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Dr.Rajiv Shah
Foot & Ankle Surgeon
‘Foot &Ankle Orthopaedics’
Vadodara, Surat, Gujarat
AP MortiseLateral
 AP view
 Tibiofibular clear
space
 Tibiofibular overlap
 Talar tilt angle
 Lateral talar shift
 Shenton’s line
 Arcuate line
 Mortise view
 Medial clear
space
 Talocrural angle
 Ankle instability
sign
IncreasedTibio-fibular clear spaceTibio- fibular overlapTalarTilt angle
Shenton line of ankle
Arcuate Line/Dime sign
Increased medial Clear SpaceDisturbedTalocrural angle
Lateral talar shift signInsignificant sign!Ankle instability sign
LAT X-rays
Position of talus at
ankle mortise
Position of posterior
malleolus
Dome of the talus:
centered under and
congruous with tibial
plafond
Posterior malleolus
fractures & direction
of fibular injuries can
be identified
Avulsion
fractures of the
talus by the
anterior capsule
can be identified
 Neutral triangle
 Bone quality
 Bohler’s Angle
 20-40 degrees
 Can be depressed
in both intra and
extra articular fx
 Limited usefulness
 Crucial angle of
Gissane
 Dense cortical bone
margins of the STJ
 Reconstitution is a
must for calcaneal
fractures
11
• Haglund’s deformity
• Parallel pitch lines of Pavlov
12
BRODEN’SVIEW
14
40 deg
20-30 deg10 deg
16
17
Lecture 3 shah radiology in foot and ankle
 Foot is plantar
flexed, 15 degree
pronated and the
beam is angled 15
degree toward the
head
 It shows the medial
column along the
talar head and neck
AP ObliqueLateral
Lecture 3 shah radiology in foot and ankle
 Talo-First MT line
(Normal = 0
degrees)
 Hallux valgus
 Talonavicular
Coverage Angle
(Normal = 0-7
degrees)
Useful for planning of
treatment forAAFD
 Lateral border of 1st
metatarsal is aligned with
lateral border of 1st
(medial) cuneiform
 Medial border of 2nd
metatarsal is aligned with
medial border of 2nd
(intermediate) cuneiform
 Medial border
of 4th
metatarsal
aligned with
medial border
of cuboid
 Medial and lateral
borders of the 3rd
(lateral) cuneiform
should align with
medial and lateral
borders of 3rd
metatarsal
 Lateral margin of
the 5th
metatarsal can
project lateral to
cuboid by up to
3mm on oblique
view
Lecture 3 shah radiology in foot and ankle
 IM space
between 1st and
2nd metatarsals
is equal to space
between the
medial and
middle
cuneiforms
• The medial cuneiform-second MT space should
be evaluated for the "fleck sign" indicating
avulsion of the Lisfranc ligament.
Lecture 3 shah radiology in foot and ankle
Talo-First MT line
(a.k.a Meary’s line)
 Normal = 0
degrees
 Useful for analysis
for treatment of
AAFD
 LateralView
 Superior border of
second metatarsal
is continuous with
superior border
second cuneiform
 No dorsal nor
plantar
displacement of
metatarsal bases
SIGNS OF HINDFOOTVARUS
 Increased Calcaneal pitch
angle
 “posterior” fibula
 “double talar-dome” sign
 “see-through” sign
 Routine view
 Anterior process
calcaneus
 Cuboid -5th metatrsal
 To delineate medial column
abnormalities & injuries
AP Foot Lateral Foot
Lecture 3 shah radiology in foot and ankle
Non-weight bearing Weight bearing
Weight
bearing/standing
views provide
stress & will
demonstrate
subtle lisfranc
injury
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle
(HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle
(HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle
(HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal
angle (HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle
(HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
1. Hallux-interphalangeal angle
- nml: 6-24 deg
2. Distal metatarsal articular angle
(DMAA)
- nml: 6-18 deg
3. Hallux-metatarsophalangeal angle
(HV)
- nml: 0-20 deg
4. First intertarsal angle (IMA)
- nml: < 9 deg
5. Metatarsal break angle
- nml: 140 deg
6. Talocalcaneal angle
- nml: 30-50 deg (child)
- 15-30 deg (>5 yo)
Weight-BearingNonWeight-Bearing
 Disruption of
angles on
weight
bearing xrays
suggestAAFD
1. Lateral talocalcaneal angle
- nml: 25-30 deg
2. 5th metatarsal base height
- nml: 2.3-3.8 cm
3. Calcaneal pitch angle
- nml: 10-30 deg
4. Bohler’s angle
- nml: 22-48 deg
1. Lateral talocalcaneal angle
- nml: 25-30 deg
2. 5th metatarsal base height
- nml: 2.3-3.8 cm
3. Calcaneal pitch angle
- nml: 10-30 deg
4. Bohler’s angle
- nml: 22-48 deg
1. Lateral talocalcaneal angle
- nml: 25-30 deg
2. 5th metatarsal base height
- nml: 2.3-3.8 cm
3. Calcaneal pitch angle
- nml: 10-30 deg
4. Bohler’s angle
- nml: 22-48 deg
1. Lateral talocalcaneal angle
- nml: 25-30 deg
2. 5th metatarsal base height
- nml: 2.3-3.8 cm
3. Calcaneal pitch angle
- nml: 10-30 deg
4. Bohler’s angle
- nml: 22-48 deg
Lecture 3 shah radiology in foot and ankle
Lecture 3 shah radiology in foot and ankle
Lecture 3 shah radiology in foot and ankle
 Stress
radiography is
gold standard
for detection of
ankle instability
 Anterior drawer
test
 Talar tilt test
Stress views
 Performed by
tilting the hindfoot
and looking for a
suction sign or
asymmetric
movement.
 Positive stress test :
talar tilt > 15 degrees
side to side diff of 10
.
Ankle in 20 degree of
plantar flexion
The tibia is pushed
posteriorly against the
fixed foot
positive test - >0.5 to1
cm or side to side diff
of 3 mm
Ankle off the
edge of table
Rotated
externally
Let it fall
Cross table view
Deltoid
incompetence
Gravity Stress views
Midfoot Stress views
 Assess
 Fractures, stress
fractures, growth
plate fractures
 Neoplasms &
infections
 Foreign bodies
 Osteochondral
lesions
 AVN
 Arthritis
 Congenital
abnormalities
 3-D
reconstructions
56
Calcaneus Fracture
Lisfrancs
Dislocation
Fracture LowerTibia
CT Scan
 Axial cuts across
tibiofibular interval
 Axial cuts at ankle
mortise
 Reduction
 Widening
 Rotation
 Fibular clear space
 Axial cut 1 cm
above joint
 Line from flat
anterolateral
surface of fibula to
anterior tubercle of
tibia
 Must be within
2mm from anterior
surface of tibia
Most reliable CT sign!
USG: Advantages
 Most effective for superficial structures like
tendons & ligaments
 Dynamic
 Allows for direct palpation of painful areas
during imaging
 Comparison with opposite side
 Easy & cheap
 User dependent
 Inadequate joint visualization
 Poor osseous visualization
USG: Normal tendon
Tendinosis
PartialTear
CompleteTear
USG:Tendon
pathologies
Achilles tendon tear
64
 Magical effect
 Subluxating tendon
 Presence of
implants/metals
Plantarflexion: gap
in Achilles tendon
narrows to less
than 1 cm
Dorsiflexion:
gap
widens to
more than 2
cm
Achilles longitudinal
Achilles longitudinal
Lecture 3 shah radiology in foot and ankle
--Anterior tibial tendon (yellow arrowhead) impinged by screw head
(lg. white arrow) with fluid/synovitis (sm. arrows)
-
68
 Excellent soft
tissue visualization
 Anatomical details
Assessment of
Trauma
Neoplasms/masses
Arthritis,
Inflammation
AVN
Tarsal coalition
RSD
Tissue T1 T2
Cortex Low Low
Ligaments Low Low
Articular cart Intermed Intermed
Red marrow Intermed Intermed
Old blood High High
Osteomyelitis Low High
Sarcoma Low High
Marrow edema Low High
Fat High Intermed
Pus Intermed High
Lecture 3 shah radiology in foot and ankle
AxialT2 FS Coronal PD FS Treated with screw
 OsTrigonum Syndrome
 TarsalTunnel Syndrome
 Haglund’s Syndrome
 Os Peroneum Syndrome
 AnterolateralGutter Syndrome
 SinusTarsi Syndrome
 Areas of increased metabolic activities
 99mTc methylene diphosphonate (MDP)
 Assess
 Tumors & -like conditions
 Metabolic disorders
 Trauma
 AVN
 Arthritis
 Infection
 RSD
SLIDE COURTESY: DR.SELENE PAREKH
74

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Lecture 3 shah radiology in foot and ankle

  • 1. Dr.Rajiv Shah Foot & Ankle Surgeon ‘Foot &Ankle Orthopaedics’ Vadodara, Surat, Gujarat
  • 3.  AP view  Tibiofibular clear space  Tibiofibular overlap  Talar tilt angle  Lateral talar shift  Shenton’s line  Arcuate line  Mortise view  Medial clear space  Talocrural angle  Ankle instability sign
  • 4. IncreasedTibio-fibular clear spaceTibio- fibular overlapTalarTilt angle
  • 5. Shenton line of ankle Arcuate Line/Dime sign Increased medial Clear SpaceDisturbedTalocrural angle
  • 6. Lateral talar shift signInsignificant sign!Ankle instability sign
  • 7. LAT X-rays Position of talus at ankle mortise Position of posterior malleolus
  • 8. Dome of the talus: centered under and congruous with tibial plafond Posterior malleolus fractures & direction of fibular injuries can be identified Avulsion fractures of the talus by the anterior capsule can be identified
  • 9.  Neutral triangle  Bone quality  Bohler’s Angle  20-40 degrees  Can be depressed in both intra and extra articular fx  Limited usefulness
  • 10.  Crucial angle of Gissane  Dense cortical bone margins of the STJ  Reconstitution is a must for calcaneal fractures
  • 11. 11 • Haglund’s deformity • Parallel pitch lines of Pavlov
  • 12. 12
  • 14. 14
  • 16. 16
  • 17. 17
  • 19.  Foot is plantar flexed, 15 degree pronated and the beam is angled 15 degree toward the head  It shows the medial column along the talar head and neck
  • 22.  Talo-First MT line (Normal = 0 degrees)  Hallux valgus  Talonavicular Coverage Angle (Normal = 0-7 degrees) Useful for planning of treatment forAAFD
  • 23.  Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform  Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate) cuneiform
  • 24.  Medial border of 4th metatarsal aligned with medial border of cuboid  Medial and lateral borders of the 3rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal  Lateral margin of the 5th metatarsal can project lateral to cuboid by up to 3mm on oblique view
  • 26.  IM space between 1st and 2nd metatarsals is equal to space between the medial and middle cuneiforms
  • 27. • The medial cuneiform-second MT space should be evaluated for the "fleck sign" indicating avulsion of the Lisfranc ligament.
  • 29. Talo-First MT line (a.k.a Meary’s line)  Normal = 0 degrees  Useful for analysis for treatment of AAFD
  • 30.  LateralView  Superior border of second metatarsal is continuous with superior border second cuneiform  No dorsal nor plantar displacement of metatarsal bases
  • 31. SIGNS OF HINDFOOTVARUS  Increased Calcaneal pitch angle  “posterior” fibula  “double talar-dome” sign  “see-through” sign
  • 32.  Routine view  Anterior process calcaneus  Cuboid -5th metatrsal
  • 33.  To delineate medial column abnormalities & injuries
  • 36. Non-weight bearing Weight bearing Weight bearing/standing views provide stress & will demonstrate subtle lisfranc injury
  • 37. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 38. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 39. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 40. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 41. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 42. 1. Hallux-interphalangeal angle - nml: 6-24 deg 2. Distal metatarsal articular angle (DMAA) - nml: 6-18 deg 3. Hallux-metatarsophalangeal angle (HV) - nml: 0-20 deg 4. First intertarsal angle (IMA) - nml: < 9 deg 5. Metatarsal break angle - nml: 140 deg 6. Talocalcaneal angle - nml: 30-50 deg (child) - 15-30 deg (>5 yo)
  • 44.  Disruption of angles on weight bearing xrays suggestAAFD
  • 45. 1. Lateral talocalcaneal angle - nml: 25-30 deg 2. 5th metatarsal base height - nml: 2.3-3.8 cm 3. Calcaneal pitch angle - nml: 10-30 deg 4. Bohler’s angle - nml: 22-48 deg
  • 46. 1. Lateral talocalcaneal angle - nml: 25-30 deg 2. 5th metatarsal base height - nml: 2.3-3.8 cm 3. Calcaneal pitch angle - nml: 10-30 deg 4. Bohler’s angle - nml: 22-48 deg
  • 47. 1. Lateral talocalcaneal angle - nml: 25-30 deg 2. 5th metatarsal base height - nml: 2.3-3.8 cm 3. Calcaneal pitch angle - nml: 10-30 deg 4. Bohler’s angle - nml: 22-48 deg
  • 48. 1. Lateral talocalcaneal angle - nml: 25-30 deg 2. 5th metatarsal base height - nml: 2.3-3.8 cm 3. Calcaneal pitch angle - nml: 10-30 deg 4. Bohler’s angle - nml: 22-48 deg
  • 52.  Stress radiography is gold standard for detection of ankle instability  Anterior drawer test  Talar tilt test Stress views  Performed by tilting the hindfoot and looking for a suction sign or asymmetric movement.  Positive stress test : talar tilt > 15 degrees side to side diff of 10 . Ankle in 20 degree of plantar flexion The tibia is pushed posteriorly against the fixed foot positive test - >0.5 to1 cm or side to side diff of 3 mm
  • 53. Ankle off the edge of table Rotated externally Let it fall Cross table view Deltoid incompetence Gravity Stress views
  • 55.  Assess  Fractures, stress fractures, growth plate fractures  Neoplasms & infections  Foreign bodies  Osteochondral lesions  AVN  Arthritis  Congenital abnormalities  3-D reconstructions
  • 56. 56
  • 58. CT Scan  Axial cuts across tibiofibular interval  Axial cuts at ankle mortise  Reduction  Widening  Rotation  Fibular clear space
  • 59.  Axial cut 1 cm above joint  Line from flat anterolateral surface of fibula to anterior tubercle of tibia  Must be within 2mm from anterior surface of tibia Most reliable CT sign!
  • 60. USG: Advantages  Most effective for superficial structures like tendons & ligaments  Dynamic  Allows for direct palpation of painful areas during imaging  Comparison with opposite side  Easy & cheap  User dependent  Inadequate joint visualization  Poor osseous visualization
  • 64. 64  Magical effect  Subluxating tendon  Presence of implants/metals
  • 65. Plantarflexion: gap in Achilles tendon narrows to less than 1 cm Dorsiflexion: gap widens to more than 2 cm Achilles longitudinal Achilles longitudinal
  • 67. --Anterior tibial tendon (yellow arrowhead) impinged by screw head (lg. white arrow) with fluid/synovitis (sm. arrows) -
  • 68. 68  Excellent soft tissue visualization  Anatomical details Assessment of Trauma Neoplasms/masses Arthritis, Inflammation AVN Tarsal coalition RSD
  • 69. Tissue T1 T2 Cortex Low Low Ligaments Low Low Articular cart Intermed Intermed Red marrow Intermed Intermed Old blood High High Osteomyelitis Low High Sarcoma Low High Marrow edema Low High Fat High Intermed Pus Intermed High
  • 71. AxialT2 FS Coronal PD FS Treated with screw
  • 72.  OsTrigonum Syndrome  TarsalTunnel Syndrome  Haglund’s Syndrome  Os Peroneum Syndrome  AnterolateralGutter Syndrome  SinusTarsi Syndrome
  • 73.  Areas of increased metabolic activities  99mTc methylene diphosphonate (MDP)  Assess  Tumors & -like conditions  Metabolic disorders  Trauma  AVN  Arthritis  Infection  RSD SLIDE COURTESY: DR.SELENE PAREKH
  • 74. 74