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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
8.1.3 Calcaneo-Fibular Ligament
Anatomical scheme of the calcaneo-fibular liga-
ment is shown in Fig. 8.7. The foot is placed flat
on the table. The probe is placed on a coronal
plane with the proximal edge over the fibular
malleolus tip (Figs. 8.8a, b). The ligament lies
deep to the peroneal tendons but its visibility is
impaired by its curvilinear course. To assess the
ligament correctly, the patient must be asked to
dorsally flex the ankle (Fig. 8.9a). A superficial
displacement of the peroneal tendons (Fig. 8.9b)
allows for differentiating partial from complete
tears of the calcaneo-fibular ligament.
8.1.4 Peroneal Tendons
The peroneal tendons must be evaluated on a
short axis scan (Fig. 8.10). The evaluation must
be commenced with horizontal axial scans of the
proximal to lateral malleolus. At this level, the
peroneal muscles and their distal myotendinous
junction can be seen. Then, the probe must be
moved following a curvilinear line that turns
around the lateral malleolus tip (Figs. 8.11a, b).
The peroneus brevis tendon has a typical cres-
cent appearance and is located deep to the per-
oneus longus tendon, which has a typical oval
shape. A long axis scan is not useful in the eval-
uation of peroneal tendons, except when assess-
ing their distal bone insertions.
Sometimes an accessory tendon can be seen
(peroneus quartus tendon), it is usually located
posteriorly and medially to the peroneal ten-
dons.
The peroneus brevis tendon arises from the
peroneus brevis muscle, located in the later-
al compartment of the leg. It courses distal-
ly under the peroneus longus tendon, turns
around the peroneal malleolus, and inserts
on the base of the fifth metatarsal bone.
The peroneus longus tendon arises from the
peroneus longus muscle, adjacent to the per-
oneus brevis. It courses distally over the per-
oneus brevis tendon, turns around the per-
oneal malleolus, then crosses the foot plant
medially, and inserts on the tuberosity of the
first metatarsal bone, as well as on the first
cuneiform and on the second metatarsal
bone.
The peroneal tendons have a common sheath
around their malleolar reflection and are sta-
bilized by a retinaculum.
The peroneus quartus may arise from the
peroneus brevis muscle, or from the fibula,
or from distal fibers of the peroneus longus.
In most cases, this tendon courses posterior-
ly to the peroneal tendons. Its possible inser-
tions are the calcaneal tubercle, the fifth
metatarsal bone, and the cuboid.
Lateral Compartment
119
Fig. 8.7 Anatomical scheme of the calcaneo-fibular liga-
ment (*). F, fibula; Ti, tibia; T, talus; C, calcaneus; S, tarsal
scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones
8 Ankle
120
Fig. 8.8a Probe position to evaluate the calcaneo-
fibular ligament
Fig. 8.8b Long axis evalua-
tion of the calcaneo-fibular
ligament (*). F, fibula;
C, calcaneus; ttP, peroneal
tendons
Fig. 8.9a Dynamic assessment of the
calcaneo-fibular ligament in dorsal flexion
Fig. 8.9b Dynamic evalua-
tion of the calcaneo-fibular
ligament (*) with the ankle
in full dorsal flexion.
Peroneal tendons (ttP) are
displaced superficially due
to calcaneo-fibular liga-
ment integrity. F, fibula; C,
calcaneus
Lateral Compartment
121
Fig. 8.10 Anatomical scheme of the peroneal tendons.
PB, peroneus brevis tendon; PL, peroneus longus tendon;
F, fibula; T, talus; C, calcaneus; Cu, cuboid;
V, fifth metatarsal
Fig. 8.11a Probe position sequence to
evaluate the peroneal tendons
Fig. 8.11b Short axis scan of the peroneal tendons behind the fibular malleolus. PL, peroneus
longus; PB, peroneus brevis; F, fibula
Fig. 8.12 Ankle position to evaluate the medial compart-
ment
Fig. 8.13 Anatomical scheme of the deltoid ligament:
1a, tibio-navicular ligament (anterior superficial bundle);
1b, anterior tibio-talar ligament (anterior deep bundle);
2, tibio-calcaneal ligament (middle bundle); 3, posterior
tibio-talar ligament (posterior bundle); C, calcaneus;
S, scaphoid; T, talus; St, substentaculum tali; Ti, tibia
8.2 Medial Compartment
The patient lies supine on the bed, with the
knee flexed at about 90°, and the foot is slight-
ly externally rotated (Fig. 8.12). Anatomical
scheme of the deltoid ligament is shown in Fig.
8.13.
8.2.1 Deltoid Ligament
The anterior tibio-talar ligament can be assessed
with the ankle in a neutral position (Figs. 8.14a, b).
The middle and posterior bundles must be
assessed with the ankle in full dorsal flexion. The
middle bundle is evaluated with the probe orient-
ed on a coronal plane and one edge positioned on
the medial malleolus tip (Figs. 8.15a, b).
To assess the posterior bundle, the distal
edge of the probe must be moved posteriorly
(Figs. 8.16a, b).
The deltoid ligament has a triangular shape.
It arises from the tibial malleolus, then it
splits into four bundles: two of them are
anterior, one is median, and one is posterior.
Anterior bundles
• Tibio-navicular ligament: superficial,
inserts on the dorsal aspect of the scaphoid
• Anterior tibio-talar ligament: deep to the
tibio-navicular ligament, inserts on the
medial aspect of the talus
Median bundle
• Tibio-calcaneal ligament: inserts on the
substentaculum tali
Posterior bundle
• Posterior tibio-talar ligament: inserts pos-
teriorly on the medial aspect of the talus.
8 Ankle
122
Medial Compartment
123
Fig. 8.14a Probe position to evaluate the anterior
tibio-talar ligament
Fig. 8.14b Scan of the anterior
tibio-talar ligament (arrow-
heads). mm,
medial tibial
malleolus; T, talus
Fig. 8.15a Ankle and probe position to evaluate
the tibio-calcaneal bundle
Fig. 8.15b Scan of the tibio-cal-
caneal ligament (arrowheads),
deep to the posterior tibial ten-
don (TP) seen on short axis.
mm,
medial tibial malleolus;
T, talus; C, calcaneus
8 Ankle
124
Fig. 8.16a Ankle and probe position to evaluate
the posterior tibio-talar ligament
Fig. 8.16b Scan of the posteri-
or tibiotalar ligament showing
its superficial (circle) and
deep (*) components;
mm, tibial medial malleolus;
T, talus; TP, posterior tibial
tendon
8.2.2 Tarsal Tunnel
The structures that are contained into the tarsal
tunnel (medial to lateral) are the posterior tib-
ial tendon, the tibial neurovascular bundle,
the flexor digitorum longus tendon, and the
flexor hallucis longus tendon (Fig. 8.17).
The tarsal tunnel can be assessed on axial
scans placing one edge of the probe on the tip
of the medial malleolus and the other on the
Achilles tendon. The posterior tibial tendon
must be evaluated along its whole course with
axial scans, up to its main insertion on the nav-
icular bone. This area must be assessed careful-
ly, also with longitudinal scans, due to the com-
plexity of the enthesis that could produce
anisotropy artifacts. The presence of an acces-
sory navicular bone is an extremely common
finding. The flexor digitorum longus and flex-
or hallucis longus tendons must be scanned
with the same approach described for the pos-
terior tibial tendon.
The tibial neurovascular bundle can be easily
seen between the posterior tibial tendon and the
flexor digitorum longus tendon (Figs. 8.18a-c).
The tibial nerve runs in the tarsal tunnel. This
is the site where extrinsic compressions can
occur. Distally, it splits into two terminal branch-
es: the lateral and the medial plantar nerve.
Medial Compartment
125
Fig. 8.17 Anatomical scheme of the struc-
tures running into the tarsal tunnel. 1, poste-
rior tibial tendon; 2, flexor digitorum longus
tendon; 3, flexor hallucis longus tendon; *,
tibial nerve; Ti, tibia; C, calcaneus;
T, talus; S, scaphoid
8 Ankle
126
Fig. 8.18a Probe position and movements to evaluate
the tarsal tunnel
Fig. 8.18b Axial scan of the tarsal
tunnel. TP, posterior tibial tendon;
FDL, fle
xor digitorum longus ten-
don; arrowheads, tibial nerve;
FHL, flexor hallucis longus ten-
don; mm, tibial medial malleolus
Fig. 8.18c Longitudinal scan of
posterior tibial tendon’s insertion
(arrowheads) on navicular bone (Sc)
8.3 Posterior Compartment
8.3.1 Achilles Tendon
Anatomical scheme of the Achilles tendon is
shown in Fig. 8.19. The patient lies prone with
the ankle hanging out of the bed. The Achilles
tendon is assessed using both short and long
axis scans, from the myotendinous junction to
the enthesis. However, tendon thickness must
be measured on short axis only (Figs. 8.20a, b,
8.21a, b).
Dynamic long axis scans are useful to eval-
uate biomechanical relationships among the
enthesis, the retrocalcaneal bursa, the Kager’s
fat pad, and the postero-superior calcaneal
tubercle.
Dynamic scans in passive plantar and dorsal
flexion of the ankle allow for a differential
diagnosis between incomplete and complete
rupture.
On the medial side of the Achilles tendon,
the plantaris gracilis tendon can be fre-
quently seen. This is a very thin accessory
tendon that can be confused with residual
fibers of the Achilles tendon in the case of
full-thickness tears.
Posterior Compartment
127
Fig. 8.19 Anatomical scheme of Achilles tendon: T,
Achilles tendon; K, Kager’s fat pad;
*, precalcaneal bursa; arrowhead, retrocalcaneal bursa;
C, calcaneus
8 Ankle
128
Fig. 8.20a Probe position to evaluate
the Achilles tendon on long axis
Fig. 8.20b Longitudinal scan of Achilles tendon (arrowheads)
Fig. 8.21a Probe position to eval-
uate the Achilles tendon on short
axis
Fig. 8.21b Axial scan of the Achilles tendon (arrowheads)