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 Long Axis Posterior Talofibular Ligament Anterior Inferior Tibiofibular Ligament PL PB FibFibula Tibia Fibula Tib Tib F 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 6.