographs of the ankle. a bone scan combined with a white blood cell scan can be as sensitive and more specific for the detection of osteomyelitis than MRI. and lateral (Fig. we use a set of wooden steps (Fig. 47-42C) is somewhat more difficult to obtain because it is usually not possible to lower the x-ray tube all the way down to the floor. which can be difficult to detect with radiographs. Consequently. (A discussion of US of the ankle and foot is beyond the scope of this chapter. particularly wooden splinters.” (This was not ballroom dancing.
able to acquire larger volumes of patient data with each gantry rotation. The raw data tend not to be archived. a Jones fracture (arrow). thus.47 Ankle and Foot 2239 47 Figure 47-41.and three-dimensional images reformatted from the source images are the ones primarily used for diagnostic and planning purposes and ultimately sent to the PACS for archiving. In the past decade. Non–weight-bearing radiographic ankle series in a 37-year-old with lateral ankle pain after an acute inversion injury. Anteroposterior view (A) and mortise view (B) demonstrate a normal appearance of the ankle joint. and with any interval spacing between slices. the multiplanar two. The technologist must be careful always to include the base of the fifth metatarsal on at least one view of all ankle radiographic series. they are temporarily stored on the scanner’s hard drive and are overwritten as the hard drive becomes full (often after 24 hours). single-slice helical scanners have evolved into multislice scanners.or long-term storage.indd 2239 9/9/2008 5:34:15 PM . covering the desired volume faster minimizes artifacts related to patient motion as well as minimizing the amount of time the patient has to lie still on the scanner table. These images are oriented in a plane axial to the scanner gantry. (The region outlined by the dashed rectangle is magnified and displayed to the right). A B C the source images. However. The source images are reconstructed from the raw data using a variety of filtered backprojection algorithms. These source images can be viewed by the radiologist as desired and can be sent to the picture archiving and communications system (PACS) for short. Once the raw data are overwritten. Fractures of the base of the fifth metatarsal often present clinically as lateral ankle pain. This technology has largely been driven by the desire to scan the entire chest within a single breath-hold and the coronary arteries in a single heartbeat. Close inspection of the base of the fifth metatarsal on the lateral view of the ankle reveals a proximal diaphyseal fracture. Although a multislice CT scanner is not absolutely required for bone CT. Achieving the highest-resolution two-dimensional reformatted images requires the source images to be Ch047-A05375. These axial source images can then be reformatted into two-dimensional slices in any desired plane and of any desired width. or into threedimensional volume-rendered images. C. helical data can be reconstructed at any slice width. no additional source images can be reconstructed. the modern bone CT scan consists of the acquisition of three sets of imaging data. Thus. it behooves the CT technologist to create whichever source image data sets are needed for future reformats. The lateral ankle view reveals no abnormalities of the hindfoot. Because of its volumetric nature.
feet together in the center of the gantry. • Protocol for Foot. The central x-ray beam (dashed arrow) passes through the foot. 47-45A). (The latest versions of all the UW musculoskeletal protocol sheets can be viewed and downloaded for free at www.2240 VII Imaging of the Musculoskeletal System A B Figure 47-43.Edu/ MSKprotocols. ankle. C. which typically consist of merely dozens of images per plane. In most radiology departments the x-ray tube cannot be lowered to the floor. Thin and overlapping source images also yield good three-dimensional reformatted images. B. held together by screws. and Tibia (Distal) Scanning Technique At the UW we have developed our “F/A/T” protocol—a single scanning protocol that allows us to create multiplanar reformatted images optimized to visualize the foot. using a smoothing reconstruction algorithm (called a “standard” algorithm by some manufacturers) for threedimensional reformatting. although we save them in a separate imaging folder from the multiplanar reformatted images. the source images should be reconstructed at intervals such that they overlap each other. of images—twice that if both edge-enhanced and smoothed data sets are created. and distal tibia. threedimensional images by their nature represent a smooth rendering of the volumetric data. Ankle. Method of obtaining weight-bearing lateral view. the thin overlapping source images may consist of hundreds. but on the wooden box in Figure 47-43.Wisc. We use an edge-enhanced reconstruction algorithm (called a “bone” algorithm by some CT manufacturers) to yield two-dimensional reformatted images with sharp cortical detail. Unless the contralateral foot contains reconstructed into relatively thin slices. striking the x-ray cassette held upright between the feet. At our institution we choose to store these source images permanently on our PACS. The heel spur (black arrow in C) at the origin of the plantar fascia is of doubtful clinical significance in this normal volunteer who has never had heel pain. (This person is not standing on screws. Depending on the length of the body part being scanned. with legs straight. C Figure 47-42. A. and edge-enhanced Ch047-A05375. oblique view. often the width of a detector element. The upward-pointing white arrow was placed by the technologist to indicate the patient was standing. or sometimes thousands. from lateral to medial. Anteroposterior view. We typically scan through both ankles and feet simultaneously because this position is most comfortable for the patient and allows us to compare the injured side with the contralateral normal side when questions arise regarding subtle alignment abnormalities.) The patient is positioned supine on the CT table.) source images can yield excessively noisy threedimensional images. To minimize the stair-step quantization artifact that can occur between axial slices. We have found that a 50% overlap (interslice interval equals one-half slice width) works well. We create a second set of source images. and toes pointing up at the ceiling (Fig. lateral view.indd 2240 9/9/2008 5:34:17 PM .Radiology. Weight-bearing radiographic foot series in an asymptomatic 41-year-old male volunteer. Weight-bearing lateral views can be obtained by having the patient stand on a wooden box. However.
Scout views are obtained in both the AP and lateral projections (Fig. This indicates that the patient has a nonrigid flat-foot deformity (pes planus).indd 2241 9/9/2008 5:34:22 PM . demonstrable only with weight bearing. 47-45B) or to a box (Fig. Importance of weight-bearing view. Example of a foot holder we built to help keep patients’ feet centered in the CT scanner in neutral position. The coverage should begin superior to both syndesmoses and extend below the calcanei. we have used a box. B. Non–weight-bearing lateral view. We typically scan using 120 kVp at less than 200 mA. 47-45C) helps to hold the feet in neutral position and to prevent motion during the scan. which are comminuted fractures involving the plafond. obtained portably. toes pointing to the ceiling. coverage is extended superiorly to include more of the distal tibia. The scanning FOV should be set wide enough to include both the right and left lateral malleoli. metal. the long axis of the talus (solid white line) is now angled downward relative to the first metatarsal (solid black line). On this image.47 Ankle and Foot 2241 47 Figure 47-44. suggesting normal alignment. A B A B C Figure 47-45. 47-46). Ch047-A05375. for most patients this is less than 25 cm. A. Same patient as in A. feet together. The patient is positioned supine on the CT table with her legs straight. A. the long axis of the talus (dashed white line) is parallel to the long axis of the first metatarsal (dashed black line). including it in the scanning field-of-view (FOV) does not cause excessive streak artifacts and does not increase the radiation exposure to organs in the torso. obtained upright at a follow-up clinic visit 3 months later. In cases of pilon fractures. On this weightbearing lateral view. C. In lieu of a dedicated foot holder. B. Securing the patient’s feet to a dedicated holder (Fig.
osteochondral lesions). more of the distal tibia is covered (dashed rectangle). Ankle/Distal Tibia Protocol. portions of which are shown in Figure 47-47. Oblique coronal and oblique axial Reformatting Technique At the UW we have identified at least 15 different ways that we are commonly asked to create two-dimensional reformatted images of the ankle and foot. Forefoot/Midfoot Protocol. malleoli. the other a smoothing standard algorithm for reformatting in threedimensions. Long-axis and short-axis planes are reformatted both parallel and perpendicular to the sagittal length of the first metatarsal. straight axial images are created in a plane parallel to the bottom of the foot. Navicular Protocol. is best obtained off an axial reference image that has been obliqued to include the entire length of the first metatarsal. 47-47A) is centered on the ankle joint.or three-dimensional reformatted images are desired. our surgeons prefer that the mortise coronal and mortise sagittal images be reformatted at 1 mm.2242 VII Imaging of the Musculoskeletal System Figure 47-46. straight sagittal images are reformatted along a plane parallel to the long axis of the foot.g. using an axial reference image through the top of the ankle mortise. Both sets of source images are sent to the PACS for archival storage and can be accessed any time in the future if additional two. and this allows for a 50% overlap between slices. one uses an edge-enhanced bone algorithm for the twodimensional multiplanar reformatted images. We reconstruct two sets of source images. mortise coronal and mortise sagittal images are created parallel and perpendicular to an imaginary line through the anterior cortex of the medial and lateral malleoli. pilon. Our forefoot/midfoot protocol (see Fig. Oblique coronal and oblique axial images are reformatted in planes both perpendicular and parallel to the posterior facet of the subtalar joint. sagittal to the first metatarsal. which are images most of us primarily view. Our hindfoot/midfoot protocol (see Fig. Anteroposterior (A) and lateral (B) scout CT views. Using a midsagittal reference image. 47-47C) is primarily used to assess the alignment of the Lisfranc joint and the integrity of the adjacent bones. However. we increase the resolution by creating thin (1 mm) reformatted images in a small (6 cm) FOV. we find that creating reformatted images that are 3 mm thick at 3-mm intervals (no gap or Ch047-A05375.g. talar body) and the subtalar joint (e... calcaneus. Straight axial images are reformatted in a plane parallel to the bottom of the foot. for osteochondral lesions of the talar dome. juvenile Tillaux) or of the talar dome (e. The other three planes are reformatted off a midsagittal reference image. These are delineated on our downloadable protocol sheets.indd 2242 9/9/2008 5:34:23 PM .g. Because these thin overlapping slices yield hundreds of source images.g. 47-47D) is used to assess the healing of a known navicular fatigue fracture that has perhaps been previously diagnosed by MRI. Our dedicated navicular protocol (see Fig. A B We can achieve the highest resolution on the reformatted images by reconstructing the source images at a width equal to the width of the narrowest detector. we store these source images on the PACS in their own folder—a folder separate from where we store the reformatted images. The reformatting protocols are centered on the anatomic divisions illustrated in Figures 47-5 and 47-48. We find that it works best to create reformatted images in three planes relative to the first metatarsal shaft. The scanning field should cover both ankles and should extend from above the syndesmosis to below the calcaneus (white rectangles).. This protocol is used for scanning fractures of the distal tibia (e.. The reconstruction interval between source images is equal to onehalf the detector width. Then. A sagittal reference image that best delineates the entire length of the first metatarsal is selected. yielding images of higher resolution but also with more noise. Because these navicular fatigue fractures tend to be incomplete hairline cracks. triplane. Hindfoot/Midfoot Protocol. 47-47B) is centered on the Chopart joint and is used to evaluate hindfoot fractures (e. For distal tibial fractures. overlap between reformatted slices) yields crisp images that do not appear noisy. In cases of pilon fractures. Using an axial reference image. tarsal coalitions). The third plane. Our ankle/distal tibia protocol (see Fig.
This protocol is appropriate for distal tibial fractures (pilon. Straight axial (off a sagittal) 3 × 3 mm 4. Sagittal (off an axial) Figure 47-47. Ch047-A05375. This protocol is appropriate for forefoot fractures (Lisfranc dislocation. may have to oblique reference image to see 1st metatarsal) 3 × 3 mm All planes are relative to 1st metatarsal 1. talar body. and juvenile Tillaux) and for talar dome fractures (osteochondral lesions of the talus [OLT]. malleoli. C. D. B. Mortise coronal (off an axial) 3 × 3 mm 1 × 1 mm 3. Forefoot/midfoot protocol. triplane.indd 2243 9/9/2008 5:34:25 PM . Sagittal (off an axial. osteochondritis dissecans). Ankle/distal tibia protocol. metatarsals). Short axis (off a sagittal) 3 × 3 mm D Navicular (stress fracture) Reformat 6 cm FOV Reformat 1 × 1 mm 1 and 2. Straight sagittal (off an axial) 2. Axial (long axis) (off a sagittal) Standard: 3 × 3 mm 2. and subtalar joint) and for tarsal coalitions. This protocol is appropriate for hindfoot fractures (calcaneus. These are portions of our University of Wisconsin foot/ankle/distal tibia (F/A/T) protocol sheet. Hindfoot/midfoot protocol.47 Ankle and Foot 2243 47 A Ankle/distal tibia (centered on ankle joint) 2. Oblique coronal (off a sagittal) Standard: 3 × 3 mm 3 × 3 mm C Forefoot/midfoot (centered on Lisfranc joint) 3. Coronal and axial (off a sagittal) 3. Oblique axial (off a sagittal) 3 × 3 mm 1. Mortise sagittal (off an axial) 3 × 3 mm 1 × 1 mm 1. A. Navicular protocol. Straight axial (off a sagittal) Standard: 3 × 3 mm For OLT: 3 × 3 mm B Hindfoot/midfoot (centered on Chopart joint) 3.
The imaging planes. images are reformatted off a sagittal reference image. the knee coil can be used with the patient’s foot held in plantar flexion. The parameters used at the UW for our GE 1. shown with the curved blue line. Custom cushioned inserts (Fig. We use a dedicated foot and ankle coil (Fig. Ch047-A05375. the most up to date of which can be found at our website (http://www. (410) 594-9403. Beekley Corporation. Beekley MR-Spots. Such a marker needs to be conspicuous on all imaging sequences. and oblique sagittal images are reformatted off an axial reference image. *IZI Multi-Modality Radiographic Markers. shown with the angled green line. with the bottom of the foot perpendicular to the tibia. Sometimes we have to be creative in our coil selection to accommodate the patient’s physical limitations (Fig. The marker should be placed there.2244 VII Imaging of the Musculoskeletal System Figure 47-48. http://www.izimed. Baltimore. Anatomic division and major joints shown on a sagittal CT. Also. 47-52). 150 Dolphin Road.indd 2244 9/9/2008 5:34:27 PM . 7020 Tudsbury Road. separates the hindfoot from midfoot. Although the neutral positioning shown in Figure 47-50A is fine for imaging the ankle and hindfoot. IZI Medical Products. • Magnetic Resonance Imaging • Coils and Markers When imaging the ankle or foot with MR. 47-51). Although markers are commercially available. 47-49) that incorporates a chimney-like extension so that the toes can be included in the FOV. Do not be dissuaded when the patient initially points to a wide area. http://www. sequences.com. as it would be if the patient were standing. In these circumstances. shown with the yellow line. Bristol. it would not be appropriate for the phalanges. Some designs of knee coils have an open top that allows the toes to protrude (Fig. the technologist should see if having the patient lie prone makes it more comfortable to maintain plantar flexion. including fat-suppressed sequences. separates the midfoot from forefoot. ask the patient to point to one spot with one finger—which.Edu/MSKprotocols). that is.* generic capsules containing vitamin E or docusate sodium (Colace) are often used. (860) 583-4700. and should be placed on the patient in such a way as not to deform the contour of the skin. The joint between the talus and calcaneus (Ca) is the subtalar joint. This chimney design also helps to hold the patient’s foot and ankle in a neutral position. The Lisfranc joint. This dedicated foot and ankle coil incorporates a chimney-like extension (arrow) so that the phalanges can be included in the field of view. and FOV should be optimized to take advantage of the characteristics of the MRI scanner and coil being used. such as across the midfoot or around the malleoli. Figure 47-49. Whenever possible. patients tend to feel less claustrophobic when prone. and even the selection of which coil to use will vary depending on the clinical circumstances. The joint between the tibia (Ti) and talus (Ta) is the ankle joint (AJ). Markers can be helpful to draw the attention of both the technologist acquiring the images and the radiologist interpreting the images. • Scanning Technique Imaging Planes We use at least nine standard imaging planes in our foot and ankle MRI protocols (Fig. interslice gap.Wisc. when encouraged.com. This is typical. No one standardized protocol can answer all possible questions. 47-50A). an extremity coil should be used. the posterior facet (P-STJ) is shown with the red line. The Chopart joint. CT 06010. The exact slice thickness. it is vital to understand the clinical question that the scan is being requested to address. MD 21244. Instead. 47-50B) help to keep the heel immobilized and centered in the coil. We encourage our technologists to place a marker over the sight of maximal tenderness or near a nonhealing ulcer. they usually can do.beekley. When it is necessary to image the toes.5-T scanners are spelled out in detail on our MRI scanning parameters and protocols sheets. Radiology. and a foot coil as in Figure 47-49 is not available.
A B C D Figure 47-51. B. T1-weighted image with fat suppression after the administration of intravenous gadolinium shows diffuse enhancement of the subcutaneous fat. A.47 Ankle and Foot 2245 47 A B Figure 47-50. 47-52B) are set up off a straight sagittal reference image. Because of difficulty positioning the patient. Instead. T1-weighted. The straight sagittal slices are set up off an axial scout image and are oriented parallel to the long axis of the foot. This is our primary plane for imaging the Ch047-A05375. A second pad next to the coil (black arrow) give the contralateral foot a place to rest. The straight sagittal plane (see Fig. Straight axial slices (see Fig. we used a torso coil and covered the leg and ankle. Because the patient was physically unable to straighten her legs. either a sagittal scout image or one of the midsagittal slices from the preceding acquisition. large field-of-view image covering the entire leg as well as the ankle. D. we could not use the foot coil. Most of the other imaging planes are acquired relative to a straight sagittal reference image. B. indicative of cellulitis. and it is usually the first plane acquired in all of our ankle and foot MRI protocols. The straight axial slices should be roughly perpendicular to the long axis of the tibia and if the ankle is held in the neutral position will be roughly parallel to the bottom of the foot. The clinical concern was for infection in and around the ankle joint. The slices should begin well proximal to the level of the malleoli and extend distal to the calcaneus. Lateral radiograph shows soft tissue swelling. At least two axial orientations are typically used. This is a 41-year-old with paraplegia from spina bifida who is essentially frozen in the fetal position. Inversion recovery image shows no bone marrow edema but diffuse edema of the subcutaneous fat. 47-52A) is our survey plane. A customized foam pad (white arrow) helps immobilize the hindfoot being scanned. The gray arrow points to inadequate fat suppression at the edge of the coil. A. The lack of enhancement and edema in the bone marrow exclude osteomyelitis.indd 2245 9/9/2008 5:34:31 PM . C. Example of a patient who could not be positioned in the foot or knee coil. a portion of the other leg is also within the coil. A knee coil can be used to scan the ankle. The open top on this knee coil allows the toes to extend through the coil while keeping the foot in neutral position. a common occurrence with large fields of view.
Ch047-A05375.2246 VII Imaging of the Musculoskeletal System A B C D F E G H I Legend on opposite page.indd 2246 9/9/2008 5:34:33 PM .
47-52F) are set up off a straight axial reference image taken through the top of the talar dome. E. This is one of the primary planes used for imaging osteochondral lesions of the talus (OLT).) This is a good secondary plane to evaluate the tendons and tarsals. 47-7 to review the anatomy of the posterior facet of the subtalar joint. and it is also good for looking at the malleoli and the ankle ligaments. (The marker [m] indicates the site of maximal tenderness. rather than the straight sagittal plane. either a sagittal scout image or one of the midsagittal slices acquired in A. (Refer to Fig. and it is also good for looking at the malleoli and the ankle ligaments. Long-axis images are obtained off a short-axis reference image through the metatarsals and are oriented to try to include all five. With regard to the forefoot. helps keep the foot in place relative to the scanner. The oblique coronal slices are oriented perpendicular to the posterior facet of the subtalar joint. if the ankle is held in the neutral position. and the slices are oriented perpendicular to the mortise coronal slices. will be roughly parallel to the bottom of the foot. 47-52E) are used much more often then straight coronal slices and are set up off the same sagittal reference slice as previously. 47-52H). 47-52D). Oblique coronal slices (see Fig. This is our primary plane for imaging the tarsal bones. Mortise sagittal slices are set up off the same straight axial reference image as in F. This is the survey plane for OLT. A. and to avoid potential ambiguity we refer to the short-axis and long-axis planes relative to the metatarsals. rather than coronal or axial.) D. an example of which is shown in Figure 47-52I. F. we have found that there is come confusion among technologists as to the coronal and axial planes. This is our primary plane for imaging the ankle tendons. The standard imaging planes we use for MRI of the foot and ankle. as in Figs. These slices are set up off a sagittal reference image. 47-52G) are set up off the same straight axial reference image as previously. are oriented roughly perpendicular to the plantar aponeurosis. and it is the first plane acquired in all of our ankle and foot MRI protocols. Mortise coronal slices are set up off a straight axial reference image taken through the top of the talar dome. is the survey plane we use for OLTs. we prefer to refer to the short-axis and long-axis planes. This axial reference image can be either an axial scout image or one of the straight axial slices acquired in B. we prefer to use the short-axis and long-axis planes delineated in H and I when the clinical question involves the forefoot. The straight axial slices should be roughly perpendicular to the long axis of the tibia and. (Although the field of view can be enlarged to include the metatarsals and phalanges in their entirety. Oblique axial slices are set up off the same straight sagittal reference image as in B and are oriented parallel to the long axis of the metatarsals. Figure 47-52. The oblique coronal slices are oriented perpendicular to the posterior facet of the subtalar joint. Oblique coronal slices are used much more often then straight coronal slices and are set up off the same sagittal reference slice as in B. and the slices are oriented perpendicular to the mortise coronal slices. Oblique axial slices (see Fig. This yields a series of short-axis slices that cut transversely through the metatarsals and phalanges. set up off a sagittal reference image. (See Fig. and the slices should include all of the tarsals from the back of the calcaneus through the metatarsal bases. 47-49 and 47-50. 47-52I). (Using a cushioned foot holder. Short-axis images are obtained off a straight sagittal reference image and are oriented perpendicular to the long axis of the metatarsals. 47-7 to review the anatomy of the posterior facet of the subtalar joint. H. Straight axial slices are set up off a straight sagittal reference image. There are at least three ways to orient slices in the coronal plane.indd 2247 9/9/2008 5:34:33 PM . This axial reference image can be either an axial scout image or one of the straight axial slices from a preceding acquisition.) This is a good secondary plane to evaluate the tendons and tarsals. This is our primary plane for imaging the tarsal bones. Most of the other imaging planes are acquired relative to a straight sagittal reference image. This is the best way to obtain a side-by-side comparison of the metatarsals and is used when evaluating for stress fractures or osteomyelitis. Ch047-A05375. metatarsals on individual slices. and the slices should include all of the hindfoot and midfoot. or at least four. 47-52C) are set up off the same straight sagittal reference image as previously but are oriented parallel to the long axis of the metatarsals. The slices are aligned parallel to a line drawn between the medial and lateral malleoli. The white lines represent the orientation. A short-axis image through the metatarsals is shown in I. This is the best way to obtain a side-by-side comparison of the metatarsals and is used when evaluating for stress fractures or osteomyelitis.) This is our survey plane. Long-axis images are obtained off a short-axis reference image through the metatarsals and are oriented to include all five. and the slices should include all of the tarsals from the back of the calcaneus through the metatarsal bases. The slices are aligned parallel to a line drawn between the medial and lateral malleoli. Short-axis images are obtained off a straight sagittal reference image and are oriented perpendicular to the long axis of the metatarsals (see Fig. but not the actual number or spacing. metatarsals on individual slices (see Fig. B. and are used primarily when evaluating the plantar fascia. Least commonly used is the straight coronal plane (see Fig. This is one of the primary planes used for imaging osteochondral lesions of the talus (OLTs). I. to avoid ambiguity. and the slices should include all of the hindfoot and midfoot. Straight sagittal slices are set up off an axial scout image and are oriented parallel to the long axis of the foot.47 Ankle and Foot 2247 47 ankle tendons and is also useful for the ankle ligaments and syndesmosis. C. of the slices. G. or at least four. Straight coronal slices. Mortise sagittal slices (see Fig. This is a good plane to evaluate for bone marrow edema in the forefoot. The slices should begin well proximal to the level of the malleoli and extend distal to the calcaneus.) With regard to the forefoot. Mortise coronal slices (see Fig. are used primarily when evaluating the plantar fascia and should be oriented roughly perpendicular to the plantar aponeurosis. This.
all of the metatarsals. because protondensity–weighted images are relatively insensitive for fluid. Information can be found at http://www. the U. If the radiologist observes edema in the talar dome. Likewise.gov/cder/drug/infopage/gcca. the FOV needs to include the distal tibia and fibula. such as in rheumatoid arthritis (Fig. from “nonspecific edema from other causes” that does not enhance. IVGd can help distinguish an enhancing phlegmon from a nonenhancing pus pocket. However. and the midfoot tarsal bones back to the Chopart joint. When the tendons are the site of clinical concern. there are particular circumstances in which its use is invaluable. images can then be acquired in the mortise coronal and mortise sagittal planes (our OLT protocol). being inherently fat sensitive. particularly the edema-sensitive sequence. We start with straight sagittal images to survey the bones. For a foot MRI. we find that we get the best images when we use inversion recovery for the straight sagittal survey plane and T2-weighted sequences in all other planes.* Whenever possible. If no bone marrow edema is found. This can be either a fatsuppressed fast-spin echo T2-weighted sequence or an inversion recovery sequence.indd 2248 9/9/2008 5:34:34 PM . and the bases of the metatarsals. Although for the most part these two sequences are equivalent (Fig. • Use of Contrast Although the intravenous administration of a gadoliniumbased contrast agent (IVGd) is not needed for most musculoskeletal MRI. which demonstrates contrast enhancement of the edematous skin. 47-54).fda. we use proton-density–weighted images. T1-weighted images. Tears in the substance of the ankle tendons are usually best seen with proton-density– weighted images (Fig. Food and Drug Administration (FDA) has issued warnings describing the risk for nephrogenic systemic fibrosis (NSF) after exposure to gadolinium-containing contrast agents in patients with acute or chronic severe renal insufficiency. fatsuppressed (A) and inversion recovery (B) MRIs in a 35-year-old with plantar fasciitis. IVGd can distinguish cellulitis. we run edema-sensitive sequences in all the planes we image. 47-53). a distinction that may not otherwise be seen on noncontrast T1-weighted or T2-weighted images. as well as the edema in the adjacent heel fat pad (white arrowheads) and in the bone marrow at its origin (white arrow). we use IVGd when there is a clinical concern for an inflammatory arthropathy or synovitis. all of the tarsal bones. Sequences Because detecting abnormally edematous signal in the bones.2248 VII Imaging of the Musculoskeletal System Figure 47-53. For an ankle MRI. The oblique coronal plane well images the medial and lateral ankle tendons in cross section as they curve under the malleoli. and surrounding soft tissues is the key to all musculoskeletal MRI. If the marrow edema is in a metatarsal. that patient should be screened in accordance to your institution’s policies. When they are available. *During the year leading up to the publication of this chapter. A B Protocols Our ankle/foot MRI protocols call for acquiring images in three of the standard planes and typically take 45 to 60 minutes. this is usually best demonstrated with short. they should always be read side-by-side with edemasensitive images to look for abnormal amounts of fluid in the tendon sheaths. the radiologist should check these first sets of sagittal survey images. Also. we prefer to use IVGd whenever possible in cases of infection.S. Both of these sagittal images of the calcaneus delineate the plantar aponeurosis (open arrowheads). 47-55). well demonstrate the normal fat in yellow bone marrow as well as the subcutaneus fat and the deeper fat between muscles and tendons. tendons. Before any contrast agent is administered to any patient. Comparison of T2-weighted. The straight axial plane well images all 10 of the ankle tendons in cross section at and above the level of the ankle joint. we generally proceed with our tendon protocol (straight axial and oblique coronal) unless some other site is clinically requested. If there is edema elsewhere in the tarsal bones. in the straight axial and oblique coronal planes. indicative of active tenosynovitis. the sagittal FOV can be enlarged to include the ankle and forefoot. In cases in which the area of clinical concern is vague. Ch047-A05375. We use T1 weighting in all imaging planes whenever the tendons are not the primary site of interest. along with T2weighted sequences. The IVGd causes T1 signal enhancement of the hypervascularized inflammatory synovium (pannus) but not of the adjacent synovial fluid. oblique axial and oblique coronal images are acquired (our tarsal stress fracture protocol). the FOV needs to include all of the phalanges.and long-axis images (our metatarsal stress fracture protocol).
47 Ankle and Foot 2249 47 Figure 47-54. proton-density (PD)–weighted (B). 47-58). fat-suppressed T1-weighted images can be obtained before the administration of IVGd to be compared side-by-side with the postcontrast fat-suppressed T1weighted images.36 The contrast-enhanced tissue can be made all the more conspicuous on T1-weighted images by suppressing the signal from fat. At UW. We sometimes use IVGd when we detect a soft tissue mass that is bright on T2-weighted sequences and we wish to confirm whether it is solid (Fig. Ankle and Foot Injuries • Ankle Mortise Fractures • Malleoli/Syndesmosis 12 Fractures of the medial and lateral malleoli are commonly the result of twisting injury of the talus in ankle mortise. CT axial images through Ch047-A05375. A B C A B Figure 47-55. This is a sideby-side comparison of the same straight axial slice acquired using T1-weighted (A). When there is a concern that the degree of fat suppression may not be uniform throughout the image. 47-56) or cystic (Fig. particularly the abnormally increased signal in the split/abnormally flattened peroneus brevis tendon (white arrowhead). IVGd is also useful for the detection of Morton’s neuroma by MRI (Fig. and T2weighted (C) images. Peroneus brevis tear in a 62-year-old. we prefer to image Morton’s neuroma with ultrasonography rather than MRI. and we use fat suppression on nearly all of our postcontrast images. The bright T2 signal in A in the posterior tibial (white arrow) and flexor digitorum longus (white arrowhead) tendon sheaths is shown to be enhancing pannus in B. 47-57). the bright T2 signal in A adjacent to the extensor digitorum longus (black arrow) and the anterolateral ankle joint (black arrowhead) is shown to be nonenhancing fluid surrounded by a thin rim of enhancing synovium in B. Although T1 shows the fat best and T2 shows the fluid best. Comparison of T2 weighting with fat suppression (A) and T1 weighting with fat suppression after intravenous gadolinium (B) in a 65year-old with rheumatoid arthritis.indd 2249 9/9/2008 5:34:35 PM . In comparison. PD shows the tendons best. Radiographs are usually sufficient for the management of what are typically simple fractures.
Short-axis T1-weighted (E). Sagittal T2-weighted fat-suppressed image shows the mass to be homogeneously bright. B.2250 VII Imaging of the Musculoskeletal System A B Figure 47-56. Sagittal T1-weighted fat-suppressed image after intravenous gadolinium administration shows heterogeneous enhancement. A. This is the classic appearance of a simple cyst. D. This is the classic appearance of a schwannoma. T2-weighted fat-suppressed (F). C. with no invasion into the overlying subcutaneus fat or the underlying talus. E F G Ch047-A05375. There is a small lobule distal to the main cyst. Lateral radiograph shows a round soft tissue mass posterior to the talus. Lateral radiograph shows a round soft tissue mass dorsal to the metatarsals. Synovial cyst in a 51-year-old. B. Schwannoma in a 67-year-old. A. Sagittal T1weighted fat-suppressed image after intravenous gadolinium (IVGd) shows enhancement of only the thin synovial lining but not the cyst fluid. confirming that this is a vascularized mass and not a cyst. D. C D A B C D Figure 47-57.indd 2250 9/9/2008 5:34:38 PM . Sagittal T1-weighted image shows the mass to be homogeneously relatively dark. and T1-weighted fat-suppressed post-IVGd (G) images through the cyst demonstrate the same signal characteristics as in the sagittal plane. Sagittal T1-weighted image shows the mass to be homogeneously relatively dark. The gray arrows in F and G indicate areas of inadequate fat suppression near the fifth toe. Sagittal inversion recovery image shows the mass to be heterogeneously bright. C.
pushing it away from the *Bernhard Georg Weber (1927-2002). The tibia is connected to the fibula by the intraosseous membrane (IOM). a Swiss orthopedist.47 Ankle and Foot 2251 47 A B C Figure 47-58. In fact. The syndesmotic ligaments. Schematic. Skeletal model. Figure 47-59. T2-weighted fat-suppressed images of Morton’s neuromas usually show little (open arrowhead). The lateral avulsive forces may cause strain or tearing of the talofibular ligaments. the anterior and posterior tibiofibular ligaments (Tib-Fig Lig). LM. the anterior and posterior tibiofibular ligaments. he designed a new hip prosthesis and developed a tibial realignment osteotomy procedure to treat prematurely degenerated knees. or they may cause an avulsion fracture through the lateral malleolus. A. Where the distal fibula fits into a groove in the distal tibia is the syndesmosis. pulling it off the fibular shaft. To understand the mechanism of syndesmotic injury. nearly gave up medicine and surgery to pursue his dream of becoming an architect. The marker (m) indicates the site of maximum tenderness. the compressive forces on the medial side can fracture through the medial malleolus. a sheet of connective tissue that runs along the length of the diaphyses. Left. Figure 47-60 illustrates how either inversion or eversion rotational injuries to the talus cause both avulsive and compressive forces on the malleoli. both ankles are useful when the integrity of the syndesmosis is questioned. edema. skiing and tennis. are modeled in green. His skill at skiing was such that he was certified as a championship instructor. Besides fracture treatment. he recognized that orthopedics would satisfy his interest in medicine and technology and his need for artistic expression. Morton’s neuromas are seldom more conspicuous than this on T1-weighted images. it applies avulsive pulling forces on the lateral side of the mortise and compressive pushing forces on the medial side. B. if any. though. The integrity of the ankle joint is maintained laterally by the anterior and posterior talofibular ligaments. medial malleolus. T1-weighted image demonstrates a small lobule of decreased signal (black arrow) between and below the heads of the second and third metatarsals. The deltoid ligament (Delt Lig) is shown in blue. C. The administration of intravenous gadolinium makes the vascularized Morton’s neuroma (arrow) much more conspicuous on this T1-weighted fat-suppressed image. radiographically on the left and schematically on the right. he underwent this realignment procedure himself bilaterally to enable him to continue with two of his passions. we find it is helpful to review the Weber* staging system for ankle fractures. maintain the integrity of this syndesmotic joint. Models of the ankle mortise. and medially by the deltoid ligament. On the left is a skeleton model showing the relationship of the talus to the malleoli and syndesmosis.indd 2251 9/9/2008 5:34:40 PM . On the right is a schematic. The intraosseous membrane (IOM) is shown in yellow. Morton’s neuroma in a 44-year-old: short-axis images through the second metatarsal head. Figure 47-59 shows two models of the ankle mortise. lateral malleolus. During his surgical training in Zurich. Figure 47-60A illustrates a Weber type A injury. The syndesmotic ligaments. As the talus undergoes an inversion rotational injury. The anterior and posterior talofibular ligaments (Talo-Fib Lig) are modeled in purple. Right. Conversely. MM. Ch047-A05375.
(If the compressive forces extend proximally up the length of the IOM. Schematic showing the mechanism of a Weber type A ankle fracture. it applies avulsive pulling forces on the lateral side of the mortise and compressive pushing forces on the medial side. Anteroposterior radiograph of the ankle showing a horizontal avulsion fracture through the medial malleolus and an obliquely vertically oriented compression fracture through the distal fibular. above the level of the syndesmosis. Left. except now the compressive forces extend through the syndesmosis. Right.indd 2252 9/9/2008 5:34:45 PM . Weber type A. Anteroposterior radiograph of the ankle showing medial displacement of the talus relative to the tibia. a horizontal avulsion fracture through the lateral malleolus. Left. As the talus undergoes an eversion rotational injury. Weber type B. As the talus undergoes an inversion rotational injury. it applies avulsive pulling forces on the medial malleolus and compressive pushing forces on the fibula. Schematic showing the mechanism of a Weber type B ankle fracture. below the level of the syndesmosis. Weber injuries. Right. The syndesmosis is disrupted and abnormally widened. C. Schematic showing the mechanism of a Weber type C ankle fracture. tearing the tibiofibular ligaments and the distal intraosseous membrane (IOM). Right.2252 VII Imaging of the Musculoskeletal System A B Figure 47-60. Left. Structures are as identified in Figure 47-59. A. this is referred to as a Maisonneuve fracture [not illustrated]. Weber type C. and a vertically oriented compression fracture through the medial malleolus. This is the same as a Weber type B. and an obliquely vertically oriented compression fracture through the distal fibular. with the oblique fracture higher up on the fibula. fracturing through the proximal fibula up near the knee. with no overlap between the tibia and fibula. B. a horizontal avulsion fracture through the medial malleolus. Anteroposterior radiograph of the ankle showing lateral displacement of the talus relative to the tibia.) C Ch047-A05375.
Avulsion fractures are horizontally oriented. above the level of the syndesmosis. Compression fractures are more obliquely or vertically oriented. avulsion fractures can be distinguished from compression fractures by the orientation of the fracture margins. A. CT of Weber type C injury. radiographically on the left and schematically on the right. was the first to describe external rotation as a contributing mechanism in the production of ankle fractures. Identifying this high fibula fracture is important to recognizing that the syndesmotic ligaments are disrupted.indd 2253 9/9/2008 5:34:46 PM . The medial avulsive forces may cause strain or tearing of the deltoid ligaments. or they may cause a horizontal avulsion fracture through the medial malleolus. Determining the integrity of the syndesmosis is an important surgical consideration because syndesmotic injuries usually require screw fixation. except now the compressive lateral forces extend through the syndesmosis. Pilon is French for “pestle. and is thus not imaged on ankle radiographs. with the avulsive pulling forces on the medial malleolus and the compressive pushing forces on the lateral side. and the juvenile Tillaux35 and triplane38 fractures in adolescents. Figure 47-60C illustrates a Weber type C injury. in a direction roughly perpendicular to the lines of force. Radiographically. Three fractures in particular that typically come to CT are the pilon10 fracture in adults. pected when the ankle radiographs demonstrate an avulsion fracture through the medial malleolus without an accompanying fibula fracture. Indeed. In this case the obliquely oriented fibula fracture will be higher up. tearing the tibiofibular ligament as well as the distal IOM. this is a clue that you may be looking at a Maisonneuve. Figure 47-60B illustrates a Weber type B injury. B. because radiographically the syndesmosis may not appear abnormally widened if not stressed. radiographically on the left and schematically on the right. a CT scan can be helpful (Fig. The syndesmotic ligaments and IOM remain intact. When the integrity of the syndesmosis is unclear based on physical examination and radiographs. Scanning in the axial plane through both ankles simultaneously allows for side-by-side comparison of the widths of the injured and uninjured syndesmoses. characteristic of a Weber type C injury. • Fracture through the Tibial Plafond Intra-articular fractures through the tibial plafond often require surgical open reduction with internal fixation (ORIF) to restore the anatomic alignment of the articular surfaces. in the same direction as the force. Mortise coronal image shows widened syndesmosis (black arrows) and the high fibula fracture (white arrow). a French surgeon and a student of Guillaume Dupuytren. The compressive forces on the lateral side cause a vertically oblique fracture through the fibula. and multiplanar reformatted CT scans are often instrumental in such surgical planning. Axial images through both ankles show the abnormally widened left syndesmosis (black arrows) compared with the width of the contralateral normal right syndesmosis (white arrows). sometimes the fibula fracture is so high that it occurs through the proximal fibula. This is the same mechanism as a Weber type B injury. the father of radiology in France. they are typically not Ch047-A05375.47 Ankle and Foot 2253 47 Figure 47-61. and was first used to describe this fracture in 1911 by Étienne Destot. Pilon Fracture Pilon fractures are any tibial fracture that involves the distal articular plafond and are typically the result of an axial loading force. pilon fractures can produce significant comminution with multiple displaced fracture fragments. If the fibular fracture is distal to the syndesmosis it is characterized as a Weber type B. near the knee joint.” an instrument used for crushing or pounding. Although these comminuted fractures invariably require internal fixation. A Right Left B tibial plafond. Here the talus is undergoing an eversion rotational injury. When they are the result of a highenergy injury. and radiographs that include the entire length of the fibula should be obtained. 47-61). This is referred to as a Maisonneuve* fracture and can be sus*Jules Germain François Maisonneuve (1809-1897). such as a fall from height or a high-speed motor vehicle front-end collision. This principle is the key to understanding the Weber fractures. If you cannot tell from ankle radiographs whether you are looking at a Weber type B or C.
they never cause any CT streak artifacts across the reformatted fracture margins (see Fig. Because these nonmetallic bars are made of materials (usually carbon fiber) that block very few x-rays from reaching the detectors. and D) and through the tibia proximal to the fracture (this pin is not seen in Fig. as illustrated in Figure 47-62. and frontal and lateral views are needed to appreciate their multiplanar nature (Fig. Notice the good visualization of the calcaneus cortex in Figure 47-62B and D. Traumatic fractures are considered surgical emergencies because of the high risk of avascular necrosis. Type 5 fractures are rare and are crush injuries to the growth plate. metallic streak artifacts are often not appreciable. Type 3 fractures extend from the physis through the epiphysis at the end of the bone. typically disrupting the articular surface at a joint. the physis. 47-62A and B) to nonmetallic connecting bars (gray arrows in Fig. 47-63B and C.* These fractures have a characteristic appearance. Because they involve the cortical bone and the overlying articular hyaline cartilage. 47-62B and D). 47-64D to F) and often reveal more deformity of the articular surface than would be anticipated from radiographs alone. Osteochondral fractures notoriously occur on convex articular surfaces. Even with anatomic internal fixation. and the metaphysis. Juvenile Tillaux Fracture Juvenile Tillaux fractures are Salter-Harris type 3 fractures. for although the suffix “itis” by definition implies inflammation. These fractures always occur laterally because the distal tibial physis fuses from medial to lateral as a child matures (Fig. after the external fixator is in place. and osteochondritis dissecans. because the clamps are always placed proximal and distal to the pilon fracture. B. fractures displaced more than 2 mm should have orthopedic consultation and surgery to restore the congruity of the joint surface. such external fixation hardware is no impediment to obtaining the CT images the surgeon requires. 47-60). The fracture is the result of an external rotation force pulling on the anterior tibiofibular ligament. osteochondral lesion. and then wait several days for the swelling of the surrounding soft tissues to reduce before returning to the operating room for the more anatomic ORIF of the pilon fracture. and CT can be useful to confirm the presence of abnormal medullary sclerosis suspected radiographically (Fig. Text continued on p. they are referred to as osteochondral fractures. to distinguish them from osteochondral lesions at other sites. • Osteochondral Lesions of the Talus Fractures of the talar dome are insidious. The last term is the oldest and perhaps the most misleading. 47-64A to C): the epiphysis fracture running vertically in a sagittal orientation (plane 1). white *The Salter-Harris system is applied to fractures that involve the growth plate (physis) at the ends of skeletally immature bones. The patients with significantly displaced fractures may go to the operating room the day of the injury for traction reduction and external fixation to restore relative alignment to the mortise. triplane fractures occur in adolescents in whom the lateral growth plates have not yet fused. 47-66). The metal pin-bar clamps block many x-rays from reaching detectors and thus will cause some CT streak artifacts. and patients usually go straight from the emergency department to the operating room without stopping at CT (although CT scans of displaced fractures of the body of the talus can be dramatic. Coronal and sagittal images are useful to demonstrate the degree of displacement particularly at the articular surface (Fig. they are nearly radiolucent and cause no CT streak artifacts (see Fig. the surgeon will percutaneously drill thick metal pins through the calcaneus (white arrows in Fig. When minimally displaced. 47-62A to C). 47-63B). A gross example is indicated by the green arrow in Figure 47-2. 47-62). Generically. They typically occur at the medial edge or posterolateral corners of the talar dome and are thought to be the result of an impaction of the talar dome on the tibial plafond during an inversion or eversion twisting injury. the most common. While minimally displaced juvenile Tillaux fractures are usually treated nonoperatively. triplane fractures can be difficult to see radiographically. However. these fractures have been referred to by many names. histologically these lesions have not been shown to be inflammatory. Triplane Fracture Triplane fractures are Salter-Harris type 4 fractures. avascular necrosis sometimes occurs. the physeal fracture running horizontally in the axial plane (plane 2). including osteochondral defect. including the femoral condyles of the knee and capitellum of the elbow. It is these nonmetallic bars that span the length of the fracture and maintain the tibia length. These pins are rigidly attached by metal clamps (white arrowheads in Fig. We prefer the term osteochondral lesions of the talus. Type 2. and the metaphyseal fracture running obliquely vertically in a coronal orientation (plane 3). juvenile Tillaux fractures occur exclusively in adolescents in whom the lateral growth plates have not yet fused. As such. Type 1 refers to simple transverse fractures that involve the physis only. which is only minimally affected by streaking caused by the metal pin-bar clamps. Refer to the illustrations of Weber injuries (see Fig. Fig. This means that these patients typically receive their CT scans during this interim period. particularly on CT. usually between the ages of 12 and 15 years. • Talar Fractures 3. refers to fractures that involve the physis and the adjacent metaphysis.47 Talar fractures can be thought of as either traumatic or insidious. 47-65). 2260 Ch047-A05375. Type 4 fractures involve the epiphysis. Using our standard bone CT scanning protocol of thin/overlapping slices.2254 VII Imaging of the Musculoskeletal System surgical emergencies.indd 2254 9/9/2008 5:34:47 PM . However. causing avulsion of the anterolateral corner of the distal tibial epiphysis (Fig. 47-63A). To maintain alignment between the hindfoot and leg. Multiplanar CT scans are ideally suited to visualize these fractures in all planes (Fig. arrow). 4762A. Like the juvenile Tillaux fracture. 47-62C).
B. Anteroposterior radiograph showing an external fixation device. These will cause no CT streak artifacts. and as such they are barely discernible on this radiograph (gray arrows). C. This is the type of visual information the surgeon needs to plan the open reduction and internal fixation. Coronal plane CT scan. The carbon fiber connecting bars (gray arrows) cause no CT streak artifacts across the fractures. The white arrow shows the percutaneous pin passing through the calcaneus. The longitudinal carbon fiber connecting bars are barely radiopaque. A. The carbon fiber connecting bars (gray arrows) cause no CT streak artifacts across the fractures.47 Ankle and Foot 2255 47 A B C D Figure 47-62. Axial plane CT scan through the level of the fractured plafond. Sagittal plane showing the talar dome impacted into a large cortical gap in the plafond. and the proximal pin-bar clamps (black arrowheads)—are below and above the pilon fracture and thus will not be in the axial CT scanning plane through the fracture. the distal pin-bar clamps (white arrowheads).indd 2255 9/9/2008 5:34:49 PM . Ch047-A05375. The radiopaque hardware that could potentially cause streak artifacts on CT—the thick metal pin through the calcaneus (white arrows). The CT streak artifacts from the metal percutaneous pin (white arrows) and pin-bar clamps (white arrowheads) are all distal to the pilon fracture and only minimally effect visualization of the calcaneus cortex. D. Pilon fracture.
during cheerleading. A.indd 2256 9/9/2008 5:34:50 PM . Coronal CT image shows the Salter-Harris type 3 fracture with a longitudinal component through the epiphysis (arrow) and a transverse component through the unfused lateral physis (white arrowheads). she landed very forcefully on the left foot with the ankle twisted. Because CT showed that the fracture fragments were displaced more than 2 mm. A CT series was requested to assess the degree of fracture displacement. Sagittal CT image shows the Salter-Harris type 3 fracture with a longitudinal component through the epiphysis (arrow) and a transverse component through the unfused physis (arrowheads).2256 VII Imaging of the Musculoskeletal System A B C Figure 47-63. The fused medial physis is indicated by the black arrowheads. C. Axial CT image through both distal tibial physes demonstrates the avulsion fracture of the left anterolateral quadrant (sad face). A Salter-Harris type 3 fracture was seen on outside radiographs (not shown). Juvenile Tillaux fracture in a 13-year-old who reported hearing or feeling a snap when. B. Ch047-A05375. Postoperatively the patient did well after being non–weight bearing in a cast for 6 weeks and in a weight-bearing boot for 4 weeks. open reduction and internal fixation was performed electively 1 week after the injury.
running horizontally in the axial plane (plane 2). C. running horizontally in the axial plane. running obliquely vertically in the coronal plane (plane 3). Continued Ch047-A05375. When minimally displaced.indd 2257 9/9/2008 5:34:51 PM . the fracture margins can be difficult to see on radiographs.47 Ankle and Foot 2257 47 A B C Figure 47-64. Lateral non–weight-bearing radiograph. The white arrow points to the physis fracture. The arrowheads point to the metaphysis fracture. running vertically in the sagittal plane (plane 1). The black arrow points to the epiphysis fracture. Triplane fracture in a 13-year-old who twisted an ankle in a sledding accident. The arrow points to the physis fracture. Non–weight-bearing anteroposterior (A) and mortise (B) radiographs.
running obliquely vertically in the coronal plane (plane 3). CT scanning was performed after closed reduction and casting to assess the degree of fracture displacement.2258 VII Imaging of the Musculoskeletal System E D F Figure 47-64. Sagittal CT scan.indd 2258 9/9/2008 5:34:53 PM . D. After surgery. The white arrow points to the physis fracture. Axial CT scan. the patient was non–weight bearing in a cast for 4 weeks and was pain free after 1 week in a walking boot. cont’d D to F. and open reduction and internal fixation was performed the next day. E. 47-63A). The arrow points to the physis fracture. F. Coronal CT scan. The avulsion fracture of the anterolateral quadrant (sad face) resembles the juvenile Tillaux fracture (see Fig. The black arrow points to the epiphysis fracture. Ch047-A05375. These images clearly showed the surgeons that the closed reduction still had unacceptable displacement. running horizontally in the axial plane (plane 2). running horizontally in the axial plane (plane 2). The surrounding plaster cast causes no streak artifacts and helps to immobilize the patient’s ankle during scanning. running vertically in the sagittal plane (plane 1). The arrowheads point to the metaphysis fracture.
The patient was sent for CT to better visualize the fracture. A.47 Ankle and Foot 2259 47 A B Figure 47-65. The sagittal plane tells the whole story: the body of the talus (b-Ta) has been sheered off the head and posteriorly displaced behind the ankle mortise. C. Our initial casted lateral radiograph revealed a vertical fracture (arrowhead) through the body of the talus. D. In the axial plane. C. B. indicating that this was an open fracture. Midsagittal CT scan obtained 5 days after the CT scan in part C revealed a broad band of sclerosis in the talar dome and body.indd 2259 9/9/2008 5:34:54 PM . The coronal plane shows no talus between the tibia (Ti) and calcaneus (Ca). Development of avascular necrosis (AVN) of the talus after trauma in a 25-year-old who was transferred to our emergency department with the ankle already in a cast. characteristic of AVN. A. we recognize the head of the talus (h-Ta) by its articulation with the navicular (N). are scattered around the fracture fragments. the body of the talus appears more sclerotic than the surrounding bones. C A B Figure 47-66. Small collections of air. C D Ch047-A05375. No sclerosis is present in the talus. CT scan of a 69-year-old patient transferred to our emergency department after having undergone nonsurgical reduction and casting of an open ankle fracture-dislocation. the patient was immediately taken to the operating room. but the body of the talus behind the head is missing. B. Intraoperative radiograph reveals anatomic reduction of the fracture with two screws. On a lateral radiograph obtained 8 weeks later. seen as black on CT. Because of the risk of AVN with talus fractures.
Anteroposterior and mortise radiographs in which the cortical fracture of the lateral corner of the talar dome is so nondisplaced it is barely discernible (arrow). the presence of synovial fluid around a large fragment can help to differentiate between stages II and III. Acute talar dome fracture in a 23-year-old who fell from a ladder. 47-70).indd 2260 9/9/2008 5:34:57 PM .” is the same as Berndt and Harty stage IV (Fig. this is because many of these fractures are so nondisplaced that they can be difficult to see radiographically (Fig. Several staging systems have been proposed.2260 VII Imaging of the Musculoskeletal System Figure 47-67. 47-68).8 an orthopedic surgeon from the Cleveland Clinic. and it may take months for the OLT to be radiographically apparent (Fig. At the UW we have a special reformatting protocol just for such talar dome fractures (see Fig. Around the same time as Anderson but half a world away. 47-72). Mortise coronal CT images obtained the same day well demonstrate the cortical fragment (arrow) as well as the full extent of the fracture (arrowheads). In unattached fragments this signal was as bright as fluid. MRI is better at showing the integrity of the overlying articular hyaline cartilage and the underlying bone marrow. Magnetic Resonance Imaging and Staging Although CT is good at showing a displaced fragment and the size of the talar dome defect.” is the same as Berndt and Harty stage III.” In the process of tabulating their data. Anderson went on to question the utility of MRI over CT in making this determination (Fig. leaving behind a subchondral cyst. but with bone marrow edema on MRI (Fig. Madison. analyzed 24 cases of what they called “transchondral fractures of the talus. even in retrospect. Anderson called stage II “incomplete separation of the fragment.” However. “an arbitrary classification was developed to aid understanding of the mechanism of the fracture and to help in determining the appropriate treatment. Stage IIA cysts are thought to develop from stage I injuries with post-traumatic necrosis of bone and subsequent resorption of the necrotic trabeculae. Anderson and colleagues2 from Australia modified this staging system based on the MRI appearance of the fracture. and these patients were thought not to need surgery. undisplaced fragment. “In the T2 weighted image. “unattached. 47-67). 47-47A) that includes 1-mm-thin slices reformatted with no gaps in the mortise coronal and mortise sagittal planes. But sometimes. C and D. “formation of a subchondral cyst” (Fig. A B C D Radiology and Computed Tomography Although the development of a symptomatic OLT can often be traced to a specific injury. De Smet and coworkers19 from the University of Wisconsin. In part. 47-69). Stable fragments were defined as being fixed firmly with fibrous tissue or fibrocartilage. working with Harty. an anatomist from the University of Pennsylvania. Unstable fractures are those that can be shown by MRI to be partially attached or unattached. radiographs are usually read as normal early on. and surgery confirmed that these fragments were surrounded Ch047-A05375.” requiring demonstration of an intact attachment by either CT or MR (Fig. 47-73). Anderson stage III. and these fractures were thought to require more aggressive treatment with surgery or prolonged immobilization. In 1959. the initial radiographs truly are negative. Anderson noted. A and B. “displaced fragment. Edema-sensitive MRI is used to detect OLTs that are radiographically occult and also is used to stage known OLTs to assess for healing potential or need for surgery. were correlating surgical and MRI findings and dividing OLTs into stable or unstable lesions.” This staging system was based solely on the radiographic appearance of the fracture: Stage Stage Stage Stage I: A small compression fracture II: Incomplete avulsion fragment III: Complete avulsion without displacement IV: Avulsed fragment displaced within the joint Thirty years later. 47-71). De Smet showed that the key factor in distinguishing stability from instability by MRI is the presence of bright signal on T2-weighted images at the interface between the fragment and the donor site. Berndt. Anderson stage IV. Anderson added a stage IIA. Anderson called stage I “subchondral trabecular compression” and defined it as radiographically negative.
Mortise coronal reformatted CT well shows the extent of the OLT (black arrows). Osteochondral lesion (OLT) in a 9year-old with right ankle pain. C and D. 1-mm reformatted images yield edges with sharper margins. the same mortise view reveals a subtle lesion in the medial talar dome (arrows). without any specific trauma. even in retrospect. Nine months later. F. E F Ch047-A05375. A.47 Ankle and Foot 2261 47 A B C D Figure 47-68. medial malleolus. lateral malleolus. CT scans obtained 1 month after the radiograph in part B well demonstrate the medial osteochondral lesion of the talus (open and black arrows). Ta. Axial source images through both ankles demonstrate not only the symptomatic OLT in the posterior medial corner of the right talar dome (black arrows). The patient was treated conservatively and was asymptomatic bilaterally. MM.indd 2261 9/9/2008 5:34:59 PM . but an asymptomatic OLT in the posterior medial corner of the left talar dome (white arrows). talus. LM. E. The thinner. Mortise radiograph. B. is negative for a lesion in the medial talar dome. The difference between C and D is the way the images were reformatted: C was reformatted using our hindfoot protocol (3 × 3 mm in the oblique coronal plane). whereas D was reformatted using our specialized OLT protocol (1 × 1 mm in the mortise coronal plane).
C.) A B Figure 47-70. Anderson stage II osteochondral lesion of the talus—incomplete separation of fragment. MD. B.indd 2262 9/9/2008 5:35:01 PM . A. mortise coronal CT scan. mortise coronal T2-weighted fat-suppressed MRI. Mortise radiograph.) A B C D Ch047-A05375. MD. (Courtesy of Richard Kijowski. mortise coronal T1-weighted MRI. D. Mortise coronal T1-weighted (A) and T2-weighted fat-suppressed (B) images show bone marrow edema (arrows) emanating from the lateral corner of the talar dome. Anderson stage I osteochondral lesion of the talus—subchondral trabecular compression.2262 VII Imaging of the Musculoskeletal System Figure 47-69. The white arrow in B and D shows where the fragment is still attached to the donor site. The black arrow points to the fragment and the black arrowheads to the donor site. (Courtesy of Richard Kijowski. The overlying cortex and cartilage are intact.
mortise coronal T1-weighted MRI. Anderson stage III osteochondral lesion of the talus—unattached. MD. Mortise radiograph. B. B. undisplaced fragment.47 Ankle and Foot 2263 47 Figure 47-71. mortise coronal T2-weighted fat-suppressed MRI. (Courtesy of Richard Kijowski.indd 2263 9/9/2008 5:35:02 PM . All images show the unattached nondisplaced fragment (short arrows). D. A.) A B C D Ch047-A05375. D. There is edema of the underlying bone marrow (long white arrow). All images show the subcortical cyst of the medial talar dome with a thin sclerotic border (black arrows). mortise coronal T1-weighted MRI. C. The overlying cortex is intact except for a small focal irregularity (short white arrow). mortise coronal CT scan. MD. C. mortise coronal T2-weighted fat-suppressed MRI. Mortise radiograph. mortise coronal CT scan. (Courtesy of Richard Kijowski. A. Anderson stage IIA osteochondral lesion of the talus—formation of a subchondral cyst.) A B C D Figure 47-72. Arrowheads point to the donor site. Long arrow points to edema at the donor site.
” similar to the Anderson stage IIA lesions. 47-76). These seminal works by Anderson and De Smet and colleagues point out the need for close communication between radiologists and orthopedic surgeons with regard to imaging and managing patients with OLT. All images show the displaced fragment (arrowheads) as well as the talar donor site (short arrows). In the partially attached fragments. The stable lesions did not have increased T2 signal at their interface (Fig. LPT fractures are often difficult to see radiographically (Fig. often athletic trauma. whether high.2264 VII Imaging of the Musculoskeletal System Figure 47-73. in particular. Like OLT. 47-77). Snowboarding. 47-79). 47-78B) and oblique coronal planes (Fig. they are best visualized in the sagittal (Fig. A. or low on T2-weighted images. 2269 Ch047-A05375. the decision as to whether to treat the patient conservatively or surgically often comes down to determining whether the fracture is stable and has a potential for continued healing. D. De Smet also found several patients with “focal oval or spherical lesions resembling cysts. is so often cited that fractures of the LPT are also referred to as snowboarder’s ankle. normal. indicated by the brown arrow on gross Figure 47-4C and on sagittal CT Figure 47-7A. Long arrows point to marrow edema at the donor site. 47-75). MD.” It is incumbent on anyone who looks at radiographs of the ankle to scrutinize the LPT on all views because these fractures can be subtle and sometimes are seen only on frontal views (Fig.indd 2264 9/9/2008 5:35:03 PM . mortise coronal CT scan. 47-78A) and are best imaged with CT. LPT fractures are the result of trauma. although at surgery these were found to be filled with loose granulation tissue rather than fluid. although vertically oriented LPT fractures can occur (Fig. Because LPT fractures are typically transversely oriented in the axial plane. These were all at the bases of unstable lesions. and at surgery this was found to represent loose granulation tissue.48 The LPT fracture lines tend to be transversely oriented (Fig. the interface line was more irregular and not as bright as fluid.) A B C D by joint fluid. LPT fractures are often diagnosed months after injury. B. 47-78C) to appreciate the size of the fracture fragment as well as the extension of the fracture line into the subtalar joint. C. Mortise radiograph. 47-74). or unstable and at risk of dislocating. mortise coronal T2weighted fat-suppressed MRI. Text continued on p. and reports in the orthopedic literature state that “40% are missed at initial presentation. mortise coronal T1-weighted MRI. (Courtesy of Richard Kijowski. • Lateral Process of Talus The lateral process of the talus (LPT) is the pointed anterolateral corner of the posterior facet of the subtalar joint. Anderson stage IV osteochondral lesion of the talus—displaced fragment. Once the diagnosis of OLT has been established. was not useful in distinguishing stable from unstable lesions (Fig.” De Smet also noted that the signal within the fragment. De Smet speculated that “these defects were traumatic cysts that were filled by the reactive tissue forming at the unstable interface.
Anteroposterior (A) and mortise (B) radiographs demonstrate the OLT of the medial talar dome (open arrow). with diffuse ankle pain for the past year. C. The corresponding mortise coronal T2-weighted fatsuppressed image shows no bright signal around the OLT. Osteochondral lesion of the talus (OLT) in a 26-year-old with a remote history of an ankle strain. Mortise coronal T1-weighted image demonstrates the OLT of the medial talar dome (open arrow). indicating that it is stable. A B C D Ch047-A05375.indd 2265 9/9/2008 5:35:05 PM . MRI was obtained 1 week later. D.47 Ankle and Foot 2265 47 Figure 47-74.
transversely oriented LPT fracture (arrowheads).2266 VII Imaging of the Musculoskeletal System 47 Ankle and Foot 2266 47 Figure 47-75. C. Anteroposterior (A) and mortise (B) radiographs demonstrate a subtle OLT of the medial talar dome (open arrow). This artifact can be avoided by reconstructing source images with a 50% overlap. Osteochondral lesion of the talus (OLT) in a 14-year-old with ankle pain. This lack of overlap yields reformatted images with some stair-step artifacts that can be seen in the metatarsal shaft.) Ch047-A05375. B. Coronal T1-weighted image demonstrates the OLT of the medial talar dome (open arrow). indicating it is unstable. (This scan was performed using an older protocol. Lateral radiograph demonstrates the slightly displaced. D. MRI was obtained 2 months later. the patient was treated nonoperatively with casting and then with physical therapy. with source images 1 mm thick at 1-mm intervals. Lateral process of the talus (LPT) fracture in a 17-year-old gymnast who landed awkwardly after a vault. Sagittal CT confirms the LPT fracture (arrowheads) seen in A. Given the relatively small size of this fracture. The corresponding coronal T2-weighted fat-suppressed image shows a bright line of fluid (arrows) around the OLT.indd 2266 9/9/2008 5:35:07 PM . A B C D A B Figure 47-76. A.
Fracture of lateral process of the talus (LPT) in a 22-year-old who walked away from a motor vehicle collision and presented 1 day later with ankle pain. vertically oriented LPT fracture (arrowhead). both of no clinical significance. with extension into the posterior facet of the subtalar joint (arrowheads). B C Ch047-A05375. Subtle lateral process of the talus (LPT) fractures in a 28-year-old who sustained multiple injuries from a motor vehicle collision. B and C. A. The patient did well after 6 weeks of non–weight bearing.indd 2267 9/9/2008 5:35:09 PM . Lateral radiograph does not clearly demonstrate the fracture. Incidentally noted is an os trigonum (white arrow) and a bone island (black arrow). reformatted in the direct sagittal (B) and oblique coronal (C) planes. CT scans obtained the same day as A. Both planes well demonstrate the transverse LPT fracture.47 Ankle and Foot 2267 47 Figure 47-77. A Figure 47-78. Lateral radiograph demonstrates a minimally displaced. and no surgery was required.
Anteroposterior radiograph reveals the large LPT fragment (white arrow) as well as a medial fragment (open arrow). Lateral radiograph does not clearly demonstrate the LPT fracture. Fracture of lateral process of the talus (LPT) in a 45year-old who was the driver in a front-end automobile collision. too small to characterize. C. D and E. (There is also a Mitek suture anchor in the lateral malleolus. Mortise radiograph shows a tiny ossicle (white arrow) between the LPT and lateral malleolus.) F G Ch047-A05375. Image through the middle facet of the subtalar joint (M-STJ) shows the large LPT fragment (arrow). There is a small ossicle (gray arrow) just behind the subtalar joint that could be mistaken for an os trigonum but is in fact a small fragment off the posterior corner of the talus. reformatted in the oblique coronal plane. CT scans obtained the same day as the radiographs. Lateral (F) and mortise (G) radiographs were obtained after the LPT fracture was repaired with two screws. as well as the separate fragment off the medial talus (arrow). perpendicular to the subtalar joint. E. D. Surgery was performed 1 week later.indd 2268 9/9/2008 5:35:11 PM . after the soft tissue swelling had diminished. A more posterior image demonstrates the LPT fracture extending into the posterior facet (arrowhead). A. B.2268 VII Imaging of the Musculoskeletal System A B C D E Figure 47-79.
angled perpendicular to the subtalar joint. Austria. Thus. Here in Wisconsin. more serious injuries that need to be addressed. the same raw data can also be reconstructed into images centered on the spine with a smaller FOV and thinner (1 mm). Our CT hindfoot/midfoot reformatting protocol (see Fig. 47-47B) also includes straight sagittal and straight and oblique axial images to assess for extension into the calcaneocuboid joint (see Fig. overlapping source images can then be reformatted into sagittal (see Fig. Surgeons prefer to operate on the calcaneus from the lateral side. the wedge-shaped LPT is driven into the calcaneus at the angle of Gissane. that was later named for him. it is important to evaluate for related injuries.9 When calcaneal fractures are identified. Therefore. with fractures typically occurring as the result of traumatic axial loading. is the primary imaging plane in the assessment of calcaneal fractures. One additional clinical point regarding calcaneal fractures: they tend not to be surgical emergencies. such as can occur with a front-end automotive collision or falling from a height and striking the ground feet first. Lumbar compression fractures related to axial loading forces are particularly associated with calcaneal fractures. 47-80G) images are less sensitive to bone marrow edema than are fat-suppressed T2-weighted (see Fig.33 The calcaneus is the most commonly fractured tarsal bone. patients who present to the emergency department with bilateral calcaneal fractures should also be evaluated for lumbar spine fractures at the time of the initial trauma workup.indd 2269 9/9/2008 5:35:11 PM . 47-80K and 47-81C). 4780F) and proton-density–weighted (see Fig. 47-81E). 47-80J. For this reason. This fracture invariably involves the calcaneal articular surface of the posterior facet of the subtalar joint (see Figs. Although CT images of the spine are well suited to demonstrate the presence or absence of cortical fragments displaced into the vertebral canal as well as the overall alignment of the spine. 47-39). 47-81B). an occasionally seen normal variant that resides between the APC and the lateral pole of the navicular (see Fig. The same traumatic axial loading that drives the talus into the calcaneus also drives the lumbar vertebrae together. These thin. 47-80H and I) or inversion recovery images. 47-82). and although he did not describe the dislocation that now Text continued on p. Although this scan is designed to reconstruct the raw data into large FOV images that are relatively thick (5 mm) to assess for soft tissue organ injury. MRI is used to visualize epidural hematomas and other possible soft tissue causes for neural compromise. Like LPT fractures. 4780E) and other planes. He was the head of the AUVA-Hospital in Vienna. 47-80A) or by a compression deformity of the calcaneus with flattening of “Böhler’s* angle” (see Fig. • Lisfranc Dislocation Dislocations along the tarsometatarsal joint are not uncommon. 47-80L and 47-81D). The fracture then propagates inferiorly and medially (see Fig.18. APC fractures are more common in women and are the result of an inversion injury while the foot is in plantar flexion. Jacques Lisfranc was a very aggressive surgeon in Napoleon’s army. indicated by the orange box on gross Figure 47-4C and the red arrow on sagittal CT Figure 47-7A. • Anterior Process of the Calcaneus The APC is the upper outer corner of the calcaneus where it articulates with the cuboid. The os calcaneus secondarius can be thought of as a forme fruste of tarsal coalition. Calcaneal fractures can usually be recognized on the lateral radiograph by the presence of lucent fracture lines and displaced fragments (see Fig. One potential pitfall in the diagnosis of an APC fracture is the os calcaneus secondarius. 47-81C). but the Lisfranc joint is also a common site for dislocation in diabetic patients with peripheral neuropathy. we have hunters falling from their tree-mounted deer stands. These can be the result of severe acute trauma. T1-weighted (see Fig. This hospital was an international model during his time as the leading surgeon there. Even when APC fractures are only minimally displaced they have a tendency for nonunion despite prolonged immobilization (Fig. meaning that they will not directly visualize the middle facet and sustentaculum tali. overlapping slices (see Fig. the preoperative CT scan of the calcaneus does not need to be performed emergently when there may be other. 47-84). APC fractures can be easily overlooked. Surgeons typically wait for several days after the initial trauma for the soft tissue swelling to decrease before operating. Fig. Assessment of the integrity of the middle facet of the subtalar joint is an important part of preoperative surgical planning. 47-80C). and this structure should be carefully scrutinized on all lateral radiographs of the ankle and foot (Fig. CT is useful for both detecting these fractures and following their progress. such as when wearing high-heeled shoes. taculum tali and the middle facet to varying degrees (see Figs. 47-83). An example of the workup of such a patient with nondisplaced lumbar fractures is outlined in Figure 47-80. involving the susten*Lorenz Böhler (1885-1973) is most notable as the creator of modern accident surgery. 47-80D). 2277 Ch047-A05375.47 Ankle and Foot 2269 47 • Calcaneal Fractures 6. As a clinical aside. and the risk of a lumbar burst fracture with fragments retropulsed into the vertebral canal is high. the oblique coronal plane. At the UW it is typical for severely traumatized patients to receive a contrast-enhanced CT scan of the abdomen and pelvis as part of the initial trauma workup (see Fig. they require the preoperative CT scan to show them these structures. and it should not articulate with the cuboid as the APC does. fracturing and depressing the calcaneus (see Fig. As mentioned in a footnote earlier in this chapter. With traumatic axial loading. CT can be used to distinguish an acute APC fracture from the normal-variant accessory ossicle (Fig. 47-80B).
E.and proton-density–weighted images do not well demonstrate the L1 fracture. lucent fracture lines are clearly seen (arrowheads). E F G Ch047-A05375. As part of the trauma workup. Lateral radiographs of the left (A) and right (B) ankles were obtained. Böhler’s angle is flattened (compare with part N. overlapping. a CT scan of the abdomen and pelvis was performed. In the left ankle.indd 2270 9/9/2008 5:35:13 PM .2270 VII Imaging of the Musculoskeletal System A B C D Figure 47-80. landing feet first. after open reduction and internal fixation [ORIF]). it was necessary to evaluate the lumbar spine for fractures. The same raw data from the large field-of-view (FOV) scan of the abdomen and pelvis were reconstructed into thin. Because of the mechanism causing bilateral calcaneal fractures. small FOV images centered on the lumbar spine as source images (D). Bilateral calcaneal fractures in a 25-year-old who fell from a three-story parking garage. Sagittal reformatted CT image of the lumbar spine shows the thin fracture through the anterosuperior corner of L1 (arrowhead). MR sagittal T1. F and G. The arrowheads point to a fracture through the anterosuperior end plate of L1. hence the presence of oral contrast in the colon on the anteroposterior scout image (C). In the right ankle.
The small back spots with the fractured calcaneus are air. J. Continued M-STJ LPT P-STJ ST K L Ch047-A05375. Coronal oblique images through the posterior (K) and middle (L) facets of the subtalar joint were obtained.47 Ankle and Foot 2271 47 H I LPT J Figure 47-80. In this patient. indicating that this was an open fracture that was subsequently reduced. Displayed are images of the right calcaneus.indd 2271 9/9/2008 5:35:15 PM . MR sagittal and coronal fatsuppressed T2-weighted images show bone marrow edema throughout the superior halves of the L1 and L2 vertebral bodies. where the wedge-shaped LPT was driven into the calcaneus at the angle of Gissane. the fracture also extends through the sustentaculum tali (ST) into the middle facet (black arrowhead). The calcaneus is fractured just below the LPT. Sagittal image through the lateral process of the talus (LPT). These calcaneal fractures typically begin with impaction from the LPT. cont’d H and I. and there is extension into the posterior facet (white arrowhead). a CT scan was performed through both ankles simultaneously and reformatted in multiple planes for each ankle individually using our hindfoot protocol. The next day.
indd 2272 9/9/2008 5:35:17 PM . Axial image through the calcaneocuboid joint (CCJ) shows that this joint is not involved in this patient. cont’d M.2272 VII Imaging of the Musculoskeletal System Böhler’s angle N CCJ M Figure 47-80. Böhler’s angle is restored (compare with B). Ch047-A05375. After ORIF of the calcaneal fracture. N.
none of the calcaneus should be below the lateral malleolus (LM). Calcaneal fracture in a 40-year-old who fell from a 4-foot ladder. causing wide separation of the posterior facet of the subtalar joint (bidirectional arrow). Normally. Axial CT scan through the calcaneocuboid joint (CCJ) shows involvement of this joint (arrowhead). black arrow) drove into the calcaneus. There are often laterally displaced fragments (black arrow). CCJ E Ch047-A05375. D. CT scan in the sagittal plane shows where the lateral process of the talus (LPT.indd 2273 9/9/2008 5:35:19 PM .47 Ankle and Foot 2273 47 LPT NA PC A B LM M-STJ ST C D Figure 47-81. C. CT scan in the coronal oblique plane through the middle facet (arrow) shows that in this patient the sustentaculum tali (ST) is in one large piece and that the fracture does not extend into the middle facet. E. CT scan in the coronal oblique plane through the posterior facet of the subtalar joint demonstrates the typical inferomedial direction of the fracture (dashed arrow). landing on the heel. Lateral radiograph shows a calcaneal fracture. A. Incidentally seen is a nonosseous tarsal coalition (arrowheads) between the anterior process of the calcaneus (APC) and the navicular (N). B.
a repeat CT scan was requested. The patient did well after nonoperative treatment with a non– weight-bearing cast for 12 weeks. Ch047-A05375. C. Sagittal reformatted image shows the ACP fracture disrupting the superior cortex (arrow). The acute fracture margins are not corticated. non–weight-bearing foot radiograph shows a nondisplaced APC fracture (white arrowheads in magnified dashed box). including 4 months of non–weight bearing and 4 months with a bone stimulator. Anterior process of the calcaneus (APC) fracture in a 48-year-old who fell while standing on a picnic table. CT scans were also obtained on the same day as the initial radiographs. The patient was initially treated conservatively.indd 2274 9/9/2008 5:35:21 PM . Radiographs 6 months later show that the APC fracture is still unhealed. When the patient remained symptomatic 7 months later. A. The arrowheads in the magnified dashed box show the minimally displaced lucent fracture lines through the APC. Anterior process of the calcaneus (APC) fracture in a 29-year-old who tripped down some steps. The contralateral right foot serves as a useful normal comparison when both feet are included in the small scanning field of view. This lateral radiograph was obtained in the emergency department the next day. Source axial images through both hindfeet reveal the minimally displaced transverse fracture (white arrowheads in dotted magnified box) of the left APC.2274 VII Imaging of the Musculoskeletal System APC Figure 47-82. A C B D Figure 47-83. sustained a twisting injury to the foot. Oblique. B. D.
The axial source images reveal that the transverse fracture remains nonunited (arrowheads in magnified dashed box). Ch047-A05375. Oblique radiograph obtained 9 months after surgery reveals that the fracture lines are essentially healed and barely discernible (arrowheads).indd 2275 9/9/2008 5:35:22 PM . H. Because CT confirmed the clinical suspicion that the APC fracture was not healing. The sagittal image shows that the fracture margins are becoming sclerotic and corticated (arrow). cont’d E. G.47 Ankle and Foot 2275 47 E F G H Figure 47-83. Oblique radiograph obtained portably in the recovery room immediately after open reduction and internal fixation shows the lucent fracture line (arrowheads) bridged by a Whipple-type Herbert screw. surgical intervention was warranted. F. a sign of nonunion.
The axial source scan confirms that this is an acute fracture with sharp but nonsclerotic margins (arrowheads in dashed magnified box).indd 2276 9/9/2008 5:35:23 PM . margins (arrowheads in dotted magnified box) on the vertically oriented fracture. Lateral radiograph shows the small APC fracture resembling an os calcaneus secondarius (arrowheads in magnified dashed box). C.2276 VII Imaging of the Musculoskeletal System A B C Figure 47-84. CT scans were obtained the next day. Sagittal scan through the APC demonstrating sharp. complaining of pain along the lateral midfoot. B. A. Anterior process of the calcaneus (APC) fracture in a 34-year-old who presented to the urgent care clinic 1 day after a minor motor vehicle collision. noncorticated. Ch047-A05375.
relative to the tarsal bones. Normally there is perfect alignment between the first metatarsal base and first (or medial) cuneiform. Lisfranc dislocations can be difficult to discern radiographically. the base of the second metatarsal extends more proximally across the Lisfranc joint than do the other metatarsals. and (C) oblique radiographs. The Lisfranc dislocations are subdivided into two categories based on what happens to the first metatarsal relative to the other four. works well. 47-86). each 10 degrees apart. it is called homolateral (Fig. it is called divergent. When only minimally displaced. Lateral (A). 47-86H and 47-87F and G). In a Lisfranc dislocation. between the second metatarsal and the second (or middle) cuneiform. Example of a Lisfranc amputation in a 53-year-old who has had chronic peripheral neuropathy of unknown cause since 16 years of age. If the first metatarsal dislocates laterally along with the second to fifth metatarsals. a threedimensionally reformatted CT scan may prove useful in presurgical planning (see Figs. cuboid. 2282 Ch047-A05375. the bases of the fourth and fifth metatarsals should be perfectly aligned with their individual facets on the cuboid (see Fig. and close attention should be paid to the Lisfranc joint on all views of the foot. We find that a series of 36 images. 47-87). Thus. the second to fifth metatarsals are dislocated laterally. One clue that a nondisplaced Lisfranc dislocation may be present is fracture fragments off the base of the second metatarsal. Also. If the first metatarsal diverges from the other four metatarsals. A B C bears his name. 47-86A and B). The three-dimensional nature of these dislocations can best be appreciated by creating a series of three-dimensional images rotated along longitudinal and transverse axes and played as a movie loop on the PACS. 47-88). When a Lisfranc fracture is grossly displaced. As shown on the three-dimensional CT in Figure 47-5. or if the first metatarsal dislocates medially (Fig. or dorsolaterally. when dislocations occur along the Lisfranc joint. However.indd 2277 9/9/2008 5:35:24 PM . 2. Cu. remaining aligned with the medial cuneiform (Fig. and between the third metatarsal and the third (or lateral) cuneiform. a CT scan is not needed to confirm the diagnosis. an example of which is shown in Figure 47-85. he did describe an amputation along the tarsometatarsal joint. and 3 indicate the first. second. and third cuneiforms. because the exact location of dislocated metatarsals may be difficult to discern based solely on radiographs. 1.47 Ankle and Foot 2277 47 Figure 47-85. it Text continued on p. anteroposterior (B).
The base of the second metatarsal (II. The patient returned 2. He had been having episodes of passing out and falling. and because of peripheral neuropathy he had no sensation in his foot. second (2). with lateral dislocations of all five metatarsals.indd 2278 9/9/2008 5:35:26 PM . and third (3) cuneiforms and the first (I). consistent with the patient’s history of diabetes. second (II). although he did not remember these episodes well. arrowhead) is not articulating with anything. as well as between the cuboid (Cu) and the fourth (IV) and fifth (V) metatarsals. Ch047-A05375. Anteroposterior (D) and oblique (E) radiographs illustrate a homolateral Lisfranc dislocation. He did not remember injuring himself. The patient was 49 years of age at presentation and had diabetes mellitus.2278 VII Imaging of the Musculoskeletal System C A B D E Figure 47-86. Example of progression from normal to neuropathic Lisfranc dislocation. He ambulated normally without the assistance of a walker or cane. The first metatarsal (I) is not articulating with the first cuneiform (1) but is instead articulating with the second cuneiform (2). Lateral radiograph shows normal alignment between the midfoot and forefoot. He first noticed swelling and blisters on his foot the morning the following radiographs were taken. Arterial calcifications (arrow) are present. Anteroposterior (A) and oblique (B) radiographs reveals normal anatomic alignment between the first (1). C. and third (III) metatarsals.5 years later.
indd 2279 9/9/2008 5:35:28 PM . A CT scan was obtained to understand better the extent of the dislocation. Lateral radiograph shows the dorsal dislocation of the second metatarsal (arrowhead). three-dimensional (3D) reformatted images can help in understanding the relative locations of the bones. and dorsal dislocation of the second through fourth metatarsals. In cases of complex fracture-dislocations. Ch047-A05375. cont’d F. This 3D image as viewed from above shows lateral displacement of all five metatarsals. Axial oblique scan shows that none of the metatarsals are articulating with their appropriate tarsals. G.47 Ankle and Foot 2279 47 F G H Figure 47-86. H.
navicular. Divergent Lisfranc dislocation in a 34-year-old who was the front passenger in a motor vehicle accident.2280 VII Imaging of the Musculoskeletal System A B C E D Figure 47-87. The black arrowhead points to the base of the fourth metatarsal. Radiographs were obtained in the emergency department. Straight axial (long-axis) (D) and coronal oblique (long-axis) (E) images through the Lisfranc joint show that none of the metatarsals (II to V) is articulating properly with its respective tarsal bone. Ch047-A05375. D and E.indd 2280 9/9/2008 5:35:29 PM . Anteroposterior (A) and oblique (B) views of the foot reveal lateral dislocation of the second through fifth metatarsals. Cu. CT scans were obtained to aid in surgical planning. which is not articulating with anything. C. N. The white arrow points to a fragment fractured off the base of the second metatarsal. The Lisfranc dislocation is less obvious on the lateral view. A closed reduction was attempted at the bedside but was unsuccessful. cuboid. although the base of the fourth metatarsal (black arrowhead) is not articulating with anything.
G. and lateral (J) radiographs show that seven screws were required to restore the anatomic alignment of the Lisfranc joint. F G H I J Ch047-A05375. Postoperative anteroposterior (H). cont’d F and G. Three-dimensional reformatted views help in understanding the multiplanar nature of the Lisfranc dislocation.indd 2281 9/9/2008 5:35:31 PM . The view from below the foot (“Star Wars” view) shows a large fragment off the base of the second metatarsal (white arrow) and a smaller fragment off the third metatarsal (black arrow).47 Ankle and Foot 2281 47 Figure 47-87. oblique (I). Viewed from above. F. the second through fifth metatarsals can be seen to be dislocated dorsally and laterally.
The patient was taken to the operating room for open reduction and internal fixation of the femoral fracture with an intramedullary nail. Anteroposterior (A) and oblique (B) radiographs demonstrate medial dislocation of the first metatarsal and lateral dislocation of the second through fourth metatarsals. • Arthritis 45 The hallmarks of osteoarthritis—nonuniform joint space narrowing accompanied by the formation of osteophytes. Divergent Lisfranc dislocation in a 22-year-old who was driving on the highway when struck by another car going the wrong way. 47-90). The patient also sustained a fracture of the contralateral femoral shaft. 47-89). the surgeon was able to apply longitudinal traction on the first ray and achieve closed anatomic reduction of the Lisfranc joint. In some cases. In these patients. Ch047-A05375. C. In other cases. after the swelling had diminished. particularly when compared with the normal contralateral side (Fig. axial oblique CT images can help to demonstrate subtle offsets at the tarsometatarsal joints. the dislocations along the Lisfranc joint may be manifest only when a lateral stress is applied to the forefoot. Oblique port intra-operative radiograph. for elective fixation of the Lisfranc joint. The patient returned to the operating room 1 week later. the nonstressed CT scan may fail to demonstrate the degree of potential displacement (Fig.indd 2282 9/9/2008 5:35:32 PM .2282 VII Imaging of the Musculoskeletal System A B D C Figure 47-88. Once the patient was fully anesthetized. is common for a base of the second metatarsal to be sheared off or avulsed. D.
The presence of the fragments along the Lisfranc joint raised the concern that this may represent a Lisfranc dislocation. slightly more plantar and more angled than C. which was treated with a boot and non– weight bearing. Anteroposterior (A) and oblique (B) non–weight-bearing radiographs were obtained. concerned because the pain was not diminishing. and third cuneiform-metatarsal joints. through the lateral tarsometatarsal joint. C. Axial oblique scan through both medial Lisfranc joints. Close scrutiny of the Lisfranc joint on the oblique view (dashed box) reveals small fractures off the bases of the second and first metatarsals (arrowheads).47 Ankle and Foot 2283 47 LEFT LEFT A B C D Figure 47-89. Axial oblique scan. The patient bicycled home and continued to walk on this foot for 3 days before coming to the emergency department. In the normal right foot there is anatomic alignment across the first. On the normal right side the articular surfaces of the fifth metatarsal (V) and the cuboid (Cu) are aligned (white arrows). In the injured left foot there is lateral subluxation of the first (white arrow) and third (black arrow) metatarsals as well as small fragments off the second metatarsal (white arrowhead) and second cuneiform (black arrowhead). Subtle Lisfranc dislocation in a 39-year-old who fell backward down a 3-foot wall and injured the left foot. These findings confirmed that the patient had sustained a disruption of the Lisfranc joint. The Lisfranc joint appears anatomically aligned. On the left. D. second. C and D. CT scans were performed to assess the integrity of the tarsometatarsal joint. the lateral corner of the fifth metatarsal (black arrow) is laterally displaced relative to the cuboid’s impacted lateral corner (open arrowhead).indd 2283 9/9/2008 5:35:34 PM . Ch047-A05375.
indd 2284 9/9/2008 5:35:35 PM . such as the ankle and subtalar joints. A. 3 days later the patient was taken to the operating room for open reduction and internal fixation (D). The cortical erosions caused by gout form slowly and can take as long as a decade to be manifest radiographically. Because of the degree of soft tissue swelling. 47-55) as well as small cortical erosions before they become radiographically apparent. cularized synovium and thickened pannus (see Fig. But some joints. 47-91). injuring the foot. The alignment of the Lisfranc joint is relatively maintained. the boot was exchanged for a cast. MRI after the administration of intravenous contrast well demonstrates abnormally vas- Ch047-A05375. • Gout Gout is uric acid crystal deposition arthropathy with a predilection for the foot. Postcasting anteroposterior radiograph reveals that there is lateral displacement of the first (white arrow) and second (black arrow) metatarsals. Initial radiograph shows the fracture off the base of the second metatarsal (arrow). the patient was initially treated with a boot. B. These erosions are classically described as being well circumscribed with sharp overhanging edges. nondiabetic patient who mis-stepped from a high curb and landed awkwardly. When the soft tissue swelling subsided 4 days later. A B C D subcortical sclerosis. we prefer MRI to CT when crosssectional imaging is required. and in such cases CT should be well able to demonstrate all these osteoarthritic changes (Fig. Subtle Lisfranc dislocation in a 56year-old. C. particularly the first metatarsophalangeal joint. Because this demonstrated that the Lisfranc joint was not stable. can be difficult to profile radiographically.2284 VII Imaging of the Musculoskeletal System Figure 47-90. Axial CT scan obtained 5 days later showed the second metatarsal fracture to be essentially nondisplaced and the first and second tarsometatarsal joints to be in anatomic alignment. and subcortical round lucencies called geodes—are typically well seen radiographically. The diagnosis of gout is confirmed when an aspirate of • Rheumatoid Arthritis For rheumatoid arthritis.
C.indd 2285 9/9/2008 5:35:37 PM . and subcortical sclerosis (white arrowheads). corticated margins (black arrowheads) are seen in both talar domes. CT scan of osteoarthritis in a 71-yearold patient. B C Ch047-A05375.47 Ankle and Foot 2285 47 A Figure 47-91. A. Coronal scan demonstrates nonuniform narrowing medially in both mortises (black arrows). Sagittal scan demonstrates nonuniform joint space narrowing (black arrows) as well as a small anterior osteophyte (white arrow). Axial scan through the tops of both ankle joints demonstrates nonuniform narrowing of the medial ankle mortise bilaterally (black arrows). B. subcortical geodes (black arrowheads). Many small geodes with well-circumscribed.
these tend to cause relatively little CT streak artifact. A B joint fluid reveals strongly negative birefringent crystals under a polarizing microscope. • Arthrodesis When the chronic pain from severe arthritis cannot be controlled medically. When patients remain symptomatic after an attempted arthrodesis. A. A 34-year-old man came to the emergency department complaining of acute onset of nontraumatic pain of his left great toe. Initially. 47-92). There is also a marginal erosion of the medial first metatarsal head (white arrow). A thin. However. And even though the patient no longer has any motion at that joint after arthrodesis. rather than what it truly was: an eroded lateral sesamoid. if any. Anteroposterior radiograph of the left foot. that fused joint should be pain free. B. this was mistakenly thought to present a periosteal reaction from the first metatarsal. whereas on the left only a thin shell of the eroded lateral sesamoid remains (ellipse). Once solid bony fusion across the joint has been achieved. before arthrodesis the joint may have been so limited by pain and lack of articular hyaline cartilage that the patient may have had very little functional range of motion to begin with. CT scans of the feet obtained for other reasons may unexpectedly reveal the finding of gout (Fig. curved line was observed just outside the lateral diaphyseal cortex of the first metatarsal (ellipse). with the area in the dashed box magnified to the right. white. a surgical arthrodesis may be desirable. Although there may be several metal plates and screws within the scanning FOV.indd 2286 9/9/2008 5:35:38 PM . CT can be used to assess the degree of solid bony bridging. Axial CT scan through the sesamoids of the great toes bilaterally shows two normal sesamoids on the right. CT is seldom used in the workup of gout.2286 VII Imaging of the Musculoskeletal System Figure 47-92. especially when Ch047-A05375.
in searching our database for examples for this chapter. as well as pes planus (flat-foot) and peroneal muscle spasm (clonus on inversion stress). Seen best radiographically on the lateral view (Fig. 2293 Ch047-A05375. A talar beak is an indirect sign of a tarsal coalition. slightly sclerotic margins with sharp overhanging edges. Although abnormal bone coalitions have been reported throughout the body. certain locations predominate. In the hindfoot. in which there is a fibrous or cartilaginous union between the bones. cast immobilization.43 The exact cause of the peroneal spasm is uncertain.” which means “to grow together and form a union.46 An example of the latter was already seen as an incidental finding in Figure 47-81B. • Tarsal Coalitions 17. and molded orthoses. or nonosseous. and between the APC and the lateral pole of the navicular. 47-94). In the wrist. we are apt to find asymptomatic coalitions and other incidental variants. Shortaxis (coronal) CT scan confirms the erosion of the left lateral sesamoid (ellipse) as well as an erosion in the adjacent metatarsal head (arrow). Text continued on p. The subtalar joint complex consists of the subtalar joint itself and the talonavicular and calcaneocuboid joints. we found that bilaterality was the rule. Symptoms usually manifest between 12 and 16 years of age and worsen with increasing age. However. the talar beak is not part of the coalition but a result of it. Both erosions have well-defined. Axial CT scan proximal to B reveals the marginal erosion seen radiographically in the left medial first metatarsal head (white arrow) and an erosion in the right second cuneiform (black arrow). in which there is a solid cortical bridge between the bones. Conservative treatment options include anti-inflammatory medication and a trial of reduced activity. 47-95A) or on a sagittal CT (Fig. for example. such as the os calcaneus secondarius (a forme fruste of calcaneonavicular coalition). in the contralateral foot (Fig. characteristic of gout. the source images consist of thin.32 The term coalition comes from the verb “coalesce. If conservative treatment fails. D. 47-95C). Aspiration of the patient’s left great toe metatarsophalangeal joint yielded uric acid crystals. and limitation of motion of any one of these joints limits the motion of the other joints. however. Perhaps because our CT protocol entails scanning both feet. not the cause.47 Ankle and Foot 2287 47 C D Figure 47-92.indd 2287 9/9/2008 5:35:40 PM .” These abnormal unions are either osseous. The altered biomechanics across the talonavicular joint can result in a traction spur (enthesophyte) arising from the dorsal head of the talus. According to the literature. cont’d C. tarsal coalitions most commonly occur across the middle facet of the subtalar joint. tarsal coalitions are bilateral in 50% to 60% of cases. surgical options include resection of the coalition and arthrodesis if secondary osteoarthritis has developed. 47-93). overlapping slices (Fig.37 The clinical syndrome of tarsal coalition consists of pain and reduced or absent subtalar motion. carpal coalitions usually occur between the lunate and triquetrum. peroneal muscle tightness is the result of tarsal coalition. These joints function in unison during the gait cycle.4.
The patient is experiencing persistent pain. He underwent arthrodesis surgery 3 years ago. and lateral (C) radiographs reveal a plate and several screws across the ankle mortise and syndesmosis. mortise (B).indd 2288 9/9/2008 5:35:41 PM . Anteroposterior (A). Mortise coronal (D) and mortise sagittal (E) images clearly show no bony bridging throughout the ankle mortise (black arrowheads). and this was revised 1 year ago because of failure of fusion. Although the metal obscures visualization of portions of the mortise. D E Ch047-A05375. CT scans were requested to see if any fusion was present. D and E.2288 VII Imaging of the Musculoskeletal System A B C Figure 47-93. Attempted arthrodesis. no bony fusion is seen medially (black arrowheads). The patient is a 68year-old farmer who injured his ankle 6 years earlier when he misstepped getting off his tractor.
and lateral (H) radiographs no longer demonstrate residual lucency along the mortise. One operation and 16 months later. cont’d Although there are some metallic streak artifacts.indd 2289 9/9/2008 5:35:43 PM . F G H I J Ch047-A05375. Mortise coronal (I) and mortise sagittal (J) CT scans now reveal solid bony fusion between the tibia (Ti). and fibula (Fi). anteroposterior (F). the resolution is high enough to visualize the widely spaced cancellous threads of the lag screw in the talus (white arrow) and the narrowly spaced cortical threads of the syndesmotic screw (white arrowhead).47 Ankle and Foot 2289 47 Figure 47-93. talus (Ta). mortise (G).
Incidentally seen is an asymptomatic coalition on the left (white arrowhead) between the abnormally broad APC and the navicular. B C Ch047-A05375. an os calcaneus secondarius (OCS). On the right foot is the symptomatic abnormal joint (arrowhead) between the broad APC and the navicular. Axial oblique CT scan through the bottoms of the talar heads (H) shows the symptomatic coalition on the right foot (black arrowhead) between the elongated anterior process of the calcaneus (APC) and the navicular (N). Oblique radiograph shows the abnormal joint in this nonosseous coalition (arrowheads in magnified dashed box). On the left is an extra bone. Axial oblique CT scan slightly plantar to B. C.indd 2290 9/9/2008 5:35:45 PM . B. A.2290 VII Imaging of the Musculoskeletal System A Figure 47-94. articulating with both the APC and navicular. Calcaneonavicular coalition in an 11year-old with right foot pain.
H. Fluoroscopic spot views were obtained at the beginning (F) and end (G) of the resection. F and G. Sagittal CT scan of the right foot shows the nonosseous coalition (arrowhead) between the navicular and APC. Ch047-A05375.47 Ankle and Foot 2291 47 D E F G H Figure 47-94. Postoperative radiograph shows the calcaneus and navicular no longer in contact with each other (white rectangle). Surgery was elected. cont’d D.indd 2291 9/9/2008 5:35:47 PM . Sagittal CT scan of the left foot shows the OCS between the navicular and APC. The white rectangle in G outlines the resection site. The pointer in F is a metal instrument that the surgeon uses to localize the coalition fluoroscopically. E.
noncongruent articular surfaces. is aggravated by athletics. Oblique radiographs of the right (C) and left (D) feet reveal no coalition between the calcaneus and navicular (bidirectional arrows). There is also a nonosseous coalition of the left middle facet (black arrowheads). The pain is worse on the right. A. Sagittal CT scan of the right foot reveals the talar beak (arrow) as well as a portion of the solid osseous coalition across the subtalar joint (arrowhead).2292 VII Imaging of the Musculoskeletal System A C B D F E Figure 47-95. F. Lateral radiograph of the less symptomatic left ankle shows no enthesophyte arising from the dorsal head of the talus. E. Tarsal coalition in a 29-year-old radiology resident with a long history of bilateral foot pain. B.indd 2292 9/9/2008 5:35:49 PM . Lateral radiograph of the more symptomatic right ankle reveals a talar beak (arrow). Ch047-A05375. CT scan in the coronal oblique plane through the middle facets of both subtalar joints demonstrates solid osseous coalition across the right middle facet (white arrowheads). as manifest by a joint that is abnormally broad with irregular. and was improved with custom orthoses.
and nerves. images obliqued to be perpendicular to the subtalar joint are the key imaging plane (Fig. otherwise innocuous volume-occupying lesions. An elongated APC and an asymptomatic calcaneonavicular coalition may be seen as incidental findings on radiographs and CTs obtained for other reasons. In nonosseous coalitions. 47-99B. For this reason. are difficult to demonstrate with conventional radiographs because these radiographs do not well profile the middle facet. And although an elongated APC may not cause a symptomatic coalition. 47-95F). These retinacular fibers help prevent the medial tendons from becoming dislocated and can be identified on highresolution images (Fig. it may be at increased risk of fracture (Fig. Because the tarsal tunnel is a relatively tight space. • Calcaneonavicular Coalition Of the two common locations for tarsal coalitions. With osseous coalitions. 47-96B). Lateral radiographs of the right (C) and left (D) ankles reveal elongated anterior processes of the calcaneus bilaterally (arrows). 47-96A). Calcaneonavicular coalition seen radiographically in this 21-year-old who has been complaining of left ankle pain for at least 7 years. blood vessels. black arrowheads). a broad. This is a nonosseous coalition. 47-95F. 47-96). Nonosseous coalitions across the middle facet are not difficult to recognize by CT because they do not look like the flat. 47-95F. with no contact between them. The roof of the tarsal tunnel is the flexor retinaculum. the subtalar range of motion of the left foot is half that of the asymptomatic right. fibrous band extending between the medial malleolus and the medial tubercle of the calcaneus (Fig. it is abnormal any time they get close enough to each other to form a joint (see Fig. 47-97). • Talocalcaneal Coalition Talocalcaneal coalitions. the articular surfaces are not smooth or congruous and tend to have an overgrown appearance (see Fig.47 Ankle and Foot 2293 47 A B Figure 47-96. sometimes called an ant-eater sign (Fig. see Fig. solid bony ankylosis is present across the middle facet (see Fig. An additional example of nonosseous middle facet coalition is shown in Figure 47-98. On physical examination. Both are spaces confined by the underlying bones and overlying fibrous ligaments through which pass tendons. 47-96C and D). which occur across the middle facet of the subtalar joint.indd 2293 9/9/2008 5:35:50 PM . Another radiographic indication of a calcaneonavicular coalition is the presence of an elongated APC. calcaneonavicular coalitions can often be seen radiographically on the oblique view (Fig. Normally. C D Talar beaks occur less frequently with nonosseous coalition because some subtalar motion remains. let alone a solid bony bridge. B. uniform middle facet we typically see on coronal oblique CT. These bilateral “ant-eater” signs suggest that the patient has an asymptomatic calcaneonavicular coalition on the right that was not radiographically apparent on the oblique view (A). such as synovial cysts (Fig. A. Oblique radiograph of the asymptomatic right midfoot shows the normal relationship between the calcaneus (Ca) and navicular (N). white arrowheads). 47-31). coronal CT Ch047-A05375. 47-99A). the calcaneus and navicular do not touch (see Fig. Oblique radiograph of the symptomatic left foot shows the abnormal joint (arrowheads) between the calcaneus and navicular. • Tarsal Tunnel Syndrome The tarsal tunnel in the ankle is analogous to the carpal tunnel in the wrist.
CT scans were obtained the same day. Lateral radiograph obtained when the patient came into the emergency department the next day revealed the previously asymptomatic elongated APC (arrows). On the left. The patient was treated nonoperatively with a non–weight-bearing cast. B and C. Coronal CT scan reveals an abnormal vertical orientation of the right middle facet (white arrow). healing was evident radiographically. navicular). who was wearing sandals. or rarely even varicose veins. • Navicular Stress Fractures 34 Navicular stress fractures begin at the dorsal. Twenty-three weeks later. A. the injury was essentially asymptomatic. central. Five weeks after that. focal synovitis. an ultrasonic bone stimulator was used. landed awkwardly and felt a large “pop” after forcefully inverting the foot. The patient. When no healing was seen radiographically 9 weeks later.22.30 • Stress Injuries When the foot is subjected to new or excessive forces.2294 VII Imaging of the Musculoskeletal System A B C Figure 47-97. Figure 47-98. such as a change in physical activity or an increased level of workout. small nerve sheath tumors. certain bones may be subjected to a disproportionate amount of the increased stress and exhibit a stress response. The pattern of stress response depends on which bone is involved and how long it has been untreated. proximal navicular where it articulates with the head of the talus Ch047-A05375.indd 2294 9/9/2008 5:35:51 PM . can potentially impinge on the posterior tibial nerve. N. Sagittal (B) and axial (C) scans revealed the APC fracture (black arrowheads) as well as the incidental finding of a calcaneonavicular nonosseous coalition (white arrowhead. 47-100). Careful scrutiny also reveals disruption of the cortex (arrowhead). the talar-side middle facet has an abnormal rounded cortical surface (black arrow). indicating a nondisplaced APC fracture. Bilateral nonosseous coalitions of the middle facet of the subtalar joint in an 8-year-old. Anterior process of the calcaneus (APC) fracture in a 51-year-old who was playing a jumping game.
In our practice. Tarsal tunnel containing a synovial cyst (arrow): axial (A) and sagittal (B) T2-weighted fatsuppressed images. these will be radiographically occult. initial radiographs are often negative. MRI is more sensitive than CT for the detection of the bone marrow edema that develops before the cortex breaks (see Fig. 47-102 and 47-103). such fatigue injuries are commonly seen in college athletes. 47-101A). These fractures tend to be the result of repetitive injuries rather than a specific traumatic event. When MRI demonstrates just bone marrow edema without a breach in the cortex. and our sports medicine physicians prefer we use the term stress reaction. (Artist. CMI. We use stress fracture to refer to bones that exhibit a discrete line extending through the cortex by MRI. At the UW we have Ch047-A05375. Location of the tarsal tunnel. Axial high-resolution T1-weighted image shows the medial neurovascular bundle (dotted ellipse) deep to the flexor retinaculum (arrows). CT. Although navicular fatigue fractures may be suspected clinically. or plain radiography (Figs.47 Ankle and Foot 2295 47 Tarsal tunnel re r xo um Fle acul tin A B Figure 47-99. As with most stress fractures. may be too sensitive to assess fracture healing. owing to its exquisite sensitivity to marrow edema. A B (Fig. M. MS. 47-101). But MRI. deep to the flexor retinaculum. A.indd 2295 9/9/2008 5:35:53 PM .) B. Figure 47-100. Schenk. Often the athlete’s prognosis and the length of time needed to rest the fatigue injury depend on whether the cortex is broken. Illustration of the location of the tarsal tunnel (arrow). and MRI is the next imaging study ordered to confirm the diagnosis.
Fat-suppressed T2-weighted image at that same location. Fat-suppressed T2-weighted image in the same plane. D. shows abnormally bright signal throughout the navicular (arrows). Short-axis. shows abnormally bright signal throughout the navicular (arrows). oblique axial T1-weighted image shows abnormally dark bone marrow in the central third of the navicular. E. The markers (m) indicate the proximal and distal extents of the patient’s pain. Sagittal T1-weighted MRI shows abnormally dark bone marrow in the dorsal half of the navicular (arrow).2296 VII Imaging of the Musculoskeletal System A C B D Figure 47-101. Navicular stress reaction in a 36-year-old avid runner who had recently begun marathon training. A. being more sensitive for edema. B. None of these MRIs demonstrates a discrete fracture line. being more sensitive for edema. E F Ch047-A05375. being more sensitive for edema. F.indd 2296 9/9/2008 5:35:55 PM . emanating from the proximal articular surface adjacent to the head of the talus (arrow). Long-axis. C. shows abnormally bright signal throughout the navicular (arrows). and we call this a stress reaction rather than a stress fracture. Sagittal inversion recovery (IR) image. oblique coronal T1-weighted image just distal to the talonavicular joint shows abnormally dark bone marrow in the dorsal central portion of the navicular (arrow).
47-103C to F). they may be difficult to appreciate on sagittal CT images and are better seen on oblique coronal (see Fig. MRI was obtained 4 days later. navicular fatigue injuries begin at the dorsal. it is useful to have a standard protocol (as in Fig. 47-102G) images. Continued A B C developed a specific CT protocol that reformats the images in thin. the cortical disruption starts at the dorsal/central/proximal site on the navicular and propagates in a plantar direction vertically in the sagittal plane (see Fig. 1-mm slices using a small. Navicular fatigue (stress) fracture in a 16-year-old who developed midfoot pain while cross-country skiing. Whether seen by CT or MRI. When stress reactions progress to stress fractures. they are best seen on images that are reformatted into a small FOV with thin slices. A. 47-103). 47-47D) to help retain uniform reformatting parameters from one scan to the next (see Fig. 47-102) or in an oblique sagittal plane (see Fig. 47-47D). 6-cm FOV centered on the navicular (see Fig. This is illustrated by the white arrows in Figure 47-101. central. Because of the primarily sagittal orientation of these fractures. Because they tend to be nondisplaced incomplete fractures. Because these patients may undergo serial CT scans to follow the progress of fracture healing. More fluid-sensitive fat-suppressed T2weighted or inversion recovery images show bone marrow edema emanating from this dorsal/central/proximal site. Axial oblique T1.(B) and fat-suppressed T2-weighted (C) images reveal a discrete fracture in the middle third of the navicular (arrowhead) as well as diffuse bone marrow edema. Anteroposterior radiograph of the foot reveals a subtle nondisplaced fracture in the middle third of the navicular (arrowhead in magnified dashed box). This is illustrated by the black arrows pointing to the dark regions of bone marrow on the T1-weighted images in the stress reaction in Figure 47-101. Ch047-A05375.indd 2297 9/9/2008 5:35:56 PM . 47-102F) and oblique axial (see Fig.47 Ankle and Foot 2297 47 Figure 47-102. proximal navicular where it articulates with the head of the talus.
and MRI. The plantar fascia itself may be abnormally thickened. calcaneal stress fractures are seen as a black line on sagittal T1-weighted images (Fig. An MRI of plantar fasciitis reveals edema around the origin of the aponeurosis. and physical examination revealing tenderness along the medial calcaneal tuberosity. and the diagnosis is typically made based on clinical symptoms • Metatarsal Stress Fractures Metatarsal stress fractures occur at such characteristic locations that some carry eponyms. cont’d Coronal oblique T1. 47-104A). running perpendicular to the trabeculae. reformatted using a 6-cm field of view in the oblique coronal (F) and oblique axial (G) planes. Jones Fracture.2298 VII Imaging of the Musculoskeletal System D E Figure 47-102. Plantar fasciitis is the most common cause of pain in the inferior aspect of the heel. Degenerative changes from repetitive microtrauma in the origin of the plantar fascia cause traction periostitis and microtears. Patients with atypical clinical presentations or who fail conservative therapies may benefit from MRI to determine if their pain is indeed related to the plantar fascia or to some other etiology such as a tarsal stress fracture. nonsteroidal anti-inflammatory medication. The Jones fracture occurs at the proximal metadiaphysis of the fifth metatarsal and is seen radiographically as a transverse lucency (see Fig. ultrasonic therapy. 47-104B) surrounded by bone marrow edema on fat-suppressed T2-weighted (Fig. Most patients with plantar fasciitis respond to conservative treatments that include calf stretching. beginning from the dorsal cortex (arrowhead) and extending inferiorly in the sagittal plane. A CT scan obtained 2 months later. see Fig. resulting in pain and inflammation. and occasionally casting. • Plantar Fasciitis Plantar fasciitis is a stress reaction occurring at the origin of the plantar aponeurosis from the calcaneus.indd 2298 9/9/2008 5:35:57 PM . On MRI. these fractures are seen as a white sclerotic line on the lateral view (Fig. When radiographically apparent. 2304 Ch047-A05375. orthoses. they are commonly seen as the result of repetText continued on p. and extending inferiorly and slightly anteriorly. a nuclear medicine bone scan. reveals that the fracture remains nonunited (arrowhead) and the bones are diffusely osteopenic from the patient’s being non–weight bearing. 47-106. typically at the medial calcaneal tubercle. 47-104C) and inversion recovery (Fig. 47-41C). The relationship between plantar fasciitis and heel spurs has never been firmly established. but not extending completely to the plantar cortex.(D) and fat-suppressed T2-weighted (E) images show that this is an incomplete fracture. 47-104D) images. Although Jones fractures can be caused by a single traumatic injury. Figure 47-105 is a an example of a calcaneal stress fracture that was subtle on initial radiographs and was ultimately imaged using CT. F G • Calcaneal Stress Fractures Calcaneal stress fractures occur in a characteristic location. 47-53). arising from the posterior third of the calcaneal tuberosity beginning at the superior cortex a few centimeters anterior to the Achilles insertion. and there may be edema in the underlying calcaneal bone marrow (Fig.
suggesting that it is healing. obtained 3 months after D. obtained 2 months after the MRI. during which time the patient was weight bearing in a boot and using the bone stimulator. Coronal oblique T1. which are now wider and more distinct than on the first CT scan (C). Ch047-A05375. The final CT scan was obtained 9 months after E. Shown here is the same coronal oblique slice. The first CT scan. Navicular stress fracture in a 20-year-old college decathlete complaining of lateral ankle pain not localized to the navicular. The fracture (white arrowhead) is very narrow.indd 2299 9/9/2008 5:35:59 PM . obtained 1 month after C. C. from scans taken over a period longer than 1 year. consistent with continued interval healing. when the patient’s symptoms returned. during which time the patient resumed his training regimen.47 Ankle and Foot 2299 47 A B C D E F Figure 47-103. E. reveal the dark fracture line extending from the dorsal cortex (arrowhead) in a plantar-lateral direction. noncorticated margins. The fracture line (gray arrowhead) is much less distinct. The fracture (black arrowhead) has recurred along the original fracture lines. Serial CT scans using our navicular protocol were ordered to follow the progress of healing. F.(A) and fat-suppressed T2-weighted (B) images. just distal to the talonavicular joint. The third CT scan. just distal to the talonavicular joint. An MRI requested to evaluate the ankle joint found no abnormalities in or around the ankle but revealed abnormal bone marrow signal limited to the navicular. during which time the patient was non–weight bearing on this foot and using an ultrasonic bone stimulator. with indistinct. The fracture line (dark gray arrowhead) is now barely discernible. D. The second CT scan.
C. B.indd 2300 9/9/2008 5:36:00 PM . making the bone marrow edema more conspicuous. Incidentally seen is an os peroneum (arrow). Arrowheads show the calcaneal stress fracture. Sagittal inversion recovery (IR) image shown for comparison with the T2FS image (C). a common normal variant. Lateral radiograph shows a sclerotic band (black arrowheads) in the characteristic position of a calcaneal stress fracture. Midsagittal T1-weighted image shows the characteristic well-defined black line (arrowheads) of a calcaneal stress fracture.2300 VII Imaging of the Musculoskeletal System A B C D Figure 47-104. A. Ch047-A05375. perpendicular to the trabeculae (white arrowheads). On the IR image. D. the normal fatty bone marrow is very dark. The corresponding midsagittal T2-weighted fat-suppressed (T2FS) image also shows the dark fracture line (arrowheads) as well as surrounding bone marrow edema. Calcaneal stress fracture in a 62-year-old.
The normal left calcaneus is included for comparison. A. CT scans in the axial (B) and sagittal (C) planes show the sclerotic line in the right calcaneus (arrowheads).indd 2301 9/9/2008 5:36:01 PM .47 Ankle and Foot 2301 47 A B C Figure 47-105. Calcaneal stress fracture in a 14-year-old cross-country runner. Continued Ch047-A05375. Lateral radiograph shows a subtle sclerotic band (arrowheads in the magnified dashed box).
2302 VII Imaging of the Musculoskeletal System D E F G Figure 47-105. Ch047-A05375. both-feet-on-detector (D) and lateral (E) views. cont’d Bone scan images.indd 2302 9/9/2008 5:36:02 PM . Midsagittal T1-weighted (F) and T2-weighted fat-suppressed (G) images show the characteristic well-defined black line (arrowheads) of a calcaneal stress fracture. Incidentally noted is normal activity in the distal tibial physis (arrowheads) in this skeletally immature patient. as well as edema in the surrounding bone marrow. show increased activity in the right calcaneal tuberosity.
47 Ankle and Foot 2303 47 A B C D E F Figure 47-106. Plantar fasciitis in a 52-year-old with chronic bilateral heel pain. Sagittal T1-weighted image of the contralateral right foot also demonstrates a thickened plantar fascia (arrows). The calcaneal bone marrow edema is less conspicuous than on more fluid-sensitive sequences. Open arrow points to OS trigonum. B.) Incidentally seen is a normal os trigonum (open arrow in A to C) with bone marrow signal isointense to the normal bone marrow in the other bones.indd 2303 9/9/2008 5:36:03 PM . respectively. E. Ch047-A05375. Sagittal T1-weighted image reveals thickening of the plantar fascia (white arrows). F. Coronal T2weighted fat-suppressed image demonstrates a line of fluid (white arrowhead) as well as some focal bone marrow edema (black arrowhead) deep to the origin of the plantar fascia (white arrow). A. Coronal T2-weighted fat-suppressed image shows the bone marrow edema (white arrowhead) radiating from the medial-plantar surface of the calcaneus. (“med” and “lat” represent the medial and lateral sides of the image. C. at the origin of the plantar fascia. The corresponding sagittal inversion recovery (IR) image reveals edema (white arrowhead) deep to the plantar fascia (white arrow). D. The left (A to C) and right (D to F) hindfeet were scanned individually. The corresponding IR images reveal extensive bone marrow edema along the plantar portion of the calcaneus (arrowheads).
second and third metatarsals respond to stress by forming a periosteal reaction. the *In his 2006 academic dissertation for the University of Helsinki. the two sesamoids plantar to the head of the first metatarsal are present in 100% of the population. radiologists tend to have a “blind spot” when it comes to the sesamoids. although this may be imperceptible or subtle early on (Fig. which occurs in high-performance athletes. 47-107). there are some helpful statistics to keep in mind. D. Subsequent radiographs (not shown) demonstrated solid bony bridging 1 month later. a multipartite lateral sesamoid bone is an uncommon variant. The first radiographic reports of march fractures were in 1897.26:465-471. found in only 1% of normal feet. itive stress in athletes. elective internal fixation with a lag screw was performed the next day. And although a multipartite medial sesamoid bone is a common normal variant found in 13% to 30% of the population. When symptoms are referable to the lateral sesamoid and radiographs reveal it to be multipartite. MRI is useful in confirming the diagnosis when it is suspected in athletes with radiographically occult injuries (Fig. The march fracture is found most commonly in the mid. stress fractures in the second and third metatarsals occur in individuals who have previously led relatively sedentary lifestyles. Sormaala cites these two references: Schulte: Die sogenannte Fussgeschwulst. This fracture was first reported by Breithaupt in 1855. Bone Stress Injuries of the Foot and Ankle (http://ethesis.indd 2304 9/9/2008 5:36:04 PM . 47-92). However. then suddenly increase their level of activity. Early Jones fracture in a 21-year-old college athlete. Although the other sesamoid bones of the foot are present in less than 10% of people. Because of the high propensity for Jones fractures to have delayed union or nonunion. A.pdf).55:872. and a destructive process should be considered (see Fig. this should be diagnosed as a fracture (Fig. Far lateral sagittal inversion recovery (IR) image reveals bone marrow edema throughout the fifth metatarsal. Arch Klin Chir 1897. On the initial anteroposterior radiograph of the base of the fifth metatarsal there is a very subtle periosteal reaction (white arrow). part of the normal early healing response.fi/julkaisut/laa/kliin/vk/ sormaala/bonestre. Unlike the Jones fracture.”25 The Jones fracture is well recognized to have a high rate of nonunion or delayed union because of the relative hypovascularity of this portion of the fifth metatarsal. March Fracture.* Radiographically. B. when looking at the sesamoids of the first metatarsophalangeal joint. although MRI or a nuclear Ch047-A05375. or as in the case of Sir Robert Jones.2304 VII Imaging of the Musculoskeletal System B C A D Figure 47-107. • Sesamoid Stress Fractures Sesamoid stress fractures are notoriously difficult to diagnosis radiographically. Deutsche Militärärztliche Zeitschrift 1897. Stechow: Fussödem und Röntgenstrahlen. C. Edema-sensitive MRI reveals abnormally bright marrow signal in the diaphysis as well as bright periosteal reaction outside the cortex. Follow-up anteroposterior radiograph 2 weeks later reveals bone resorption (arrowheads) along the questionable lucency in A. prompting orthopedic surgeons to recommend early screw fixation.” This was of course 40 years before Röntgen’s discovery of x-rays.16 Absence of either the medial (tibial) or lateral (fibular) sesamoids is always abnormal. “whilst dancing. Perhaps because of their varying presence and appearance. There is a questionable lucency (open arrowheads) extending transversely through the lateral cortex. Sagittal IR image through the asymptomatic fourth metatarsal for comparison revealed normal dark marrow signal. 47-109). Additional diagnostic imaging should not be required.11 when he described foot pain and swelling in military recruits in the Prussian army who were forced to go on long marches—hence the name “march fracture.helsinki. 47-108).to distal diaphysis of the second metatarsal and less often in the third.
and edema of the adjacent medial soft tissues. Sagittal T1-weighted (F) and inversion recovery (G) images through the marker (m) indicating the site of maximal tenderness show edema in and around the second metatarsal. the thickened medial cortex/ periosteum. A. B C D E F G Ch047-A05375. Long-axis T1-weighted image through the second metatarsal well illustrates the anatomy. C.indd 2305 9/9/2008 5:36:06 PM . B.47 Ankle and Foot 2305 47 A Figure 47-108. but not the pathology. Short-axis T1-weighted (D) and T2-weighted fat-suppressed (E) images through the metatarsal shafts reveal edema in the second metatarsal bone marrow and in the adjacent medial soft tissues overlying the periosteal reaction. Corresponding long-axis T2-weighted fat-suppressed image reveals bone marrow edema throughout the second metatarsal diaphysis. Second metatarsal stress fracture in a 22-year-old who developed foot pain during a 1week vacation in which the patient did a lot of walking in sandals. Oblique radiograph reveals a periosteal reaction along the medial cortex (white bracket in magnified dashed box).
Although MRI can demonstrate abnormal marrow signal in the sesamoids. medicine bone scan could be obtained if confirmation is necessary.indd 2306 9/9/2008 5:36:08 PM . made worse with weight bearing and extension of the great toe. In particular. A bipartite lateral sesamoid is an uncommon variant. and when symptomatic should be interpreted as a fracture. and sesamoid (C) radiographs all clearly show the transverse split across the lateral sesamoid of the great toe. Here radiographs are of limited value. Short-axis T1-weighted (D) and inversion recovery (E) images through the marker (m) indicating the site of maximum pain show normal bone marrow signal in the medial sesamoid (white arrow) and bone marrow edema in the lateral sesamoid (black arrow). the both-feet-on-the-detector view is extremely effective for localizing abnormal radiotracer uptake to one of the sesamoids (see Fig. 47-110). present in only 1% of the population. 47-110C). for 1. Fractures of the medial sesamoid are more difficult to diagnose radiographically because this sesamoid is not infrequently multipartite in normal people.5 years before the diagnosis was made. The imaging of sesamoiditis is one of the few instances when we recommend a nuclear medicine bone scan over an MRI. oblique (B). and more sensitive imaging modalities are often required. and all imaging planes should be carefully scrutinized. Short-axis images are particularly helpful in comparing the marrow signal from the medial and lateral sesamoids side-by-side (Fig.2306 VII Imaging of the Musculoskeletal System A D B C E Figure 47-109. owing to the small size of these bones this may be present on only a single slice. Fracture of the lateral sesamoid in a 34-year-old who complained of localized pain plantar and lateral to the first metatarsal head. Ch047-A05375. Anteroposterior (A).
Infection Osteomyelitis is always a diagnostic dilemma. Although it is true that radiographs are insensitive to the bone marrow and soft tissue edema seen on MRI. radiographs may reveal findings that. C. not to mention the presence of orthopedic hardware. Short-axis T1-weighted (A) and T2-weighted fat-suppressed (B) images show normal bone marrow signal in the lateral sesamoid (white arrow) and bone marrow edema in the medial sesamoid (black arrow). radiographs are crucial to screen for the presence of metal. First. Third. rather than MRI. preferably within the last week. for the workup of osteomyelitis. For this reason. are diagnostic for osteomyelitis. 47-112) in a bone deep to a nonhealing ulcer or unresponsive cellulitis are as diagnostic as MRI for active osteomyelitis. we require that the pre-MRI radiographs be recent. Gas in the soft tissues. This patient failed to respond to conservative therapy and ultimately had the medial sesamoid resected. Periosteal reactions. dislocation. • Magnetic Resonance Imaging Ultimately. such as from a gas-forming organism. an MRI for osteomyelitis should not be read in isolation. can be diagnostic. The bone marrow and soft tissue edema seen with MRI in patients with sterile neuropathic osseous changes may be indistinguishable from infection.” Thus. It is difficult to arrive at the correct diagnosis without a thorough clinical workup and complete understanding of any prior surgical resections or debridements. debris.” and this is perhaps symbolic of the dilemma. the bone marrow edema caused by infection looks just like the bone marrow edema caused by a stress response as well as the edema caused by a nonhealing fracture or even a healing fracture. And because neuropathic collapse can occur relatively quickly and go unnoticed by a patient with an insensate foot (Fig.” myelos meaning “marrow. New cortical erosions (Fig. localizes the increased uptake to the medial sesamoid of the left foot. Second. and disorganization. Bone scan. MRI is extremely sensitive for the detection of marrow inflammation. 47-111). particularly in the feet of diabetic patients who may be insensate and thus unknowingly stepped on pins. osteomyelitis literally means “inflammation of bone marrow. Fracture of the medial sesamoid in a 27-year-old with a several-month history of pain localized to the head of the first metatarsal. particularly the aggressive periosteal reaction of acute osteomyelitis or the thick involucrum of chronic osteomyelitis (Fig.indd 2307 9/9/2008 5:36:09 PM .” and itis meaning “inflammation. the Charcot joint. 47-113). increased density. it is easier to rule out osteomyelitis by MRI than it is to confirm its presence. bothfeet-on-detector view. and for this reason at the UW we recommend that patients who exhibit radiographic findings of a Charcot joint undergo a nuclear medicine bone scan and white blood cell scan. in the proper clinical setting. they are not without value. and at the UW we insist on having recent radiographs before we will perform an MRI for infection. • Imaging Techniques • Radiography Radiographs are essential in the workup of osteomyelitis. The term osteomyelitis comes from the Greek roots osteon meaning “bone. The absence of increased bone marrow signal on a good edema-sensitive MRI effectively Ch047-A05375. By MRI. in diabetic feet it is necessary to screen for the joint-centered collapse that is typically seen with peripheral neuropathy. but it is not specific for the inflammation caused by infection.47 Ankle and Foot 2307 47 A C B Figure 47-110. These radiographic findings have been described as “the six Ds”: destruction. distension. is easily detected on radiographs yet may be hard to interpret on MRI because it can cause susceptibility artifacts similar to those caused by metal.
could have a similar appearance but would not be expected to exhibit such rapid changes.indd 2308 9/9/2008 5:36:12 PM . Incidentally seen is a metallic foreign body (white arrowhead). A B Ch047-A05375. Same oblique view just 2 months later reveals a new erosion in the medial cortex of the fourth middle phalanx (white arrow). Rapid onset of severe Charcot neuropathic collapse in a diabetic patient. A B C D Figure 47-112. Marginal erosions from noninfectious inflammatory arthropathies such as rheumatoid arthritis.Figure 47-111. Oblique radiograph of the toes reveals subtle erosions in the lateral cortex of the fourth middle phalanx (arrow) and the lateral head of the fourth proximal phalanx (black arrowhead). not an uncommon finding in patients who are insensate because of peripheral neuropathy. Radiographic evidence of active osteomyelitis in a 39-year-old. B. Anteroposterior (A) and oblique (B) radiographs show anatomic alignment along the Lisfranc joint. or crystalline arthropathies such as gout. Anteroposterior (C) and oblique (D) radiographs only 3 months later reveal complete destruction of the Lisfranc joint. A. The rapid onset of this erosion is highly suggestive of osteomyelitis.
47 Ankle and Foot
Figure 47-113. Evolution of involucrum in chronic osteomyelitis in a patient with diabetes. A, Anteroposterior radiograph reveals a somewhat lamellated periosteal reaction around the diaphysis of the fifth metatarsal. B, Six weeks later, the periosteal reaction is thicker and more mature. C, Eleven weeks later, the periosteal reaction has developed the thick, irregular appearance of an involucrum. The underlying metatarsal has become a dead and sclerotic sequestrum.
Figure 47-114. Early neuropathic changes in a 66year-old with a long history of diabetes. Oblique axial T1-weighted (A) and T2-weighted fat-suppressed (B) images show marrow edema throughout the midfoot bones.
rules out the diagnosis of osteomyelitis. However, the converse is not true. Although the presence of bone marrow edema may be due to infection, the edema may represent a sterile stress response owing to the altered biomechanics of the patient walking on a neuropathic foot that has not yet collapsed. Indeed, marrow edema diffusely involving several of the tarsal bones can indicate neuropathic precollapse (Fig. 47-114), and such patients need to be treated with a prolonged period of non–weight bearing. The diagnosis of osteomyelitis can be presumed when MRI shows not only marrow edema but also abscess in the adjacent soft tissues (Fig. 47-115) or a sinus tract communicating from the infected bone to the skin.1 IVGd-based contrast is extremely helpful in diagnosing the abscess, which exhibits thick, irregular enhancement peripherally but not centrally (see Fig. 47-115H and K).
• Brodie’s Abscess
Brodie’s* abscess is a chronic intraosseous abscess resulting from incomplete resolution of acute osteomyelitis and isolation of the infection by surrounding bone. These abscess pockets are typically found in the metaphyses of skeletally immature children, and the usual pathogen is Staphylococcus aureus. However, the organisms tend to be of low virulence,
*Sir Benjamin Collins Brodie (1783-1862) was an English physiologist and surgeon who pioneered research into bone and joint disease. His most important work is widely acknowledged to be the 1818 treatise Pathological and Surgical Observations on the Diseases of the Joints, in which he attempts to trace the beginnings of disease in the different tissues that form a joint and to give an exact value to the symptom of pain as evidence of organic disease. This volume led to the adoption by surgeons of more conservative measures in the treatment of diseases of the joints, with consequent reduction in the number of amputations and the saving of many limbs and lives.
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2310 VII Imaging of the Musculoskeletal System
Figure 47-115. Developing calcaneal osteomyelitis in a 63-year-old diabetic patient. A, Lateral radiograph of the calcaneus shows intact cortex along the plantar surface (white arrowheads). Incidentally seen is mural calcification of the posterior tibial artery (gray arrowheads). Such arterial calcifications are common in diabetic patients. B, Midsagittal T1-weighted image shows no bone destruction. C, Corresponding sagittal inversion recovery (IR) image shows little, if any, bone marrow edema. D, Corresponding sagittal post– intravenous (IV) gadolinium contrast T1-weighted fatsuppressed image reveals diffuse enhancement of the plantar soft tissues, indicative of cellulitis, but no nonenhancing abscess pockets. When the patient’s symptoms did not respond to antibiotics, repeat imaging was obtained 2 weeks later. E, Lateral radiograph now demonstrates loss of cortex along the plantar surface of the calcaneus (arrowheads). F, Midsagittal T1-weighted image reveals infiltration of the fatty heel pad (arrows). G, Corresponding sagittal inversion recovery image reveals fluid bright signal (arrows) in the soft tissues adjacent to the calcaneus, as well as bone marrow edema in calcaneus (arrowheads). H, Corresponding sagittal post-IV gadolinium contrast T1-weighted fat-suppressed image reveals a nonenhancing abscess pocket (arrows) as well as enhancing bone marrow (arrowheads). Coronal T1-weighted (I), inversion recovery (J), and post-IV gadolinium contrast T1weighted fat-suppressed (K) images through the abscess pocket confirm the findings seen in the sagittal plane: an abscess pocket (gray, white, and black arrows) adjacent to the osteomyelitis (white arrowhead) of the planter surface of the calcaneus.
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Figure 47-116. Brodie’s abscess in a young child. A, Anteroposterior radiograph of the asymptomatic right leg. B, Anteroposterior radiograph of the swollen left leg reveals a lucency in the distal fibula metaphysis (arrow in the magnified dashed box). This lucency has a well-defined and sclerotic margin, indicating chronicity. There are also thick, chronic periosteal reactions (arrowheads) extending up the diaphysis. C, Coronal T1-weighted image through the distal fibula confirms the radiographic findings of a thick chronic periosteal reaction (white arrowheads), as well as the well-circumscribed dark line (open arrowheads) around the lesion corresponding to the sclerotic margin. D, The corresponding coronal T2-weighted fat-suppressed image shows that the well-circumscribed lesion (arrow) is as bright as fluid and thus probably cystic. E, The corresponding coronal T1-weighted fat-suppressed post–intravenous (IV) gadolinium contrast image not only confirms that the lesion (arrow) is mostly nonenhancing and thus mostly cystic, but demonstrates peripheral enhancement, in some places thick (black arrowhead), characteristic of an abscess, in this case an intraosseous or Brodie’s abscess. (There is inadequate fat suppression of the heel pad [large white arrowhead] on both of the fat-suppressed sequences, D and E.) F to H, Axial images through the fibular abscess reveal it to be isointense to muscle on T1-weighted image (F, arrow) and fluid bright on T2-weighted fat-suppressed image (G, arrow), with peripheral but not central enhancement on fat-suppressed T1-weighted image after IV gadolinium (H, arrow). There are edema and enhancement of the soft tissues surrounding the fibula, indicating an active inflammatory component to this chronic Brodie’s abscess.
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47-117). usually close to the calcaneus. and MRI is useful in determining the tissue type as well as demonstrating the relationship of the mass to the adjacent anatomic structures. relieved by aspirin. The classic history is pain at night. however. proton-density–weighted (B). Because most tumors have nonspecific signal characteristics. these tumors should be initially evaluated radiographically. Radiographs show an intramedullary lucency with surrounding sclerosis. 47-119A). although they can exhibit postcontrast enhancement (see Fig. Like all bone lesions. and T2-weighted (C) images reveal that the lesion (arrows) is relatively dark on all sequences and confined to the fat of the plantar heel pad. although in the foot. The presence of hemosiderin can be detected on gradient echo and precontrast fat-suppressed T1-weighted images (Fig. and the vascularized proliferative synovium should exhibit some contrast enhancement (Fig. An osteoid osteoma is a relatively common cause of bone pain in adolescents and young adults. the density of which depends on the chronicity of the abscess. Thin-slice CT well demonstrates the lucent nidus as well as the tiny sclerotic component that is characteristically associated with it (Fig. secondary to hemosiderin deposition (Fig. CT is also used by radiologists for the purpose of percutaneously ablating the nidus. Plantar fibroma in a 44-year-old. osteoid osteomas are seen as a nonspecific edema pattern emanating from a tiny. Synovial cysts or ganglia are among the most common soft tissue “masses” found around the foot and ankle. On MRI. Both diseases show areas of decreased signal on T1-images. the latter being Osseous tumors are much less common than soft tissue tumors of the foot and ankle. MRI after the administration of IV contrast reveals an intraosseous abscess with peripheral but not central enhancement (Fig. protondensity–images. Morton’s neuromas usually occur between the heads of the second and third or third and fourth metatarsals and are also usually dark on noncontrast images.indd 2312 9/9/2008 5:36:21 PM .20 Benign bone neoplasms are more common than malignant ones. 47-57). Plantar fibromas can have variable signal characteristics but are typically dark on all sequences (Fig. 47-119B to D). • Benign Tumors The most common benign tumors of the foot are enchondromas and osteoid osteomas. Primary bone tumors of the feet are rare. 47-116B). 47-118D). generally presenting with persistent local pain. These are usually found in the plantar fat adjacent to the aponeurosis. accounting for only 4% of all bone tumors. 47-118E). nerve sheath tumors such are schwannomas are heterogeneously bright on T2weighted and inversion recovery images. In comparison.2312 VII Imaging of the Musculoskeletal System A B C Figure 47-117. accounting for approximately 10% of all benign bone tumors. A thick chronic periosteal reaction may also be present (Fig. 47-56). 47-118A to C). and they demonstrate heterogeneous contrast enhancement (see Fig. and it is not uncommon for cultures of such aspirates to yield no growth. MRI. Osteoid osteomas are one of the few tumors that are better imaged by CT than MRI. dark nidus (see Fig. 47-116E). MRI is often unable to render a specific preoperative diagnosis.29 a joint-centered synovial proliferative condition. Clinical symptoms are often mild. is useful in localizing tumors and staging their extent. Coronal T1-weighted (A). Giant cell tumor of the tendon sheath is a localized form of pigmented villonodular synovitis. and T2-weighted images. These are uniformly bright on fluidsensitive images and exhibit minimal if any peripheral enhancement after the administration of IVGd-based contrast (see Fig. 47-58). • Bone Tumors 28 Tumors • Soft Tissue Masses Soft tissue tumors of the feet and ankle are common. Ch047-A05375. most bone neoplasms are primary tumors because metastases to the foot are rare.
indd 2313 9/9/2008 5:36:23 PM . High-grade chondrosarcomas have a calcified matrix that appears radiographically sclerotic (see Fig. consistent with the presence of blood products of varying ages. non–aggressive-appearing interface with the normal bone (see Fig. B. the intraosseous lipoma is uniformly isointense to fat on all sequences. 47-121C and D). The tendons themselves—posterior tibial (T). By MRI. 47-121A). 47-122). 47-120B to D).47 Ankle and Foot 2313 47 A B C D E Figure 47-118. except for a signal void corresponding to the sclerotic focus (Fig. which has a propensity for the calcaneus (Fig. Giant cell tumor of the tendon sheath in a 19-year-old with a palpable medial mass. C. and one of the few tumors that arise from the epiphysis in a skeletally immature patient. Intraosseous lipomas of the calcaneus are rare but have a characteristic radiographic appearance in that they are well circumscribed and nearly totally lucent except for a tiny central sclerotic focus (Fig. Straight axial T1-weighted image through the mass (arrow) demonstrates that it lies within the soft tissues medial to the navicular (N). D. • Malignant Tumors The most common primary malignant tumor of the foot is chondrosarcoma. indicative of the vascularity of this synovial proliferation. A. Corresponding axial post–intravenous gadolinium fat-suppressed T1-weighted image demonstrates heterogeneous enhancement. Radiographically. By MRI. 47-120A). chondroblastomas can have either a lucent or chondroid matrix. The corresponding axial proton-density–weighted image shows that the mass has grown through a split tendon sheath (arrowheads). talus (Ta). Chondroblastomas can expand the cortex but should not cross the unfused growth plate (Fig.and T2-weighted sequences. flexor digitorum longus (D). 47-122A) and dark on T1. The corresponding axial T2-weighted image shows that the mass (arrow) has heterogeneous signal intensity. consistent with methemoglobin. and sustentaculum tali (ST) but does not invade the bones. Chondroblastomas are rare benign cartilaginous neoplasms. Corresponding axial precontrast fat-suppressed T1-weighted image reveals that some signal in the mass is brighter than the surrounding suppressed fat. these lesions may exhibit considerable edema in the surrounding soft tissues. Chondrosarcomas are not highly vascularized tumors and Ch047-A05375. and flexor hallucis longus (H)—are intact and normal in appearance with no evidence of tumor involvement. but the tumor itself should have a sharp. E.
Midsagittal T1weighted image shows that the mass is purely epiphyseal. Chondroblastoma in a 16-year-old. Axial CT scan through the level of the syndesmosis. Corresponding T2-weighted fat-suppressed image. B. a common finding with chondroblastomas. Axial T1-weighted image through same level as A. D. Corresponding sagittal cartilage-sensitive sequence (fat-suppressed three-dimensional gradient echo) reveals signal intensity in this cartilaginous tumor that is nearly as bright as the nearby normal articular hyaline cartilage. A. A. The low-intensity nidus (white circle) is unmasked by the bright signal of the surrounding marrow edema. B. deforming but not crossing the distal physis in this patient who is not yet skeletally mature. A B C D Ch047-A05375. Sagittal inversion recovery (IR) image reveals bone marrow edema around the small nidus (white circle). Lateral radiograph demonstrates an expansile mass arising from the back of the tibia. The nidus is the small lucent lesion (black circle). The low-intensity nidus (white circle) is masked by the surrounding marrow edema. Figure 47-120.indd 2314 9/9/2008 5:36:24 PM . D. C.2314 VII Imaging of the Musculoskeletal System A B C T1 T2fs D IR Figure 47-119. C. There is also edema in the adjacent soft tissues (arrows). Corresponding sagittal T2-weighted image shows heterogeneous bright signal in the mass. Osteoid osteoma in a 19-year-old with symptoms clinically thought to be due to a tibial stress fracture.
Sagittal post–gadolinium contrast fat-suppressed T1-weighted image demonstrates enhancement only at the periphery of the osseous and soft tissue masses. This enhancement pattern is due to the relative hypovascularity of chondrosarcomas. Sagittal fat-suppressed T2-weighted image reveals marrow edema only at the periphery of the sclerotic region. Lateral radiograph of the contralateral left calcaneus is shown for comparison.indd 2315 9/9/2008 5:36:27 PM . The central sclerotic focus (black arrowhead) is dark on all imaging sequences. Midsagittal T1-weighted image shows the signal intensity of the lipoma (open arrowheads) to be isointense to that of the surrounding fatty bone marrow. D. A. Lateral radiograph of the right calcaneus shows the lucent lesion in the anterior half with a well-circumscribed border (open arrowheads). however. C D Ch047-A05375. Chondrosarcoma arising from the calcaneal tuberosity 30-year-old. extensive bright signal in the soft tissues immediately plantar to the calcaneus. Lateral radiograph. there is a small sclerotic focus (black arrowhead). C D A B Figure 47-122. indicating that the tumor is extending out of the bone and into the soft tissues.47 Ankle and Foot 2315 47 A B Figure 47-121. C. D. This patient complained of heel pain for 10 months until the sclerosis in her calcaneus was recognized. Intraosseous lipoma discovered as an incidental finding in a 43-year-old. B. characteristic of an intraosseous lipoma. B. On the corresponding T2-weighted fat-suppressed image. the fat in the lipoma suppresses to a degree similar to that of the surrounding fatty bone marrow so that it is nearly inconspicuous. C. Centrally. There is. intraosseous or otherwise. Sagittal T1-weighted image shows diffusely decreased signal in the calcaneus corresponding to the radiographic sclerosis. should be isointense to fat on all imaging sequences. A. A lipoma.
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