Frequently Missed Findings in Acute Ankle Injury

Abstract

Most acute ankle injuries involve the lateral ligament complex. There are several other structures that can be injured during acute ankle trauma and therefore can be responsible for the patient's acute presentation or for continuing pain. Some of these injuries are less common than others and thus can be more frequently missed during the initial patient presentation. Continued pain and disability following acute ankle trauma that is not responding to routine conservative treatment should alert the clinician and the radiologist for the possibility of injuries other than the common lateral ligament sprain. In this article we describe those injuries that are often overlooked during acute ankle assessment. These include the less common ankle ligaments injuries, fractures, and tendon-related abnormalities.

Keywords

Ankle injury - missed - ligament - fracture - tendon

• References

• 1 Kannus P, Renström P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am 1991; 73 (2) 305-312
• 2 Birrer RB, Fani-Salek MH, Totten VY, Herman LM, Politi V. Managing ankle injuries in the emergency department. J Emerg Med 1999; 17 (4) 651-660
• 3 Mansour R, Jibri Z, Kamath S, Mukherjee K, Ostlere S. Persistent ankle pain following a sprain: a review of imaging. Emerg Radiol 2011; 18 (3) 211-225
• 4 Renstrom PA. Persistently painful sprained ankle. J Am Acad Orthop Surg 1994; 2 (5) 270-280
• 5 Broström L. Sprained ankles. 3. Clinical observations in recent ligament ruptures. Acta Chir Scand 1965; 130 (6) 560-569
• 6 Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998; 19 (10) 653-660
• 7 McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 2013; 21 (6) 1328-1337
• 8 Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat 2003; 25 (5–6) 379-386
• 9 Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med 1991; 19 (3) 294-298
• 10 Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 1995; 77 (6) 847-856
• 11 Vogl TJ, Hochmuth K, Diebold T , et al. Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Invest Radiol 1997; 32 (7) 401-409
• 12 Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int 1995; 16 (3) 128-131
• 13 Beumer A, van Hemert WL, Niesing R , et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 2004; (423) 227-234
• 14 Milz P, Milz S, Putz R, Reiser M. 13 MHz high-frequency sonography of the lateral ankle joint ligaments and the tibiofibular syndesmosis in anatomic specimens. J Ultrasound Med 1996; 15 (4) 277-284
• 15 Milz P, Milz S, Steinborn M, Mittlmeier T, Putz R, Reiser M. Lateral ankle ligaments and tibiofibular syndesmosis. 13-MHz high-frequency sonography and MRI compared in 20 patients. Acta Orthop Scand 1998; 69 (1) 51-55
• 16 Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Refresher Courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics 2000; 20 ( Spec No): S153-S179
• 17 Cheung Y, Rosenberg ZS. MR imaging of ligamentous abnormalities of the ankle and foot. Magn Reson Imaging Clin N Am 2001; 9 (3) 507-531 , x
• 18 Brown KW, Morrison WB, Schweitzer ME, Parellada JA, Nothnagel H. MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 2004; 182 (1) 131-136
• 19 Kim S, Huh YM, Song HT , et al. Chronic tibiofibular syndesmosis injury of ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging. Radiology 2007; 242 (1) 225-235
• 20 Lektrakul N, Chung CB , Lai Ym, et al. Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology 2001; 219 (3) 802-810
• 21 Balen PF, Helms CA. Association of posterior tibial tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging. AJR Am J Roentgenol 2001; 176 (5) 1137-1143
• 22 Taillard W, Meyer JM, Garcia J, Blanc Y. The sinus tarsi syndrome. Int Orthop 1981; 5 (2) 117-130
• 23 Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology 1993; 186 (1) 233-240
• 24 Huang CK, Kitaoka HB, An KN, Chao EY. Biomechanical evaluation of longitudinal arch stability. Foot Ankle 1993; 14 (6) 353-357
• 25 Kitaoka HB, Ahn TK, Luo ZP, An KN. Stability of the arch of the foot. Foot Ankle Int 1997; 18 (10) 644-648
• 26 Mengiardi B, Zanetti M, Schöttle PB , et al. Spring ligament complex: MR imaging-anatomic correlation and findings in asymptomatic subjects. Radiology 2005; 237 (1) 242-249
• 27 Toye LR, Helms CA, Hoffman BD, Easley M, Nunley JA. MRI of spring ligament tears. AJR Am J Roentgenol 2005; 184 (5) 1475-1480
• 28 Mansour R, Teh J, Sharp RJ, Ostlere S. Ultrasound assessment of the spring ligament complex. Eur Radiol 2008; 18 (11) 2670-2675
• 29 Chhabra A, Subhawong TK, Carrino JA. MR imaging of deltoid ligament pathologic findings and associated impingement syndromes. Radiographics 2010; 30 (3) 751-761
• 30 Shibuya N, Ramanujam CL, Garcia GM. Association of tibialis posterior tendon pathology with other radiographic findings in the foot: a case-control study. J Foot Ankle Surg 2008; 47 (6) 546-553
• 31 Borton DC, Saxby TS. Tear of the plantar calcaneonavicular (spring) ligament causing flatfoot. A case report. J Bone Joint Surg Br 1997; 79 (4) 641-643
• 32 Chen JP, Allen AM. MR diagnosis of traumatic tear of the spring ligament in a pole vaulter. Skeletal Radiol 1997; 26 (5) 310-312
• 33 Subhas N, Sundaram M. Diagnosis: isolated spring ligament tear demonstrated on magnetic resonance imaging. Orthopedics 2007; 30 (1) 1 , 70–72
• 34 Tryfonidis M, Jackson W, Mansour R , et al. Acquired adult flat foot due to isolated plantar calcaneonavicular (spring) ligament insufficiency with a normal tibialis posterior tendon. Foot Ankle Surg 2008; 14 (2) 89-95
• 35 Weerts B, Warmerdam PE, Faber FW. Isolated spring ligament rupture causing acute flatfoot deformity: case report. Foot Ankle Int 2012; 33 (2) 148-150
• 36 Yao L, Gentili A, Cracchiolo A. MR imaging findings in spring ligament insufficiency. Skeletal Radiol 1999; 28 (5) 245-250
• 37 Desai KR, Beltran LS, Bencardino JT, Rosenberg ZS, Petchprapa C, Steiner G. The spring ligament recess of the talocalcaneonavicular joint: depiction on MR images with cadaveric and histologic correlation. AJR Am J Roentgenol 2011; 196 (5) 1145-1150
• 38 Harish S, Jan E, Finlay K , et al. Sonography of the superomedial part of the spring ligament complex of the foot: a study of cadavers and asymptomatic volunteers. Skeletal Radiol 2007; 36 (3) 221-228
• 39 Harper MC. Deltoid ligament: an anatomical evaluation of function. Foot Ankle 1987; 8 (1) 19-22
• 40 Klein MA. MR imaging of the ankle: normal and abnormal findings in the medial collateral ligament. AJR Am J Roentgenol 1994; 162 (2) 377-383
• 41 Muhle C, Frank LR, Rand T , et al. Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 1999; 19 (3) 673-683
• 42 Mengiardi B, Pfirrmann CW, Vienne P, Hodler J, Zanetti M. Medial collateral ligament complex of the ankle: MR appearance in asymptomatic subjects. Radiology 2007; 242 (3) 817-824
• 43 Noto AM, Cheung Y, Rosenberg ZS, Norman A, Leeds NE. MR imaging of the ankle: normal variants. Radiology 1989; 170 (1 Pt 1) 121-124
• 44 Deland JT, de Asla RJ, Sung IH, Ernberg LA, Potter HG. Posterior tibial tendon insufficiency: which ligaments are involved?. Foot Ankle Int 2005; 26 (6) 427-435
• 45 Stiell I, Wells G, Laupacis A , et al; Multicentre Ankle Rule Study Group. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ 1995; 311 (7005) 594-597
• 46 Kelly AM, Richards D, Kerr L , et al. Failed validation of a clinical decision rule for the use of radiography in acute ankle injury. N Z Med J 1994; 107 (982) 294-295
• 47 Warren NP, Knottenbelt JD. The Ottawa Ankle Rules and missed fractures of the talus. Emerg Med J 2001; 18 (6) 521
• 48 Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Foot Ankle Int 1999; 20 (12) 789-793
• 49 Keene JS, Lange RH. Diagnostic dilemmas in foot and ankle injuries. JAMA 1986; 256 (2) 247-251
• 50 Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?. J Bone Joint Surg Br 2005; 87 (1) 41-46
• 51 Schibany N, Ba-Ssalamah A, Marlovits S , et al. Impact of high field (3.0 T) magnetic resonance imaging on diagnosis of osteochondral defects in the ankle joint. Eur J Radiol 2005; 55 (2) 283-288
• 52 Schmid MR, Pfirrmann CW, Hodler J, Vienne P, Zanetti M. Cartilage lesions in the ankle joint: comparison of MR arthrography and CT arthrography. Skeletal Radiol 2003; 32 (5) 259-265
• 53 El-Khoury GY, Alliman KJ, Lundberg HJ, Rudert MJ, Brown TD, Saltzman CL. Cartilage thickness in cadaveric ankles: measurement with double-contrast multi-detector row CT arthrography versus MR imaging. Radiology 2004; 233 (3) 768-773
• 54 Bonvin F, Montet X, Copercini M, Martinoli C, Bianchi S. Imaging of fractures of the lateral process of the talus, a frequently missed diagnosis. Eur J Radiol 2003; 47 (1) 64-70
• 55 Boon AJ, Smith J, Zobitz ME, Amrami KM. Snowboarder's talus fracture. Mechanism of injury. Am J Sports Med 2001; 29 (3) 333-338
• 56 Paulos LE, Johnson CL, Noyes FR. Posterior compartment fractures of the ankle. A commonly missed athletic injury. Am J Sports Med 1983; 11 (6) 439-443
• 57 Kim DH, Berkowitz MJ, Pressman DN. Avulsion fractures of the medial tubercle of the posterior process of the talus. Foot Ankle Int 2003; 24 (2) 172-175
• 58 Nakai T, Murao R, Temporin K, Kakiuchi M. Painful nonunion of fracture of the entire posterior process of the talus: a case report. Arch Orthop Trauma Surg 2005; 125 (10) 721-724
• 59 Bhanot A, Kaushal R, Bhan R, Gupta PN, Gupta RK, Bahadur R. Fracture of the posterior process of talus. Injury 2004; 35 (12) 1341-1344
• 60 Hodge JC. Anterior process fracture or calcaneus secundarius: a case report. J Emerg Med 1999; 17 (2) 305-309
• 61 Ouellette H, Salamipour H, Thomas BJ, Kassarjian A, Torriani M. Incidence and MR imaging features of fractures of the anterior process of calcaneus in a consecutive patient population with ankle and foot symptoms. Skeletal Radiol 2006; 35 (11) 833-837
• 62 Pao DG, Keats TE, Dussault RG. Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection. AJR Am J Roentgenol 2000; 175 (2) 549-552
• 63 Le Minor JM. Comparative anatomy and significance of the sesamoid bone of the peroneus longus muscle (os peroneum). J Anat 1987; 151: 85-99
• 64 Wander DS, Galli K, Ludden JW, Mayer DP. Surgical management of a ruptured peroneus longus tendon with a fractured multipartite os peroneum. J Foot Ankle Surg 1994; 33 (2) 124-128
• 65 Pessina R. Os peroneum fracture. A case report. Clin Orthop Relat Res 1988; 227: 261-264
• 66 Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH. Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain. Foot Ankle Int 1994; 15 (3) 112-124
• 67 Brigido MK, Fessell DP, Jacobson JA , et al. Radiography and US of os peroneum fractures and associated peroneal tendon injuries: initial experience. Radiology 2005; 237 (1) 235-241
• 68 Sammarco GJ. Peroneus longus tendon tears: acute and chronic. Foot Ankle Int 1995; 16 (5) 245-253
• 69 Brandes CB, Smith RW. Characterization of patients with primary peroneus longus tendinopathy: a review of twenty-two cases. Foot Ankle Int 2000; 21 (6) 462-468
• 70 Vainio K. The rheumatoid foot; a clinical study with pathological and roentgenological comments. Ann Chir Gynaecol Fenn Suppl 1956; 45 (1) 1-107
• 71 Truong DT, Dussault RG, Kaplan PA. Fracture of the os peroneum and rupture of the peroneus longus tendon as a complication of diabetic neuropathy. Skeletal Radiol 1995; 24 (8) 626-628
• 72 Wang X-T, Rosenberg ZS, Mechlin MB, Schweitzer ME. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features. Radiographics 2005; 25 (3) 587-602
• 73 Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg 2003; 42 (4) 215-220
• 74 Bencardino JT, Rosenberg ZS. Normal variants and pitfalls in MR imaging of the ankle and foot. Magn Reson Imaging Clin N Am 2001; 9 (3) 447-463, x
• 75 Bencardino JT, Rosenberg ZS, Serrano LF. MR imaging features of diseases of the peroneal tendons. Magn Reson Imaging Clin N Am 2001; 9 (3) 493-505, x
• 76 Rosenberg ZS, Beltran J, Cheung YY, Colon E, Herraiz F. MR features of longitudinal tears of the peroneus brevis tendon. AJR Am J Roentgenol 1997; 168 (1) 141-147
• 77 Goodwin MI, O'Brien PJ, Connell DG. Intra-articular fracture of the calcaneus associated with rupture of the peroneus longus tendon. Injury 1993; 24 (4) 269-271
• 78 Cheung Y, Rosenberg ZS, Magee T, Chinitz L. Normal anatomy and pathologic conditions of ankle tendons: current imaging techniques. Radiographics 1992; 12 (3) 429-444
• 79 Fornage BD, Rifkin MD. Ultrasound examination of tendons. Radiol Clin North Am 1988; 26 (1) 87-107
• 80 Thermann H, Hoffmann R, Zwipp H, Tscherne H. The use of ultrasonography in the foot and ankle. Foot Ankle 1992; 13 (7) 386-390
• 81 Nazarian LN, Rawool NM, Martin CE, Schweitzer ME. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Radiology 1995; 197 (1) 275-278
• 82 Church CC. Radiographic diagnosis of acute peroneal tendon dislocation. AJR Am J Roentgenol 1977; 129 (6) 1065-1068
• 83 Oden RR. Tendon injuries about the ankle resulting from skiing. Clin Orthop Relat Res 1987; (216) 63-69
• 84 Szczukowski Jr M, St Pierre RK, Fleming LL, Somogyi J. Computerized tomography in the evaluation of peroneal tendon dislocation. A report of two cases. Am J Sports Med 1983; 11 (6) 444-447
• 85 Mota J, Rosenberg ZS. Magnetic resonance imaging of the peroneal tendons. Top Magn Reson Imaging 1998; 9 (5) 273-285
• 86 Shellock FG, Feske W, Frey C, Terk M. Peroneal tendons: use of kinematic MR imaging of the ankle to determine subluxation. J Magn Reson Imaging 1997; 7 (2) 451-454
• 87 Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol 2004; 183 (4) 985-988
• 88 Ouzounian TJ, Myerson MS. Dislocation of the posterior tibial tendon. Foot Ankle 1992; 13 (4) 215-219
• 89 Perlman MD, Wertheimer SJ, Leveille DW. Traumatic dislocations of the tibialis posterior tendon: a review of the literature and two case reports. J Foot Surg 1990; 29 (3) 253-259
• 90 Bencardino J, Rosenberg ZS, Beltran J , et al. MR imaging of dislocation of the posterior tibial tendon. AJR Am J Roentgenol 1997; 169 (4) 1109-1112
• 91 Rolf C, Guntner P, Ekenman I, Turan I. Dislocation of the tibialis posterior tendon: diagnosis and treatment. J Foot Ankle Surg 1997; 36 (1) 63-65
• 92 Scheller AD, Kasser JR, Quigley TB. Tendon injuries about the ankle. Orthop Clin North Am 1980; 11 (4) 801-811
• 93 Ouzounian TJ, Anderson R. Anterior tibial tendon rupture. Foot Ankle Int 1995; 16 (7) 406-410
• 94 Bianchi S, Zwass A, Abdelwahab IF, Zoccola C. Evaluation of tibialis anterior tendon rupture by ultrasonography. J Clin Ultrasound 1994; 22 (9) 564-566