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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
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120 Chapter 5
AB
Figure 5-5. LX view of the EHL tendon. (A) Probe placement. (B) LX view of the EHL tendon (white arrows). The
underlying muscle of the EHL (white stars) can be seen. (A = dorsalis pedis artery.)
AB
Figure 5-6. LX view of the EDL tendon. (A) Probe placement. (B) LX view of the EDL tendon (white arrow).
3. Relevant anatomy: There are 3 tendons on the anterior aspect of the ankle. From medial to
lateral, they are the tibialis anterior, extensor hallucis longus (EHL), and extensor digitorum
longus (EDL). The dorsalis pedis artery and deep peroneal nerve are present deep to the tendons in the middle, right under the EHL tendon.1
4. Points to remember: The synovial sheath of the extensor tendons of the ankle typically does not
contain fluid. Tenosynovitis should be considered in the presence of even a small amount of
1
fluid.
Anterior Inferior Tibiofibular Ligament
Relevant anatomy is shown in Figure 5-7.
Figure 5-7. Relevant anatomy of the anterolateral ligaments of the ankle.
Ankle and Foot 121
1. Patient position: Ankle in slight plantar flexion and inversion
2. Probe/transducer position: The probe is placed along the ligament bridging the distal tibial and
the fibula (Figure 5-8).
AB
Figure 5-8. Anterior inferior tibiofibular ligament. (A) Probe placement. (B) Anterior inferior tibiofibular ligament
(white arrow) between the tibia and fibula.
3. Relevant anatomy: The ligament is obliquely oriented from the anterior margin of the fibular
tubercle of the tibial to the anterior margin of the distal fibular shaft and lateral malleolus.
The thickness of the ligament ranges from 2.6 to 4 mm, and the length measures about 12 to
15.5 mm.
osseous membrane.
2,3
The ligament is a f lattened band and is partially blended with the anterior inter-
4
4. Points to remember: The anterior inferior tibiofibular ligament has an important role in the
stability of the distal tibiofibular joint. Injury to this ligament may result in instability and
widening of the ankle mortise.
2
122 Chapter 5
Anterior Talofibular Ligament
1. Patient position: Ankle in slight plantar flexion and inversion
2. Probe/transducer position: The probe is placed along the ligament bridging the talus and fibula
anteriorly (Figure 5-9).
AB
Figure 5-9. Anterior talofibular ligament. (A) Probe placement. (B) Anterior talofibular ligament (white arrow)
between the talus and fibula.
3. Relevant anatomy: The ligament connects the anterolateral border of the lateral malleolus and
lateral surface of the talar neck. Some fibers of the ligament blend with the tibiotalar capsule.
Its primary function is to restrain the anterior displacement of the talus with respect to the
fibula and tibia.
4. Points to remember: The anterior talofibular ligament is the most commonly injured ligament
of the lateral collateral complex of the ankle.
2,4
2
Ankle and Foot 123
Deep Peroneal Nerve
1. Patient position: Foot in neutral or slight plantar flexion
2. Probe/transducer position: The probe is placed transversely over the anterior ankle to visual-
ize 3 tendons; from medial to lateral, they are the tibialis anterior, EHL, and EDL. The deep
peroneal nerve is seen deep to the EHL tendon, accompanied with an artery (Figure 5-10).
A
B
C
Figure 5-10. Deep peroneal nerve. (A) Probe placement. (B) The deep peroneal nerve (white arrow) is seen deep to
the EHL tendon, accompanied by the dorsalis pedis artery (white A) at the level of anterior ankle. (C) Color Doppler
ultrasound image showing the dorsalis pedis artery (black A) and deep peroneal nerve (white arrow).
3. Relevant anatomy: The deep peroneal nerve and dorsalis pedis artery are together at the level
of the anterior ankle. The deep peroneal nerve gives a motor branch to the extensor digitorum
brevis and extensor hallucis brevis in the foot. It also gives sensory branches to the ankle joint
and dorsal aspect of the first web space.
4. Points to remember: The branching pattern of the deep peroneal nerve may differ. In some
ankles, the dorsalis pedis artery may be accompanied by medial and lateral branches of the
deep peroneal nerve at the level of the anterior ankle.
124 Chapter 5
LATE RA L ANKLE
Peroneal Tendons
Relevant anatomy is shown in Figure 5-11.
Figure 5-11. Relevant anatomy of the peroneal tendons.
1. Patient position: Prone with the foot over the edge of the table
2. Probe/transducer position:
a. SX view: The probe is placed transversely between the lateral malleolus and the Achilles
tendon to visualize the peroneal tendons in stacked formation behind the fibula.
Ankle and Foot 125
b. LX view: From the SX view, the probe is rotated 90 degrees to align with the LX of the
tendons (Figures 5-12 through 5-15).
AB
Figure 5-12. SX view of the peroneal tendons. (A) Probe placement. (B) SX view of the peroneal tendons behind the
lateral malleolus. Shown are the peroneus longus (yellow arrow), peroneus brevis (white arrow), and peroneus brevis
muscle (white star).
AB
Figure 5-13. LX view of the peroneal tendons. (A) Probe placement. (B) LX view of the peroneal tendons behind the
lateral malleolus. Shown are the peroneus longus (yellow arrow) and peroneus brevis (white arrow).
126 Chapter 5
Figure 5-14. SX view of the peroneal tendons from the proximal to distal levels around the lateral malleolus and lateral
foot. (PB = peroneus brev is; PL = p eroneus longus.)
Ankle and Foot 127
A
B
Figure 5-15. (A) LX view of the peroneal tendons from the proximal to distal level around the lateral malleolus and
lateral foot. The peroneus longus (PL) tendon wraps around the lateral foot to enter the plantar aspect of the foot
(note the hypoechoic tendon due to anisotropy). The peroneus brevis (PB) tendon attaches on the lateral aspect of the
tuberosity at the base of fifth metatarsal (MT). (B) LX view of the peroneus longus on the plantar aspect of the foot.
(i) Relevant anatomy. (ii) The peroneus longus tendon (white arrows) from the lateral aspect to the plantar aspect of
the foot, inserting on the plantar aspect of the base of first metatarsal. (iii) Probe placement.
3. Relevant anatomy: The peroneus brevis is deeper than the peroneus longus. At the level of the
distal end of the fibula or tip of the lateral malleolus, the calcaneofibular ligament (CFL) runs
deep to the peroneal tendons in a direction roughly perpendicular to the tendons.
4. Points to remember: The peroneal tendons take a sharp turn around the tip of the lateral mal-
leolus as they course along the lateral border of the foot. An anomalous muscle, the peroneus
5
quartus, may be present as a third tendon, along with the peroneus brevis and longus.
It
should not be confused with a split tear of the peroneus brevis.
128 Chapter 5
Calcaneofibular Ligament
1. Patient position: Ankle in slight dorsiflexion
2. Probe/transducer position: The probe is placed along the CFL, bridging the tip of the lateral
malleolus and the lateral surface of the calcaneus. Alternatively, the peroneal tendons can be
followed in the SX view as they wrap around the lateral malleolus, and the CFL is seen under
the tendons, between the lateral malleolus and calcaneus (Figure 5-16).
A
B
C
D
Figure 5-16. CFL. (A) Probe placement.
(B) LX view of the CFL (white arrow)
with overlying peroneal tendons in
the SX view. (C) Relevant anatomy and
probe placement. (D) SX view of the
CFL (white arrow) with overlying peroneal tendons in the LX view. Due to anisotropy, the CFL appears hypoechoic.
Tilting the probe can make the CFL hypoechoic or hyperechoic.
3. Relevant anatomy: The CFL is a long cord-like ligament that runs deep to the peroneal tendons
(see Figure 5-7). The primary function of the CFL is to restrain inversion of the calcaneus with
respect to the fibula.
2
4. Points to remember: With ankle dorsif lexion, the peroneal tendons move superficially. If there
is no superficial displacement of the peroneal tendons upon dorsiflexion, a tear of the CFL
should be considered.
MEDIAL ANKLE
Tarsal Tunnel and Its Contents
Relevant anatomy is shown in Figure 5-17.
Ankle and Foot 129
Figure 5-17. Relevant anatomy of the medial ankle/tarsal tunnel structures.
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