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lateral ankle avulsion fracture radiology
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lateral ankle avulsion fracture radiology
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lateral ankle avulsion fracture radiology
lateral ankle avulsion fracture radiology
Using the Salter-Harris classification as a template, Dias and Tachdjian (35) classified ankle fractures in skeletally immature patients on the basis of the foots position at the time of trauma and the direction of the abnormal force. High grade "sprain" injuries consist of either The right image shows a vertical fracture of the medial malleolus (arrow). 4. The variably sized tibial Thurston-Holland fragment has a predominantly posterior location. Type B injuries involve partial incongruity that affects the first ray in isolation (partial medial incongruity, type B1) or one or more of the lateral four MT bones (partial lateral incongruity, type B2). Things become very easy once you remember the fixed order of the injuries: The injury mechanism that causes a Weber B fracture can stop at any stage. The ankle is a ring structure consisting of the tibia, fibula and the talus. Os sub fibulare is noted (anatomical variant). About 80% of these injuries occur in a plantar-flexed inverted foot, resulting in medial and superior dislocation (65); lateral dislocation results if the foot is everted. Injury mechanisms include both low-impact injuries and high-impact trauma such as a motor vehicle crash or fall from a significant height. https://radiopaedia.org/articles/weber-classification-of-ankle-fractures (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. 28). The rarity of foot fractures among infants and toddlers can be explained by the proportionately larger number of cartilaginous components in their skeleton, which causes the pediatric foot to have high elastic resilience. Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. The closure then extends to the medial side, while the lateral side closes last. Clin Orthop Relat Res. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Babu V, Feger J, Feger J, et al. Lauge-Hansen N. Fractures of the Ankle. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The midfoot consists of five tarsal bones and their articulations. There is also a tertius fracture (stage III). Potential Pathologies Associated with Adolescent Ankle Injuries: MT fractures. Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. In addition, distal phalangeal fractures that extend through the nail matrix (ie, Pinckney fractures) are considered to be open fractures with a high risk of osteomyelitis if they are not treated adequately. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament, The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops, an isolated tertius fracture is very rare. Scroll through the images to see how the injury follows a clockwise fixed order. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). Bernhard Georg Weber. 1998;69(1):43-7. Table 3: Dias-Tachdjian Classification of Physeal Ankle Fractures. Provides insight into the trauma mechanism. If an avulsion fracture is present, there will be immediate pain over the outside aspect of the foot and associated with significant swelling and localised tenderness over the 5th metatarsal. History of the injury will be similar to that of an ankle sprain (plantarflexor inversion). A stage II is considered an unstable ankle fracture. The pronationexternal rotation (Fig 9) fracture pattern manifests as a distal tibial growth plate fracture, frequently with a small laterally based fracture fragment. Joint depression can be assessed at comparisons with the contralateral foot. Figure 24. Certain fracture types have been identified as being associated with an overall higher risk of complications (Table 5). (b) Lateral hindfoot radiograph shows the multipartite, fragmented, sclerotic appearance of a developing calcaneal apophysis. Tibiofibular syndesmotic integrity is usually maintained (46). Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. In such cases, point-of-care US may be helpful for excluding ligament injury (29). Stage IV: rupture of posterior tibiofibular ligament. The practical application of this classification is intended to facilitate closed reduction by immobilizing the ankle in a direction opposite to the direction of the injury. In Weber B stage 2 is stable, but stage 3 and 4 are unstable. Sedentary level activity and low-energy injury were more common in the avulsion fracture group than in the ligament rupture group (77% vs 37%, respectively, P = .001; 68% vs 43%, respectively, P = .004). They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). Foot radiograph findings were unremarkable. Unable to process the form. Navicular Fractures.Navicular bone fractures are often missed. Abstract. Mild effusion in the anterior recess of the ankle joint. As the exorotation force continues the anterior syndesmosis will rupture (stage 2). Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails And just like in a Weber B, you can get injury to the anterior syndesmosis, fibula and finally the posterior syndesmosis. 25). Stage III: rupture of interosseous membrane + high fibular fracture. Distal tibial physeal closure occurs in a unique eccentric pattern (Fig 1) over a period of 18 months, typically between 12 and 15 years of age in girls and between 14 and 18 years of age in boys. Pott P. Some Few General Remarks on Fractures and Dislocations. 27, No. Swelling. Figure 16. Physeal widening was noted at the anterior distal tibia on the accompanying lateral radiograph (not shown). Figure 27. The fracture was not detected on the antero-posterior (AP) view of ankle (Fig. stage 1 which is the medial injury, where it all starts. This case is more challenging.This fibula fracture is at the level of the syndesmosis and maybe some people would call this a Weber B fracture, but it doesn't look like a Weber B. They have a bimodal Either is acceptable. Ankle lateral malleolus avulsion fracture with os subfibulare. This phenomenon most commonly occurs when anatomic reduction has not been achieved, an interfragmentary gap is larger than 3 mm, or an articular cartilage injury has occurred. Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL)and calcaneofibular ligaments (CFL). Associated injury to the peroneus longus tendon may be present. Is there an avulsion of the lateral malleolus. For example, lack of a tibiofibular overlap on the mortise view can be a normal variant in skeletally immature patients and should not be mistaken for syndesmotic disruption. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. Dias-Tachdjian Classification of Ankle Fractures.In the Dias-Tachdjian classification system, radiologic classification models to describe ankle fractures in adults, including the Lauge-Hansen model (34), are used in conjunction with Salter-Harris classifications to describe injury patterns relative to the physis (35). The keystone wedging of the second MT bone into the medial cuneiform bone supports the entire tarsometatarsal articulation. Triplane fractures occur during the early phases of physeal closure, and juvenile Tillaux fractures occur when physeal fusion is almost complete; therefore, neither of these transitional tear types is complicated by significant physeal arrest. This leaflet explains the ongoing management of your injury. Thickening of the anterior talofibular ligament and calcaneofibular ligament without loss of continuity. For example, necrotizing fasciitis can be seen with calcaneal fractures that are related to lawn mower injuries (48). Revista Brasileira de Ortopedia, Vol. Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. Secondary ossification centers of the MT and phalangeal bones develop when a child is aged 624 months, and the calcaneal apophysis develops when a child is aged 5-12 years (13). Primary tibial and fibular ossification is present at birth (11). Premature physeal arrest at the distal tibia is one of the most feared complications; rates of up to 66.7% have been reported in the literature (8082). Figure 19b. You can look at the next images for a discussion of the images. ADVERTISEMENT: Supporters see fewer/no ads. Since this fracture is usually not visible on x-rays of the ankle, you wanna study the ankle x-rays to look for stage 1 and 4, which can be a clue to image the whole lower leg to look for a high fibula fracture. The more lateral of these lines corresponds to the anterior tibia, and the more medial line is the incisura fibularis of the posterolateral tibia articulating with the fibula. The navicular bone articulates with the three cuneiform bones and occasionally the cuboid bone. High twist-like fibula fracture above the level of the syndesmosis. As in each The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament (fig. (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. Normal developmental appearances of the ankle with age in three boys. Normal developmental appearances of the ankle with age in three boys. The ankle is a ring structure consisting of the tibia, fibula and the talus. Below is an example of a pronation-exorotation fracture (fig. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. The Drawings illustrate the triplane fracture types described by Rapariz et al (39). Figure 19a. Most other physeal closures start centrally and expand peripherally. An approach to reading an ankle radiograph can be read here. At first sight it just looks like only a tertius fracture. There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). Please enter your credentials below! This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. Skin tenting signifies soft-tissue injury. An x-ray does not exclude ligament damage. Three standard (AP, oblique, and lateral) radiographic views are usually adequate for the detection of fifth MT fractures. No other fractures were seen. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. Persistent physeal widening to greater than 3 mm seen on coronal and sagittal reformatted CT images signifies periosteal entrapment and requires a surgical treatment approach (24). Figure 13a. In children, snowboarding has been found to be associated with lateral talar process fractures, which are rare (59,60). Although the ankle fork in a Weber B/C fracture is initially symmetrical, there may still be a ligament rupture. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. L = left. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. Local soft tissue was swollen. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. Records the default button state of the corresponding category & the status of CCPA. Ligament damage may be inferred by an abnormal configuration of the ankle fork. II. Growth arrest is uncommon with types I and II Salter-Harris fractures. Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Figure 2a. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. According to Bozic et al (15), the medial clear space on anteroposterior (AP) and mortise radiographic views significantly decreases with age (Fig 2) to less than 4 mm in adults. Accessory centers of ossification adjacent to the ankle and foot bones can mimic avulsion fractures on radiographs. This is a normal developmental variant; there is no associated soft-tissue swelling. 10, No. The cuneiform bones begin to ossify in the 1st postnatal year. In addition, they may be open or closed. Os sub fibulare is noted (anatomical variant). In that case the ankle is unstable and may dislocate. When the x-rays of the ankle show no obvious fracture like a Weber A or B, then the question is: could this be a Weber C fracture? stage 2 is injury to the anterior syndesmosis, which is usually not visible, unless there is a Tillaux fracture. The central portion closes first. 2015;205(5):1061-7. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. Presented as an education exhibit at the 2018 RSNA Annual Meeting. Limping or an inability to walk, if the broken bone is Weber B and Weber C fractures are very different in the type of fibula fracture. Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Talar neck fractures are much more common than talar body fractures, which, in turn, are more common than lateral and posterior process fractures. A sagittally oriented apophysis (white arrow) at the base of the fifth MT bone also is seen. Disruption of the tibiofibular joint seen on static radiographs signifies syndesmotic injury. Various stages (I IV) of trauma mechanism of supination-exorotation according to Lauge-Hansen. Figure 2c. The fracture mechanism that leads to a Weber C fracture is called pronation exorotation or PER and we will discuss it in the next section. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). When we look at the algoritm, you can see, that a tertius can be found in a Weber B fracture in stage 3 and in a Weber C fracture in stage 4. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Cartilaginous precursors of the immature skeleton can cause normal developmental phenomena to be mistaken for injury and injuries to go unrecognized if they involve the cartilage only. These injuries represent approximately 13% of all pediatric osseous injuries. A Salter-Harris type IV fracture of the medial distal tibia (arrow) with a medial Thurston-Holland fragment and some associated comminution also is seen. The deforming mechanism is often supinationexternal rotation, although other mechanisms have been reported (38). Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). The second break can be a fracture or ligament damage (= sprain/tear/rupture). Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. In view of the widened medial clear space, this is a rupture of the medial collateral ligaments (stage IV). Fractures of the cuboid can present with varying swelling and deformity of the lateral midfoot. Fibular fracture under the level of the syndesmosis, Fibular fracture at the level of the syndesmosis. Oblique fibula fracture at level of syndesmosis. The navicular bone ossifies between the ages of 2 and 4 years and may have multiple ossification centers. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. In the Bozic et al study (15), the incisura fibularis appeared at a mean age of approximately 8 years in girls and approximately 11 years in boys. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. A Salter-Harris type II fracture involves at least part of the physis width and a contiguous portion of the metaphysis, which create a so-called wedge-shaped Thurston-Holland fragment, which represents a triangular portion of the metaphysis attached to the epiphysis (25). {"url":"/signup-modal-props.json?lang=us\u0026email="}, Di Muzio B, Ankle lateral malleolus avulsion fracture with os subfibulare. Just by looking at the images, you can understand the trauma mechanism (scroll). A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) 2007;458:40-1. AP radiograph of both legs obtained as part of a skeletal survey for possible nonaccidental trauma shows bilateral bucket-handle fractures (arrows) at the distal tibiae. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest, Centers for Disease Control and Prevention, Factors that Increase Risk of Getting Arthritis. The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. If the force is high enough, the medial malleolus can be pushed away as it were (= vertical fracture) by the rotating talus (stage II) (fig. The osseoligamentous complex of the distal tibiofibular syndesmosis stabilizes the ankle mortise. While their presence usually does not change the therapeutic approach, occasionally a large fragment may require a separate fixation screw. An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. The Ottawa ankle and foot rules (OAFR) (Table 1) represent a clinical decision algorithm for medical imaging in patients suspected of having ankle and midfoot fractures (5). It is our job as radiologists to find clues on the x-rays of the ankle that will lead us to these high fibula fractures and the algoritm will help us. (b) AP radiograph of the right foot in an 8-year-old girl shows contiguous MT fractures: a nondisplaced second MT bone fracture (arrow) and displaced slightly comminuted third and fourth MT bone fractures (arrowheads). 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Using the Salter-Harris classification as a template, Dias and Tachdjian (35) classified ankle fractures in skeletally immature patients on the basis of the foots position at the time of trauma and the direction of the abnormal force. High grade "sprain" injuries consist of either The right image shows a vertical fracture of the medial malleolus (arrow). 4. The variably sized tibial Thurston-Holland fragment has a predominantly posterior location. Type B injuries involve partial incongruity that affects the first ray in isolation (partial medial incongruity, type B1) or one or more of the lateral four MT bones (partial lateral incongruity, type B2). Things become very easy once you remember the fixed order of the injuries: The injury mechanism that causes a Weber B fracture can stop at any stage. The ankle is a ring structure consisting of the tibia, fibula and the talus. Os sub fibulare is noted (anatomical variant). About 80% of these injuries occur in a plantar-flexed inverted foot, resulting in medial and superior dislocation (65); lateral dislocation results if the foot is everted. Injury mechanisms include both low-impact injuries and high-impact trauma such as a motor vehicle crash or fall from a significant height. https://radiopaedia.org/articles/weber-classification-of-ankle-fractures (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. 28). The rarity of foot fractures among infants and toddlers can be explained by the proportionately larger number of cartilaginous components in their skeleton, which causes the pediatric foot to have high elastic resilience. Ankle fractures in children can be broadly categorized as avulsion and physeal fractures. The closure then extends to the medial side, while the lateral side closes last. Clin Orthop Relat Res. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Babu V, Feger J, Feger J, et al. Lauge-Hansen N. Fractures of the Ankle. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously. Injury mechanisms include stubbing or kicking injuries, dropped objects falling on the toe(s), and falls from a height. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The midfoot consists of five tarsal bones and their articulations. There is also a tertius fracture (stage III). Potential Pathologies Associated with Adolescent Ankle Injuries: MT fractures. Ossification of the anterolateral distal tibial metaphysis leads to the creation of two separate lines in this radiographic projection; the more lateral line (not shown) corresponds to the anterior tibia, and the more medial line is the incisura fibularis (white line), which articulates posteriorly with the fibula. In addition, distal phalangeal fractures that extend through the nail matrix (ie, Pinckney fractures) are considered to be open fractures with a high risk of osteomyelitis if they are not treated adequately. Tibiotalar dislocation in a 14-year-old girl that occurred after a trampoline injury. The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament, The ligaments at the medial side of the ankle are exposed to high stress and an avulsion fracture develops, an isolated tertius fracture is very rare. Scroll through the images to see how the injury follows a clockwise fixed order. (a) Mortise radiograph of the ankle in a 2-year-old boy shows a wide medial clear space (black arrow), prominent tibiofibular interval (single-headed white arrow), and small relative fibular width (double-headed arrow). Bernhard Georg Weber. 1998;69(1):43-7. Table 3: Dias-Tachdjian Classification of Physeal Ankle Fractures. Provides insight into the trauma mechanism. If an avulsion fracture is present, there will be immediate pain over the outside aspect of the foot and associated with significant swelling and localised tenderness over the 5th metatarsal. History of the injury will be similar to that of an ankle sprain (plantarflexor inversion). A stage II is considered an unstable ankle fracture. The pronationexternal rotation (Fig 9) fracture pattern manifests as a distal tibial growth plate fracture, frequently with a small laterally based fracture fragment. Joint depression can be assessed at comparisons with the contralateral foot. Figure 24. Certain fracture types have been identified as being associated with an overall higher risk of complications (Table 5). (b) Lateral hindfoot radiograph shows the multipartite, fragmented, sclerotic appearance of a developing calcaneal apophysis. Tibiofibular syndesmotic integrity is usually maintained (46). Salter-Harris type III fracture of the distal tibia in a 13-year-old boy. In such cases, point-of-care US may be helpful for excluding ligament injury (29). Stage IV: rupture of posterior tibiofibular ligament. The practical application of this classification is intended to facilitate closed reduction by immobilizing the ankle in a direction opposite to the direction of the injury. In Weber B stage 2 is stable, but stage 3 and 4 are unstable. Sedentary level activity and low-energy injury were more common in the avulsion fracture group than in the ligament rupture group (77% vs 37%, respectively, P = .001; 68% vs 43%, respectively, P = .004). They are connected by 3 ligaments (the medial/lateral collateral ligaments and the interosseous ligament). Foot radiograph findings were unremarkable. Unable to process the form. Navicular Fractures.Navicular bone fractures are often missed. Abstract. Mild effusion in the anterior recess of the ankle joint. As the exorotation force continues the anterior syndesmosis will rupture (stage 2). Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails And just like in a Weber B, you can get injury to the anterior syndesmosis, fibula and finally the posterior syndesmosis. 25). Stage III: rupture of interosseous membrane + high fibular fracture. Distal tibial physeal closure occurs in a unique eccentric pattern (Fig 1) over a period of 18 months, typically between 12 and 15 years of age in girls and between 14 and 18 years of age in boys. Pott P. Some Few General Remarks on Fractures and Dislocations. 27, No. Swelling. Figure 16. Physeal widening was noted at the anterior distal tibia on the accompanying lateral radiograph (not shown). Figure 27. The fracture was not detected on the antero-posterior (AP) view of ankle (Fig. stage 1 which is the medial injury, where it all starts. This case is more challenging.This fibula fracture is at the level of the syndesmosis and maybe some people would call this a Weber B fracture, but it doesn't look like a Weber B. They have a bimodal Either is acceptable. Ankle lateral malleolus avulsion fracture with os subfibulare. This phenomenon most commonly occurs when anatomic reduction has not been achieved, an interfragmentary gap is larger than 3 mm, or an articular cartilage injury has occurred. Hawkins type II displaced talar neck fracture in a 15-year-old girl with left ankle deformity, ecchymosis, and swelling after she fell from an aerial cheerleading spin and landed on her left leg. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL)and calcaneofibular ligaments (CFL). Associated injury to the peroneus longus tendon may be present. Is there an avulsion of the lateral malleolus. For example, lack of a tibiofibular overlap on the mortise view can be a normal variant in skeletally immature patients and should not be mistaken for syndesmotic disruption. Treatment strategies, whether conservative or surgical, are aimed at restoring articular congruency and functional alignment and, for pediatric patients specifically, protecting the physis. Dias-Tachdjian Classification of Ankle Fractures.In the Dias-Tachdjian classification system, radiologic classification models to describe ankle fractures in adults, including the Lauge-Hansen model (34), are used in conjunction with Salter-Harris classifications to describe injury patterns relative to the physis (35). The keystone wedging of the second MT bone into the medial cuneiform bone supports the entire tarsometatarsal articulation. Triplane fractures occur during the early phases of physeal closure, and juvenile Tillaux fractures occur when physeal fusion is almost complete; therefore, neither of these transitional tear types is complicated by significant physeal arrest. This leaflet explains the ongoing management of your injury. Thickening of the anterior talofibular ligament and calcaneofibular ligament without loss of continuity. For example, necrotizing fasciitis can be seen with calcaneal fractures that are related to lawn mower injuries (48). Revista Brasileira de Ortopedia, Vol. Toddlers with calcaneal stress fractures who are just learning to walk refuse to bear weight. Secondary ossification centers of the MT and phalangeal bones develop when a child is aged 624 months, and the calcaneal apophysis develops when a child is aged 5-12 years (13). Primary tibial and fibular ossification is present at birth (11). Premature physeal arrest at the distal tibia is one of the most feared complications; rates of up to 66.7% have been reported in the literature (8082). Figure 19b. You can look at the next images for a discussion of the images. ADVERTISEMENT: Supporters see fewer/no ads. Since this fracture is usually not visible on x-rays of the ankle, you wanna study the ankle x-rays to look for stage 1 and 4, which can be a clue to image the whole lower leg to look for a high fibula fracture. The more lateral of these lines corresponds to the anterior tibia, and the more medial line is the incisura fibularis of the posterolateral tibia articulating with the fibula. The navicular bone articulates with the three cuneiform bones and occasionally the cuboid bone. High twist-like fibula fracture above the level of the syndesmosis. As in each The syndesmosis consists of the anterior/posterior tibiofibular ligament and the interosseous ligament (fig. (a) AP radiograph of the distal lower extremity, including the ankle, shows medial dislocation at the tibiotalar joint with surrounding soft-tissue swelling. Normal developmental appearances of the ankle with age in three boys. Normal developmental appearances of the ankle with age in three boys. The ankle is a ring structure consisting of the tibia, fibula and the talus. Below is an example of a pronation-exorotation fracture (fig. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. The Drawings illustrate the triplane fracture types described by Rapariz et al (39). Figure 19a. Most other physeal closures start centrally and expand peripherally. An approach to reading an ankle radiograph can be read here. At first sight it just looks like only a tertius fracture. There may be extremely subtle sclerosis or no visible abnormality at radiography, and, thus, MRI may be required (Fig 19). Please enter your credentials below! This is always stage 2 and is unstable, whether you see a fracture of the lateral malleolus or not. Skin tenting signifies soft-tissue injury. An x-ray does not exclude ligament damage. Three standard (AP, oblique, and lateral) radiographic views are usually adequate for the detection of fifth MT fractures. No other fractures were seen. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. Persistent physeal widening to greater than 3 mm seen on coronal and sagittal reformatted CT images signifies periosteal entrapment and requires a surgical treatment approach (24). Figure 13a. In children, snowboarding has been found to be associated with lateral talar process fractures, which are rare (59,60). Although the ankle fork in a Weber B/C fracture is initially symmetrical, there may still be a ligament rupture. The patient presented with ecchymosis of the arch and tenderness at the first and second tarsometatarsal joints. L = left. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. Local soft tissue was swollen. Injuries of the midfoot include fractures of individual bones and fracture dislocations involving the midtarsal (ie, talonavicular and calcaneocuboid) or tarsometatarsal articulations. (a) Coronal fluid-sensitive MR image of the foot shows diffusely high signal intensity (arrow) throughout the navicular bone. Records the default button state of the corresponding category & the status of CCPA. Ligament damage may be inferred by an abnormal configuration of the ankle fork. II. Growth arrest is uncommon with types I and II Salter-Harris fractures. Vallier et al (58) divided Hawkins type II fractures into two subtypes (IIa and IIb) (Fig 17), which are used to predict the development of osteonecrosis. Figure 2a. (b) Accompanying lateral radiograph shows the dislocation at the tibiotalar joint to be posterior. According to Bozic et al (15), the medial clear space on anteroposterior (AP) and mortise radiographic views significantly decreases with age (Fig 2) to less than 4 mm in adults. Accessory centers of ossification adjacent to the ankle and foot bones can mimic avulsion fractures on radiographs. This is a normal developmental variant; there is no associated soft-tissue swelling. 10, No. The cuneiform bones begin to ossify in the 1st postnatal year. In addition, they may be open or closed. Os sub fibulare is noted (anatomical variant). In that case the ankle is unstable and may dislocate. When the x-rays of the ankle show no obvious fracture like a Weber A or B, then the question is: could this be a Weber C fracture? stage 2 is injury to the anterior syndesmosis, which is usually not visible, unless there is a Tillaux fracture. The central portion closes first. 2015;205(5):1061-7. (a) AP radiograph of the ankle shows a distal tibial fracture (single-headed arrow) with lateral displacement and slight angulation of the Tillaux fragment. Presented as an education exhibit at the 2018 RSNA Annual Meeting. Limping or an inability to walk, if the broken bone is Weber B and Weber C fractures are very different in the type of fibula fracture. Both the tibiofibular overlap on AP and mortise views and the relative fibular width on AP views increase with age. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. Talar neck fractures are much more common than talar body fractures, which, in turn, are more common than lateral and posterior process fractures. A sagittally oriented apophysis (white arrow) at the base of the fifth MT bone also is seen. Disruption of the tibiofibular joint seen on static radiographs signifies syndesmotic injury. Various stages (I IV) of trauma mechanism of supination-exorotation according to Lauge-Hansen. Figure 2c. The fracture mechanism that leads to a Weber C fracture is called pronation exorotation or PER and we will discuss it in the next section. (b) Mortise radiograph of the ankle in an 11-year-old boy shows a slight decrease in the medial clear space (black arrow), a narrowed tibiofibular interval (single-headed white arrow) with no overlap yet seen, and a slightly widened distal fibula (double-headed arrow). When we look at the algoritm, you can see, that a tertius can be found in a Weber B fracture in stage 3 and in a Weber C fracture in stage 4. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. Cartilaginous precursors of the immature skeleton can cause normal developmental phenomena to be mistaken for injury and injuries to go unrecognized if they involve the cartilage only. These injuries represent approximately 13% of all pediatric osseous injuries. A Salter-Harris type IV fracture of the medial distal tibia (arrow) with a medial Thurston-Holland fragment and some associated comminution also is seen. The deforming mechanism is often supinationexternal rotation, although other mechanisms have been reported (38). Because the midtarsal talonavicular and calcaneocuboid joints act in unison, they are often injured together (10). The second break can be a fracture or ligament damage (= sprain/tear/rupture). Since repeated attempts at closed reduction can result in physeal damage, they should be performed with caution. In view of the widened medial clear space, this is a rupture of the medial collateral ligaments (stage IV). Fractures of the cuboid can present with varying swelling and deformity of the lateral midfoot. Fibular fracture under the level of the syndesmosis, Fibular fracture at the level of the syndesmosis. Oblique fibula fracture at level of syndesmosis. The navicular bone ossifies between the ages of 2 and 4 years and may have multiple ossification centers. AP upright radiograph of the pelvis and lower extremities obtained for leg length assessment (not shown) showed leg length discrepancy, with the left lower extremity slightly shorter than the right one. In the Bozic et al study (15), the incisura fibularis appeared at a mean age of approximately 8 years in girls and approximately 11 years in boys. (b) Sagittal proton-densityweighted MR image shows a nondisplaced linear fracture (arrow) of the navicular bone. A Salter-Harris type II fracture involves at least part of the physis width and a contiguous portion of the metaphysis, which create a so-called wedge-shaped Thurston-Holland fragment, which represents a triangular portion of the metaphysis attached to the epiphysis (25). {"url":"/signup-modal-props.json?lang=us\u0026email="}, Di Muzio B, Ankle lateral malleolus avulsion fracture with os subfibulare. Just by looking at the images, you can understand the trauma mechanism (scroll). A subgroup of pediatric ankle fractures called transitional fractures occur during the 18-month developmental window (in girls aged 1215 years and boys aged 1418 years) 2007;458:40-1. AP radiograph of both legs obtained as part of a skeletal survey for possible nonaccidental trauma shows bilateral bucket-handle fractures (arrows) at the distal tibiae. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest, Centers for Disease Control and Prevention, Factors that Increase Risk of Getting Arthritis. The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. If the force is high enough, the medial malleolus can be pushed away as it were (= vertical fracture) by the rotating talus (stage II) (fig. The osseoligamentous complex of the distal tibiofibular syndesmosis stabilizes the ankle mortise. While their presence usually does not change the therapeutic approach, occasionally a large fragment may require a separate fixation screw. An associated complete fracture through the distal fibula (*), with medial displacement of the detached distal fibular epiphysis, also is present. The Ottawa ankle and foot rules (OAFR) (Table 1) represent a clinical decision algorithm for medical imaging in patients suspected of having ankle and midfoot fractures (5). It is our job as radiologists to find clues on the x-rays of the ankle that will lead us to these high fibula fractures and the algoritm will help us. (b) AP radiograph of the right foot in an 8-year-old girl shows contiguous MT fractures: a nondisplaced second MT bone fracture (arrow) and displaced slightly comminuted third and fourth MT bone fractures (arrowheads). 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