Easily Missed Fractures of the Ankle & Foot page 1 of 18 Easily Missed Fractures Search for on EVERY Ankle view: Easily Missed 1) MM & LM (Weber) 2) OLT (OCD) Previous Fractures 3) 5th MT (Jones, Avulsion) Talk 4) LPT Foot & Ankle Search for on EVERY Foot view: 5) APC This but first… 6) MT Talk Anatomy: Tarsal 7) Lisfranc Bones & Joints ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Talus Talus Dome Latin: “Ankle” Center of Ankle Joint Body Head ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Tarsal Bones & Joints Mortise: Woodworking Term Ankle Joint Dome pla·fond\plà-fōn\ n [fr. plat flat + fond bottom] MORTISE ceiling formed by the underside of a floor TENON Plafond Mortise ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 2 of 18 Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Talus Tibia Talo-Navicular Joint Navicular sits on Head like a hat Navicular Navicular Head of Head Navicular Talus of Talus Talo-Navicular Calcaneus subluxation Posterior Tibial Tendon (PTT) Disfunction ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Sub-Talar Sub-Talar Sustentaculum* Tali Joint Joint Anterior 3 Facets Middle Talus Calcaneus Posterior * Latin: “a supporting structure” ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Sub-Talar Calcaneus Joint Talus Cuboid ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 3 of 18 Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Calcaneo-Cuboid Joint Chopart Joint Lateral Process Talus Anterior Process Cuboid Calcaneus Cuboid Calcaneus ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints IV 2 V 1 3 Navicular Cuboid I Navicular Cuboid II The Navicular III Talus IV V Talus DOES NOT 1 2 3 articulate with Cuboid the Calcaneus Navicular ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomic Divisions Anatomy: 3D META- FORE- TARSALS FOOT LISFRANC 1 2 3 MID- CHOPART N Cu FOOT Ta Ca TARSALS HIND- FOOT ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 4 of 18 Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane MM Syndesmosis Ti Ta Fi LM ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane 2 1 N 3 N TNJ Ta Cu M-STJ P-STJ Ca ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane GOOD FOR: Syndesmosis Talonavicular Joint Calcaneocuboid Joint Cu Navicular-cuneiform Joints CCJ Ca Tarsal-metatarsal Joints NOT GOOD FOR: Ankle Joint Subtalar Joint ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 5 of 18 Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Sagittal Plane CT: Sagittal Plane Reformatted off Axial reference image Reformatted off Axial reference image Medial Slice Middle Slice Ti Ti TNJ TNJ Ta Ta P-STJ N ST N Ca 1 I M-STJ M-STJ ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Sagittal Plane CT: Sagittal Plane Reformatted off Axial reference image SECONDARY PLANE FOR: Lateral Slice Ankle Joint Ti Sub-Talar Joint AJ P-STJ Talo-Navicular Joint Ta LPT Calcaneo-Cuboid Joint APC Ca Navicular-Cuneiform Joints Cu Tarsal-Metatarsal Joints NOT GOOD FOR: CCJ Syndesmosis ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Coronal Plane (2 schemes) CT: Coronal Plane (2 schemes) 1) Mortise Coronal: Reformatted off Axial 2) Oblique Coronal: Reformat off Sagittal Aligned between Malleoli Perpendicular to P-STJ GOOD FOR: GOOD FOR: Distal Tibial Fractures Hindfoot Fxs Malleoli MM Sub-Talar Joint Tillaux, Triplane Talus Pilon LM Calcaneus Talar Dome Fxs (OLT) Tarsal (Mortise Sagittal, perpendicular to this) Coalitions ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 6 of 18 UW 2-Page CT Protocol Sheets Anatomy: Cross-Sectional CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ Ti AJ Fi Ta P-STJ Ca ©Ken L Schreibman, PhD/MD 2008 www.radiology.wisc.eduschreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Oblique Coronal Plane CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ Sagittal ref image perpendic to P-STJ P-STJ ST M-STJ ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Oblique Coronal Plane CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ GOOD FOR: Sub-Talar Joint Ankle Joint NOT GOOD FOR: Talo-Navicular Joint A-STJ Calcaneo-Cuboid Joint Navicular-Cuneiform Joints Tarsal-Metatarsal Joints ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 7 of 18 Easily Missed Fractures Lateral Process Talus Search for on EVERY Ankle view: 1) MM & LM (Weber, Adolescent) 2) OLT (OCD) 3) 5th MT (Jones & Avulsion) 4) LPT ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Lateral Process Talus Fracture Lateral Process Talus Fracture 17 yo F gymnast, 29 yo F, landed wrong s/p MVA after vault Lateral View Lateral View ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Lateral Process Talus Fracture Lateral Process Talus Fracture 40 yo M, s/p 24 yo M, construction motorcycle worker fell 15 feet accident Lateral View Lateral View AP View AP View ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 8 of 18 Fracture of the lateral process of the talus is a common, yet frequently missed, injury. It is the second most common fracture of the talar body, accounting for 24% of these injuries, yet it has been documented that 40% of fractures of the lateral process of the talus are missed at initial presentation. ©Ken L Schreibman, PhD/MD 2006 schreibman.info Mechanism of foot/ankle injuries related to snowboarding Twisting Collision 12% with Tree Falling 8% Getting 75% off Lift 4% Collision with Skier 1% Getting on Lift 1% The Snowboarder’s Foot and Ankle Kirkpatrick, et al Am J Sports Med 1998: 26 271-277 Lateral Process Talus Fracture Ankle Injuries 29 yo snow boarder 5-6% of all alpine skiing injuries CT: Axial 12-38% of all snowboarding injuries LPT Fractures CT: Coronal CT: Sagittal 15% of snowboarding ankle injuries 2% of all snowboarding injuries The Snowboarder’s Foot and Ankle Kirkpatrick, et al Courtesy of Paul Hsieh, Colorado Am J Sports Med 1998: 26 271-277 ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 9 of 18 Easily Missed Fractures Anterior Process Calcaneus Search for on EVERY Ankle view: 1) MM & LM (Weber) 2) OLT (OCD) 3) 5th MT (Jones, Avulsion) 4) LPT Search for on EVERY Foot view: 5) APC ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info Anterior Process Calcaneus Fx APC FxFx: Search for on every foot view 29 yo F, tripped down some steps Obl AP 6 months later… ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info APC Fx: Best seen on CT APC Fx: May require fixation 29 yo F, tripped down some steps 29 yo F, tripped down some steps CT day of injury CT 6-months after injury 9-months post-surgery RIGHT LEFT RIGHT LEFT Acute margins Sclerotic margins ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 10 of 18 Elongated APC:APC “Anteater sign” Elongated APC: “Anteater sign” Unlike the normal triangular APC. 1) More easily fractured Elongated APC has blunt tip Even from minor trauma like an anteater’s snout.