7. This is 24 year old male with chronic ankle pain. Avulsion fractures are so much more common than the presence of an os subtibiale that in the context of a symptomatic patient after ankle trauma, the finding of an osseous structure below the medial malleolus should be considered and treated as a fracture [27]. A peroneus quartus can be removed in the cases in which it is causing pathology. In children with chronic pain and instability associated with an os subfibulare, surgical excision of the os subfibulare combined with reconstruction of the anterior talofibular ligament and a modified Brostrm procedure was effective in restoring ankle stability, eliminating pain, and permitting return to the preinjury functional level. He has also been an invited faculty member at various conferences, including Teleradiology in IRIA 2008 and 2011, Hospital Build Middle East, Congress of the Brain Tumor Radiology in Neuro-oncology Society. World J Nucl Med 14:205208. The main differential is avulsion fractures of the distal fibula. She denied any prior trauma. The tendon is deep to the tibialis anterior and extensor hallucis longus tendon [59]. A third peroneus can be found with a prevalence of up to 95% in cadaveric studies [38]. 2022 BioMed Central Ltd unless otherwise stated. CAS Foot Ankle Int 23:5155. 6: L164-177. These represent Shepherds or Cedells fractures, respectively [9, 12]. 5. J Orthop Surg Res. There are a number of other accessory peroneal muscles, with names such as peroneus accessorius, peroneocalcaneus externum, peroneus digiti minimis and peroneus quartus. But test results provide little insight into how he died King Tut wasn't murdered by a blow to the head, nor was his chest crushed i NBE has introduced FNB for Interventional Radiology, Breast imaging and Body Imaging. In some cases, it may cause compression of the posterior tibial nerve, and associated tarsal tunnel syndrome has been described in cases in which the accessory soleus inserts onto the medial calcaneus. [1-6] Os peroneum can fracture following an inversion and may mimic sport injury. Instability may be present, which can be a reliable tool to confirm avulsion fracture, and rule out os subfibulare. Alignment has been maintained. Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion. The differential diagnosis of an os trigonum comprises fractures of the lateral or medial tubercles of the posterior process of the talus. Repetitive plantar flexion is a continuous requirement in activities such as ballet, basketball or soccer [5, 7]. MR was performed with the suspicion of talonavicular osteoarthritis at the time. In cases when non-union has occurred, the fragments are usually resected [14]. Os Subfibulare Definition small piece of bone adjacent to inferior fibula Epidemiology incidence 1-2% of population Pathoanatomy may represent avulsion fx of ATFL that secondarily ossifies or accessory ossification center Presentation symptoms may be asymptomatic may have ankle pain (symptomatic os subfibulare) Rehabilitation outcome was evaluated after 3 months of intervention as the following: good response group . Chemic Young adult presented with lateral force injury and right nasal bone tenderness pictures show possible high fracture of right side better We live in an era where a scientist has to think about being politically correct. a Sagittal FSE T1 in a 56-year-old man referred for follow-up after Achilles reconstructive surgery. The Foot and Ankle Online Journal, 2010, on Os Subfibulare: A case report of painful fibular accessory ossicle, Management of an open crush fracture to the foot from a lawnmower injury: A case report, The clinical and patient centered outcomes following surgical correction of tailors bunion in an acute hospital based podiatric surgery service, Fluoroquinolone-induced Achilles tendinopathy A case report and management recommendations, Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report, Congenital amniotic band constriction of the proximal tibia: A Yucatan project case report, Distal lower extremity manifestations in spina bifida patients of the Yucatan Peninsula: A 24-year retrospective case series, Management of a dislocated talar dome fracture with ankle arthrodiastasis and open reduction internal fixation: A case report, A case of recurrent hyperostotic macrodactyly. She attempted various shoe gear and multiple courses of anti-inflammatory medication with no benefit or symptomatic relief. Semin Musculoskelet Radiol 6:153161. Since symptoms were recalcitrant, exploration and removal of the ossicle was performed. The muscle arises from the lower third of the anterolateral tibia and interosseous membrane and inserts onto the anterolateral aspect of the neck of the talus. Abstract The os subtibiale is a rare, genuine accessory bone and normal variant related to the posterior colliculus of the medial malleolus. 6 Os subfibulare is sometimes a cause of ankle pain, in which case it is called symptomatic os subfibulare. The most common accessory ossicles in the ankle and foot are the os trigonum, the accessory navicular (among the different three types, type II is the most common) and the os intermetatarseum, in this order. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gaillard F, Baba Y, Saber M, et al. Brodie JT, Dormans JP, Gregg JR, Davidson RS (1997) Accessory soleus muscle. All ECR 2023 tickets are valid for onsite and online access during March 1-5, 2023! Google Scholar. Yun SJ, Jin W, Kim GY et al (2015) A different type of talocalcaneal coalition with os sustentaculum: the continued necessity of revision of classification. The accessory ossicle was separated easily. It is where there is a spiral fracture of the proximal fibula along with ankle instability. At a mean follow-up of 4.5 years (range, 2.1 to 13.2 years), the mean Foot and Ankle Outcome Score was 91.4 (range, 87 to 98) out of 100, with all but one patient returning to the preinjury recreational level. In a series of asymptomatic volunteers, its prevalence was estimated on 1% [44]. Differential diagnosis It should not be mistaken for: os vesalianum pedis Os peroneal fracture with associated peroneus longus tendinopathy. 2020 Jan;28(1):298-304. doi: 10.1007/s00167-019-05718-6. Frontal Oblique Lateral X-ray Frontal Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. Why do best medical graduates choose Radiology? Keats TE (1992) The foot. Foot Ankle Int 26:890893. There are two theories regarding the origin of os subfibulare. [11]. This os can become symptomatic in cases of chronic abnormal mobility (shearing), in which degenerative changes across the synchondrosis occur. On x-ray there can be syndesmotic widening. 11: MRI, T2 fat sat; Os trigonum syndrome References: Department of Radiology, Hospital de So Joo, . 36-year-old woman referred for follow-up of an osteochondral lesion. Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. Sammarco GJ, Conti SF (1994) Tarsal tunnel syndrome caused by an anomalous muscle. Manage cookies/Do not sell my data we use in the preference centre. AJR Am J Roentgenol 205:10611067. Cheung YY, Rosenberg ZS, Colon E, Jahss M (1999) MR imaging of flexor digitorum accessorius longus. Aparisi Gmez, M., Aparisi, F., Bartoloni, A. et al. Lee DJ, Shin HS, Lee JH, Kyung MG, Lee KM, Lee DY. Accessibility Because ankle trauma is the most common indication for radiological examination of the ankle, the accessory ossicle can be mistaken by a fracture [26]. If they do not assimilate to the tibial epiphysis, they appear as a separated medial malleolus [25]. The first is that the ossicles are caused by an avulsion fracture 1,5 and the second is . Part of the anterior talar fibular ligament was sutured to the lateral malleolus. The accessory muscle inserts in the quadratus plantae (white arrows). 13). There are two theories regarding the origin of os subfibulare. This has rounded margins. It is connected to the lateral tubercle of the posterior process of the talus by a fibrocartilaginous synchondrosis and in close vicinity to the flexor hallucis longus tendon [6]. Clinically, in these cases, there will be swelling, effusion and pain. These occur when there is a direct impact on a supinated foot and are frequently seen in association with severely comminute intraarticular calcaneal fractures, although they can also be found isolated. It is useful for the radiologist to be familiar with the characteristics of these anatomical variants to avoid misdiagnosis. In most instances, os subfibulare is found incidentally on radiographs. Incidental finding of an accessory soleus. Findings are compared with previous MR, performed 10years before. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. Conclusions: Look for loose bodies and damage to the lateral aspect of the talus, which may require debridement. Medial to this, there is a small ossified body (black arrow). Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. Accepted: July, 2010 Seipel R, Linklater J, Pitsis G, Sullivan M (2005) The peroneocalcaneus internus muscle: an unusual cause of posterior ankle impingement. [8] The accessory ossicles most commonly observed, in order of frequency, are the tibiale externum, os trigonum and os peroneum. 40-year-old man, incidental finding of a small os supratalare (white arrow), as well as an os trigonum. Accessory muscles can occasionally represent an incidental finding on radiographs, but are mainly incidentally noted on MRI and CT. The soleus is located in the deep posterior compartment and arises from the proximal fibula, the posterior (soleal line) and medial tibia and a fibrous line bridge in between tibia and fibula. The tendon arises from the extensor hallucis longus tendon or muscle, in most of the cases, and inserts onto the first metatarsophalangeal joint capsule. When this is markedly prominent, the same mechanism of plantar flexion described above [2, 11] causes similar pathology in the surrounding anatomical elements (Fig. J Foot Ankle Surg 55:173175. Z Orthop Ihre Grenzgeb 125:302307. os sustentaculum os intermetatarseum (between the 1st and second metatarsal) os subfibulare: historically, this has been considered to be an accessory ossicle located just below the ditsal fibular epiphysis; it is distinguished from a fracture by its smooth borders, and by the fact that a fracture will preferentially involve the physis; Address correspondence to: Vasu Pai MS, D[orth], National board [Orth], FICMR, FRACS, MCh[Orth]. The flexor digitorum accessorius longus can arise from any structure in the posterior compartment but is seen to arise more frequently from the medial margin of the tibia or from the lateral aspect of the fibula distal to the origin of the flexor hallucis longus. Sobel M, Levy ME, Bohne WH (1990) Congenital variations of the peroneus quartus muscle: an anatomic study. Clin Anat May 2005 18(4): 239-244. It is more commonly bilateral and seen in males. Download : Download high-res image (331KB) These include accessory ossicles, additional sesamoid bones, variations in number and configuration of sesamoid bones, coalitions, bipartitions and variants in the soft tissues, such as accessory muscles. a Coronal T2-weighted fast field echo (FFE) demonstrates a talocalcaneal coalition (white arrows). References 2 articles feature images from this case 9 public playlists include this case Related Radiopaedia articles Accessory ossicles of the foot Os subfibulare Sesamoid bones have a different anatomical nature. Accessory tali have also been described in association with a partial duplication of the medial column of the foot, in the reported case causing fixed pes equinus deformity [35]. Article Ogden JA, Lee J (1990) Accessory ossification patterns and injuries of the malleoli. Lack of clinical symptoms and history of trauma and lack of a donor site in the calcaneus are two important features that would suggest the presence of a calcaneus secundarius [23]. Patient was referred for radiographs with the suspicion of Achilles tendinopathy in the contralateral leg. There was a palpable bony swelling that felt hard and fixed to the antero-inferior aspect of the lateral malleolus. Accessory Ossicles of the Foot and Ankle: Disorders and a Review of the Literature. a 17-year-old man referred with the suspicion of peroneal tenosynovitis. Anomalous multifocal ossification of the os calcis. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. A case report describing os subfibulare is presented. Os subfibulare is an ossicle where the proximal end of the lateral ankle ligaments attaches [1,2]. Most accessory ossicles will represent an incidental finding on radiographs. 2). Published: August, 2010, ISSN 1941-6806 Operative Indications and Treatment for Chronic Symptomatic Os Subfibulare in Children. This accessory muscle can be used for tendon transfer or graft. Weinstein SL, Bonfiglio M (1975) Unusual accessory (bipartite) talus simulating fracture. Pain and tenderness along the medial aspect of the foot will be the main clinical symptoms [13]. Here is my attempt to explain the charm of this branch. Symptoms of os trigonum syndrome may result from all the situations mentioned above and consist of chronic or recurrent pain with stiffness, soft tissue swelling and tenderness to palpation in the postero-lateral aspect [8]. There are several different types of accessory bones and they are grouped according to their position, shape and relationship with the adjacent bone. Insights Imaging 10, 74 (2019). The patient is put in supine position. Epub 2019 Oct 30. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. The insertion is very variable and will determine the different given names. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. The presence of oedema on MRI confirms the presence of acute fracture [21]. Incidence of accessory ossicles and sesamoid bones in the feet: A radiographic study of the Turkish subjects. The posterior impingement view has been shown to be more sensitive than the lateral view in the detection of an os trigonum [9]. [Clinical outcome of arthroscopic excision of the os subfibulare in ankle pain]. The tendon normally runs along the extensor digitorum longus tendon and inserts on the dorsal surface of the shaft of the fifth metatarsal. Knee Surg Sports Traumatol Arthrosc. It was tender on deep palpation. While os subfibulare . The os subfibulare is a rounded shaped ossicle with well corticated margins different from the fragment of a fracture that has a sharp fracture margin without sclerosis. 11). Springer Nature. CT reveals an os subfibulare (white arrow) to the tip of the lateral malleolus with pseudoarthrosis (yellow arrow) of the fragment. Initially, this was interpreted as a non-united fracture. An os peroneum is a small accessory bone of the foot located at the lateral plantar aspect of the cuboid within the substance of the peroneus longus tendon as it arches around the cuboid. After suture removal, the ankle was protected in range-of-motion brace for six weeks. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. An extension of the phenotype or a new syndrome? Its prevalence is estimated in between 1 and 25% [1, 2]. The .gov means its official. A radiograph can confirm the presence of the os subfibulare and assess the size of the ossicle. Miller TT. A thigh tourniquet is applied to provide a bloodless operative field. Department of Radiology, Auckland City Hospital - Auckland District Health Board (ADHB), 2 Park Road, Grafton, Auckland, 1023, New Zealand, Department of Radiology, Hospital Vithas Nueve de Octubre, Calle Valle de la Ballestera, 59, 46015, Valencia, Spain, Maria Pilar Aparisi Gmez&Francisco Aparisi, Department of Diagnostic Imaging, Bambino Ges Children Hospital, Piazza SantOnofrio 4, 00165, Rome, Italy, Department of Orthopaedics and Traumatology, Malteser Krankenhaus St. Josefshospital, Kurfrstenstrasse 69, 47829, Krefeld, Germany, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S.Orsola-Malpighi Hospital, Via G. Massarenti 9, 40138, Bologna, Italy, Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71100, Foggia, Italy, Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, 40136, Bologna, Italy, You can also search for this author in In this case, the operative findings revealed a mobile, separate ossicle attached to the lateral malleolus with an established pseudo-arthrosis. The peroneocalcaneus internus muscle is a rare accessory muscle. It can be multiple and bilateral and is usually asymptomatic [24]. Radiology 1994; 193:255-257. Accessory muscles are also generally asymptomatic and discovered incidentally on imaging studies. Epidemiology It's a rare variant with a reported incidence of ~1% (range 0.2-2.4%) 1. Os subfibulare is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported 1. Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. 44-year-old man referred with the suspicion of Achilles tendinopathy. There was no evidence of instability or locking of the ankle joint. There are two theories regarding the origin of os subfibulare. Ahn JH, Kim YC, Kim HY (2013) Arthroscopic versus posterior endoscopic excision of asymptomatic os trigonum: a retrospective cohort study. MeSH It typically inserts onto the quadratus plantae or flexor digitorum longus [46] (Fig. Foot Ankle Int 16:646650. Surgical excision resulted in complete, symptomatic relief. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory . All authors equally contributed in writing the manuscript. Injury to the synchondrosis is one of the causes of symptomatic os trigonum. The accessory ossicle is at the anterior medial portion of the malleolus giving it a bifid appearance. Mellado JM, Ramos A, Salvad E, Camins A, Dans M, Saur A (2003) Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. Clin Sports Med 27:263277. These fractures can sometimes be missed, and they need fixation; otherwise, they may result in pseudoarthrosis. They usually are asymptomatic. This is medial to the flexor hallucis longus and is included in the flexor retinaculum. (Fig. The main differential of an os tibiale is avulsion fractures, which are common in the context of ankle trauma. Teaching points by Dr MGK Murthy Pedicloryl has now become omnipresent in all Radiology departments for sedating children. Stiedas process. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. Knee Surg Sports Traumatol Arthrosc. The presence of the third peroneus is normally asymptomatic; however, snapping of its tendon over the lateral dome of the talus has been described [39]. Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. Mellado JM, Ramos A, Salvado E, Camins A, Danus M, Sauri A. Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis.Eur Radiol Dec 2003 Suppl. Os subfibulare is a separated ossicle at the tip of the lateral malleolus and inferior portion of the fibular tuberosity of the ankle which is rarely reported. Mechanical irritation or joint instability may produce local pain and tenderness and contribute to recurrent ankle sprains. Cookies policy. The peroneal muscles are two, the peroneus longus and peroneus brevis. Materials and methods 38 patients with chronic lateral ankle pain and os subfibulare underwent a standardized rehabilitation program. c Reconstructed coronal CT image in the same patient, demonstrating the os sustentaculi (arrowhead), in close relation with the sustentaculum tali. What is Os Naviculare Syndrome? doi: 10.3827/faoj.2010.0308.0003, Os subfibulare is a rarely reported ossicle involving the inferior portion of the fibular tuberosity of the ankle. The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. The os subfibulare can be found distal to the tip of the lateral malleolus, with round or comma-shaped morphology, and is asymptomatic [ 25 ]. There are two theories regarding the origin of os subfibulare. A rare associated problem with the presence of a peroneocalcaneus internus is the possibility to fail to recognise this separately from the flexor hallucis longus in arthroscopy (mistaking it with the flexor hallucis longus tendon), which may lead to an altered surgical approach, and potential injury to the neurovascular bundle. An os supratalare is an accessory ossicle of the foot located at the superior aspect of the talar head or neck. volume10, Articlenumber:74 (2019) Madhuri V, Poonnoose PM, Lurstep W (2009) Accesory os subtibiale: a case report of misdiagnosed fracture. sharing sensitive information, make sure youre on a federal Sweed TA, Ali SA, Choudhary S (2016) Tarsal tunnel syndrome secondary to an unreported ossicle of the talus: a case report. Results: Karasick D, Schweitzer ME (1996) The os trigonum syndrome: imaging features. 3. On MRI, there will be subchondral bone marrow oedema and fluid [15]. A case report. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. A case report. As an incidental finding, an os calcaneum secundarium was noted. It is normally asymptomatic but has also been described to cause snapping over the lateral dome of the talus [39]. AJR Am J Roentgenol 172:475479. The muscle and tendon are located in the anterior compartment of the leg, arising from the anterior aspect of the distal fibula and the extensor digitorum longus muscle. Yu SM, Yu JS (2015) Calcaneal avulsion fractures: an often forgotten diagnosis. A small rounded structure could have already represented a sequel of avulsion injury but was described as an ossicle in the absence of acute trauma. The most likely explanation is that anomalous ossification centers, not yet fused to the body of the epiphysis, have been subjected to trauma, causing disruption to the fibrous or cartilaginous attachment and results in a fibrous union or pseudo-arthrosis. Differential diagnosis Currently, this is viewed as a developmental skeletal variation, likely resulting from failure of fusion of a secondary lateral tubercle ossification centre that forms at about 713years of age, and normally fuses at about 14years of age [1, 3,4,5]. Several rare accessory bones in the hindfoot have been described, such as an accessory calcaneus, by Krause and Rouse [30], and bipartite configurations of the talus that can be mistaken by fractures [31,32,33]. 2019 Sep;27(9):2774-2780. doi: 10.1007/s00167-018-5055-7. They run posteriorly to the lateral malleolus, the brevis more anterior than the longus. Suhana E, Das S (2011) Accessory extensor digiti secundus muscle: some interesting facts. The different types of insertion define the different types of classified accessory soleus [53] (Fig. The peroneus quartus is a pronator. Accessory solei have a prevalence of 0.75.5% according to cadaveric studies [52]. c Sagittal plane CT reconstruction with soft tissue algorithm in the same patient also allows visualisation of the muscle, extending to insert in the calcaneus (black arrowhead). The tendon is medial and posterior to the brevis and longus peroneal tendons. Jul 2009. Am J Sports Med 35:13771379. Bookshelf Os subfibulare can cause impingement on the anterior talofibular ligament, producing anterolateral ankle impingement ( Figure 5, A and B). Differential diagnosis includes fractures of the sustentaculum tali, which are also rare. Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. a AP radiograph in a 67-year-old woman, history of inversion injury. In the cases of Shepherds fracture, there will be postero-lateral tenderness with pain on movement of the subtalar joint and with passive movement of the flexor hallucis longus. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-7648, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":7648,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/os-peroneum/questions/2548?lang=us"}, Case 11: in a case of avulsion fracture 5th metatarsal styloid, Avulsion fracture of the 5th metatarsal styloid (Pseudo-Jones), Iselin disease: traction apophysitis base of the 5th metatarsal, Apophysis of 5th metatarsal (illustration), posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. Patient cannot recall trauma or pain in the lateral aspect of the foot. MRI and CT are more sensitive and specific, and in the case of MRI, intrinsic muscular changes and relations with adjacent structures can be evaluated to investigate the aforementioned associated pathologies [44, 53]. CAS Unable to load your collection due to an error, Unable to load your delegates due to an error. The precise cause of symptoms in patients is conjectural. Separated ossicles at the tip of the lateral malleolus, the condition known as os subfibulare, are sometimes a cause of ankle pain. Os calcaneus secundarius. Turati M, Leone G, Zanchi N, Omeljaniuk RJ, Brahim L, Zatti G, Courvoisier A, Bigoni M. BMC Surg. Kinoshita M, Okuda R, Morikawa J, Abe M (2003) Tarsal tunnel syndrome associated with an accessory muscle. [1] Short- to Medium-term Outcomes After a Modified Brostrm Repair for Lateral Ankle Instability With Immediate Postoperative Weightbearing. Mellado JM, Salvad E, Camins A, Ramos A, Saur A (2002) Painful os sustentaculi: imaging findings of another symptomatic skeletal variant. Chandoga I, Vajczikov S (2012) Talus partitus. This is connected to the posterior aspect of the sustentaculum tali by a fibrocartilaginous synchondrosis. Am J Sports Med. An accessory soleus may present as a soft tissue mass in the postero-medial aspect of the ankle. The flexor hallucis longus is used as a landmark for the medial margin of safety in arthroscopic surgery [44]. Keles-Celik N, Kose O, Sekerci R et-al. Krause JO, Rouse AM (1995) Accessory calcaneus: a case report and literature review. eCollection 2014 Sep. Yamaguchi S, Akagi R, Kimura S, Sadamasu A, Nakagawa R, Sato Y, Kamegaya M, Sasho T, Ohtori S. Knee Surg Sports Traumatol Arthrosc. . statement and In the tarsal tunnel, the tendon or low-lying fibres of the muscle can create a compromise of space, and so the presence of a flexor digitorum accessorius longus has been linked to tarsal tunnel syndrome [47]. If one of these fractures is suspected, CT or MRI should be performed to fully characterise, given the implications for treatment [21] (Fig. 1A and B) There was an accessory ossicle at the lateral malleolus. This normally represents an incidental finding, which can easily be missed on conventional AP and lateral radiographic projections. Insights Imaging 4:581593. a-d Axial FSE T1 images at different planes from proximal to distal show the course of a flexor digitorum accessorius longus. The 2016 World Health Organization Classification of Tumors of the Central Nervo All contents copyrights with Sumer Sethi. Magn Reson Imaging Clin N Am 9:567578. Diagram of the location of the most common accessory bones around the ankle and hindfoot. The main differential in these cases has to be done with a fracture. Increased technetium-99m intake is another typical feature linking symptoms to the presence of an os trigonum [2], although bone scans are currently not so widely used due to the increased use of MRI. Cases J 2:8512. Just as the ossicle, these fractures are easy to miss on conventional radiographic projections and better demonstrated on oblique views. Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. J Pediatr Orthop 10:306316. Chepuri NB, Jacobson JA, Fessell DP, Hayes CW (2001) Sonographic appearance of the peroneus quartus muscle: correlation with MR imaging appearance in seven patients. In these cases, it is occasionally very difficult to establish the diagnosis and distinguish a sequel of an old fracture from a true small ossicle. 9). In summary, symptomatic os fibulare is extremely rare. 3. Catel-Manzke syndrome: a case report of a female with severely malformed hands and feet. Note also the presence of an os trigonum. 1 It is a result of an unfused accessory ossification center or an avulsion fracture of the anterior talofibular ligament.1, 2 Avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension on the anterior talofibular ligament attached to . Just as with the previously seen ossicles, the diagnosis can be established with the clinical background, and the typical irregularity of margins of fracture and no cortication described [22]. by Vasu Pai MS, D[Orth], National board [Orth], FICMR, FRACS, MCh[Orth]1, The Foot and Ankle Online Journal 3 (8): 3. The accessory tendon of the peroneus quartus, separated by a tissue plane from the other peroneal tendons, can be mistaken for a tear, but distinguishing it becomes easy by following the tendon to its own independent muscle belly [42]. We report four cases of symptomatic os subfibulare in four children about 9 years old. b Axial fast spin-echo T1 (FSE T1) better depicts the presence of foci of subchondral bone oedema and subchondral bone cysts in both aspects of the synchondrosis (white arrows). PMC Shands AR Jr. Accessory bones of foot: x-ray study of feet of 1,054 patients. 8600 Rockville Pike Miller TT (2002) Painful accessory bones of the foot. This is more commonly seen than true ossicles. Mosel LD, Kat E, Voyvodic F. Imaging of the symptomatic type II accessory navicular bone. Sammarco GJ, Henning C (2007) Peroneus tertius muscle as a cause of snapping and ankle pain: a case report. Case presentation includes radiographic and computed tomography findings with discussion of various accessory ossicles and their respective incidence in the lower extremity. The os trigonum syndrome constitutes a subtype of posterior ankle impingement syndrome [2, 5]. In general, accessory ossicles commonly observed in order of frequency of the lower extremity include: tibiale externum, os trigonum and os peroneum. In the absence of an os peroneum, a fibrocartilaginous nodule can be found in the same region. Krapf D, Krapf S, Wyss C (2015) Calcaneus secundarius a relevant differential diagnosis in ankle pain: a case report and review of the literature. In general, cadaveric and radiological studies demonstrate similar prevalence, approximately 10% on MRI [41] and 22% on ultrasound [42]. In 3,460 radiographs of patients over 7 years of age, the os tibiale externum was the most common accessory bone. The os trigonum is one of the most common accessory ossicles in the ankle and foot. It can be round but is more often triangular in shape and is located in the space in between the anteromedial aspect of the calcaneus, the cuboid, the talar head and the tarsal navicular (Fig. Bencardino JT, Rosenberg ZS (2001) MR imaging and CT in the assessment of osseous abnormalities of the ankle and foot. The peroneocalcaneus internus inserts on a small tubercle on the medial aspect of the calcaneus, below the sustentaculum (Fig. Fig. 1 Trainee house surgeon, Wellington Medical School, New Zealand. This orientates towards a sequel of old fracture as opposed to an accessory ossicle. Mosby-Year book, St Louis. Occasionally, limitation of movement, posterior ankle impingement and flexor hallucis longus tenosynovitis have also been described in association to its presence. Methods: The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. Incidental finding of a peroneocalcaneus internus. 2) Three-dimensional images show the ossicle with a local pseudo-arthrosis of the large os subfibulare along the distal anterior edge of the lateral malleolus. All symptoms were relieved by excision of the ossicle and reconstitution of the collateral ligament. Google Scholar. The os sustentaculi represents a very rare skeletal variant of the ankle and foot region, with a prevalence that has been estimated in 0.30.4% [1, 3]. This is located in between the talus and the calcaneus (white arrowhead). South Med Surg 1931 93: 326-334. J Bone Joint Surg Am 76:13081314. This review aims to describe and illustrate the imaging findings related to the presence of accessory ossicles and muscles in the ankle and hindfoot through different techniques, with special attention to those variants that associate factors of clinical relevance or that trigger challenges in the differential diagnosis. Journal of Bone and Joint . Os peroneum. ----------------------------------- Maffucci syndrome is characterized by benign enlargements of cartilage (enchondromas); bone deformities; and dark, irregularly shaped Radiology is an increasingly favored specialty for medical graduates. On CT images, irregularity and sclerosis, or changes related to degenerative change on the articular surfaces of the synchondrosis, may be present as a result of chronic stress and abnormal movement [10]. It can be mistaken with a flexor digitorum accessorius longus, but its location posterior to the flexor hallucis longus, as opposed to the neurovascular bundle, and its insertion on the calcaneus, as opposed to the flexor digitorum longus or quadratus plantae, help on distinction [38]. Axial FSE T1 images in different planes (a) proximal and (b) distal demonstrate the incidental finding of a peroneus quartus (white arrow). If fractured, the injury can extend through a segment of the malleolus. It is more common in males and it is unusual to find it bilaterally. Think about it. Similar to the os subtibiale, this represents persistence of an accessory ossification centre, as opposed to an unfused secondary ossification centre, which is more commonly found. Figure 2 Computed tomography images show a fibular ossicle or os subfibulare at the distal end of the fibular with pseudo-arthrosis. 11..Mancuso JE, Hutchison PW, Abramow SP, Landsman MJ. Magn Reson Imaging Clin N Am 25:1126. The os subfibulare can be found distal to the tip of the lateral malleolus, with round or comma-shaped morphology, and is asymptomatic [25]. It tends to be noted if there is an increase in muscle mass and activity, and sometimes, there is associated pain, triggered by exercise, that could be explained by the increase of intrafascial pressure or insufficient blood supply [52, 53]. Coronal FSE T1 in two slices, from (d) posterior to (e) anterior in the same patient nicely depicts the PCI tendon (black arrow) parallel to the flexor hallucis longus (white arrow), descending to insert into the calcaneus, below the sustentaculum (black arrowhead), more medial than the flexor hallucis longus (white arrowhead). 5). Correspondence to Clinical presentation and surgical treatment of distal fibular non-union with talus chondral lesions in a pediatric patient: a case report. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). One surgical report found that up to 12% cases of tarsal tunnel were caused by flexor digitorum accessorius longus [44, 48]. The most common insertion is on the calcaneus, known as peroneocalcaneus externum, with a prevalence of 7991% [44]. Yammine K (2015) The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. Clin Orthop Relat Res. Cheung Y (2017) Normal variants: accessory muscles about the ankle. Orthop Trauma 26:149154. a Lateral and (b) AP projection of the ankle and hindfoot: 1os trigonum, 2os sustentaculi, 3os calcaneus secundarius, 4os subtibiale, 5os subfibulare, 6os supratalare, 7os talotibiale, 8talus secundarius. These foci are not anatomically separate entities, even though they can appear to be radiographically. Foot Ankle Int. 21k followers. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. Accessory ossicle of the lateral malleolus. The muscle arises from the anterior aspect of the distal fibula and the extensor digitorum longus muscle, with the tendon normally running along the extensor digitorum longus tendon and inserting on the dorsal surface of the shaft of the fifth metatarsal. Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH (1997) Peroneus quartus muscle: MR imaging features. In the cases of fracture, besides from the background of trauma that may suggest it, on CT or MRI assessment, the edges will be irregular, not corticated and comminution is possible [2]. Sookur PA, Naraghi AM, Bleakney RR, Jalan R, Chan O, White LM (2008) Accessory muscles: anatomy, symptoms, and radiologic evaluation. There is a small avulsion of the tip of the malleolus, in keeping with injury to the lateral collateral ligament (arrow head). Accessory anatomical structures in the ankle and hindfoot are a common incidental finding. J Bone Joint Surg Br 90:10491054. This is followed by os tibiale (20%), os trigonum (10%), os peroneum (9%), os subfibulare (2%), os supranaviculare (1%) and os supratalare (0.9%). The AI model improved the identification of locomotive syndrome among elderly individuals . Figure 1 The anterior posterior (A) and Oblique (B) radiograph showing a large accessory ossicle or os subfibulare to the tip of the right lateral malleolus. JBJS March 1987 69B (2):317-9. A third peroneus muscle and tendon located in the anterior compartment is a common finding that can be found with a prevalence of up to 95% in cadaveric studies [38]. 8. The presence of the muscle is normally asymptomatic, given it is not directly related to the neurovascular bundle. The os calcaneus secundarius is a rare accessory ossicle of the foot, estimated to have a prevalence between 0.6 and 7% [1, 3]. Mellado JM, Rosenberg ZS, Beltran J, Colon E (1997) The peroneocalcaneus internus muscle: MR imaging features. Foot Ankle Int 19:120122. 66-year-old woman, presented with pain in the posterior and lateral ankle.
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