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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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140 Chapter 5
Posterior Inferior Tibiofibular Ligament
Relevant anatomy is shown in Figure 5-36.
Figure 5-36. Relevant anatomy of the posterior ligaments of the ankle.
1. Patient position: Ankle in slight dorsif lexion and eversion
2. Probe/transducer position: The probe is placed along the ligament, bridging the distal tibia and
fibula posteriorly (Figure 5-37).
A
Figure 5-37. Posterior tibiof ibular ligament. (A) Probe placement with the ankle in dorsiflexion and eversion. (B) Posterior tibiofibular
ligament (wh ite arrow) bet ween the tibia and the fibula (lateral malleolus).
B
3. Relevant anatomy: The ligament is obliquely oriented from the posterior tubercle of the tibial
shaft to the posterior aspect of the lateral malleolus.
4. Points to remember: The posterior inferior tibiofibular ligament is much stronger than the
anterior inferior tibiofibular ligament and is rarely involved in ankle sprains.
Ankle and Foot 141
Posterior Talofibular Ligament
1. Patient position: Ankle in slight dorsiflexion
2. Probe/transducer position: The probe is placed along the ligament, bridging the talus and
fibula posteriorly (Figure 5-38).
AB
Figure 5-38. Posterior talofibular ligament. (A) Probe placement with the ankle in dorsiflexion. (B) Posterior
talofibular ligament (white arrows) between the talus and fibula (Fib; lateral malleolus).
3. Relevant anatomy: The ligament connects the lateral tubercle of the posterior process of the
talus to the posterior aspect of the lateral malleolus. The ligament is intracapsular but extrasynovial. It is the deepest ligament of the lateral collateral complex. The primary function of
the ligament is to restrain the posterior displacement of the talus.
4. Points to remember: Full dorsiflexion puts the ligament under the greatest strain. The poste-
rior talofibular ligament is rarely involved in ankle sprains because the bony stability protects
the ligament in dorsiflexion. Due to its deep location, there is a limited window to scan the
ligament, and the ligament can only be partially visualized.
142 Chapter 5
HINDFOOT
Subtalar Joint
The subtalar joint is divided into the anterior subtalar joint (ASTJ) and posterior subtalar joint
(PSTJ). There is lack of communication between the ASTJ and PSTJ; therefore, the anterior and
posterior joints should be evaluated separately (Figure 5-39).
11
Figure 5-39. Relevant anatomy of the subtalar joint.
Ankle and Foot 143
AnteriorSubtalarJoint(MedialApproach)
1. Patient position: Supine with the leg externally rotated to examine the medial aspect of the foot
2. Probe/transducer position: The probe is placed to bridge the medial malleolus and distal pole
of the sustentaculum tali. While keeping the distal part of the probe fixed on the sustentaculum tali, the proximal part of the probe is rotated anteriorly toward the navicular bone until
the ASTJ is visualized (Figure 5-40).
11
A
Figure 5-40. ASTJ (medial approach). (A) Probe placement between the sustentaculum tali and the navicular bone. (B)
ASTJ (white arrow). (N = navicular bone; ST = sustentaculum tali.)
B
3. Relevant anatomy: The spring ligament overlying the talar cartilage is visualized at this level.
Overlying the spring ligament is the oblique SX view of the tibialis posterior tendon.
4. Points to remember: The sustentaculum tali is an important bony landmark and needs to be
correctly identified to scan the ASTJ.
PosteriorSubtalarJoint(MedialApproach)
1. Patient position: Supine with the leg externally rotated to examine the medial aspect of the foot
2. Probe/transducer position: Initially the probe is placed in the LX to bridge the medial malleo-
lus and distal pole of the sustentaculum tali. The probe is then moved posterior to the medial
malleolus in the same orientation to scan the FHL tendon in the LX view. The PSTJ is visualized underneath the FHL tendon (Figure 5-41).
11
A
underneath the FHL tendon. (B) Subtalar joint (white arrow) and overlying FHL tendon. The posterior tibiotalar joint
(white triangle) can be seen proximally.
B
Figure 5-41. PSTJ (medial approach). (A) Probe placement posterior to the
medial malleolus to visualize the FHL tendon. The subtalar joint is seen
144 Chapter 5
3. Relevant anatomy: The tibiotalar joint is immediately proximal to the PSTJ in the view.
4. Points to remember: There is communication between PSTJ and the posterior recess of the
tibiotalar joint (ankle joint).
PosteriorSubtalarJoint(LateralApproach)
1. Patient position: Supine with the leg internally rotated to examine the lateral aspect of the foot
or side-lying with the foot to be examined on the top to access the lateral aspect of the foot
2. Probe/transducer position: Initially the probe is placed in the LX to bridge the tip of the lateral
malleolus and lateral calcaneal surface. The probe is then moved slightly anterior to the lateral
malleolus in the same orientation to scan the PSTJ, visualizing 3 bony landmarks: calcaneus,
talus, and distal end of the fibula (lateral malleolus; Figure 5-42).
11
A
Figure 5-42. PSTJ (lateral approach). (A) Probe placement anterior to the lateral malleolus in the LX orientation,
bridging the lateral malleolus, talus, and calcaneus. (B) Subtalar joint (white arrow).
B
3. Relevant anatomy: Three bony landmarks are the calcaneus, talus, and fibula (lateral malleolus). The PSTJ is between the calcaneus and talus. The peroneus longus and brevis are visualized overlying the bony landmarks.
4. Points to remember: There is communication between the PSTJ and the posterior recess of the
tibiotalar joint (ankle joint).
Ankle and Foot 145
PosteriorSubtalarJoint(PosteriorApproach)
1. Patient position: Side-lying with the foot to be examined on the top to scan the posterior aspect
or lying prone to examine the posterior aspect; ankle in neutral or slightly dorsiflexed
2. Probe/transducer position: The probe is placed along the LX of the Achilles tendon with the
distal end of the probe on the calcaneus bone. The depth of the scan is increased to visualize
the PSTJ, deep to Kager’s fat pad (Figure 5-43).
11
A
Figure 5-43. PSTJ (posterior approach). (A) Probe placement along the LX of the Achilles tendon. The depth of the
scan is increased to visualize the PSTJ, deep to Kager’s fat pad. (B) PSTJ (white arrow). (Ach = Achilles tendon.)
B
3. Relevant anatomy: Three bony landmarks are the distal tibia, talus, and calcaneus. The
Achilles tendon and Kager’s fat pad overlie the PSTJ.
4. Points to remember: Adding dorsiflexion helps visualize the PSTJ better.
146 Chapter 5
Plantar Fascia
Relevant anatomy is shown in Figures 5-44 and 5-45.
Figure 5-44. Relevant anatomy of the plantar fascia.
Figure 5-45. Relevant anatomy of the lateral cord of the plantar fascia and other attachments at the fifth metatarsal
(MT) base.
Ankle and Foot 147
1. Patient position: Prone with the foot to be examined over the edge of the table
2. Probe/transducer position: The probe is placed along the LX of the plantar fascia with the
proximal end of the probe on the medial calcaneal tuberosity to scan the central cord (Figures
5-46 and 5-47). For the lateral cord, the probe is moved laterally toward the fifth metatarsal
(Figure 5-48).
A
Figure 5-46. Central cord of the
plantar fascia. (A) Probe placement.
(B) LX view of the central cord of the
plantar fascia (white arrow). (C) SX view
of the central cord of the plantar fascia
(white arrow).
B
C
Figure 5-47. Panoramic view of the
central cord of the plantar fascia
(white arrows).
148 Chapter 5
A
Figure 5-48. (A) Lateral cord of the plantar fascia (white
arrows) between the calcaneus and the tuberosity of the
fifth metatarsal (MT). (B) Relevant anatomy and probe
placement.
B
3. Relevant anatomy: There are 2 cords of the plantar fascia that originate from the medial calcaneal tuberosity: central cord and lateral cord. The central cord continues distally and divides
into 5 fascicles to attach to the plantar plate of each toe. The lateral cord of the plantar fascia
changes its course from plantigrade orientation to sagittal orientation as it attaches to the
lateral aspect of the fifth metatarsal tuberosity.
12,13
4. Points to remember: The lateral cord of plantar fascia enthesopathy at the fifth metatarsal
tuberosity may be suspected in nontraumatic foot pain arising from the fifth metatarsal base.
12
Ankle and Foot 149
MIDFOOT
Lateral Ligaments
The dorsal calcaneocuboid ligament and dorsal talonavicular ligament are shown in Figure 5-7.
1. Patient position: Foot in slight inversion for the calcaneocuboid ligament; foot in plantar flex-
ion for the dorsal talonavicular ligament
2. Probe/transducer position:
a. Dorsal calcaneocuboid ligament: The distal end of probe is placed over the base of the
fifth metatarsal, which is an initial bony landmark, then the probe is moved proximally to
visualize the calcaneocuboid joint (Figure 5-49).
A
C
B
Figure 5-49. Dorsal calcaneocuboid ligament. (A) Probe placement with
the foot in slight inversion. The distal end of the probe is placed over the
base of the fifth metatarsal, which is the initial bony landmark, then the
probe is moved proximally to visualize the calcaneocuboid joint. (B) Dorsal
calcaneocuboid ligament (white arrows) between the calcaneus and the
cuboid bone. (C) Relevant anatomy and probe placement.
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