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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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130 Chapter 5
1. Patient position: Supine
2. Probe/transducer position: The probe is placed along the flexor retinaculum at the level of the
medial malleolus to scan the contents of the tarsal tunnel in the SX view (Figure 5-18). The
LX view of each structure can be obtained by rotating the probe 90 degrees from the SX view
(Figures 5-19 through 5-22).
A
Figure 5 -18. SX vi ew o f t he t ar sa l tu nn el
(medial ankle). (A) Probe placement. (B)
SX view of the medial ankle showing
the tibialis posterior tendon (white
arrow), FDL tendon (red arrow), posterior tibial artery (white A), posterior tibial nerve (yellow arrow), vein (V), and FHL
tendon (blue arrow) with hypoechoic muscle under the tendon. Also shown is the flexor retinaculum (white triangle).
A
B
B
Figure 5-19. LX view of the
tibialis posterior tendon.
(A) Probe placement.
(B) LX view of the tibialis
posterior tendon (white
arrow).
A B
Figure 5-20. LX view of
the FDL tendon. (A) Probe
placement. (B) LX view of the
FDL tendon (white arrow).
Ankle and Foot 131
AB
Figure 5-21. LX view of the posterior tibial nerve. (A) Probe placement. (B) LX view of the posterior tibial nerve (white
arrow). (A = artery.)
A
Figure 5-22. LX view of the FHL tendon. (A) Probe placement on the posteromedial aspect of the ankle along the
posterior ankle joint. (B) LX view of the FHL tendon (white arrow).
B
3. Relevant anatomy: From anterior to posterior, structures are arranged in the following order:
t ibialis posterior, flexor digitorum longus (FDL), posterior tibial artery, posterior tibial nerve,
vein, and f lexor hallucis longus (FHL).
4. Points to remember: The FHL tendon should not be confused with the posterior tibial nerve
because they both appear as hyperechoic structures at this level. Using dynamic examination
by passively flexing and extending the big toe may help differentiate the FHL from the posterior tibial nerve.
132 Chapter 5
Deltoid Ligament Complex
The deltoid ligament, or medial collateral ligament, complex has 2 layers: (1) a deep layer that
extends from the medial malleolus to the talus and consists of the anterior and posterior tibiotalar
ligaments and (2) a superficial layer in a triangular shape that extends from the medial malleolus
to the navicular bone, spring ligament, and calcaneus. The superficial layer consists of the tibionavicular ligament, tibiospring ligament, and tibiocalcaneal ligament (Figure 5-23).
Figure 5-23. Relevant anatomy of the deltoid ligament.
Ankle and Foot 133
1. Patient position: Ankle in dorsiflexion for posterior tibiotalar (Figure 5-24), tibiocalcaneal
(Figure 5-25), and tibiospring ligaments (Figure 5-26). Ankle in plantar flexion for anterior
tibiotalar (Figure 5-27) and tibionavicular ligaments (Figure 5-28). Ankle in dorsif lexion for
medial talocalcaneal ligament (Figure 5-29).
A
B
C
Figure 5-24. Posterior tibiotalar ligament. (A) Probe placement with the
ankle in dorsiflexion. (B) Posterior tibiotalar ligament (white arrow) between
the tibia and the talus, with the overlying tibialis posterior (TP) and FDL
tendons. (C) Relevant anatomy and probe placement.
AB
C
Figure 5-25. Tibiocalcaneal ligament. (A) Probe placement with the ankle
in dorsiflexion. (B) Tibiocalcaneal ligament (white arrows) between the tibia
and the sustentaculum tali (ST). (C) Relevant anatomy and probe placement.
134 Chapter 5
AB
C
Figure 5-26. Tibiospring ligament. (A) Probe placement with the ankle in
dorsiflexion. (B) Tibiospring ligament (white arrows) between the tibia and
the spring ligament (SP). (C) Relevant anatomy and probe placement.
AB
C
Figure 5-27. Tibionavicular ligament. (A) Probe placement with the ankle in
plantar flexion. (B) Tibionavicular ligament (white arrows) between the tibia
and the navicular bone (N). (C) Relevant anatomy and probe placement.
AB
C
Figure 5-28. Anterior tibiotalar ligament. (A) Probe placement with the ankle
in plantar flexion. (B) Anterior tibiotalar ligament (white arrows) between the
tibia and the talus. (C) Relevant anatomy and probe placement.
AB
Ankle and Foot 135
C
Figure 5-29. Medial talocalcaneal ligament. (A) Probe placement with
the ankle in dorsiflexion. (B) Medial talocalcaneal ligament (white arrows)
between the sustentaculum tali (ST) and the medial tubercle of the talus (T).
(C) Relevant anatomy and probe placement.
2. Probe/transducer position: The probe is placed along the ligament scanned in the LX, keeping
one end of the probe fixed at the medial malleolus and moving the other end of the probe in a
fan-shape movement from the talus to the sustentaculum tali of the calcaneus, the superomedial
portion of the spring ligament, the dorsomedial aspect of the navicular bone, and the anteromedial aspect of the talus to scan the medial collateral complex (see Figures 5-24 through 5-29).
3. Relevant anatomy: The deep layer is much stronger than the superficial layer. The entire medial collateral ligament complex acts like a unit to stabilize the ankle and resist eversion. There
is an interlacing of the fibers of the tibionavicular, tibiospring, and spring ligament complex.
136 Chapter 5
4. Points to remember: An isolated tear of the deltoid ligament is rare. A deltoid ligament tear is
usually associated with other injuries of the ankle, such as a lateral malleolus fracture, or a
less common injury, such as an avulsion fracture of the medial malleolus. The tibionavicular
ligament is present in 55% of the population. The tibiocalcaneal ligament is present in 88% of
the population.
be attributed to normal anatomical variation. The posterior tibiotalar ligament is the thickest
ligament of the medial collateral ligament complex.
The tibiotalar ligament complex may appear hypoechoic on ultrasound due to fiber orientation and interspersed fat between the tendon fascicles. The tibiocalcaneal band appears as a
thin band with the posterior tibialis tendon overlying it.
2
The anterior tibiotalar ligament is a very thin ligament, and its absence can
2
POSTERIOR ANKLE
Achilles Tendon
1. Patient position: Prone with foot over the edge of the table
2. Probe/transducer position:
a. LX view: The probe is placed along the Achilles tendon, with the calcaneus bone in view.
The Achilles tendon is scanned from the bony insertion site at the calcaneus to the muscletendon junction proximally (Figures 5-30 and 5-31).
b. SX view: The probe is placed transversely across the Achilles tendon, which is scanned in
an inferior-to-superior direction to visualize the entire tendon (Figure 5-32).
AB
Figure 5-30. LX view of the Achilles tendon. (A) Probe placement. (B) LX view of the
Achilles tendon showing Kager’s fat pad (white star).
Figure 5-31. Panoramic LX view of the Achilles tendon from the calcaneal insertion to the myotendinous area showing
the hyperechoic Kager’s fat pad (white star).
Ankle and Foot 137
Figure 5-32. SX view of the Achilles tendon at different levels from distal to proximal.
138 Chapter 5
3. Relevant anatomy: The calcaneal tuberosity has 3 facets: superior, middle, and inferior
(Figure 5-33). The retrocalcaneal bursa overlies the superior facet. The middle facet is divided
into 2 parts: The fascicles of the lateral head of the gastrocnemius tendon attach on the lateral
aspect of the middle facet, and the fascicles of the soleus tendon attach to the medial aspect of
the middle facet. The fascicles of the medial head of the gastrocnemius attach on the inferior
facet (Figure 5-34).
6
Figure 5-33. Facets of the calcaneal tuberosity.
A
B
Figure 5-34. (A) Facets of the calcaneal tuberosity. (B) LX view of the Achilles
tendon showing the superior (S), middle (M), and inferior (I) facets.
Kager’s fat pad is a triangular region made up of the Achilles tendon, flexor hallucis tendon,
and a wedge of fat adjacent to the calcaneus bone.
7
Ankle and Foot 139
4. Points to remember: The most superficial part of the Achilles tendon is formed by the medial
gastrocnemius, which inserts on the entire width of the calcaneal tuberosity.
It has been reported that the Achilles tendon may be continuous with the plantar fascia via
the paratenon (Figure 5-35).
6,8
A
Figure 5-35. (A) Probe placement. (B) Achilles tendon (big white arrow) continuous with the plantar fascia (yellow
arrow) via the paratenon (small white arrows).
B
The plantaris tendon is absent in 6% to 8% of the population.9 When present, the plantaris
tendon attaches to the middle facet on the medial aspect. There are variations in the plantaris
tendon insertion footprint reported in the literature.10
During plantar flexion, Kager’s fat pad extends into the retrocalcaneal bursa as far as the
enthesis. In neutral position, Kager’s fat pad gets retracted so that the tendon is against the
bone (the superior tuberosity of the calcaneus).
7
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