Eur Radiol (2003) 13:L164L177 DOI 10.

1007/s00330-003-2011-8

M U S C U L O S K E L E TA L

J. M. Mellado A. Ramos E. Salvad A. Camins M. Dans A. Saur

Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis

Received: 21 October 2002 Revised: 12 May 2003 Accepted: 2 July 2003 Published online: 6 August 2003 Springer-Verlag 2003 J. M. Mellado () A. Ramos E. Salvad A. Camins A. Saur Institut de Diagnstic per la Imatge, Hospital Universitari de Tarragona Joan XXIII, Carrer Doctor Mallafr Guasch 4, 43007 Tarragona, Spain e-mail: rmidi@hjxxiii.scs.es Tel.: +34-97-7250690 Fax: +34-97-7250691 M. Dans Department of Nuclear Medicine, Hospital Universitari de Tarragona Joan XXIII, Carrer Doctor Mallafr Guasch 4, 43007 Tarragona, Spain

Abstract Accessory ossicles and sesamoid bones are frequent findings in routine radiographs of the ankle and foot. They are commonly considered fortuitous and unrelated to the patients complaint; however, they may eventually cause painful syndromes or degenerative changes in response to overuse and trauma. They may also suffer or simulate fractures. Our aim was to review, illustrate and discuss the imaging findings of some of the more frequent accessory ossicles and sesamoid bones of the ankle and foot region, with particular emphasis on those that may be of clinical significance or simulate fractures.

Keywords Ankle Foot Accessory ossicles Sesamoid bones Normal variant Computed tomography Magnetic resonance

Introduction
Many skeletal variations of the ankle and foot may be found, including different accessory ossicles and sesamoid bones, bipartitions and coalitions [1]. They may be bilateral, or coexist in a single extremity, and they are prone to considerable variation; most are developmental abnormalities and are generally considered incidental radiographic findings [2]. Accessory ossicles commonly derive from unfused accessory ossification centers. They may appear to be normal subdivisions of ordinary bones or nearby additional free elements [1]. The most common accessory ossicles of the ankle and foot are the os trigonum, the accessory navicular and the os intermetatarseum. There are also other less frequent accessory bones, e.g. the os sustentaculi, the os supranaviculare, the os vesalianum, the os calcaneus secundarius, the os subtibiale and the os subfibulare [1, 2, 3].

Sesamoid bones are partially or totally embedded in the substance of a corresponding tendon. Anatomically they are part of a gliding mechanism that reduces friction and protects the tendon [1]. Various sesamoid bones may be found in the ankle and foot, e.g. the os peroneus, within the peroneus longus tendon, and the hallux sesamoids, within the slips of the flexor hallucis brevis tendon at the level of the first metatarsal head [1, 2, 3]. Most accessory ossicles and sesamoid bones of the ankle and foot remain asymptomatic; however, they have increasingly been examined in the radiology literature, because they can cause painful syndromes or degenerative changes in response to overuse and trauma. They may also suffer or simulate fractures and restrict the range of motion [4, 5, 6]. They have traditionally been evaluated by means of conventional radiography or scintigraphy [2, 3, 4]. More recently, CT and MR imaging have added to the understanding of their clinical rel-

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Table 1 Accessory ossicles and sesamoid bones of the ankle and foot region Accessory/sesamoid bone Os trigonum Prevalence (%) 125 [1, 3, 4] Clinical significance Synchondrotic degeneration or tear [4, 5, 6, 7, 8, 9]. Posterior ankle impingement syndrome [4, 5, 6, 7, 8, 9]. Flexor hallucis longus tendon entrapment [10] Synchondrotic degeneration or tear [4, 5, 6, 13, 14, 15]. Posterior tibial tendon dysfunction or tear [4, 5, 6, 13, 14, 15, 16] Synchondrotic degeneration [19]. Painful syndrome [18, 19] Painful syndrome [4, 6, 17, 21]. Hallux valgus [4, 21] Painful syndrome [22] Painful syndrome [17, 23] None [2] None [26] Painful syndrome [4, 11, 26, 27]a Painful os peroneum syndrome [6, 28]. Fracture, diastasis [6, 28] Fracture, stress fracture, diastasis [6, 30]. Chondromalacia, osteonecrosis, infection [6, 30] Differential diagnosis Shepherds fracture [7, 9, 11]. Cedells fracture [12]. Pseudoarthrosis [7, 9] Type-I accessory navicular [1]. Navicular tuberosity avulsion fracture [11] Isolated fracture of the sustentaculum tali [11] Lisfranc fracture dislocation [11] Cortical avulsion fracture of the navicular or talar head [11] Avulsion fracture at the base of the fifth metatarsal [1, 11] Avulsion fracture of the anterosuperior calcaneal process [11, 23, 24] Medial malleollus avulsion fracture [11, 26] Lateral malleolus avulsion fracture [11, 26, 27] Painful os vesalianum. Bipartite os peroneum [6, 28] Bipartite tibial sesamoid [1, 2, 6, 30]. Soft tissue derangements of the forefoot [6, 30]

Type-II accessory navicular Os sustentaculi Os intermetatarseum Os supranaviculare Os vesalianum Os calcaneus secundarius Os subtibiale Os subfibulare Os peroneum Hallux sesamoid bones

212 [1, 6] 0.30.4 [1, 3] 1.210 [1, 3] 1 [3] 0.1 [3] 0.67 [1, 3] 0.9 [3] 2.1 [3] 9 [3] Close to 100 [1]

a True os subfibulare has no clinical significance; however, old non-united avulsion fractures of the lateral malleolus may present with a painful syndrome, causing the so-called painful os subfibulare

evance and helped to distinguish them from fractures [5, 6]. Our purpose is to review, illustrate and discuss the imaging findings of some of the most frequent accessory ossicles and sesamoid bones of the ankle and foot region, with particular emphasis on those that may be of clinical significance or simulate fractures (Table 1).

Os trigonum
The os trigonum is one of the largest and most common accessory ossicles in the ankle and foot region, with an estimated prevalence of 125% [1, 3, 4]. It is connected to the lateral tubercle of the posterior process of the talus by a fibrocartilaginous synchondrosis. Although initially interpreted as an old non-united fracture, it is currently viewed as a developmental skeletal variation, most likely deriving from the failure of a secondary ossification center to fuse [1, 2, 3, 4, 5, 6, 7, 8, 9]. The os trigonum commonly presents as an incidental radiographic finding (Fig. 1a) [2, 3]. The CT scans and MR imaging may detect associated bone and soft tissue

abnormalities and thus complement each other in evaluating its potential clinical significance [5, 6]. Single or repetitive forced plantar flexion of the foot may precipitate degeneration (Fig. 1b) or tear (Fig. 1c) of the synchondrosis. A large os trigonum may associate with flexor hallucis longus tenosynovitis (Fig. 1d, e) or entrapment. Repetitive impingement of the os trigonum against the adjacent soft tissues may generate pain and swelling in the posterior aspect of the ankle, leading to os trigonum syndrome, one of the subtypes of posterior ankle impingement syndrome. On such clinical setting, the combination of bone marrow oedema, flexor hallucis longus tenosynovitis, joint effusion and increased technetium-99m uptake supports the diagnosis of os trigonum syndrome (Fig. 1fh) [4, 5, 6, 7, 8, 9, 10]. The os trigonum may be radiographically confused with fractures of the lateral or medial tubercles of the posterior process of the talus, the so-called Shepherds or Cedells fractures [11, 12]. These fractures are the result of acute impingement between the posterior lip of the tibia and the calcaneus on extreme flexion of the ankle. The patient usually complains of pain in the posterior aspect of the ankle and tenderness posterior to the lateral mall-

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Fig. 1ah Os trigonum in five different patients. a A 50-year-old woman examined for Mortons neuroma. Lateral ankle radiograph shows incidental os trigonum (arrow). b A 45-year-old man suffering from chronic tenderness and pain on his left ankle joint. The CT section shows a large os trigonum (arrow). Subchondral cysts adjacent to the synchondrosis (arrowheads) are seen, reflecting chondro-osseous degenerative changes. c A 21-year-old man presenting with right flat-foot deformity and avascular necrosis on the tarsal navicular. Sagittal short tau inversion recovery (STIR) image shows a fluid-filled interface (large arrowhead) between the os trigonum (arrow) and the talus, reflecting disruption of the fibrocartilaginous synchondrosis. Collapse of the necrotic tarsal navicular (small arrowheads) is also noted. d, e A 66-year-old man suffering chronic inflammatory arthritis in his left ankle joint. d Sagittal T2-weighted MR image shows a large os trigonum (arrow). Significant distention of the flexor hallucis longus tendon

sheath is also noted (arrowheads). e Axial T2-weighted MR image in the same patient shows a fluid-filled flexor hallucis longus tendon sheath (arrowheads) and an extremely thin tendon (arrow), consistent with chronic FHL tenosynovitis. The real involvement of the os trigonum in the clinical syndrome and its relationship with the MR findings remained unproved, but a loose association could not finally be excluded. fh A 20-year-old man presenting with tenderness in the posterior aspect of his right ankle. f Sagittal T1-weighted image and g sagittal STIR image show an os trigonum (arrow). Mild bone marrow oedema is found on both sides of the synchondrosis. A small adjacent effusion (arrowheads) is also noted. h Lateral view of a 99mTc-MDP bone scan in the same patient reveals increased activity in the posterior aspect of the ankle (arrow). Increased uptake is also seen in the anterior aspect of the ankle joint (arrowhead). The clinical and radiological background described above is consistent with os trigonum syndrome

eollus. Radiographically, the fragment is rarely displaced, and it may be difficult to distinguish it from true os trigonum. The CT scans and MR imaging may help to identify true fractures by detecting oblique irregular interfaces that separate incompletely corticated, eventually comminuted

fragments (Fig. 2) [7, 11]. Incomplete healing may lead to painful pseudoarthrosis [9]. If pain persists and there are no signs of healing, the fragment should be removed. The fusion of the above-mentioned secondary ossification center gives rise to the lateral tubercle of the pos-

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Fig. 2a, b A 28-year-old man presenting with recent hyperflexion injury in his left ankle and foot. He mentioned diffuse ankle pain. a Sagittal T1-weighted and b STIR images show an oblique, slightly irregular and partially intraarticular fracture line (arrowheads) involving the lateral tubercle of the posterior process of the talus (arrow). A pattern of conspicuous oedema is noted on the adjacent bone marrow, reflecting the subacute nature of the process

terior talar process, also named trigonal or Stieda process. A particularly prominent Stieda process may also cause posterior ankle impingement syndrome when forceful or repetitive plantar flexion of the foot occurs [9].

Accessory navicular
The accessory navicular, also known as os tibiale, os tibiale externum and naviculare secundarium, is adjacent to the posteromedial tuberosity of the navicular bone in 421% of individuals [1, 2, 6]. Three types of accessory navicular bones have been described. The type-II accessory navicular is a persistent accessory ossification center. It is bridged by a fibrocartilaginous synchondrosis to the navicular bone, and serves as the point of attachment for the posterior tibial tendon. It is one of the most common accessory bones in the ankle and foot, with an estimated prevalence of 212% [1, 2, 3,

4, 5, 6]. Type-II accessory navicular bones are a common, fortuitous radiographic finding (Fig. 3a, b) [2, 3]; however, their occasional clinical relevance has been emphasized in the radiology literature [4, 5, 6, 13, 14, 15, 16, 17]. When such a bone is present, the distal portion of the posterior tibial tendon may straighten, thus causing adduction forces. These altered biomechanics may lead to flat-foot deformity [5, 16, 17]. They may also cause tendon impingement on dorsiflexion of the ankle, which may be followed by tendon attrition or tear (Fig. 3c, d) [4, 5, 16, 17]. Repetitive shearing stress forces acting on a type-II accessory navicular may disrupt its synchondrosis, which may be followed by flat-foot deformity [14]. Despite the well-documented association of type-II accessory navicular bones with posterior tibial tendon dysfunction and flat-foot deformity, most patients remain asymptomatic; however, the prevalence of type-II accessory navicular bones in patients with posterior tibial tendon dysfunction is significantly higher than in the general population [16]. Occasionally, a type-II accessory navicular may become painful, and cause the so-called symptomatic accessory navicular. This clinicoradiological entity is believed to be caused by osteonecrosis of the accessory navicular. It presents more commonly in middle-aged women and causes pain and tenderness in the medial aspect of the foot. The MR imaging may be particularly useful in such clinical settings because it can demonstrate a pattern of bone marrow oedema on the accessory navicular (Fig. 3e) [4, 5, 6, 15, 17]. Type-II accessory navicular bones should be distinguished from type-I sesamoid bones within the distal segment of the posterior tibial tendon (Fig. 3f, g) [1]. Although it has been suggested that they are involved in the pathogenesis of flat-foot deformity, this has not been sufficiently proved [17]. In addition, type-II accessory navicular bones should be differentiated from avulsion fractures of the navicular tuberosity [11]. Fractures of the navicular tuberosity are the result of acute eversion of the foot and increased tension of the posterior tibial tendon. They are best seen on anteroposterior and oblique lateral radiographs, and commonly present with local tenderness associated with pain on passive eversion or active inversion. Avulsion fractures of the navicular tuberosity may associate with impaction fractures of the cuboid bone, which has been termed the nutcracker fracture. For radiographic distinction, it should be remembered that the type-II accessory navicular is usually larger and well-corticated, commonly presents bilaterally, and the line of separation from the adjacent bone is generally smoother than in a true avulsion fracture [11]. Occasionally, detachment of a type-II accessory navicular may clinically and radiographycally simulate an avulsion fracture [14]. The accessory navicular may incorporate to the navicular tuberosity, thus forming the so-called type-III acces-

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Fig. 3ag Accessory navicular bones in five different patients. a, b A 43-year-old-woman presenting with acquired flat-foot deformity. a Dorsoplantar and b lateral radiographs show a type-II accessory navicular (arrow) bridged to the posteromedial aspect of the navicular by a fibrocartilaginous synchondrosis, represented by a narrow radiolucent interface (arrowheads). c, d A 62-yearold woman presenting with painful acquired flat-foot deformity and type-II accessory navicular. The MR images show a c type-II accessory navicular (arrow) and a d interstitial tear of the posterior tibial tendon (arrow). A bony spur sharpening the medial aspect of the tendon groove (arrowhead) is also seen. e A 51-year-old woman presenting with pain and tenderness in the medial aspect of her left foot. Axial STIR image reveals a type-II accessory navicular (arrow). Obvious oedematous changes are noted on bone marrow and adjacent soft tissues, consistent with symptomatic accessory navicular. f Dorsoplantar radiograph and g axial T1weighted MR image reveal incidental type-I accessory navicular bones (arrows) in two different patients presenting with a history of ankle sprain. On the g MR image the sesamoid bone is seen within the distal portion of the posterior tibial tendon (small arrowheads). The distal portion of the spring ligament (large arrowhead) is also seen Fig. 4 Cornuate navicular in a 25-year-old man referred for medial malleollus fracture. Axial T1-weighted MR image shows a prominent navicular tuberosity (arrow), consistent with type-III accessory navicular, also known as cornuate navicular

Fig. 5ad Painful os sustentaculi in a 49-year-old man (from [19]). a Lateral radiograph shows an os sustentaculi (arrow) located posterior to the sustentaculum tali (asterisk). A faint radiolucent interface is seen in-between (arrowhead), reflecting the existence of a fibrocartilaginous synchondrosis. b Oblique coronal CT scan shows an os sustentaculi (arrow) united to the sustentaculum tali (star) and articulating with an elongated medial tubercle of the talus (asterisk). A narrow and irregular interface in-between the three bones is seen, along with subchondral cyst formation and hypertrophic margins. c Axial T2-weighted MR image shows mild bone marrow oedema on the os sustentaculi (arrow). d Sagittal STIR image shows subchondral bone marrow oedema adjacent to the synchondrosis between the os sustentaculi and the sustentaculum tali (arrows). The articulation between the os sustentaculi and the talar body (arrowhead) is also seen

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sory navicular, also known as the cornuate navicular (Fig. 4). The cornuate navicular may occasionally associate with painful conditions, adventitial bursa formation or flat-foot deformity [5, 6, 16].

Os sustentaculi
The os sustentaculi is a small accessory ossicle connected to the posterior aspect of the sustentaculum tali by a fibrocartilaginous synchondrosis. It is a very rare skeletal variant of the ankle and foot region, with an estimated prevalence of 0.30.4%. The os sustentaculi is generally considered an uncommon fortuitous radiographic finding (Fig. 5a) [1, 2, 3, 18]. The os sustentaculi may also become painful when chronic shearing stress forces lead to early degenerative changes across its synchondrosis. In such cases, CT scans accurately show signs of chondro-osseous degeneration, including cortical hypertrophy and irregularity, subchondral cyst formation and vacuum phenomenon (Fig. 5b). Complementary MR imaging may improve understanding of its clinical relevance because it reveals subchondral bone marrow oedema adjacent to the synchondrosis (Fig. 5c, d) [19]. Similar findings have been described in painful os trigonum or symptomatic accessory navicular. The os sustentaculi should not be confused with rare isolated fractures of the sustentaculum tali, which occur when the foot is supinated at the moment of impact. Their radiographic detection may be challenging, and additional oblique projections or tunnel views may be needed. Fractures of the sustentaculum tali cause pain and tenderness along the inner border of the foot. In clinical practice, fractures of the sustentaculum tali are more commonly seen in severely comminuted intraarticular calcaneal fractures. The absence of complete cortication, the slightly irregular interface of the fracture, and the history of trauma should allow ambiguous cases to be correctly diagnosed [11]. The diagnosis of isolated fractures of the sustentaculum tali should not be overlooked, as some of them may require screw fixation. The os sustentaculi may fuse to the calcaneus, thus originating the so-called assimilated os sustentaculi, which may also associate with early degenerative changes and painful conditions [20].

Fig. 6 Os intermetatarseum in a 59-year-old woman presenting with hallux valgus deformity and forefoot pain. Dorsoplantar radiograph shows a small os intermetatarseum (arrowhead). Associated hallux valgus deformity is also noted (thick arrow). The real involvement of the os intermetatarseum in the painful syndrome remained undetermined. Incidental bipartite tibial hallux sesamoid bone is seen (thin arrow)

Os intermetatarseum
The os intermetatarseum is found between the medial cuneiform and the base of the first and second metatarsals. It is one of the most common accessory ossicles of the foot, with an estimated prevalence of 1.210%. The os intermetatarseum may be round or spindle shaped. It may be found as an independent ossicle, articulating by a synovial

joint, or fused with any of the adjacent bones to form an exostosis-like process. Nevertheless, its aetiology and real prevalence remain controversial [1, 2, 3, 4, 6, 21]. The os intermetatarseum is a common incidental radiographic finding. Occasionally, it may suffer fractures or be involved in painful conditions [4, 6, 17, 21]. The symptomatic os intermetatarseum causes pain and tenderness when the dorsum of the midfoot is palpated at the level of the first intermetatarsal space, because superficial and deep peroneal nerves are compressed [6]. In these cases, radiotracer uptake may increase [6]. It has been suggested that the os intermetatarseum may associate with hallux valgus deformity (Fig. 6) [4, 21]. The os intermetatarseum should not be confused with small fractures involving the base of the second metatarsal bone, which may occur in Lisfranc fracture dislocations. Traumatic injuries of the Lisfranc joint complex are found after violent forced plantar flexion and rotation, most commonly during motor vehicle accidents. Lisfranc fracture dislocations are often associated with soft tissue injuries, and may be generally identified on conventional radiographs when malalignment, fracture or soft tissue swelling are seen [11].

Os supranaviculare
The os supranaviculare, also known as the os talonaviculare dorsale, talonavicular ossicle or Piries

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Fig. 7ac Os supranaviculare in two different patients. a A 27year-old man with chronic posterior tibial tendon tenosynovitis (not shown). The lateral radiograph shows an incidental supranavicular bone (arrow) located in the dorsal aspect of the talonavicular joint. b Sagittal T1-weighted MR image in the same patient demonstrates the round and well-corticated appearance of the accessory ossicle (arrow), unrelated to the patients disease. c Lateral ankle radiograph in a 50-year-old man suffering subtalar arthritis (not shown) reveals a small pointed os supranaviculare (arrow) fused to the navicular. A small adjacent radiolucency in the dorsal aspect of the navicular bone (arrowhead) simulates an avulsion site

plied to the foot leading to injuries of the talonavicular capsule. This type of avulsion fractures most commonly occur in middle-aged women. The injury commonly associates with the wearing of high-heeled shoes. Avulsion fractures of the dorsal margin of the talar head may associate. In order to distinguish avulsion fractures of the dorsum of the navicular and true os supranaviculare, the clinical background should be borne in mind. From the radiological standpoint, the avulsion fracture of the dorsum of the navicular is commonly represented by a thin flake of bone. Associated soft tissue swelling and lack of complete cortication support the diagnosis of avulsion injury. Nevertheless, radiographic distinction alone may be extremely challenging.

Os vesalianum
The os vesalianum is a small accessory ossicle adjacent to the tip of a well-developed tuberosity of the fifth metatarsal. It is a very rare accessory bone, with an estimated prevalence of 0.1% [3]. The original description of the os vesalianum referred to a small bone near the little toe and probably articulating with the cuboid. Although commonly incidental, it has very occasionally been reported its association with painful syndromes of the forefoot [17, 23]. The os vesalianum should be differentiated from the normal ossification centre of the tuberosity of the fifth metatarsal, which is parallel to the metatarsal shaft [1]. It should also be distinguished from avulsion fractures of the apophysis of the fifth metatarsal, which usually lie in a transverse plane [11]. Avulsion fractures of the base of the fifth metatarsal bone involve the insertion site of the peroneus brevis tendon. They are usually associated with inversion injuries and sprains and may be easily overlooked [11].

bone, is found on the dorsal aspect of the talonavicular joint, close to the midpoint. It has an estimated prevalence of 1% and is a rare incidental skeletal variant [1, 2, 3]. The os supranaviculare is easily detected on lateral ankle radiographs (Fig. 7a) or sagittal MR images (Fig. 7b). Eventually, the os supranaviculare may fuse with the rest of the tarsal navicular to form a bony spur of no clinical significance (Fig. 7c). The os supranaviculare may rarely become symptomatic [22], thus requiring radiographic survey and specific clinical assessment. In such cases, surgical resection may be required. The os supranaviculare should not be confused with cortical avulsion fractures of the tarsal navicular [11]. These fractures occur as the result of a twisting force ap-

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Fig. 8a, b Os calcaneus secundarius in a 40-year-old woman with a painful right forefoot. a Oblique radiograph incompletely reveals an os calcaneus secundarius (arrows). A slightly irregular radiolucent cleft (arrowhead) is seen between the accessory bone and the adjacent anterosuperior calcaneal process. b Axial T2-weighted MR image demonstrates the round and well-corticated appearance of the os calcaneus secundarius (arrows). The incidental accessory bone was considered unrelated to the patients complaint

Os calcaneus secundarius
The os calcaneus secundarius is located in the interval between the anteromedial aspect of the calcaneus, the cuboid, the talar head and the tarsal navicular. It may be round, although it is more often triangular. It is a rare accessory ossicle of the foot, with an estimated prevalence of 0.67% [1, 2, 3]. The os calcaneus secundarius has no clinical significance and may be incidentally found on routine radiographs (Fig. 8a) or MR studies (Fig. 8b). It has been suggested that most os calcaneus secundarius derive from recent or remote fractures of the anterosuperior calcaneal process [24]. These fractures are avulsion injuries of the bifurcate ligament secondary to inversion and forced plantar flexion. More rarely, they may be caused by eversion injury on a dorsiflexed foot. Fractures of the anterosuperior calcaneal process are considered to be rare but can be easily overlooked on conventional radiographs. Special projections, including medial and lateral oblique views, have been found useful in this regard. Early diagnosis and conservative treatment are said to be crucial if unnecessary surgery is to be avoided. Anterosuperior process fractures may clinically mimic injuries of the lateral collateral ligament, fractures of the lateral process of the talus, or fractures of the fifth metatarsal. The point of maximum tenderness in anterosuperior calcaneal process fractures is 1 cm inferior and 3 cm anterior to the talofibular ligament [24, 25]. When clinical and radiographic manifestations are unclear, MR imaging may be used (Fig. 9ac). On MR imaging, the presence of bone marrow oedema adjacent to the fracture line (Fig. 9b, c) has been found most useful for confirming clinical and radiographic suspicion of traumatic lesion [24]. As a general rule, an ovoid, small, and well-corticated appearance favours the diagnosis of accessory ossicle (Fig. 8b). Conversely, larger shapes with a wider proximal base and an altered signal on the adjacent bone marrow as seen on MR images suggest fracture (Fig. 9b, c) [24, 25]. The absence of bone mar-

row oedema in MR images suggests the existence of a healed fracture (Fig. 9d, e).

Os subtibiale
Accessory centres of ossification of the medial malleollus may appear between 7 and 10 years of age, although occasionally they may persist into adulthood, forming the so-called os subtibiale. The true os subtibiale is present in only 0.9% of adults. It may be multiple and usually remains asymptomatic [1, 2, 3, 26]. The os subtibiale should be distinguished from a persistent secondary ossification centre, which usually appears as the normal subdivision of a completely developed and normally shaped medial malleollus. More importantly, the os subtibiale should be distinguished from avulsion fractures of the medial malleollus (Fig. 10), which are not uncommon in the clinical setting of ankle trauma and derive from pronation and external rotation. When these forces are strong enough, avulsion fracture of the medial malleollus may be followed by anterior tibiofibular ligament tear and fibular fracture. Because the os subtibiale may be found during the radiographic evaluation of ankle trauma, it may be erroneously interpreted as a fracture. It has been suggested that the smooth corticated margins on both sides of the radiolucent cleft make it possible to diagnose os subtibiale correctly; however, an acutely symptomatic patient with an accessory ossification centre in the medial malleollus should be considered and treated as having a fracture. An os subtibiale may also cause chronic symptoms. The most likely source of symptoms is chondro-osseous disruption, which results in a fracture that may heal with a

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Fig. 9ae Healing fracture and chronic healed fracture of the anterosuperior calcaneal process in two different patients. ac A 54year-old man with history of inversion and plantar flexion injury. a Sagittal T2-weighted and b STIR image reveal a slightly irregular interface (arrowhead) traversing the base of the anterosuperior calcaneal process (short arrow). A pattern of bone marrow oedema (long arrow) is seen on the STIR image, supporting the diagnosis of healing fracture. c Axial T1-weighted MR image in the same patient better reveals the broad-based triangular configuration of the fractured fragment (short arrow) outlined by a hypointense line consistent with progressing union (arrowheads), with mild hypointensity on adjacent bone marrow (long arrow) which reflects bone marrow oedema. de A 28-year-old professional soccer player presenting with non-specific ankle pain. d The lateral radiograph reveals a faint radiolucency (arrowhead) at the base of an otherwise normal-shaped anterosuperior calcaneal process (arrow). e The corresponding sagittal T1-weighted MR image reveals a broad band of hypointensity (arrowheads) traversing the base of the anterosuperior calcaneal process (arrow). The findings were thought to represent completed healed fracture, unrelated to patients complaint

agnosis of traumatic injury when uptake is increased [26].

Os subfibulare
The os subfibulare is an accessory bone located under the tip of the lateral malleollus (Fig. 11). The ossicle may be round or comma shaped. Radiographic studies have found an os subfibulare in 2.1% of individuals. The os subfibulare represents the persistence of an accessory ossification centre, which should not be confused with the more common persistent secondary centre [1, 2, 3, 27]. Given the relative rarity of the os subfibulare, it has been suggested that most ossicles adjacent to the lateral malleollus are old non-united avulsion fractures (Fig. 12). Avulsion fractures of the lateral malleollus are commonly caused by inversion forces in the clinical setting of ankle sprains. Avulsion fractures of the lateral malleollus course with swelling, tenderness, painful weight bearing, painful range of motion and ankle effu-

fibrous union or may form a pseudoarthrosis. In both acute and chronic conditions, mechanical irritation is believed to be the source of local pain and tenderness. In these cases, a technetium bone scan may support the di-

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Fig. 10a, b Avulsion fracture of the medial malleollus in two different patients, to be differentiated from os subtibiale. a A 29year-old man presenting with vague heel pain after eversion injury. Anteroposterior radiograph reveals a small ossicle (arrow) adjacent to the medial malleollus. The irregular contour of the radiolucent interface in-between (arrowhead) and the clinical setting supports the diagnosis of avulsion fracture of the medial malleollus. b A 59-year-old man with history of repetitive ankle

sprains. Coronal proton-density-weighted MR image reveals mild amputation of the medial malleollus (black arrowhead). A small irregular ossicle is found in its vicinity (thick arrow), consistent with chronic displaced avulsion fracture. The deep fascicle of the deltoid ligament (white arrowhead) appears mildly heterogeneous. Chronic avulsion fracture of the lateral malleollus (thin arrow) is also present

Fig. 11 Os subfibulare in a 34-year-old man who was referred so that osteochondritis dissecans of the talar dome could be ruled out. Anteroposterior radiograph reveals a small, round and well-marginated ossicle (arrow), adjacent to the lateral malleollus, consistent with os subfibulare

Fig. 12 Avulsion fracture of the lateral malleollus in a 20-year-old man with a history of ankle sprain and instability. Sagittal T1weighted MR image reveals an anteriorly displaced avulsed bony fragment (white arrow) at the tip of the lateral malleollus. Cortical irregularity is noted at the avulsion site (black arrow). An adjacent soft tissue lesion is also noted (arrowheads), consistent with reparative granulation tissue

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sion. Ankle instability may also be present. In fact, avulsion fractures of the lateral malleollus may be associated with laxity of the anterior talofibular ligament, giving rise to the so-called symptomatic os subfibulare. Individuals with avulsion fracture of the lateral malleollus are generally older than patients with interstitial tear of the anterior talofibular ligament. The avulsed bony fragment may have well-defined cortical margins, thus making distinction from os subfibulare difficult [4, 27, 28]. From the clinical and radiographical standpoint, the use of talar-tilt stress projections may reveal ankle instability, which does not generally associate with true os subfibulare, and therefore contribute to correct management [28].

Os peroneum
The os peroneum is a round or oval-shaped sesamoid bone imbedded within the peroneus longus tendon. It is located near the calcaneocuboid joint, and may be bipartite or multipartite. The os peroneum is probably always present in a cartilaginous, fibrocartilaginous or ossified stage, although its reported radiographic prevalence is only 9%. The os peroneum is best evaluated in the oblique-lateral view of the foot [1, 2, 3, 6, 28]. The os peroneum is a common and generally fortuitous radiographic finding (Fig. 13); however, its potential ability for precipitating painful conditions has been well documented. The so-called painful os peroneum syndrome causes lateral pain, tenderness and swelling along the course of the peroneus longus tendon, and lateral pain with resisted plantar flexion of the foot [6, 28]. Pain may radiate proximally along the peroneus longus muscle. The clinical syndrome may be acute or chronic, and is caused by os peroneum fracture, hypertrophic healing of a fractured os peroneum, diastasis of a bipartite os peroneum, attrition or tear of the peroneus longus tendon proximal or distal to the sesamoid bone, or enlarged peroneal tubercle [6, 28]. Acute onset is less common and usually requires emergency care, due to either frank rupture of the peroneus longus tendon or fracture of an os peroneum, including diastasis of multipartite os peroneum. Chronic presentation may mimic a sprained ankle, and complaints may be intermittent and non-specific. The chronic syndrome is associated with attrition of the peroneus longus tendon, diastasis of a multipartite os peroneum or healing of an os peroneum fracture [28]. Tears in the peroneus longus tendon at the midfoot are said to represent a diagnostic dilemma for the clinician [29]. It has been suggested that the os peroneum may be a useful radiographic marker of peroneus longus tendon tears. When such tears occur, the radiographic study may show the displacement or migration of the os peroneum [17, 28]; however, care should be taken not to overemphasize the radiographic importance and clinical signifiFig. 13 Incidental os peroneum in a 32-year-old patient with a history of repetitive ankle sprains. The oblique radiograph reveals a small os peroneum (arrow) adjacent to the calcaneocuboid joint

cance of the os peroneum, which in most cases is incidental. In fact, none of the patients in a 9-patient series of peroneus longus tendon tears diagnosed with MR imaging were found to have an os peroneum [29]. Finally, the os peroneum should be distinguished from os vesalianum and avulsion fractures of the fifth metatarsal, which usually lie slightly more distal.

Hallux sesamoid bones

The medial and lateral hallux sesamoids are embedded within the medial and lateral slips of the flexor hallucis brevis tendon at the level of the first metatarsal head. The purpose of the hallux sesamoid bones is to provide mechanical advantage during hallux flexion, by reducing friction and reinforcing adjacent soft tissues [1, 6, 30]. The size and shape of the hallux sesamoids vary considerably. The tibial sesamoid tends to present a bipartite morphology (Figs. 6, 14a) and is more common than its lateral counterpart [6]: it can be found in as much as 33.5% of the population [30]. The pathological conditions of the hallux sesamoid complex include traumatic, degenerative, inflammatory, infectious, and ischaemic processes. Most painful conditions involving the hallux sesamoid bones are, however, related to acute trauma or chronic stress. From the radiological standpoint, distinguishing between bipartite sesamoid and true fracture of a tibial hallux sesamoid can be particularly challenging, and several suggestions have been made as to how to do so efficiently (Fig. 14a). The single medial sesamoid with a fracture is slightly larger than the lateral sesamoid, whereas the bipartite sesamoid is much larger. In addition, a fracture tends to show a sharp, radiolucent, uncorticated line,

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Fig. 14ad Painful hallux sesamoid bones in four different patients. a Dorsoplantar radiograph in a 47-year-old woman presenting with long-standing sesamoiditis in her right foot. A bipartite medial sesamoid is present (arrowhead). Mild cystic changes are found adjacent to the synchondrosis between the small (long arrow) and large (short arrow) components, consistent with synchondrotic degeneration. b A 62-year-oldwoman referred for evaluation of calcaneal spur and Mortons neuroma. Coronal T1-weighted MR image of her left foot shows osteoarthritic changes in the lateral aspect of the hallux sesamoid complex, including joint space narrowing and altered signal intensity of the subchondral bone marrow, consistent with chondromalacia (arrowheads). Ill-defined thickening of the flexor tendons of the second toe is also noted (arrow), consistent with tendinopathy. c A 48-yearold woman presenting with a clinical diagnosis of sesamoiditis on her left foot. Coronal T1weighted MR image reveals heterogeneous replacement of normal bone marrow on the tibial hallux sesamoid (arrowheads), consistent with bone marrow oedema. d A 50-year-old man presenting with clinically suspected sesamoiditis in his right foot. The plantar projection of 99mTc-HDP bone scan reveals abnormally increased uptake on the right hallux sesamoids (arrowheads), consistent with sesamoiditis. Abnormal increased uptake is also present on the base of the proximal phalanx of the left hallux (arrow), most likely reflecting hallux valgus deformity

whereas the bipartite sesamoid has two corticated fragments. The two fragments in a fractured sesamoid often fit together well, whereas the two components of a bipartite sesamoid do not. Comparison with the opposite foot and serial radiographic survey have also been proposed as ways of improving lesion characterization. In some cases, technetium bone scans and MR imaging may be used for improving diagnostic accuracy. A 99mTc-MDP bone scan should be normal in a bipartite hallux but will show increased uptake in a fractured bipartite. The MR imaging may also show bone marrow oedema in a recently fractured sesamoid [6, 30].

Chronic stress may also cause painful conditions in the hallux sesamoids, and is most commonly associated with chondromalacia, osteochondritis, osteonecrosis and stress fracture. All these entities are part of the same pathologic spectrum, share a common aetiological factor and present clinically with a painful syndrome which has been termed sesamoiditis. The MR imaging (Fig. 14b, c) has been advocated as a useful procedure for assessing such lesions. The MR imaging has been described as being particularly valuable for detecting abnormalities in bone marrow signal and associated soft tissue derangements in this particular region [30]. In some cases, a

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99mTc-MDP bone scan (Fig. 14d) may help to identify the hallux sesamoid bones as the source of painful conditions of the forefoot.

Conclusion
We review the imaging findings, potential clinical significance and differential diagnosis of some of the most common accessory ossicles and sesamoid bones of the ankle and foot. The MR imaging is particularly useful for assessing their associated painful conditions, but ra-

diographs, CT scans and scintigraphy can also make a valuable contribution. We also discuss the potential of these accessory ossicles and sesamoid bones for simulating fractures. Once again, we emphasize that most accessory ossicles and sesamoid bones of the ankle and foot merely represent fortuitous imaging findings; thus, clinical correlation and cautious interpretation of imaging studies are instrumental in the management of these patients.
Acknowledgements Acknowledgements. We express our gratitude to J. Bates and the Language Service of the Rovira i Virgili University for their assistance in preparing the manuscript.

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