Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Section 1 The Deltoid (Medial Collateral) Anatomy of the Deltoid Ligament Complex Ligament Complex
Audio: The Deltoid or Medial Collateral Ligament Audio: Section 1 - Anatomy of the Deltoid Ligament Complex
Video: Title fades on Video: Section title fades on
Tibia
Audio: The ligaments of the ankle consist of many components, all of which Audio: The talocrural joint is formed by the tibia, bula, and talus. work in concert to support the talo-crural joint during everyday and sporting activities. Video: All ligs on model - rotating Video: Highlight Tibia, Fib, Talus Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Deltoid Ligament Ankle Mortise Complex
Audio: The distal ends of the tibia and bula form the mortise in which the Audio: When studying the ankle ligaments, perhaps the most complicated to superior portion of the talus articulates. visualize is the medial collateral ligament complex also known as the Deltoid ligament due to its delta-shaped appearance. Video: Highlight Ankle mortise and Talus Video: Highlight deltoid ligament
Eversion
Excursion
Rotation
Audio: This complex of ligaments is located on the medial aspect of the ankle and provides a Audio: The deltoid ligament is a stabilizer of the talocrural joint and spans great deal of mechanical stability during movement. It acts against eversion, valgus, from the tibia to the talus, calcaneus, navicular and spring ligament via pronation, and rotatory forces as well as anterior and lateral talar excursion. its components. Video: Model shows resistance to eversion, valgus, pronation, and rotatory Video: Ghosted deltoid spanning talocrural joint. Each bone is highlighted forces as well as anterior and lateral talar excursion and labeled. Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Navicular
Sustentaculum Tali of Calcaneus Spring Ligament
Audio: The spring ligament (or plantar calcaneonavicular ligament) spans Audio: It supports the head of the talus in the talocalcaneonavicular joint and between the anterior aspect of the sustentaculum tali of the calcaneus plays a key role in maintaining the medial longitudinal arch of the foot. to the plantar surface of the navicular bone. Video: Highlight bones of attachment Video: Spring ligament, calc and nav highlighted and shown from beneath
Posterior Colliculus Super cial Layer
Audio: The medial malleolus is the attachment site of the deltoid ligament complex. It is the medial projection of Audio: The deltoid ligament consists of multiple components, but because of its complexity, its components are the distal tibia that forms the medial wall of the ankle mortise which articulates with the medial articular often de ned di erently and given di erent abbreviations in related literature. The component de nitions surface of the talus. On the medial malleolus are two tubercles called colliculi. The anterior and posterior used in this animation are based on the most recent studies which de ne 5 components of the Deltoid colliculi along with the intercollicular (or malleolar) groove between them, are the speci c attachment ligament. The complex consists o f two layers – a deep layer, and a super cial layer. sites of the deltoid ligament. Video: Highlight Medial malleolus, articular surfaces, colliculi, intercollicular Video: Highlight layers from Ant and post – 3-split screen or inset w/ ¾ groove rotating view and synced highlighting Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Tibiotalar Ligament (ATTL)
Synovial Capsule
Audio: The deep layer consists of the anterior tibiotalar and posterior Audio: This layer lies within the synovial capsule tibiotalar ligaments.
Video: Unghost ATTL and PDTL – highlight each Video: Highlight synovial capsule
Tibiospring Ligament (TSL) Synovial Capsule
Audio: The super cial layer consists of the tibionavicular, tibiospring, and tibio Audio: This layer lies super cial to the synovial capsule calcaneal ligaments.
Video: Unghost TNL, TSL, TCL and highlight each Video: Highlight synovial capsule Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Audio: A good deal of variation in both thickness and visibility exists in these Audio: In recent years, due to its high resolution, high- eld (3-Tesla) MR ligaments. Additionally because the deltoid ligament complex plays such a imaging has become an extremely useful tool in evaluating both central role in talocrural stabilization, it is very often the site of injury. normal anatomical variation as well as these pathologic conditions. Video: Deltoid slow rotating shot Video: Deltoid slow rotating shot
Audio: Audio Audio: Audio
Video: Deltoid slow rotating shot Video: Deltoid slow rotating shot Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Colliculus and Intercollicular Anterior Tibiotalar Groove Ligament (ATL)
Talus
Audio: The Anterior Tibiotalar Ligament (ATTL) is the smallest and most buried component of the Audio: ...courses distally, anteriorly, and medially to its attachment on the Deltoid Ligament Complex. It attaches to the medial malleolus at the anterior colliculus talus, just distal to the anterior portion of the medial talar articular and the anterior portion of the intercollicular groove and... surface. Video: Highlight attachments – ant colic and ant groove, distal to ant artic Video: ATTL• appears surf
1-4 mm
Audio: Its thickness ranges from 1-4mm. Audio: The ATTL is a part of the deep layer of the deltoid ligament and lies within the synovial capsule deep to the tibionavicular, tibiospring, and tibiocalcaneal ligaments. Video: Show thickness Video: Highlight ATTL with rest of Deltoid ghosted Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Colliculus, Posterior Tibiotalar Intercollicular Groove, Ligament (PTTL) and Posterior Colliculus
Talus
Audio: The Posterior Tibiotalar Ligament (PTTL) is the thickest and most robust component of the Audio: It courses distally, posteriorly and medially to its broad attachment on Deltoid Ligament Complex. It attaches to the posterior portion of the anterior colliculus, the talus, from the medial surface under the tail of the articular facet to the intercollicular groove and the anterior portion of the posterior colliculus. the posteromedial talar tubercle. Video: Highlight attachments – post part of ant colic, groove, ant part of post Video: PTTL appears colic, talus – under artic surf tail to posteromedial talar tubercle
6-11 mm
Audio: Its thickness ranges from 6-11mm it contains adipose tissue Audio: The PTTL is also a component of the deep layer of the deltoid ligament interspersed between its ber bundles. within the synovial capsule and lies partially underneath the tibiocal- caneal ligament of the super cial layer. Video: Show thickness Video: Highlight PTTL with rest of deltoid ghosted Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Colliculus
Tibionavicular Ligament (TNL) Navicular
Audio: The Tibionavicular ligament (TNL) is the most di cult component of the Deltoid Ligament Audio: ...courses distally and anteriorly to the dorsomedial surface of the Complex to visualize both in vivo and on imaging due to its orientation and inconsistent navicular. presence in patients. . It attaches to the anterior border of the anterior colliculus and...
Video: Highlight attachments – ant border of at colic, dorsomed navic Video: TNL appears
1-2 mm
Audio: It’s thickness ranges from 1-2mm. Audio: If present, the TNL is the most anterior component of the super cial layer of the Deltoid Ligament complex and is super cial to the synovial capsule. Video: Show thickness Video: Show TNL w/ rest of Deltoid ghosted Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Colliculus Tibiospring Ligament (TS L)
Spring Ligament
Audio: The Tibiospring ligament (TSL) is usually the thickest component of the Audio: The TSL courses distally and broadens to its attachment on the Deltoid Ligament Complex’s super cial layer. It attaches to the anterior superomedial plantar calcaneonavicular (spring) ligament aspect of the anterior colliculus of the medial malleolus. Video: Highlight attachments – ant part of ant colic, spring lig Video: TSL appears
1-4 mm
Audio: The TSL’s thickness ranges from 1-4mm. Audio: It is the middle component of the super cial layer of the deltoid ligament and is super cial to the synovial capsule.
Video: Show thickness Video: Show TSL w/ rest of Deltoid ghosted Project: Deltoid Ligament Animation Sequence: Section 1: Anatomy of the Deltoid Ligament Complex Date: 01//6/14
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Anterior Colliculus Tibioscalcaneal Ligament (TC L)
Sustentaculum Tali
Audio: The Tibiocalcaneal ligament (TCL) is a cord like ligament and forms the Audio: ...runs distally and slightly medially and posteriorly to its attachment posterior border of the super cial layer of the deltoid ligament. It on the medial aspect of the sustentaculum tali of the calcaneus. attaches to the medial aspect of the anterior colliculus and... Video: Highlight attachments – med part of ant colliculus, medial sustentacu- Video: TCL appears lum tali
1-3 mm
Audio: Its thickness ranges from 1-3mm. Audio: As part of the super cial layer of the deltoid ligamen, it lies super cial to the synovial capsule over the anterior portion of the PTTL.
Video: Show thickness Video: Show TCL with Rest of Deltoid ghosted Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Accurate diagnosis of ligament injury
Section 2 High resolution image quality
MRI Correlation Correct diagnoses missed by other methods
Future pathology prevention
Audio: Section 2 MRI Correlation Audio: MR imaging can play a key role in diagnosis of pathologic conditions (text list). With High- eld (3-Tesla) MR imaging radiologists can more accurately localize and characterize pathologic conditions and recognize associated injury patterns. Also, deep deltoid injury can often go unnoticed by other imaging and clinical diagnostic methods. Untreated deltoid ligament insu ciency can lead to osteoarthritis of the ankle joint Video: Section 2 title shown Video: List High- eld MRI advantages and importance
Intermediate-weighted Anatomical surroundings and attachments T2-weighted Signal intensity With and without Fat Saturation Signal intensity pattern Neutral position, slight dorsi ex- ion, or plantar exion Imaging morphology
Audio: The coronal, axial, and transverse oblique views are most helpful in imaging the components of deltoid Audio: Anatomical surroundings/attachment sites – The rst step in evaluating the components of the deltoid ligament. The foot is normally placed in neutral position (or slight plantar exion to reduce the magic ligament is to identify the bony anatomical landmarks of that slice location. This narrows the possibilities angle e ect). Other techniques recommend dorsi exion or plantar exion depending on the target of what the structures in that region might be. ligament component. Intermediate and T2-weighted imaging with and without fat-saturation are used • Signal intensity – Once the radiologist is oriented to the region, signal intensity is used as an Video: Glass plane shows di erent orientations Video: List ligament component charateristics that are evaluated. Show dorsi exion/plantar exion? List tecniques and sequencing info Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Audio: On MR imaging, the ATTL is best visualized in the coronal plane and Audio: In T2 weighted images, the signal is less consistent and can be of low or intermediate while some studies claim that it is present in only 50% of patients, intensity with a homogeneous or inhomogeneous, and sometimes striated pattern. In Intermediate weighted images, the ATTL appears as a homogeneous, thin, low intensity others claim that it is present in all patients. signal structure. Video: Plane moves through foot and stops at plane of component Video: MRI materializes over section and moves to side of screen
Audio: The ATTL usually appears to have uniform thickness and well delineat- Audio: Case image description ed borders.
Video: Component highlighted on scrolling MR Video: Component highlighted on multiple case images and characteristics listed on side of screen Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Audio: On MR imaging, the PTTL is best visualized in the coronal plane and is Audio: In T2-weighted images, the signal intensity can be low or intermediate, but the signal intensity pattern is consistently striated. In Intermediate weighted images, the PTTL has a striated appearance, similar to T2. present in all patients. If fat-suppression is used, the striated intensity pattern may not be easily visible. The striated pattern tends to be less visible in patients over 45 years old, however lack of this pattern in younger patients may indicate pathology. Video: Plane moves through foot and stops at plane of component Video: MRI materializes over section and moves to side of screen
Audio: The PTTL usually appears to thicken distally and have well delineated Audio: Case image description borders.
Video: Component highlighted on scrolling MR Video: Component highlighted on multiple case images and characteristics listed on side of screen Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Audio: On MR imaging (graphic), the TNL is best visualized in either consecutive coronal slices with Audio: According to most studies, the TNL is present in about half of the patient population. In the foot in neutral position, the coronal plane with the foot in plantar exion, the T2-weighted images, its appearance is variable and can appear as a low or intermediate transverse oblique plane, or a reconstructed plane along the length of the TNL using signal with a homogeneous or inhomogeneous signal intensity pattern. On Intermediate isotropic reformatting. weighted images, the TNL has a homogeneous, low-intensity signal. Video: Plane moves through foot and stops at plane of component Video: MRI materializes over section and moves to side of screen
Audio: The TNL usually appears to be of uniform thickness with either blurred Audio: Case image description or well delineated borders.
Video: Component highlighted on scrolling MR Video: Component highlighted on multiple case images and characteristics listed on side of screen Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Audio: On MR imaging, the TSL is best visualized in the coronal plane and is Audio: In T2-weighted images, the TSL usually appears as a low intensity signal with a homoge- always visible. neous signal intensity pattern. On Intermediate weighted images, the TSL appears the same as in T2, a low intensity signal with a homogeneous signal intensity pattern.
Video: Plane moves through foot and stops at plane of component Video: MRI materializes over section and moves to side of screen
Audio: The TSL usually appears to thicken distally and have well delineated Audio: Case image description borders.
Video: Component highlighted on scrolling MR Video: Component highlighted on multiple case images and characteristics listed on side of screen Project: Deltoid Ligament Animation Sequence: Section 2: MRI Correlation Date: 01//6/14
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Audio: On MR imaging, the TCL is best visualized in the coronal plane and is Audio: In T2-weighted images, it is usually of low intensity with a homoge- visible in most patients. neous signal intensity pattern. . On Intermediate weighted images, the TCL --- Video: Plane moves through foot and stops at plane of component Video: MRI materializes over section and moves to side of screen
Audio: The TCL either appears to have a uniform thickness or thicken distally Audio: Case image description and have well delineated borders.
Video: Component highlighted on scrolling MR Video: Component highlighted on multiple case images and characteristics listed on side of screen Project: Deltoid Ligament Animation Sequence: Section 3: Injuries Date: 01//6/14
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Distal avulsion fractures
Medial malleolar fractures
Osteochondral injuries of the Section 3 talus
Injuries Lateral ligament and syndesmosis injuries
Tibialis posterior tendon and spring ligament abnormalities
Antero/posteromedial impingement syndromes
Audio: Audio Audio: It is believed that the deltoid ligament is injured more often than previously thought, but is rarely injured in isolation. Injury usually occurs concurrently with (text list) distal avulsion fractures, medial malleolar fractures, ostechondral injuries of the talus, lateral ligament and syndesmosis injuries, tibialis posterior tendon and spring ligament abnormalities, and antero/posteromedial impingement syndromes. Video: Video Video: List concurrent injuries
Type
Grade
Audio: Of all of the components of the Deltoid Ligament, those of the deep layer are most commonly injured. It is Audio: Two main systems are used to record the characteristics of deltoid important that the super cial and deep layers be evaluated for injury and categorized separately. MR imaging is well suited for this distinction and familiarity with injury imaging patterns allows for accurate ligament injuries in a standardized fashion. diagnoses of injury to the components of one or both of these layers. Video: Video Video: Video Project: Deltoid Ligament Animation Sequence: Section 3: Injuries Date: 01//6/14
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Grade I Type I Grade II Grade III Type II
Type III
Audio: To record the location of the injury, the injury is evaluated to be of type 1 (proximal) ,type 2 Audio: In order to rate the severity, a ligament injury grading system is used when evaluating MR imaging of the (intermediate), or type 3 (distal). In the general population, it has been found that deltoid ligament. A grade 1 sprain (or mild sprain) is indicated by periligamentous edema and stretching. approximately 70% of deltoid ligament injuries are type 1, only 10% are type 2, and 20% A grade 2 sprain (or partial tear) is indicated by intra-ligamentous uid-like T2 signal, attenuation or thickening. A grade 3 (or complete disruption) is seen as a complete gap in the ligament signal. are type 3 Video: Tear types show sequencially Video: Tear grades shown sequencially
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Video: Video Video: Video