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ANKLE JOINT
RADIOGRAPHY
By Dr. Nikhil Murkey
The Ottawa Ankle Rules (OAR)
• The commonly used criteria for predicting which
  patients require radiographic images.
• R...
Projections
• Three main projections:
• AP
  • Identifies fractures of malleoli, distal tibia/fibula, plafond, talar
    d...
Antero-posterior view
The ankle is slightly
dorsiflexed so that the
plantar surface of the foot is
perpendicular to the
fi...
Measurements in AP view
 • Tibial shaft line (A). A line is drawn through
   and parallel to the tibial shaft.
 • Medial m...
Measurements in AP view
• Tibio-fibular clear space:
           - tibiofibular clear space is the cartilaginous space
  be...
Measurements in AP view




                                  Talar Tilt:- difference in width of superior
               ...
Specialized Projections (AP)
• Plantar flexion view (lazy AP view): For subtle fractures of the talar
  dome, including os...
Radiographic Stress Tests of the Ankle
• Talar Tilt Stress Test
  • Contralateral ankle used for
    comparison
  • Line i...
Lateral View of the Ankle
• The lateral surface of
  the ankle is in contact
  with the film, with the
  foot slightly dor...
Lateral View of the Ankle
Posterior tibial               Dome of the talus:
tuberosity fractures           centered under
...
Measurements in Lateral view
• Heel-Pad measurement:
  • The shortest distance between
    the plantar surface of the
    ...
Measurements in Lateral view
Boehler’s Angle:
• The three highest points on the
  superior surface of the
  calcaneus are ...
Specialized Projections (Lateral)
• Drawer view: A third person, who wears lead gloves and a lead
  apron, stabilizes the ...
Radiographic Stress Tests of the Ankle

• Anterior Drawer
  Test
 • The anterior
   drawer test
   evaluates ATFL
   integ...
Mortise view
• The ankle is slightly
  dorsiflexed so that the
  plantar surface of the foot
  is perpendicular to the fil...
Mortise X-Ray
• This is an important
  view in the
  assessment of the
  post-traumatic ankle
  for detecting subtle
  fra...
Measurements in Mortise view
• Medial clear space
  • Between lateral border of
    medial malleous and medial
    talus
 ...
Measurements in Mortise view
• Talo-crural angle is formed by:
    - line drawn parallel to articular
  surface of distal ...
Measurements in Mortise view
• Talar tilt
  • line drawn parallel to articular
    surface of distal tibia;
          - se...
Syndesmotic disruption:
• On the AP radiograph syndesmotic disruption
  is indicated by a
  • Tibial Clear Space >5mm
  • ...
AP View:
Widened medial clear
space


Mortise View:
Open mortise
(decreased tib-fib
overlap)


= Syndesmotic injury


= Su...
25 y/o volleyball player
“landed wrong” on the
right foot, “hurting” the
ankle

Radiograph shows positive
talar tilt stres...
25 y/o male tennis player
“torqued” his right ankle




        Grade III ATFL
        ankle sprain
Ankle Fracture Classification
• Danis-Weber Classification
  • Defined by location of the
    fracture line

      • Type ...
AO classification:

 • Similar to Danis-Weber scheme

 • Takes into account damage to other structures
   (usually medial ...
Pott’s classification:

 • First degree
   • unimalleolar
 • Second degree
   • bimalleolar
 • Third degree
   • trimalleo...
Weber Type A
lateral
malleolar
fracture


Treat
conservatively
28 y/o M who “twisted”
                         his left ankle while
                         playing basketball 1 day
   ...
Mortise view:
Weber C
fracture with
open mortise
and widened
medial clear
space
= deltoid &
syndesmotic
ligament
tears, wi...
Fractures
• Medial or Lateral Malleolar fracture
• Bimalleolar fracture
• Trimalleolar fracture
• Pilon fracture
• Pott’s ...
• MEDIAL MALLEOLUS
  FRACTURE AND
  ASSOCIATED DISTAL
  FIBULA FRACTURE.
  AP Ankle. Note the
  medial malleolus fracture
...
• LATERAL MALLEOLUS
  FRACTURE.
   Medial Oblique Ankle.
   Note the most common
  fracture of the lateral
  malleolus is ...
BIMALLEOLAR
FRACTURE.
AP Ankle.
 Note the
characteristic
transverse
fracture through
the medial
malleolus
(arrow), along
w...
Trimalleolar Fractures
• Unstable
  • Multiple ligamentous injuries
  • Usually involves syndesmosis

• Treatment
  • Post...
Pott’s Fracture
Pott’s fracture, as classically
described, is a partial
dislocation of the ankle, with
fracture of the fib...
Pilon (tibial plafond) fractures

                   • Fracture of distal tibial
                     metaphysis
         ...
Maisonneuve Fracture
• This fracture is caused by forceful
  inversion and external rotation of
  the ankle.
• This motion...
Dupuytren’s
fracture,
is a fracture of the
distal fibula (lateral
malleolus) with rupture
of the distal tibiofibular
ligam...
Dupuytren’s fracture
                • Mechanism similar
                  to Maisonneuve
                  fracture.
    ...
Tillaux Fracture
• Salter Harris III fracture involving avulsion of
  anterolateral tibial epiphysis.
  • Occurs in older ...
Toddler’s Fracture
Toddler’s fracture, an
undisplaced spiral fracture of
the tibia, occurs in children from
9 months to 3 ...
Ankle effusion: tear drop sign




                NORMAL                                 WITH EFFUSION
An ankle effusion ...
Soft Tissue Swelling over the Lateral Malleolus




     NORMAL                 MILD               MODERATE             SE...
Achille's Tendon Rupture




                                     This patient has a
Normal Kager's fat pad with
         ...
This patient presented to the
Emergency Department following
a fall from a ladder. Note that
Kager's fat pad is abnormal
s...
This 55 year old lady presented
to the Emergency Department
with a boggy infected area of
skin over her Achilles tendon.
T...
This patient presented to the ED
following a sports injury to the left
ankle. On examination, the patient
was unable to we...
The orientation of the
possible fibula fracture
demonstrated on the
lateral projection image
suggested that an AP ankle
po...
Diagnosis?


Charcot’s foot
Thank you.
Ankle joint radiography
Ankle joint radiography
Ankle joint radiography
Ankle joint radiography
Ankle joint radiography
Ankle joint radiography
Ankle joint radiography
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Ankle joint radiography

  1. 1. ANKLE JOINT RADIOGRAPHY By Dr. Nikhil Murkey
  2. 2. The Ottawa Ankle Rules (OAR) • The commonly used criteria for predicting which patients require radiographic images. • Radiographs are only required for those patients with • tenderness at the posterior edge or tip of the medial or lateral malleolus. • inability to bear weight (4 steps) either immediately after the injury or in the emergency room. • pain at the base of the fifth metatarsal
  3. 3. Projections • Three main projections: • AP • Identifies fractures of malleoli, distal tibia/fibula, plafond, talar dome, body and lateral process of talus, calcaneus. • Mortise • Ankle 15-35 degrees internal rotation (20-25-degrees commonly used). • Evaluate articular surface between talar dome and mortise. • Lateral: • Identifies fractures of anterior/posterior tibial margins, talar neck, displacement of talus. • Other views like AP ankle plantar flexion view, medial oblique foot view, AP of proximal fibula, etc. may also be required in conjunction with above mentioned views.
  4. 4. Antero-posterior view The ankle is slightly dorsiflexed so that the plantar surface of the foot is perpendicular to the film, which brings the weight-bearing talar surface into optimum tangential projection. Internally rotate the lower leg so that a line through the malleoli is parallel with the film surface.
  5. 5. Measurements in AP view • Tibial shaft line (A). A line is drawn through and parallel to the tibial shaft. • Medial malleolus line (B). A line is drawn tangential to the articular surface of the medial malleolus. • Lateral malleolus line (C). A line is drawn tangential to the articular surface of the lateral malleolus. • Talus line (D). A line is drawn tangential to the articular surface of the talar dome. • Tibial angle (I). The angle is formed medially between the medial malleolus line and talus line. • Fibular angle (II). The angle is formed laterally between the lateral malleolus line and talus line. Angle Average (°) Min (°) Max (°) These angles will be altered in fractures of Tibial (I) 53 45 65 the malleoli, ankle mortise instability, and Fibular (II) 52 43 63 tibiotalar slant deformities.
  6. 6. Measurements in AP view • Tibio-fibular clear space: - tibiofibular clear space is the cartilaginous space between lateral border of posterior tibia (incisura fibularis) & medial border of fibula, measured 1 cm above the joint line; - normally the clear space is less than 5-6 mm on both AP and Mortise views. (increase indicates syndesmotic and deltoid disruption). • Tibio-fibular overlap: - should be greater than 6 mm or 42% of fibular width. • Superior clear space: Difference in width of superior clear space between medial & lateral sides of joint should be < 2 mm
  7. 7. Measurements in AP view Talar Tilt:- difference in width of superior clear space between medial & lateral sides Tib-fib Clear Space > 5mm or of joint should be < 2 mm Tib-fib Overlap < 10mm may indicate syndesmotic injury > 2 degrees angulation may indicate medial or lateral disruption
  8. 8. Specialized Projections (AP) • Plantar flexion view (lazy AP view): For subtle fractures of the talar dome, including osteochondritis dissecans, plantar flexion will often demonstrate the fracture site as the posterior articular surface comes into view. • Inversion-eversion stress views: The stress is induced by a third person, who wears lead gloves and lead apron, or by the patient, who holds a strap that is looped around the sole of the foot. The views should be performed and measurements compared bilaterally. • Joint stability is defined by less than 5 deg difference between the injured and uninjured sides. • Weight-bearing AP view: Performed AP and weight bearing with a horizontal beam. This is especially valuable in showing degenerative decreased joint space and chronic instability with lateral talar tilt or lateral shift. Diastasis of the distal tibiofibular syndesmosis may also be more apparent as a widened joint with lack of tibiofibular overlap.
  9. 9. Radiographic Stress Tests of the Ankle • Talar Tilt Stress Test • Contralateral ankle used for comparison • Line is drawn across the talar dome and tibial vault • Degree of lateral opening angle is measured • Normal tilt is less than 5 deg • Considered abnormal if tilt greater than 10 deg (indicator of lateral ligament injury). • Standing Talar Tilt Stress Test: • may be more sensitive • Patient stands on an inversion stress platform with the foot and ankle in 40 deg of plantar flexion and 50 deg of inversion • External Rotation Stress Test Evaluates syndesmoses & deep deltoid ligaments
  10. 10. Lateral View of the Ankle • The lateral surface of the ankle is in contact with the film, with the foot slightly dorsiflexed. Cross the opposite leg over the leg being examined, and support the opposite knee to avoid rotation of the ankle.
  11. 11. Lateral View of the Ankle Posterior tibial Dome of the talus: tuberosity fractures centered under & direction of fibular and congruous injuries can be with tibial plafond identified Avulsion fractures of the talus by the anterior Any deformity capsule can to the be identified talus, calcaneu s or subtalar joint
  12. 12. Measurements in Lateral view • Heel-Pad measurement: • The shortest distance between the plantar surface of the calcaneus and external skin contour is measured. • Increased skin thickness, especially of the heel pad, is a frequent accompanying feature of acromegaly. • Achilles tendon thickness can be assessed on a lateral view at 1-2 cm above the calcaneus and is normally 4-8 mm in dimension. Edema from inflammatory arthritis can thicken the ligament. Average Maximum Sex (mm) (mm) Male 19 25 Female 19 23
  13. 13. Measurements in Lateral view Boehler’s Angle: • The three highest points on the superior surface of the calcaneus are connected with two tangential lines. The angle formed posteriorly is then assessed. • The angle formed posteriorly averages between 30° and 35° in most normal subjects but may range between 28° and 40° • The most common cause for an angle < 28° is a fracture with displacement through the calcaneus. Dysplastic development of the calcaneus may also disturb the angle.
  14. 14. Specialized Projections (Lateral) • Drawer view: A third person, who wears lead gloves and a lead apron, stabilizes the tibia and pulls the hind foot forward. • Flexion-extension (dancer views): These can be performed with or without weight bearing with the foot on maximal plantar and then dorsiflexion for demonstrating bony impaction anteriorly and posteriorly as a sign of impingement syndromes. • Lunge’s view: Performed weight bearing in plantar flexion, the view demonstrates the degree of impaction of the anterior tibial margin to the neck of the talus, as part of the assessment for anterior impingement syndrome. • Lazy lateral: The posterior tibial margin is a frequent site of fracture and can be best demonstrated in an off-lateral projection, with slight external rotation of the foot. In addition, signs of posterior impingement syndrome can be shown to advantage at the posterior talus and os trigonum.
  15. 15. Radiographic Stress Tests of the Ankle • Anterior Drawer Test • The anterior drawer test evaluates ATFL integrity. • Abnormal anterior translation is between 5 to 10 mm, or 3 mm more than other side
  16. 16. Mortise view • The ankle is slightly dorsiflexed so that the plantar surface of the foot is perpendicular to the film. The lower leg is then internally rotated so that the intermalleolar line forms an angle of 35° with the film. • The amount of medial rotation is open to variation, with some advocating views at 20°, 35°, and 45° to demonstrate the mortise
  17. 17. Mortise X-Ray • This is an important view in the assessment of the post-traumatic ankle for detecting subtle fractures of the distal fibula, posterior tibia, talar dome, and base of the fifth metatarsal
  18. 18. Measurements in Mortise view • Medial clear space • Between lateral border of medial malleous and medial talus • <4mm is normal • >4mm suggests lateral shift of talus • Tibiofibular overlap: should normally be more than 1 mm
  19. 19. Measurements in Mortise view • Talo-crural angle is formed by: - line drawn parallel to articular surface of distal tibia - line connecting tips of both malleoli (intermalleollar line). - this angle is normally 8 - 15 degrees. - alternative method: - angle formed by perpendicular to tibial articular surface & intermalleollar line. - this angle is normally between 75 and 87 degrees. - Shortening: - by either method this angle should be within 2 - 5 deg of opposite side. - difference of greater than this indicates fibular shortening.
  20. 20. Measurements in Mortise view • Talar tilt • line drawn parallel to articular surface of distal tibia; - second line drawn parallel to talar surface • Both lines should be parallel to each other and normal tilt angle is 0 deg (range 1.5 to 1.5 deg) • alternative method: - angle between intermalleolar line & each of these two articular surface lines is measured; - difference between these two angles is the talar tilt;
  21. 21. Syndesmotic disruption: • On the AP radiograph syndesmotic disruption is indicated by a • Tibial Clear Space >5mm • Tibio Fibular Overlap <10mm • On the mortise view a • Tibio Fibular Overlap <1mm
  22. 22. AP View: Widened medial clear space Mortise View: Open mortise (decreased tib-fib overlap) = Syndesmotic injury = Surgical referral
  23. 23. 25 y/o volleyball player “landed wrong” on the right foot, “hurting” the ankle Radiograph shows positive talar tilt stress view Lateral ligament tears -ATFL -CFL
  24. 24. 25 y/o male tennis player “torqued” his right ankle Grade III ATFL ankle sprain
  25. 25. Ankle Fracture Classification • Danis-Weber Classification • Defined by location of the fracture line • Type A: below the tibiotalar joint • Type B: at the level of the tibiotalar joint • Type C: above the tibiotalar joint • Syndesmotic ligament compromise • Lauge-Hansen Classification • Infrequently used, clinically; mostly academic
  26. 26. AO classification: • Similar to Danis-Weber scheme • Takes into account damage to other structures (usually medial malleolous) • ~2 pages of classifications
  27. 27. Pott’s classification: • First degree • unimalleolar • Second degree • bimalleolar • Third degree • trimalleolar
  28. 28. Weber Type A lateral malleolar fracture Treat conservatively
  29. 29. 28 y/o M who “twisted” his left ankle while playing basketball 1 day ago Danis-Weber Type B fibular ankle fracture
  30. 30. Mortise view: Weber C fracture with open mortise and widened medial clear space = deltoid & syndesmotic ligament tears, with fracture = surgical referral
  31. 31. Fractures • Medial or Lateral Malleolar fracture • Bimalleolar fracture • Trimalleolar fracture • Pilon fracture • Pott’s fracture • Maisonneuve’s fracture • Dupuytren’s fracture • Tillaux fracture • Toddlers fracture
  32. 32. • MEDIAL MALLEOLUS FRACTURE AND ASSOCIATED DISTAL FIBULA FRACTURE. AP Ankle. Note the medial malleolus fracture (arrowhead) and an oblique fracture of the distal fibula, along with lateral displacement of the talus. The linear subchondral radiolucency in the talar dome (arrows) is a radiographic sign for an intact blood supply to the talus (Hawkin’s sign), which represents the unlikelihood of complicating avascular necrosis.
  33. 33. • LATERAL MALLEOLUS FRACTURE. Medial Oblique Ankle. Note the most common fracture of the lateral malleolus is an oblique fracture extending upward (arrow). This fracture is best seen on the medial oblique projection • These fractures occurs as a result of outward or external rotation of the foot and is best observed on the medial oblique projection as a radiolucent oblique line with adjacent soft tissue swelling (McKenzie’s sign)
  34. 34. BIMALLEOLAR FRACTURE. AP Ankle. Note the characteristic transverse fracture through the medial malleolus (arrow), along with a spiral fracture of the lateral malleolus (arrowhead).
  35. 35. Trimalleolar Fractures • Unstable • Multiple ligamentous injuries • Usually involves syndesmosis • Treatment • Posterior slab • Urgent orthopedic consultation • ORIF
  36. 36. Pott’s Fracture Pott’s fracture, as classically described, is a partial dislocation of the ankle, with fracture of the fibula within 6-7 cm above the lateral malleolus and rupture of the distal tibiofibular ligaments of the ankle.
  37. 37. Pilon (tibial plafond) fractures • Fracture of distal tibial metaphysis • Often comminuted • Often significant other injuries • Mechanism • Axial load • Position of foot determines injury • Treatment • Unstable • X-ray tib/fib & ankle • Orthopedic consultation Source:Rosen
  38. 38. Maisonneuve Fracture • This fracture is caused by forceful inversion and external rotation of the ankle. • This motion forces the talus laterally against the fibula ( d/t either deltoid ligament tear or avulsion fracture of medial malleolus), initially producing rupture of the inferior tibiofibular syndesmosis. As the force is maintained, the fibula, freed from the tibia, continues to be displaced laterally and posteriorly. The superior tibiofibular joint, remaining intact, secures the proximal fibula so that the long lever of the fibula produces a fracture of the fibula in its proximal third.
  39. 39. Dupuytren’s fracture, is a fracture of the distal fibula (lateral malleolus) with rupture of the distal tibiofibular ligaments, diastasis of the syndesmosis, lateral dislocation of the talus, and displacement of the foot upward and outward.
  40. 40. Dupuytren’s fracture • Mechanism similar to Maisonneuve fracture. • Posterior tib-fib ligament ruptures • Interosseous membrane rips • Gross diastasis
  41. 41. Tillaux Fracture • Salter Harris III fracture involving avulsion of anterolateral tibial epiphysis. • Occurs in older adolescents, after the middle and medial parts of epiphyseal plate has closed, but before the lateral part closes (usually 12 to 15 yrs of age). • Fracture occurs after medial part of the epiphyseal plate has closed, but before the lateral part closes; resultant fracture through epiphyseal plate runs across epiphysis and distally into the joint, creating SH type 3 or 4 fracture. • External rotation forces stresses on anterior tibiofibular ligament, causing avulsion of distal tibial epiphyseal plate anterolaterally; further lateral rotation causes displacement of fracture.
  42. 42. Toddler’s Fracture Toddler’s fracture, an undisplaced spiral fracture of the tibia, occurs in children from 9 months to 3 years of age. It is caused by a fall or by the child getting a foot caught between the slats of the crib and then rolling over. The baby, often too young to verbalize its complaints, may evidence only a mysterious refusal to bear weight on the extremity.
  43. 43. Ankle effusion: tear drop sign NORMAL WITH EFFUSION An ankle effusion suggests a significant injury to the ankle joint. The anterior and posterior extra-capsular region of a normal ankle joint should appear as a fat-like density. In the presence of an ankle effusion, the capsule can become distended and may appear to have a more fluid-like density
  44. 44. Soft Tissue Swelling over the Lateral Malleolus NORMAL MILD MODERATE SEVERE • An extreme amount of soft tissue swelling does not necessarily indicate a fracture is present and is frequently seen in severe sprain injuries (tendon/ligament injuries). • In equivocal cases where you are suspecting a lateral malleolus fracture and there is little or no soft tissue swelling laterally, you would lean towards a diagnosis of no fracture.
  45. 45. Achille's Tendon Rupture This patient has a Normal Kager's fat pad with ruptured Achilles tendon clearly delineated normal Achilles (white arrow). Note the tendon changes in Kager's Fat Pad (black arrow)
  46. 46. This patient presented to the Emergency Department following a fall from a ladder. Note that Kager's fat pad is abnormal showing increased density and indistinct margins. There also appears to be a large ankle effusion. These soft tissue signs should lead you to undertake a careful examination of the bony anatomy. The patient has a fractured calcaneum.
  47. 47. This 55 year old lady presented to the Emergency Department with a boggy infected area of skin over her Achilles tendon. The patient was referred for ankle radiography with a view to establishing whether there was an underlying osteomyelitis. The infection clearly involves the deeper soft tissues with almost complete obscuration of Kagers fatpad. There is no evidence of osteomyelitis.
  48. 48. This patient presented to the ED following a sports injury to the left ankle. On examination, the patient was unable to weightbear . Swelling over the lateral malleolus of the ankle was visible clinically and radiographically. The lateral view demonstrates * an ankle effusion- (white arrows) * abnormal Kager's fat pad (grey arrow) * suggestion of fracture or accessory ossification centre (os subfibulare)- black arrow The combination of patient history, clinical signs, soft tissue signs and equivocal evidence of a fracture was sufficient for the radiographer to perform additional views
  49. 49. The orientation of the possible fibula fracture demonstrated on the lateral projection image suggested that an AP ankle position with cephalic tube angulation might align the X-ray beam with the plane of the fracture.
  50. 50. Diagnosis? Charcot’s foot
  51. 51. Thank you.
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IMA Nashik Ankle Meet

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