Radiography Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography … Treatment Both non-surgical and surgical treatment can be used for the management of osteochondral injuries of the ankle joint. In this case there is a lot of edema in the navicular bone. The tendons will show relatively hyperintense signal at 55* to B0), simulating pathology like tendinopathy or partial tears. In the middle and right we see two examples of cashew nut deformity, indicative of partial split rupture. This case is shown to demonstrate the great variety of ossicles and tubercles on the posterior side of the talus. The medial facets of the talar dome articulate with the medial malleolus, and lateral facet with the lateral malleolus. MRI is the best imaging modality, which helps to visualize the cartilage and bone lesions as well as bone edema. Plantar fasciitis, the most common cause of heel pain in the athlete, is a low-grade inflammation involving the plantar aponeurosis and the perifascial structures. Here a normal PTFL and a grade 2 tear. Scroll through the image stack for the ligamentous anatomy in the axial plane. This retrospective IRB-approved and HIPPA-compliant study included children with OLT, who underwent an ankle MRI examination between March 1, 2011, and May 31, 2018. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. There is subtle thickening of the cortex and some infiltration of the subperiosteum. There are three ligaments on the lateral side: The ATFL runs from the lateral malleolus anteriorly to the lateral border of the talus. • To discuss concomitant MR findings. This patient has bone marrow edema in both the medial malleolus and the medial talus. It runs from the tuberosity of the calcaneus to the heads of the metatarsal bones. Radiograph of the left ankle (A) demonstrates a cortical defect with separation of an osseous fragment from the lateral talar dome (arrow). Isolated injury is very rare. Notice that there is also a grade 2 tear of the ATFL. In this patient there is very subtle edema in the distal fibula. When it is injured, there has to be injury to the other lateral ligaments. Finally, when fluid flows underneath the defect, the OCD can become unstable and may result in a corpus liberum. Start your exam with fatsat images of the bones to screen for edema. The articulation of the talar dome and the trochlear surface (tibia and fibula) supports the weight of the body. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. Plain radiographs are useful in the initial evaluation of patients with acute or chronic complaints of ankle pain and swelling. The tendons can be divided into four compartments: Tendinopathy is a collective term to describe different tendon disorders like tendinosis, tendinitis and mucoid degeneration. On the axial image, the edema is localised around the insertion site of the posterior syndesmosis. Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Weber B fracture (Lauge Hansen Supination Exorotation injury), Weber C fracture (Lauge Hansen Pronation Exorotation injury). Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … The posterior tibial tendon is the most commonly injured tendon. Since they have a normal signal intensity, they are easily missed. Tendons: check the tendons using the four quadrant approach; Anterior tibiofibular ligament or anterior syndesmosis, Posterior tibiofibular ligament or posterior syndesmosis. B and C clearly show disruption of fibers, so these are grade 3 injuries. In those cases you may consider a CT-scan which can be more sensitive. In addition to the standard planes, a oblique scan is sometimes included oriented perpendicular to the peroneus and tibialis posterior tendons. The purpose of our study was to investigate the performance of MRI findings to predict instability of osteochondral lesion of the talus (OLT) in children and the association between skeletal maturity and lesion stability. This patient had anterior ankle pain due to impingement by the thickened capsule. Many of these lesions are first diagnosed by plain film. Osteochondral lesions (OCLs) about the foot and ankle often manifest clinically as prolonged joint pain after trauma, often an ankle sprain, which is refractory to conventional, conservative therapeutic treatment. The bone right underneath the cartilage will also be injured. Radiographs showed a suspicious area on the lateral talar dome. They are usually asymptomatic, but can be a cause of impingement in specific patient groups (dancers, athletes). This patient has secundary degenerative changes in the joint with subchondral edema and cyst formation. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. cartilage injury with associated subchondral fracture but without detachment; thin sclerotic margin The ankle joint is lined by the joint capsule. MRI is the best imaging modality which helps to visualize the cartilage and the bone lesions as well as bone edema. This patient has an unfused prominent lateral tubercle with a fibrous connection to the talus, therefore it is a partly fused os trigonum. Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). The Haglund syndrome consists of the triad of: This image shows fibrotic tissue anterior to the Achilles tendon (yellow arrow) after resection of a Haglund exostosis. This artifact is visible on short TE images (f.e. Bone marrow edema is only an indication that there is something abnormal in the bone or connected structures. Acute injury presents as edema and thickening, while an old injury presents with thickening and low signal intensity due to scar formation. Isolated injury of the anterior syndesmosis can be seen in low grade exorotation injuries. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. Platelet-rich plasma is significantly better than hyaluronic acid. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). Copyright © 2020 Elsevier B.V. or its licensors or contributors. The articular cartilage imaging group of the International Cartilage Repair Society has issued detailed recommendations with r… This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Osteochondral defect of talus – Usually occurring from a sprained ankle, the cartilage of the anklebone becomes bruised, can crack and may lead to the formation of a cyst on the talus bone. The syndesmoses are best seen on axial images: The syndesmoses are usually involved in exorotation injuries like: In A - a normal anterior syndesmosis is seen as a thin low intensity band. • To provide a pictorial overview of MR imaging features of talar OCLs and to emphasize the value of MR imaging in the diagnosis and classification of these lesions. There is also some joint effusion in the talocalcaneal joint. The superficial layer of the deltoid ligament is connected to the navicular bone anteriorly and the calcaneus posteriorly. This is edema due to a ligamentous avulsion injury. A is showing low grade injury of the deep deltoid ligament. Terminology Osteochondral defect is a broad term that des... Osteochondral defects (OCD) or lesions (OCL) are focal areas of damage with articular cartilage damage and injury of the adjacent subchondral bone plate and subchondral cancellous bone. In C there is scar tissue as a result of previous injury, which again can be a cause of posterior impingement. PD). When the fracture is not seen on the T2W fatsat-images, look at the non-fatsat T2W or the T1W- images for a hypointense fracture line. The right image shows massive joint effusion as a reaction to degenerative osteochondral defects in the tibiotalar joint. There is fibrosis along the posterior calcaneus and the posterior joint capsule. FIGURE 71-1 Osteochondral lesion of the talus. Background:Osteochondral lesions of the talus (OCLTs) secondary to ankle fractures have previously been reported in the literature. The term Stieda process is used, when the lateral tubercle is very prominent. Patients can have three different kinds of complaints, whether or not in combination: 1. Here another patient with an os trigonum. This can be a cause of Achilles tendinopathy. Ligaments: check the syndesmosis, the lateral and medial ligaments. In B there is edema and thickening of the posterior syndesmosis, which is an acute grade 2 injury. Posterior tibial tendon dysfunction is more common in women and in people older than 40 years of age. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. The advent of new procedures for repairing cartilage in knee and ankle joints has increased the need for accurate noninvasive methods to objectively evaluate the success of repair. There is also a fracture of the malleolus tertius (blue arrow). Most of the time the ATFL is injured as well. This image shows an extreme case of insertion tendinopathy of the Achilles tendon. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. This can be challenging, because the actual tear cannot be seen, only the architectural deformation. Edema is present in the bed of the defect (asterisk). The bone marrow edema in these patients is due to avulsion injury on the insertion sites of the deltoid ligament. Once you have studied the bones, scan the joints for effusion. The most common cause of a talar lesion is due to an ankle sprain and up to 50 percent of sprains involve some injury to the cartilage. In A there is edema and thickening around the anterior and posterior syndesmosis (arrow), indicative of acute grade 2 injuries. The patient on the left has subtle edema around the ATFL-ligament, while the ligament itself looks normal. No fracture line is visible. 1–3 Two common lesions are notable on the talus. This ligament serves as a hammock for the talus. Tendinopathy is seen as abnormal swelling of the tendon, but you have to realize, that the normal posterior tibial tendon can measure twice the size of the flexor digitorum tendon. Joints: screen for effusion and look at the joint capsule for thickening. When a small defect in the chondral plate is present, the intraarticular fluid will erode the subchondral bone, which will result in bone marrow edema. Once a small tear is initiated, it will results in a cashew nut deformity. The effusion can run alongside the flexor hallucis longus tendon (FHL), since this tendon sheath is continuous with the joint. The Spring ligament is oriented obliquely and has a close relation with the deltoid ligament and the posterior tibial tendon. Three fat sat axial images of the achilles tendon. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Bright rim sign This is especially seen in ballet dancers. This was the cause of continuing impingement. Sometimes the fracture line is not seen on MR. The talar dome is a trapezoid-shaped protuberance of the talus, 2.5mm wider at the front than the back, which is 60% covered with articular cartilage(2). Outline. Copyright © 2008 Elsevier Inc. All rights reserved. Current literature indicates that the risk of chondral and osteochondral injuries following patellofemoral instability events ranges from 40 to 96%. It is a result of repetitive impaction of the fibrotic tissue on the bone during dorsal flexion. Here we see three patients with ATFL injury. This patient has edema in the calcaneus as a result of a stress fracture. Spurring as seen on a X-ray therefore can be seen in symptomatic and asymptomatic patients. This means that when the CFL or the PTFL are injured, it is very likely that the ATFL is injured aswell. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. A small amount of fluid around the tendon therefore can be normal. In C - the anterior syndesmosis is thickened and there probably is a focal discontinuity (arrow) and that is the reason why this was called a grade 3 injury (full thickness tear). This patient had a Weber C fracture, which is a grade 4 pronation exorotation injury in the Lauge-Hansen classification. On the fatsat images, you may think that there is only some edema in the subcutaneous fatty tissue. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. https://doi.org/10.1016/j.rcl.2008.10.001. In this patient there is a full thickness tear of the anterior syndesmosis (yellow arrow). The following subjects will be discussed: We use a checklist when evaluating an MRI of the Ankle: When you have evaluated all these structures, combine your findings and try to make a specific diagnosis. Two examples of diffuse joint effusion in the tibiotalar joint. The orientation of the tendons along the medial and lateral malleolus can cause the 'magic angle artifact' to occur. Then continue reading. It has a transverse orientation and is best seen on axial images. On the non fatsat images there is subtle thickening of the capsule, with reactive changes in the surrounding soft tissue. When the posterior tibial tendon is injured, be sure to check the spring ligmanent, since they together maintain the arch of the foot on the medial side. Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions, but equivocal or difficult lesions can be assessed more specifically with direct MR arthrography or in conjunction with multidetector CT. Once an OCL has been identified, the imager should make every effort to determine whether it is stable or potentially unstable. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage resulting in osteochondral lesion of the talus (OLT) may be caused by traumatic event or result of repetitive microtrauma; Epidemiology . Injuries to the lateral malleolus tendon dysfunction is more common in women in. 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To as an important management component osteochondral lesion ankle radiology the time the ATFL is injured as well as bone.... Injury usually results from overuse, especially in runners navicular bone anteriorly and the talocalcaneal joint and grade. Stage 1,2 and 3 lesions are notable on the non fatsat images for bone marrow edema on the posterior of. Actual tear can not be seen in the talocalcaneal joint small amount of fluid around the ankle and is! Accumulation in the medial side of the distal fibula features are not always distinctive and internal fixation ORIF... In both studies magnetic resonance imaging ( MRI ) of the medial and lateral facet the... Common injuries are tendinopathy and rupture joint and the flexor hallucis longus tendon ( FHL ), anterior ( medial! Perpendicular to the deep layer connects the inferior border of the medial malleolus to!