Joint, Ligament, Nerve Entrapments

Total Page:16

File Type:pdf, Size:1020Kb

Joint, Ligament, Nerve Entrapments Joint, Ligament, Nerve Disclosures: Entrapments • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier Professor of Radiology • None relevant to this lecture Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Outline Tibiotalar Joint: effusion •Joint pathology • Anterior evaluation most sensitive – Effusion, infection, inflammatory arthritis • Plantar flexion • Ligament pathology – Anterior talofibular, calcaneofibular, tibiofibular • Hyperechoic fat pad displaced by anechoic or hypoechoic fluid • Nerve entrapment – Tibial nerve • Sensitivity: MRI > US > PF – Morton neuroma Jacobson, JA et al. AJR 1998; 170:1231 Pitfall: normal hyaline cartilage Effusion: tibiotalar joint Tibia Tibia Talus Talus Talus Sagittal Sagittal Axial Sagittal Axial Aspiration 1 Intraarticular Body Synovitis: anterolateral impingement PL/B Fibula Tibia Talus Talus Coronal Sagittal Septic Joint: talonavicular Septic Joint: • Anechoic or hypoechoic distention of joint recesses • May be hyperechoic if complicated – Possible synovitis • US or color Doppler cannot distinguish between septic and aseptic effusion* *Strouse et al. Radiology 1998; 206:731 5th Metatarsal Phalangeal Joint: septic Septic Joint: work up • If anechoic fluid: aspirate – Avoid overlying cellulitis and tenosynovitis • If hypoechoic / heterogeneous: PP – Aspirate and lavage if needed th th 5 MT 5 MT • If no distention: – Depends on clinical suspicion Sagittal Coronal – Follow-up in 24 hours or lavage 2 Synovitis: color flow Complicated Fluid vs. Synovium • Both may appear hypo- or isoechoic Findings that suggest effusion: • Displacement with transducer pressure Tibia • Joint recess collapse w/ joint movement Talus • Negative flow on color Doppler imaging RA Ankle RA ankle No flow Positive flow Inflammatory Arthritis: Inflammatory Arthritis • Gout: 1st MTP joint, others (tarsal) • Non-specific findings: • Rheumatoid: – Joint effusion – MTP joints (especially 5th) – Synovitis: hyperemia – PIP and 1st IP joints – Erosions: pitfalls • Seronegative: reactive arthritis • Rely on history, lab values, and – Variable joint distribution distribution of abnormalities – Inflammatory enthesopathy Gout: Gout: • Monosodium urate crystals: • Joint effusion / synovial hypertrophy • Double contour sign: – Negative birefringence – Monosodium urate crystal icing on cartilage • Stages: • Tophi: – Asymptomatic hyperuricemia – Hyperechoic with hypoechoic rim – Acute gouty arthritis • Erosions: – Interval asymptomatic phase – Adjacent to tophi – Chronic tophaceous gout – Medial 1st metatarsal head 3 Tibiotalar Joint Effusion: gout Gout: synovitis Tibia Talus PP Talus Sagittal Axial MT 1st Metatarsophalangeal Joint Gout: tophus Gout: Double Contour Sign PP Tibia MT Metatarsal Head Proximal Talus Phalanx 1st MTP Joint Ankle Joint T1w T2w Gad 1st Metatarsophalangeal Joint Rheumatoid Arthritis Rheumatoid Arthritis 5th MT Sagittal: dorsal Sagittal: plantar lateral th 5th MT • 5 metatarsal head – Most common site for involvement • Supplement dorsal evaluation with lateral and plantar view Erosion + Synovitis Tranverse Normal Inanc N et al. US Bio Med 2016; 42:865 4 Outline Ligament Tear: • Joint pathology – Effusion, infection, inflammatory arthritis • Hypoechoic & thickened • Ligament pathology • Acute: anechoic fluid tracking through – Anterior talofibular, calcaneofibular, tibiofibular defect indicates full-thickness tear • Nerve entrapment • Cortical avulsion: hyperechoic – Tibial nerve – Morton neuroma Anterior Talofibular Ligament Tear Trauma: ligament • Lateral: – Anterior talofibular: isolated tear in 66% Fib – Calcaneofibular Fibula Talus • 20% calcaneofibular + anterior talofibular – Posterior talofibular: dislocation Patient #1 Patient #2 Patient #3 – Anterior tibiofibular: high ankle sprain Helgason. Radiol Clin N Am 1998; 36:729 Normal Anterior Talofibular Ligament: avulsion Calcaneofibular Ligament Tear PL/B PL/B Calcaneus Patient #2 Fibula Patient #1 Talus Short Axis Long Axis Axial CT Normal 5 Anterior Inferior Tibiofibular Ligament Tear Ligament Tear: • Anterior inferior Tibia tibiofibular ligament: Fibula Tibia – Look for interosseous Fibula Fibula membrane tear if Tibia absent lower fibular fracture Patient #1 Patient #2 – Maisonneuve fracture Long Axis Maisonneuve Fracture Deltoid Ligament Tear MM T T F F Talus Transverse Normal Fibular Fracture Durkee, J Ultrasound Med 2003; 22:1369 Normal Deltoid Ligament Tear: remote Outline • Joint pathology – Effusion, infection, inflammatory arthritis MM • Ligament pathology – Anterior talofibular, calcaneofibular, tibiofibular Talus • Nerve entrapment – Tibial nerve – Morton neuroma Normal 6 Tibial Nerve (TN) TN = tibial nerve • Bifurcates in tarsal tunnel (distal tibia) MPN = medial plantar nerve – Medial plantar nerve (MPN) LPN: lateral plantar nerve – Lateral plantar nerve (LPN) MCN = medial calcaneal nerve • Plantar nerves divide into interdigital nerves ICN = inferior calcaneal nerve – Motor branches: muscles of sole of foot – Sensory: digits (via common and proper plantar digital nerves) Martinoli, RadioGraphics 2000; 20:S199 From: Louisia, Surgical and Radiologic Anatomy, 1999; 21:169. Ganglion Cyst: tarsal tunnel syndrome Tarsal Tunnel Syndrome • Entrapment of tibial nerve F P – Ganglion cyst: most common – Varicose veins, tenosynovitis – Trauma, deformity, coalition, idiopathic • Tibial nerve: FHL – May appear normal – May be hypoechoic and swollen Axial Sagittal Nagaoka, J Ultrasound Med 2005;24:1035 Ganglion Cyst: tarsal tunnel syndrome Tarsal Tunnel Syndrome: Varices Talus Calcaneus Long Axis Short Axis Medial plantar nerve impingement from ganglion cyst originating from middle facet of anterior subtalar joint 7 Morton Neuroma Morton Neuroma: • Hypoechoic 5 mm mass • Interdigital nerve entrapment – Sensitivity: 100% ; Specificity: 83% • Edema, fibrosis, necrosis – Accuracy equal to MRI • 3rd intermetatarsal space > 2nd – Nerve continuity: sagittal plane • Sharp, burning pain from • Intermetatarsal bursa metatarsal head to toes – Associated with neuroma • Females: pliable foot, high-heeled – “Neuroma-bursal complex” narrow-toed shoes From: Martinoli, Quinn T et al. AJR 2000; 174:1723 RadioGraphics Bignotti B et al. Eur Radiol 2015; 25:2254 2000; 20:S199 Cohen SL et al. J Ultrasound Med 2016; 25:3191 Morton Neuroma Technique: • Interdigital space – Transducer: MT • Plantar MT • Dorsal – Normal digital nerve difficult to visualize – Correlate with symptoms Transverse Coronal T1w Morton Neuroma Dynamic Evaluation • Compression Plantar Dorsal – Between transducer and palpation – Bursae (dorsal) compress, neuromas (plantar) do not • Sonographic Mulder Sign – Scan plantar: coronal plane – Neuroma displaces: plantar Dorsal Plantar – Palpable click Torriani M et al. AJR 2003; 180:1121 Zanetti M et al. Radiology 1997; 203:516 8 Dynamic imaging: Mulder’s Maneuver Take Home Points • Joint – Anterior recess – Effusion versus synovitis – Aspirate if concern for infection • Ligament: anatomy • Nerve entrapments – Tarsal tunnel syndrome – Morton: dynamic E-mail: [email protected] Twitter handle: @jjacobsn 9.
Recommended publications
  • Discussion Concerning Deltoid Ligament and Antero-Medial Capsule Repair in the Surgical Management of Supination External Rotati
    ISSN: 2643-4016 Wei et al. Int Arch Orthop Surg 2017, 1:001 Volume 1 | Issue 1 Open Access International Archives of Orthopaedic Surgery ORIGINAL ARTICLE Discussion Concerning Deltoid Ligament and Antero-Medial Cap- sule Repair in the Surgical Management of Supination External Rotation Ankle Fractures Wei REN1,3, Masumi MARUO HOLLEDGE1, Yong Cheng HU2,3 and Jike LU1* 1Department of Orthopedic Surgery, United Family Hospital, Beijing, China Check for 2Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China updates 3Tianjin Medical University, Tianjin, China *Corresponding author: Jike LU, Department of Orthopedic Surgery, United Family Hospital, 2 Jiangtai Lu, Chaoyang District, Beijing, China, Tel: +4008-9191-91, E-mail: [email protected] the Lauge-Hansen classification is frequently utilized. Abstract In the classification, Supination-External Rotation (SER) Objective: To evaluate the importance of ankle deltoid liga- injuries are the most common occurrences. In a clinical ment and anteromedial capsule repair in Lauge-Hansen Su- pination-External Rotation Stage IV (SER IV) ankle fractures. setting, SER stage IV (SER IV) can be seen as a fracture of the lateral malleolus (Weber B fibular fractures) on Methods: A total of 15 patients with SER IV ankle fractures radiographs, when there is no medial malleolus frac- without medial malleolus fractures, were studied. All patients were treated with lateral malleolus Open Reduction Internal ture. However, the classification indicates that SER IV Fixation (ORIF) and transsydesmotic screws with the deltoid injuries include the syndesmotic ligament rupture and ligament, as well as anteromedial capsule repair. The Lower the deltoid ligament injuries (bimalleolar equivalent). Extremity Function Scale (LEFS), Foot and Ankle Disabili- Obviously, SER IV injuries are unstable ankle fractures.
    [Show full text]
  • Ankle Ligament Injuries
    ARTIGO DE REVISÃO Ankle ligament injuries Per A.F.H. Renström, M.D., Ph.D.1 and Scott A. Lynch, M.D.2 ABSTRACT ing and/or taping can alleviate instability problems in most patients. For cases of chronic instability that are refractory Acute ankle ligament sprains are common injuries. The to bracing and external support, surgical treatment can be majority of these occur during athletic participation in the explored. If the chronic instability is associated with subta- 15 to 35 year age range. Despite the frequency of the injury, lar instability that is refractory to conservative measures and diagnostic and treatment protocols have varied greatly. bracing as outlined above, surgical treatment must address Lateral ligament complex injuries are by far the most com- the subtalar joint as well. mon of the ankle sprains. Lateral ligament injuries typically Subtalar ligament injury and instability are probably more occur during plantar flexion and inversion, which is the po- common than appreciated. Definition and diagnosis of this sition of maximum stress on the anterotalofibular liagment entity are difficult, however. Fortunately, it appears that in (ATFL). For this reason, the ATFL is the most commonly the majority of the acute injuries healing occurs with the torn ligament during an inversion injury. In more severe in- same functional rehabilitation program as that for lateral ankle version injuries the calcaneofibular (CFL), posterotalofibu- ligament sprains. lar (PTFL) and subtalar ligament can also be injured. For chronic subtalar instability an intial attempt at func- Most acute lateral ankle ligament injuries recover quickly tional rehabilitation with ankle proprioceptive training and with nonoperative management.
    [Show full text]
  • The Ligament Anatomy of the Deltoid Complex of the Ankle: a Qualitative and Quantitative Anatomical Study
    e62(1) COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED The Ligament Anatomy of the Deltoid Complex of the Ankle: A Qualitative and Quantitative Anatomical Study Kevin J. Campbell, BS, Max P. Michalski, MSc, Katharine J. Wilson, MSc, Mary T. Goldsmith, MS, Coen A. Wijdicks, PhD, Robert F. LaPrade, PhD, MD, and Thomas O. Clanton, MD Investigation performed at the Department of Biomedical Engineering, Steadman Philippon Research Institute, and the Steadman Clinic, Vail, Colorado Background: The deltoid ligament has both superficial and deep layers and consists of up to six ligamentous bands. The prevalence of the individual bands is variable, and no consensus as to which bands are constant or variable exists. Although other studies have looked at the variance in the deltoid anatomy, none have quantified the distance to relevant osseous landmarks. Methods: The deltoid ligaments from fourteen non-paired, fresh-frozen cadaveric specimens were isolated and the ligamentous bands were identified. The lengths, footprint areas, orientations, and distances from relevant osseous landmarks were measured with a three-dimensional coordinate measurement device. Results: In all specimens, the tibionavicular, tibiospring, and deep posterior tibiotalar ligaments were identified. Three additional bands were variable in our specimen cohort: the tibiocalcaneal, superficial posterior tibiotalar, and deep anterior tibiotalar ligaments. The deep posterior tibiotalar ligament was the largest band of the deltoid ligament. The origins from the distal center of the intercollicular groove were 16.1 mm (95% confidence interval, 14.7 to 17.5 mm) for the tibionavicular ligament, 13.1 mm (95% confidence interval, 11.1 to 15.1 mm) for the tibiospring ligament, and 7.6 mm (95% confidence interval, 6.7 to 8.5 mm) for the deep posterior tibiotalar ligament.
    [Show full text]
  • Medial Ankle Instability Instabilidade Medial Do Tornozelo
    AR T IGO ES P ECI A L Medial ankle instability Instabilidade medial do tornozelo Beat Hintermann1, Alexej Barg2, Markus Knupp3 Abstract While much is known about the anatomy and biomechanics of lateral ankle ligaments, the medial ankle ligaments are still poorly understood. Analogously, very little objective data is available regarding the clinical presentation of medial ankle instability. The focus of this article is to elucidate the anatomy and function of the medial ligaments, and to present our experience for diagnosis and treatment of incompetent deltoid ligament. Keywords: Ankle joint/physiology; Ankle joint/surgery; Arthroscopy; Collateral ligaments/ physiology; Collateral ligaments/surgery; Joint instability/etiology; Joint instability/ physioology; Joint instability/surgery; Ligaments, articular/anatomy & histology Resumo Até quanto é conhecida a anatomia e a biomecânica do complexo ligamentar lateral, o li- gamento medial continua mal compreendido. Analogamente, poucos relatos objetivos são direcionados ao quadro clínico da instabilidade medial. O objetivo deste artigo é elucidar a anatomia e a biomecânica do ligamento medial e mostrar a experiência no diagnóstico e na conduta da incompetência do ligamento deltóide. Descritores: Articulação do tornozelo/fisiologia; Articulação do tornozelo/cirurgia; Artroscopia; Ligamentos colaterias/fisiologia; Ligamentos colaterais/cirurgia; Instabilidade articular/etiologia; Instabilidade articular/fisiologia; Instabilidade articular/cirurgia; Ligamentos articulares/anatomia & histologia Correspondência
    [Show full text]
  • Morphological Characteristics of the Lateral Talocalcaneal Ligament: a Large-Scale Anatomical Study
    Surgical and Radiologic Anatomy (2019) 41:25–28 https://doi.org/10.1007/s00276-018-2128-8 ANATOMIC VARIATIONS Morphological characteristics of the lateral talocalcaneal ligament: a large-scale anatomical study Mutsuaki Edama1,2 · Ikuo Kageyama2 · Takaniri Kikumoto1 · Tomoya Takabayashi1 · Takuma Inai1 · Ryo Hirabayashi1 · Wataru Ito1 · Emi Nakamura1 · Masahiro Ikezu1 · Fumiya Kaneko1 · Akira Kumazaki3 · Hiromi Inaba4 · Go Omori3 Received: 9 August 2018 / Accepted: 4 September 2018 / Published online: 30 October 2018 © Springer-Verlag France SAS, part of Springer Nature 2018 Abstract Purpose The purpose of this study is to clarify the morphological characteristics of the lateral talocalcaneal ligament (LTCL). Methods This study examined 100 legs from 54 Japanese cadavers. The LTCL was classified into three types: Type I, the LTCL branches from the calcaneofibular ligament (CFL); Type II, the LTCL is independent of the CFL and runs parallel to the calcaneus; and Type III, the LTCL is absent. The morphological features measured were fiber bundle length, fiber bundle width, and fiber bundle thickness. Results The LTCL was classified as Type I in 18 feet (18%), Type II in 24 feet (24%), and Type III in 58 feet (58%). All LTCLs were associated with the anterior talofibular ligament at the talus. There was no significant difference in morphologi- cal characteristics by Type for each ligament. Conclusions The LTCL was similar to the CFL in terms of fiber bundle width and fiber bundle thickness. Keywords Calcaneofibular · Ligament · Subtalar joint · Gross anatomy Introduction features, as well as complex three-dimensional mobility, making it a challenge to conduct quantitative evaluations. Of patients with chronic ankle instability, 42% [6] present Ligaments that are associated with the stability of the with mechanical instability of the talocrural joint, and 58% subtalar joint include the calcaneofibular ligament (CFL), have mechanical instability of the subtalar joint [3], each of the lateral talocalcaneal ligament (LTCL), the interosseous them at high percentages.
    [Show full text]
  • The Attachment Sites and Attachment Areas of Deltoid Ligament Related to Clinical Implications: a Cadaveric Study
    Int. J. Morphol., 38(4):1106-1111, 2020. The Attachment Sites and Attachment Areas of Deltoid Ligament Related to Clinical Implications: A Cadaveric Study Los Sitios y las Áreas de Inserción del Ligamento Deltoideo Relacionadas con las Implicaciones Clínicas: Un Estudio Cadavérico Chanatporn Inthasan1; Yasuhito Tanaka2; Tanawat Vaseenon3 & Pasuk Mahakkanukrauh4,5 INTHASAN, C.; TANAKA, Y.; VASEENON, T. & MAHAKKANUKRAUH, P. The attachment sites and attachment areas of deltoid ligament related to clinical implications: a cadaveric study. Int. J. Morphol 38(4):1106-1111, 2020. SUMMARY: Currently, the treatment for patients with deltoid ligament injuries who require surgical treatment are anatomical repair and reconstruction. The clinicians should understand the exact knowledge of attachment areas of individual bands of deltoid ligament for a successful treatment. We studied 46 ankles of fresh frozen cadavers. The individual bands of deltoid ligament were divided to small fibers. Afterwards, each small fiber of each band was cut and marked with acrylic color on the origin and insertion followed by photo taking. Lastly, the photos of individual origin and insertion were used to calculate the attachment areas. We found six bands of deltoid ligament in all ankles except tibionavicular ligament. Moreover, we discovered deep to tibiocalcaneal and posterior to sustentaculum tali ligaments in 3 cases. Regarding the attachment area, the deep posterior tibiotalar ligament had the largest proximal and distal attachment areas which were 87.36±23.15 mm2 and 88.88±24.24 mm2, respectively. The anterior tibiotalar ligament had the least proximal and distal attachment areas which were 23.12±8.25 mm2 and 33.16±14.63 mm2, respectively.
    [Show full text]
  • Mcilroy's Ankle Injury Explained
    McIlroy’s Ankle Injury Explained By Eva Nugent MISCP The Anterior Talofibular Ligament is big news this week because of world number 1 golf player Rory McIlroy’s injury sustained while having a football “kick about” with friends. McIlroy reports sustaining a “total rupture of his left ATFL and damage to the associated ankle joint capsule”. This unfortunate injury has put his golf season in doubt with the Open Championship starting just next week the 16th of July. But what exactly is the ATFL? And what does the rehabilitation for this injury involve? The Anterior Talofibular Ligament is one of three ligaments that make of the lateral ligament complex of the ankle joint. It originates at the fibular malleoulus of the lateral shin bone (fibula) and runs forward to and attaches to the Talus (ankle bone). The other two ligaments are the Posterior talofibular ligament (PTFL) and the Calcaneofibular ligament (CFL). The function of these ligaments is to provide stability and support to the ankle joint. The ATFL specifically prevents the anterior translation of the shin in relation to the foot/ankle. The ATFL is the most commonly injured ankle ligament and is most vulnerable when the foot is pointing downwards and inwards as the body’s centre of gravity rolls over the ankle (plantarflexed and inverted position). This is commonly described as “going over on your ankle”. It is commonly injured in sports like football or GAA where unpredictable fast turns or cutting movements are involved. This is referred to as an ankle sprain and results in damage to the fibres of the ligament as they are overstretched.
    [Show full text]
  • The Ligament Anatomy of the Deltoid Complex of the Ankle: a Qualitative and Quantitative Anatomical Study
    e62(1) COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED The Ligament Anatomy of the Deltoid Complex of the Ankle: A Qualitative and Quantitative Anatomical Study Kevin J. Campbell, BS, Max P. Michalski, MSc, Katharine J. Wilson, MSc, Mary T. Goldsmith, MS, Coen A. Wijdicks, PhD, Robert F. LaPrade, PhD, MD, and Thomas O. Clanton, MD Investigation performed at the Department of Biomedical Engineering, Steadman Philippon Research Institute, and the Steadman Clinic, Vail, Colorado Background: The deltoid ligament has both superficial and deep layers and consists of up to six ligamentous bands. The prevalence of the individual bands is variable, and no consensus as to which bands are constant or variable exists. Although other studies have looked at the variance in the deltoid anatomy, none have quantified the distance to relevant osseous landmarks. Methods: The deltoid ligaments from fourteen non-paired, fresh-frozen cadaveric specimens were isolated and the ligamentous bands were identified. The lengths, footprint areas, orientations, and distances from relevant osseous landmarks were measured with a three-dimensional coordinate measurement device. Results: In all specimens, the tibionavicular, tibiospring, and deep posterior tibiotalar ligaments were identified. Three additional bands were variable in our specimen cohort: the tibiocalcaneal, superficial posterior tibiotalar, and deep anterior tibiotalar ligaments. The deep posterior tibiotalar ligament was the largest band of the deltoid ligament. The origins from the distal center of the intercollicular groove were 16.1 mm (95% confidence interval, 14.7 to 17.5 mm) for the tibionavicular ligament, 13.1 mm (95% confidence interval, 11.1 to 15.1 mm) for the tibiospring ligament, and 7.6 mm (95% confidence interval, 6.7 to 8.5 mm) for the deep posterior tibiotalar ligament.
    [Show full text]
  • The Lower Extremity Exam for the Family Practitioner
    Melinda A. Scott, D.O. THE LOWER EXTREMITY Orthopedic Associates of EXAM FOR THE FAMILY Dayton Board Certified in Primary Care PRACTITIONER Sports Medicine GOALS Identify landmarks necessary for exam of the lower extremity Review techniques for a quick but thorough exam Be familiar with normal findings and range of motion Review some special maneuvers and abnormal findings Review common diagnoses PRE-TEST QUESTIONS 20% 20% 20% 20% 20% If a patient has hip arthritis, where will he or she typically complain of pain? A. Buttock B. Low back C. Lateral hip D. Groin E. Posterior thigh 10 A. B. C. D. E. Countdown PRE-TEST QUESTIONS A positive straight leg raise test indicates 20% 20% 20% 20% 20% that the patient’s hip pain is from a A. Radicular/sciatic etiology B. Hip joint pathology C. Bursitis D. Tight Hamstrings E. Weak hip flexors 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive McMurray’s tests is indicative of 20% 20% 20% 20% 20% a possible A. ACL tear B. MCL tear C. Patellar dislocation D. Joint effusion E. Meniscus tear 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS Anterior drawer test on the knee is performed with the knee in 20% 20% 20% 20% 20% A. 30 degrees flexion B. 90 degrees flexion C. Full extension D. 45 degrees flexion E. 130 degrees flexion 10 Countdown A. B. C. D. E. PRE-TEST QUESTIONS A positive squeeze test during an ankle 20% 20% 20% 20% 20% exam is indicative of A. Syndesmotic injury B.
    [Show full text]
  • High Ankle Sprains: Diagnosis & Treatment
    High Ankle Sprains: Diagnosis & Treatment Mark J. Mendeszoon, DPM, FACFAS, FACFAOM Precision Orthopaedic Specialties University Regional Hospitals Advanced Foot & Ankle Fellowship- Director It Is Only an Ankle Sprain Evaluate Degree of Ecchymosis & Edema If Not Properly Treated Chronic Pain & Ankle Instability Epidemiology Waterman et al. JBJS 2010 states: 2 million ankle sprains per year = 2 billion in health care cost Injury results in time lost and disability in 60% of patients 30% of all sport injury Epidemiology Syndesmotic Injuries: •1% to 18% of all ankle sprains • 32% develop calcification and chronic pain •High incidence of post traumatic arthritis Greater source of impairment than the typical lateral ankle sprain Anatomy Inferior Tibiofibular Joint: defined as a syndesmotic articulation which consists of five separate portions Motion in all three planes Anatomy “Syndesmotic Ligaments: • Anterior Inferior Tibio Fibular Ligament • Posterior Inferior Tibio Fibular Ligament • Transverse Tibio Fibular Ligament • Interosseous Ligament • Interosseous Membrane Deltoid Ligament The deep portion of the deltoid ligament also contributes to syndesmotic stability Acting as a restraint against lateral shift of the talus Biomechanics of Syndesmosis RELEVANT ASPECTS OFANKLE: A considerable clearance takes place between the talus and the distal fibula, which is limited by the tibiofibular syndesmosis With normal stance, almost no twisting and shearing forces act on the ankle joint= static tibfib tension Axial loading tensions AITF and PITF with increase of 10 -17% of body weight intact syndesmosis, the intermalleolar distance increases with dorsiflexion of the talus by 1.0 to 1.25 mm Haraguchi et al. 2009 Intact syndesmosis Fibula ROTATES 2 * externally Equals ~ 2.4 mm distally 0.2-0.4 mm Anterior -posteriorly THUS Fibula moves in 3 D Ogilvie & Harris 1994 Study on Individual Ligaments for Syndesmotic Stability 35% ATIFL 33% TRANSVERSE LIG.
    [Show full text]
  • Adding Deltoid Ligament Repair in Ankle Fracture Treatment: Is It Necessary? a Systematic Review
    Foot and Ankle Surgery 25 (2019) 714–720 Contents lists available at ScienceDirect Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas Review Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review a, b c b c Sherif Dabash *, Ahmed Elabd , Eric Potter , Isaac Fernandez , Chris Gerzina , b a b Ahmed M. Thabet , William McGarvey , Amr Abdelgawad a Department of Orthopaedic Surgery, The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX, 77030, United States b Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center — El Paso, 4801 Alberta Avenue, El Paso, TX, 79905 United States c Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center — El Paso, Medical Education Building 2200, 5001 El Paso Drive, El Paso, TX, 79905, United States A R T I C L E I N F O A B S T R A C T Article history: Background: Deltoid ligament injuries are typically caused by supination-external rotation or pronation Received 30 May 2018 injury. Numerous ligament reconstruction techniques have been proposed; however, clear indications for Received in revised form 18 August 2018 operative repair have not yet been well established in the literature. Accepted 2 November 2018 Methods: We reviewed primary research articles comparing ORIF treatment for ankle fracture with versus without deltoid ligament repair. Keywords: Results: Five studies were identified with a total of 281 patients.137 patients underwent ORIF with deltoid repair, Ankle fracture while 144 patients underwent ORIF without deltoid ligament repair.
    [Show full text]
  • Why Don't We Care About the Deltoid Ligament
    Why Don’t We Care About the Deltoid Ligament Sean T. Grambart DPM FACFAS Assistant Dean of Academic Affairs, Des Moines University, College of Podiatric Medicine and Surgery Past-President, American College of Foot and Ankle Surgeons Disclosure • Bespa Global, Partner • Orthosolutions, Design Team • ACFAS Speaker Why are we discussing deltoid repairs?? Anatomy of the Deltoid Complex Superficial ligament Primary restraint to hindfoot • Originates primarily from eversion the anterior malleolus • Tibiocalcaneal (3) Primary restraint to talar external • Tibiospring (2) rotation • Tibionavicular (1) Deep ligament • Confluent with the tibiotalar joint capsule • Deep Anterior Tibiotalar (1) Knee Surg Sports Traumatol Arthrosc (2013) 21:1316–1327 • Deep Posterior Tibiotalar (2) What Camp are You In?? • No Reason to Repair the Deltoid • Deltoid repair should be performed in all patients with bimalleolar equivalent ankle fractures • Repair the deltoid only if medial-sided exposure is already required to clear soft tissue from the medial gutter • Deltoid ligament repair among high-level athletes and only after arthroscopic confirmation of complete deltoid ligament rupture. • Repair only among those who are intraoperatively unstable after ORIF What do we know biomechanically?? 21 ankles were analyzed with a motion capture system • Uninjured ankles • Ankles with SER-IV injuries • Ankles with ORIF • Ankles with ORIF and deltoid repair Journal of Orthopaedics 17 (2020) 87–90 Journal of Orthopaedics 17 (2020) 87–90 Compared to the Intact State • ORIF
    [Show full text]