Ankle Ligaments • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A

Home , Calcaneofibular ligament

Disclosures: Ankle Ligaments • Consultant: Bioclinica • Advisory Board: GE, Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier Ann Arbor, Michigan

Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.

Technique: ligaments • Hyperechoic Ligament Tear: • Fibrillar echotexture • Hypoechoic & thickened – More compact than tendon echotexture • Acute: anechoic fluid tracking through • Anisotropy defect indicates full-thickness tear • Cortical avulsion: hyperechoic

Ligament: Ant Talofib Tendon: Ant Tibialis

Anterior Talofibular Ligament Technique: lateral • Anterior talofibular • Calcaneofibular • Posterior talofibular • Anterior tibiofibular • Posterior tibiofibular Anisotropy Long Axis

From: Netter’s Atlas of Human Anatomy

1 Anterior Talofibular Ligament Calcaneofibular Ligament

PB PL Fibula

Talus Calcaneus

Long Axis

Posterior Talofibular Ligament Anterior Inferior Tibiofibular Ligament

PL PB

FibFibula Tibia Fibula Tib Tib

Post. Talofibular Ligament Short Axis Long Axis

Inferior Tibiofibular Ligament • Several bands Trauma: ligament • Accessory inferior band (Bassett ligament) • Lateral: – Seen in 80 – 90%: more horizontal – Anterior talofibular: isolated tear in 66% – Potential site of impingement – Calcaneofibular • 20% calcaneofibular + anterior talofibular – Posterior talofibular: dislocation Fib Tib Fib – Anterior tibiofibular: high ankle sprain

Helgason. Radiol Clin N Am 1998; 36:729 Radiology 2010; 254:827

2 Anterior Talofibular Ligament Tear Anterior Talofibular Ligament Tear

Fib

Fibula Fibula Talus

Talus Patient #1 Patient #2 Patient #3

Axial T1w + gado Normal Normal

Anterior Talofibular Ligament: Partial Tear Anterior Talofibular Ligament: avulsion

Fib

Talus Fibula

Talus Long Axis: Dynamic Anterior Drawer Test

Long Axis Axial CT

Anterior Talofibular Ligament Tear: remote Anterior Talofibular Ligament Repair Broström Procedure

Fibula Fibula

Talus Talus

Long Axis Axial T2w Normal Long Axis

3 Calcaneofibular Ligament Tear Anterior Talofibular + Calcaneofibular Ligament Tears

PL/B PL/B

PL/B Calcaneus Fib Fib Patient #2 Patient #1 Talus Calcaneus

Anterior Talofibular Ligament Calcaneofibular Ligament

Short Axis

Anterior Inferior Tibiofibular Ligament Tear Anterior Tibiofibular Ligament • Dynamic: widening of syndesmosis1 – Dorsiflexion and external rotation • If normal: Fibula – Interosseous ligament usually normal

• Impingement Tibia – Thick inferior fascicle (Bassett ligament)2

1Am J Sports Med 2009; 37:1009 2Skeletal Radiol 2008; 37:27 Long Axis Axial T2w

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

4 Interosseous Membrane Disruption Maisonneuve Fracture

T T F F

Transverse Normal Fibular Fracture

Transverse Durkee, J Ultrasound Med 2003; 22:1369

Deltoid Ligament Technique: medial Tib • Deltoid Ligament: C – Coronal: Talus • Tibiocalcaneal Tibiocalcaneal – Anterior: • Tibionavicular PTT • Anterior tibiotalar Tib – Posterior: N Tib • Posterior tibiotalar Talus Talus Ant. Tibiotalar / Tibionavicular Post. Tibiotalar

Deltoid Ligament Tear Spring Ligament Complex • Calcaneonavicular ligament MM – Superomedial • Perpendicular to distal PTT – Medioplantar oblique Talus – Inferoplantar longitudinal

Normal From: Radiology 2005; 237:242

5 Spring Ligament Complex: Superomedial Calcaneonavicular Ligament • Superomedial component • Associated with PTT dysfunction • Normal: hyperechoic, 2.8 – 3.4 mm thick • Abnormal: hypoechoic, thick > 4 mm, thinned or disrupted PTT PTT PTT Nav Calc Talus Talus

Harish, Skeletal Radiol 2007; 36:221 Harish, J Ultrasound Med 2008; 27:1145

Take Home Points Thank you! • Anterior talofibular ligament: – Most common See www.jacobsonmskus.com for my syllabus material and other • High ankle sprain: educational musculoskeletal – Anterior tibiofibular ligament ultrasound material – Evaluate interosseous membrane – High fibula fracture Follow on twitter: @jjacobsn