Radiographs Ankle

Diagnostic Tests Radiographs of left ankle show no evidence of fracture... 

A 50-year-old woman is seen in the emergency department complaining of a severe headache, shortness of breath, and ankle edema. Her vision is blurry and her blood pressure is 200/140 mm Hg. A blood test reveals azotemia and proteinuria. A chest radiograph reveals an enlarged cardiac silhouette. Is this a hypertensive emergency, and if so what pharmacological treatment might be considered ... 

Figure 71.9 Radiographs of the left ankle of a normal 14-year-old Tibetan boy (Panel a) and the left ankle of a 14-year-old Tibetan boy with Kashin-Beok disease (Panel b). The tarsal bones have an irregular, collapsed aspect. The distal epiphysis of the tibia is cone-shaped and the length of tibia is abnormally shorter than the fibula. Reproduced with permission from Moreno-Reyes ef a/., (1998). Massachusetts Medical Society.

Initial management should include a trial of anti-inflammatory medication, ankle bracing, and physical therapy. Many diagnostic tests are available. Sobel et al. popularized the peroneal tunnel compression test for longitudinal peroneus brevis tendon tears. This maneuver combines dorsiflexion and eversion of the foot and ankle with manual pressure on the peroneal tendons to elicit a painful response." Plain radiographs may demonstrate bony avulsions of the superior retinaculum or fractures. 

Fig. 5.9a,b. AP and lateral radiographs of the ankle show possible slight distortion of the medial malleolus with widening of the medial aspect of the distal tibia physis. Coronal STIR confirms the presence of a fracture involving the physis. There is extensive marrow oedema with a clearly visible low signal fracture line... 

Plewes DB (1994) The AAPM/RSNA physics tutorial for residents. Contrast mechanisms in spin-echo MR imaging. Radiographics 14 1389-1404 quiz 1405-1406 Pudas T, Hurme T et al. (2005) Magnetic resonance imaging in pediatric elbow fractures. Acta Radiol 46 636-644 Rand T, Ahn JM et al. (1999) Ligaments and tendons of the ankle. Evaluation with low-field (0.2 T) MR imaging. Acta Radiol 40 303-308... 

Fig. 8.1. AP radiograph of the tibia. Transverse fracture through the distal metaphysis. Acceptable angulation but note AP knee and lateral view of ankle. Malrotation of 45°...

Isolated fihula fractures are rare in children and usually result from direct blows. In adolescents however, one must be careful not to miss the Mai-soneuve fracture. This is a primary ankle injury where the tibio-fibular diastasis has been torn and the injury propagated proximally to exit often in the upper or middle third of the fibula. Radiographs of the ankle will demonstrate talar shift or fracture of the medial maleollus. Imaging of the entire fibula is required to identify the associated proximal fracture. 

Fractures of the head and neck of the fibula occur rarely in isolation and are more commonly associated with proximal tibial fractures, especially compression, bicondylar and subcondylar fractures. A spiral fracture of the proximal fibula is often associated with an ankle fracture, resulting from an external rotation force. These fractures are known as Maisonneuve fractures. Fibula head fractures can occur from direct impact, valgus stress (associated with a tibial condylar fracture), and varus injuries. Varus stresses can cause avulsion of the fibular styloid at the site of the biceps tendon and fibular (lateral) collateral ligament. Peroneal nerve injury is not uncommon with these injuries. Dislocation of the proximal fibula is often missed on the initial radiograph. 

Most ankle fractures can be adequately assessed using the standard ankle trauma series of anteroposterior, lateral and mortise views. Confusion in interpretation of radiographs can be caused by accessory centres of ossification and normal anatomical variants. In children aged 6-12 years medial (os subtibiale) and lateral (os subfibulare) accessory ossification centres are present in 20% and 1%, respectively (Powell 1961). 

For paediatric ankle injuries with normal radiographs, high resolution ultrasound has been shown to be useful in diagnosing occult fractures (SiMANOVSKY et al. 2005) and ligamentous injuries (Farley et al. 2001). The majority of these occult fractures are Salter-Harris I or II fractures of the distal fibular physis. If left undiagnosed and untreated the majority of such injuries would have a satisfactory outcome. 

Green E, Swiantkowski MF (eds) (1998) Skeletal trauma in children, 2 edn. WB Saunders,Philadelphia Hoerr NL, Pyle SI, Francis CC (1962) Radiographic atlas of the skeletal development of the foot and ankle. Charles Thomas, Springfield, 1962... 

Delfaut BM, Demondion X, Bierganski A et al (2003) Imaging of foot and ankle nerve entrapment syndromes from well-demonstrated to unfamiliar sites. RadioGraphics 23 613-623... 

Before starting the study, the examiner should always be informed regarding the patient s history, and should request a recent radiographic study of the ankle. Standard radiographs (including anteroposterior and lateral views) clearly demonstrate bone lesions that may be overlooked sonographically and can aid in the correct interpretation of unclear US findings related to disorders that are obvious on plain films. 

Fig.l6.86a-c. Synovitis of the ankle joint anterior recess, a Mid-sagittal 12-5 MHz US image over the dorsal ankle in a patient with joint effusion reveals a distended anterior joint recess (arrows) filled with hypoechoic fluid between the hyperechoic margins of the distal epiphysis of the tibia (star) and the talar head (asterisk). b Lateral radiograph reveals increased density (arrows) involving the anterior ankle, consistent with a synovial process, c The patient presented with anterior swelling (curved arrow) of the ankle... 

Fig. 16.87 a,b. Synovitis of the ankle joint posterior recess, a Sagittal 12-5 MHz US image over the posterior ankle demonstrates hypoechoic fluid (arrows) within the posterior recess of the ankle joint between the posterior malleolus (PM) and the talus, in close relation to the flexor hallucis longus tendon (fhl). b Lateral radiograph shows increased density (arrows) at the level of the posterior recess, reflecting synovitis... 

Fig. 16.91 a-c. Fracture of the lateral process of the talus in a patient with negative standard radiographs of the ankle, a Coronal 12-5 MHz US image over the lateral ankle reveals an interruption (arrow) of the hyperechoic cortical profile of the talus, consistent with a fracture of its lateral process. Note the intra-articular effusion within the posterior talocalcaneal joint (asterisks). b Oblique coronal CT reconstruction confirmed the talar fracture (arrow), c Schematic drawing of a coronal view of the ankle illustrates the position of the fracture (arrows) and the involvement of the adjacent talocalcaneal joint (asterisk)... 

Fig. 17.22a,b. Peroneal tubercle and inferior peroneal retinaculum, a Schematic drawing of a lateral view of the hindfoot illustrates the peroneal tubercle curved arrow) as a bony prominence on the anterolateral aspect of the calcaneus. The tubercle separates the two peroneal tendons. The peroneus longus tendon (PL) runs inferiorly to the tubercle, while the peroneus brevis PB) is located superior to it. The inferior extensor retinaculum (asterisk) inserts into the lateral face of the calcaneus and the apex of the tubercle. It covers and stabilizes the peroneals during ankle movements, b Axial radiograph of the calcaneus shows the peroneal tubercle (curved arrow) as a bony protrusion from the anterolateral aspect of the calcaneus (Calc)... 

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