Static and dynamic roentgenographic analysis of ankle stability in braced and nonbraced stable and functionally unstable ankles

Patients suffering from functional ankle instability were selected based on a structured interview. Talar tilt was measured using supine ankle stress roentgenographs and standing talar tilt was measured using erect ankle stress roentgenographs. A digital roentgenocinematographic analysis of a 50 degrees ankle sprain simulation was performed to measure dynamic talar tilt and inversion distance between two video images (inversion speed). A significant decrease in pathologic supine talar tilt in unstable ankles was found in the braced compared with the nonbraced situation (talar tilt = 13.1 degrees versus 4.8 degrees with brace). The talar tilt with the brace after activity was still significantly lower than the initial value without the brace. The standing talar tilt of unstable ankles was shown to be significantly lower with the orthosis than without (standing talar tilt = 16.6 degrees versus 12.0 degrees with brace). Roentgenocinematographic evaluation of ankle sprain simulation showed that the mean dynamic talar tilt during simulated sprain decreased significantly in the braced ankles compared with the nonbraced ankles (dynamic talar tilt = 9.8 degrees versus 6.4 degrees braced). A significant decrease in the digital measurement of inversion distance (from 110.6 pixels to 92.4 pixels) was observed in the total sample of 39 ankles during the initial high-speed phase of the simulated sprain. The brace significantly slows down the inversion speed.

Epiphyseal separation of the coracoid process without acromioclavicular dislocation

A patient with an epiphyseal separation through the base of the coracoid process of the shoulder associated with a grade I acromioclavicular sprain is reported. The epiphyseal separation was not visible on conventional roentgenograms. A CT scan demonstrated the abnormality. In patients with considerable intractable pain due to contusion of the shoulder, early use of CT should be considered to determine whether symptoms are caused by epiphyseal separation of the coracoid process.

Incidence and clinical significance of bone bruises after supination injury of the ankle. A double-blind, prospective study

We used MRI to study a prospective series of 95 patients with inversion injuries of the ankle and no fracture on plain radiographs. We found an incidence of bone bruises of 27%, but these made no difference to the time of return to work, limitation of walking or physical activity, or the clinical outcome scores at three months. We conclude that bone bruises have very little clinical significance after inversion injuries of the ankle.

Value of arthrography after supination trauma of the ankle

OBJECTIVE

To investigate the merits of arthrography after supination trauma of the ankle.

DESIGN AND PATIENTS

In a group of 160 consecutive patients operative exploration was performed in cases where arthrography and/or a delayed physical examination showed positive findings. In all patients arthrography was performed within 48 h after trauma. To determine interobserver agreement, all arthrograms were independently evaluated by two radiologists, both ignorant of the first assessment.

RESULTS

The prevalence of an ankle ligament lesion was found to be 76%. Of the 122 patients with a rupture of one or more ankle ligaments, 52% had an isolated anterior talofibular ligament lesion, 3% had an isolated calcaneofibular ligament lesion, and 45% had combined lesions. The site of the lesion was predominantly intraligamentous. In the determination of the presence or absence of an ankle ligament lesion, the specificity and sensitivity of the ankle arthrogram were 71% and 96% respectively. Interobserver agreement on the arthrogram was very good (kappa 0.9). In 1% of patients a clear diagnosis was not possible by means of arthrography.

CONCLUSION

Arthrography provides information of high diagnostic quality with excellent interobserver agreement and therefore remains the gold standard for early diagnosis (within 48 h) of a lateral ankle ligament rupture.

[Anterolateral fibrous impingement of the ankle. Report of 14 cases]

PURPOSE

Anterolateral fibrous impingement of the ankle is one of the causes of post-traumatic pain in the foot. We investigated the comparative accuracy of US and MRI in this condition.

MATERIAL AND METHODS

Fourteen patients were submitted to arthroscopy, plain radiography, US and MRI of the foot. The patients, all sportsmen, had a clinical history of sprains; the major symptoms were pain, swelling and clicking on foot dorsiflexion.

RESULTS

US showed anterior talofibular ligament changes in all patients and mid-low-echogenicity synovial tissue filling the lateral malleolar gutter. MRI demonstrated a small mass of synovial tissue in the gutter in 8 patients, with mid-low signal intensity before Gd-DTPA and mid-low contrast enhancement after contrast administration and no abnormal findings in 6 patients. Arthroscopy showed a small firm mass of proliferative synovium in the lateral malleolar gutter in all patients.

CONCLUSIONS

Fibrous impingement must be suspected in the sportsmen presenting typical symptoms after ankle trauma. US is poorly accurate in diagnosing this condition. MRI shows a small synovial mass in the lateral malleolar gutter in more than half the patients, but aspecific MR findings do not rule impingement our MR images must be acquired along the proper planes and with Gd-DTPA administration.

Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients

To test the ability of ultra-high frequency ultrasound (13 MHz scanner) to distinguish between intact and ruptured ligaments on the lateral side of the ankle, we examined 20 patients with an acute inversion injury with MRI and ultrasound. When judged by the MRI diagnosis, an injured anterior talofibular ligament was correctly diagnosed by ultrasound in 13 of 14 and an intact anterior talofibular ligament in 5 of 6 patients. In the case of the calcaneofibular ligament, 4 ruptured and 16 intact ligaments were diagnosed equally well with both methods. The injured anterior tibiofibular ligament was correctly diagnosed by ultrasound in 6 of 9 patients, while the intact ligament was correctly recognized in 10 of 11 patients. Our findings indicate that it is possible to distinguish injured from intact ligaments sonographically.

The injured ankle

Ankle injuries are common presenting complaints in both emergency departments and family physicians' offices. Approximately 1 million ankle injuries occur annually in the United States; most of them are sprains resulting from inversion injuries. Treatment options differ according to the grade of injury--grade I and grade II sprains usually respond to rest and immobilization, while grade III sprains require casting or, possibly, surgery. A chronic "ankle" injury should prompt evaluation for other conditions, such as talar dome lesion. Most ankle injuries can be treated adequately in the family physician's office, although some of the more serious injuries should be referred to an orthopedic specialist for further evaluation.

Syndesmotic ankle injuries in rodeo bull riders

This report describes five male rodeo bull riders, aged 18 to 32 years, who sustained syndesmotic ankle injuries during competition. The mechanism of injury was identical in each case. As the rider attempted to escape after being thrown, the bull stepped on his lateral ankle, resulting in forced external rotation. All patients delayed seeking medical care, the interval between the injury and presentation ranging from 2 days to 4 weeks. All five patients sustained significant syndesmotic tears, two with associated fibular fractures. Three patients underwent surgical stabilization, and all riders returned to competitive rodeo events, often prior to medical clearance. To the authors' knowledge, this is the first reported association between injuries caused by livestock stepping and syndesmotic disruptions.

Rupture of the flexor tendons of the little finger in fractures of the hook of the hamate bone. Report of two cases

Two cases of rupture of the flexor tendons of the little finger associated with a fracture of the hook of the hamate bone are presented. The preoperative diagnosis had not been made. Excision of the fractured hook and repair of the tendons by a short graft from the palmaris longus in one case and by the transfer of the superficial flexor of the ring finger in the other case gave a good final result. The authors remark on the rarity of reports of this fracture in the literature, the frequent occurrence of nonunion and the two complications which are exceptional; rupture of the flexor tendons and compression of the deep branch of the ulnar nerve. The fracture is mainly encountered in sports that require the grasping of a handle (tennis, golf, hockey, squash). The diagnosis is often missed at the onset because of not using the correct X-ray positioning: special incidence for the carpal tunnel view and a 3/4 view with the wrist in 45 degrees of supination and forced radial deviation.

Evaluation and diagnosis of ankle injuries

The evaluation of ankle injuries is a common challenge for family physicians. Diagnosis is made by using knowledge of the anatomy and function of the ankle joint to aid in taking an adequate history and performing an appropriate physical examination. The patient should be questioned about the mechanism of injury, previous injury, disability, treatment and pain. The ankle should be evaluated for ecchymosis, swelling, areas of tenderness and laxity. These measures help to determine what, if any, additional diagnostic procedures may be needed. Most ankle sprains are lateral, affecting the anterior talofibular, calcaneofibular and posterior talofibular ligaments. Other injuries include medial ankle sprains affecting the deltoid ligament, trauma to the Achilles and peroneal tendons, tarsal tunnel syndrome, fractures, syndesmotic sprains, synovial impingement and chronic instability. Criteria for radiographic evaluation include inability to bear weight initially or when examined, and tenderness over the medial or lateral malleolus. Accurate diagnosis is critical for appropriate treatment and minimizing functional disability.

Occult ankle fracture detected by an ankle effusion on plain radiography: a case report

Subtle ankle fractures may escape detection on plain radiography. These occult fractures can cause prolonged disability and pain. We present a case of blunt ankle trauma where plain radiography failed to reveal any bony abnormalities. The recognition of an ankle effusion on plain radiographs prompted us to perform a computed tomography (CT) scan of the ankle. The CT scan demonstrated an anterior plafond fracture of the distal tibia, which required surgical fixation. Had the fracture not been identified, our patient would have been treated inappropriately for a ligament sprain. An occult fracture should be suspected if an ankle is grossly swollen after blunt trauma, and plain radiography demonstrates an effusion. In this circumstance, performance of further imaging studies, such as conventional or CT, are advised to rule out an occult ankle fracture.

Traumatic injuries of the first ray

Injuries involving the first ray are common and can lead to significant pain and disability. The management of these injuries, both conservative and surgical, is discussed in this article. Treatment goals include recreating a uniformly plantigrade weight-bearing surface under all the metatarsal heads, preserving functional anatomy, and preventing traumatic arthritis while maintaining a supple, pliable foot. Many of these injuries can be prevented by use of proper, protective shoegear.

Subtalar stress radiography using forced dorsiflexion and supination

We investigated a new method of stress radiography of the subtalar joints using forced maximum dorsiflexion of the ankle in a supinated position. We measured transposition of the lateral process of the talus at the posterior subtalar joint in lateral views of normal amputated ankles, normal control subjects and patients with recurrent ankle sprains. The mean displacement in the control groups (n = 36) was 29.9%, significantly different from the 43.0% in patients with recurrent ankle sprains (n = 24). In the amputated specimens with intact ligaments movement was similar to that in normal subjects. Section of the calcaneofibular and the interosseous ligaments allowed much the same movement as in patients with recurrent ankle sprains. The new method is simple and useful for detecting subtalar instability.

Sonographic findings in muscle strain injury: clinical and MR imaging correlation

Both sonography and magnetic resonance imaging were performed in 57 patients with clinically suspected strain injury in lower extremity muscles. Sonography demonstrated normal findings in nine patients (16%), hyperechoic infiltration in 31 patients (54%), mass in nine patients (16%), and compound lesions of infiltration and mass in eight patients (14%). Clinically grade 2 lesions ranged from small infiltration to large compound lesions on both sonography and magnetic resonance imaging. Hyperechoic infiltration was not demonstrated on T1-weighted magnetic resonance images and with less than 50% cross-sectional muscle involvement. The mass and compound lesions were ascertained to be moderate or severe injury because the masses of the lesions had obvious hemorrhage or hematoma on magnetic resonance images.

Cortical defect of the distal fibula: variant of ossification

PURPOSE

To elucidate the nature of a normally occurring cortical defect of the distal fibula.

MATERIALS AND METHODS

In patients with sprain and nonspecific ankle pain during a 2-year period, the authors reviewed ankle radiographs, computed tomographic (CT) scans, and magnetic resonance (MR) images. Cases were added from our file. Dried skeletons and cadavers were evaluated with radiography for the presence of this cortical defect.

RESULTS

Fifteen (1.8%) of 847 radiographs in 739 patients (male, 377; female, 362; age range, 15-84 years) showed a small cortical defect in the anterior aspect at the level of the distal tibiofibular joint. The age range of the subjects with the defect (male, four; female, 11) was 16-66 years. MR imaging in two patients showed a small low-signal-intensity area at the insertion site of the anterior tibiofibular ligament. Evaluation of 148 skeletons (75 subjects) revealed similar cortical defect in two cases (1.4%).

CONCLUSION

The cortical defect of the distal fibula, at the insertion site of the anterior tibiofibular ligament, has no clinical significance and should not be confused with neoplasm.

Acute hemarthrosis of the knee in children

The purpose of this study was to determine the cause of acute hemarthrosis of the knee in a prospective pediatric patient population. Between December 1988 and August 1991, 21 consecutive children who were seen with an acute traumatic hemarthrosis of the knee had an arthroscopic evaluation. The average age of the children at the time of injury was 14 years, 3 months (range, 10 to 17 years). The mechanism of injury was a torsional strain to the knee in 12 (71%) of the 17 patients who could accurately remember the injury. The initial evaluation included a history, physical examination, and anteroposterior, lateral, sunrise, and comparison radiographs. The arthroscopic procedure was performed under general anesthesia, and the arthroscopic findings were compared with preoperative findings. During arthroscopic examination, an osteochondral fracture of the lateral femoral condyle or patella was identified in 14 (67%) of the 21 patients. Preoperative radiographs failed to identify the fracture in 5 (36%) of the 14 patients who had an osteochondral fracture. The anterior cruciate ligament was visualized and probed; an injury was found in only two cases (10%). We concluded that in children an acute traumatic hemarthrosis reflects a major injury to the knee. The children in this study had a high frequency of osteochondral fractures; ACL injuries were found in only two patients. Because of the unreliable nature of radiographic evaluation, arthroscopic evaluation is a valuable tool in differential diagnosis and treatment of acute hemarthrosis of the knee.

Bone scintigraphy findings in Lisfranc joint injury

Three-phase bone scintigraphy diagnosis of Lisfranc injury in a patient after foot trauma is discussed. Early diagnosis of Lisfranc joint injury is frequently missed and radionuclide bone scintigraphy may show a specific pattern where the x-rays are inconclusive.

Incomplete, intrasubstance strain injuries of the rectus femoris muscle

Rectus femoris muscle strain injuries commonly occur at the distal muscle-tendon junction of the quadriceps tendon. However, we have recently recognized a pattern of strain injury that consists of an incomplete intrasubstance tear at the muscle-tendon junction formed by the deep tendon of the muscle's indirect head and those muscle fibers originating from this tendon. These injuries are found more proximally within the thigh than the "classic" distal rectus femoris muscle strain. We reviewed 10 athletes with these intrasubstance tears, all of whom had diagnostic imaging performed using computed tomography or magnetic resonance imaging or both. Two of these patients required surgical intervention. The mechanism of injury usually involved kicking or sprinting. All patients had chronic thigh pain or an anterior thigh mass or both. Physical examination revealed thigh asymmetry and a nontender to mildly tender intrasubstance muscle mass. Magnetic resonance imaging demonstrated abnormal signal intensity centered about the intramuscular tendon of the indirect head of the muscle. Surgical findings included a mass of fibrous scar and fatty tissue encasing the deep tendon. Surgical removal of this fibrous mass appears curative. We contrast this injury from distal strains of the rectus femoris muscle, as well as from soft tissue neoplasms.

An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture

We performed cadaveric dissection of the rectus femoris muscle to correlate the various lesions of strain injury seen with imaging studies to the muscular anatomy. The proximal tendon is composed of a superficial, anterior portion from the direct head, and a deep intramuscular portion from the indirect head. The muscle fibers arising from the anterior superficial tendon of the direct head travel in a posterior and distal direction to insert on the posterior tendon of insertion, giving the proximal muscle a unipennate architecture. Muscle fibers from the intramuscular tendon of the indirect head originate on both the medial and lateral sides of the tendon and insert on the distal posterior tendon to create its bipennate structure. Three chronic strain injuries involving the midmuscle belly substance were explored grossly and microscopically. It appears that one type of acute strain injury occurs in the midmuscle belly with disruption of the muscle-tendon junction of the intramuscular tendon resulting in local hemorrhage and edema. More chronically, this hematoma organizes into a fatty, loose connective tissue encasement of the deep intramuscular proximal tendon. Serous fluid from the hematoma may remain within the connective tissue sheath, creating a pseudocyst with the deep intramuscular tendon of the indirect head at its center. The muscle's anatomy helps to explain a different rectus femoris strain injury.

Fibular osteochondroma presenting as chronic ankle sprain

A 19-year-old baseball player was referred for assessment of recurrent sprains of the right ankle. This was found to be secondary to a palsy of the common peroneal nerve that was compressed by an osteochondroma of the fibular neck. The lesion was resected from the fibula and the patient made a complete recovery. We present this case as an example of a rare underlying problem in a patient who was initially diagnosed as having a sports-related ankle injury.

Ligamentous injuries of the wrist

Wrist injuries occur commonly. Significant wrist injuries such as perilunate dislocation and scapholunate dissociation may occur without carpal bone fracture. The emergency physician can recognize these ligamentous wrist injuries by noting abnormalities of the shapes, joint spaces, and alignments of the carpal bones. Early diagnosis allows for prompt referral and optimal outcome.

[Comparison of echography and magnetic resonance in sprains of the external compartment of the ankle]

In most cases ankle sprains involve external compartment ligaments. In particular, the anterior talofibular ligament is involved alone in 70% of cases and together with calcaneofibular and posterior talofibular ligaments in the remaining 30% of cases. To investigate the potentials and the possible limitations of high-frequency US (7.5-13 MHz) for the preliminary assessment of the extent of damage of the capsulo-ligamentous lesions of the external ankle compartment, 25 athletes with clinical diagnosis of sprain trauma were examined with conventional radiology. Morphology and structure were studied from the semiologic point of view. US findings were compared with MR results. In all patients, US showed anterior talofibular ligament lesions alone in 13 patients and associated with calcaneofibular ligament lesions in 12 patients. The posterior talofibular and the interosseous talocalcaneal ligaments were never demonstrated by US. In 4/13 patients diagnosed by US as having isolated anterior talofibular lesions, MRI demonstrated a coexisting calcaneofibular lesion (4/13) and, in one of them, a posterior talofibular and interosseous talocalcaneal ligaments lesion. The comparison of US and MR findings in the patients US had diagnosed as having associated anterior talofibular and calcaneofibular ligaments lesions, showed 100% agreement; MRI allowed the demonstration of the lesions in the posterior talofibular and interosseous talocalcaneal ligaments in 2/12 patients. Considering the statistical prevalence of the anterior peroneal-astragalic lesions caused by ankle sprains, the use of high-frequency US as the first diagnostic approach seems justified. Nevertheless, MRI is a fundamental complement for accurately assessing damage extent.

Injuries of the distal radioulnar joint

Injuries of the distal radioulnar (DRU) joint are common. If the joint is unstable or discongruous, attempts should be made to restore anatomic alignment and stability. Although most acute injuries of the DRU joint are easily treated, they are often overlooked or misdiagnosed because they usually occur in association with other major injuries of the upper limb. Acute and chronic abnormalities are described briefly and the treatment for each is discussed. Appropriate diagnosis and management of the acute injury will yield a much higher success rate than reconstructive procedures to correct a chronic disorder. A differentiation should be made between DRU joint dysfunction and ulnar impingement against the carpus; ulnar shortening is the most commonly used technique to treat the latter condition. In an elderly patient, a Darrach procedure is the preferred treatment for a DRU joint dysfunction; in younger patients, the treatment of choice appears to be resection arthroplasty of the DRU joint with preservation of the ulnar length, the ulnar styloid, and the triangular fibrocartilage complex (TFCC). In cases of malunion of the distal radius with involvement of the DRU joint, the recommended treatment is corrective osteotomy and soft tissue reconstruction of the ligamentous support of the joint.

Lateral ankle sprains. Part I: Anatomy, biomechanics, diagnosis, and natural history

An understanding of the anatomy and biomechanics of the lateral ankle ligaments is essential to make a proper diagnosis in patients with ankle sprains. Specific radiographic stress tests can aid in differentiating single-versus double-ligament injuries and in determining their severity. Inadequately treated ankle sprains can result in chronic pain, instability, and early osteoarthritis. Thus, the proper diagnosis and initial treatment are important. This paper reviews the essential features of the anatomy, biomechanics, diagnosis, and natural history of lateral ankle sprains.