4


 


 


 

FIGURE 3-121 Illustrations of the sesamoid relationships in the axial (A) and plantar planes (B). C) Axial fat-suppressed fast SE image demonstrating the medial (M) and lateral (L) sesamoids seated in the metatarsal grooves.





 


 


 


 

FIGURE 3-122 A) Radiograph demonstrating medial and lateral sesamoids (arrows) formed from single ossification centers. B) Radiograph demonstrating a bipartite medial sesamoid (arrows) with the lateral sesamoid formed from a single ossification center. C) Hallux valgus with rotation of the sesamoids laterally out of the normal metatarsal grooves. D) T1-weighted MR image demonstrating fragmentation of the sesamoid (arrow) and degenerative changes in the first metatarsophalangeal joint with osteophyte formation (arrowhead).


Disorders of the sesamoids account for 4% of all foot injuries [165,175]. Sesamoid disorders occur more commonly in patients with frequent use of high-heeled shoes, in dancers and athletes, especially runners [5,175]. There may also be associated arthropathies. Sesamoiditis is a generic term commonly used for painful disorders of the sesamoids [5,175]. The sesamoids may become inflamed, fracture, or undergo osteonecrosis. In addition to pain, physical examination may reproduce the symptoms by dorsiflexion of the great toe [186].


Routine radiographs including AP, oblique, lateral, and sesamoid views (Fig. 3-123) may be diagnostic [16,57]. The sesamoid may be fragmented, sclerotic, or fractured (Fig. 3-124). Soft tissue swelling over the involved sesamoid is usually present as well. In subtle cases, radionuclide bone scans are useful (Fig. 3-125). Increased tracer occurs in the presence of sesamoid disorders. A normal scan excludes the diagnosis.




 


 

FIGURE 3-123 A long-distance runner with chronic pain under the first metatarsal head. AP (A) radiograph shows an absent lateral sesamoid (arrow). Sesamoid view (B) shows only a small remnant (arrow) of the lateral sesamoid resulting from avascular necrosis and bone resorption.




 


 

FIGURE 3-124 Lateral (A) and sesamoid (B) views demonstrating sclerosis and fragmentation of the medial sesamoid (arrow) due to fracture with avascular necrosis.




 

FIGURE 3-125 Technetium-99m methylene diphosphonate bone scan shows increased tracer in the sesamoids and first metatarsophalangeal due to degenerative joint disease and early avascular necrosis of the sesamoids.


In some cases, ultrasound or MR imaging is required for evaluating unresponsive sesamoid pain [64,175,186]. MR images with a small field of view and digital coil can provide excellent detail for evaluation of marrow edema, tendon and capsular disorders, and synovitis (Fig. 3-126) [14,175].




 


 

FIGURE 3-126 Marrow edema and fracture of the medial sesamoid. Axial T1- (A) and T2-(B) weighted images demonstrate marrow edema and a subtle fracture (arrow) in the medial sesamoid. There is also synovitis in the joint.


Treatment is usually conservative. Footwear changes, sesamoid pad, and anti-inflammatory medications may be sufficient. However, when conservative measure fail, resection of the sesamoids may be required (Fig. 3-127) [57].




 


 


 


 

FIGURE 3-127 Sesamoidectomy. A) Standing AP radiograph demonstrates absence of both sesamoids on the right (arrows). B) Axial T1-weighted image demonstrate the absent sesamoid (arrows) with the flexor hallucis longus tendon in normal position. Sagittal T2-weighted images (C,D) with an intact plantar plate.


Bursitis


Bursitis may involve the intermetatarsal bursae (Fig. 3-128) or occur in the plantar (adventitious bursae) (Fig. 3-129) aspect of the foot [124,161]. Studler et al. [161] recently reviewed changes in the plantar aspect of the feet in volunteers and cadaver specimens. Abnormal signal intensity on MR images was noted in 84% of 70 adult volunteers with a mean age of 45 years. Signal intensity changes were evident beneath the metatarsal heads. These findings occurred most commonly beneath the first (70%) and fifth (61%) metatarsals. Signal abnormalities varied, but 91% demonstrated low-signal intensity on T2-weighted images that correlated with fibrous tissue on histologic specimens. Contrast-enhanced imaging is important to confirm fluid filled bursae compared to other pathology such as fibrosis or neuromas. There is peripheral enhancement with plantar or intermetatarsal bursae [5]. Intermetatarsal bursae that measure less than 3 mm are often physiologic [5].




 

FIGURE 3-128 Intermetatarsal bursa. Coronal fast spin-echo T2-weighted image demonstrating an enlarged intermetatarsal (arrow) bursa between the third and fourth metatarsals.




 


 


 


 

FIGURE 3-129 Abnormal signal intensity with bursa beneath the fifth metatarsal head. Axial T1- (A) and T2- (B) weighted images demonstrate an elliptical area of abnormal signal intensity beneath the fifth metatarsal head (arrow). Sagittal T1- (C) and T2- (D) weighted images show the abnormal soft tissue collection with a small adventitious bursa (arrow in D) and area of low-signal intensity on T2- weighted image D (arrowhead) due to fibrous tissue.


Plantar bursae may be managed conservatively with foot pads or change in footwear. On occasion, anesthetic and steroid injections are indicated when conservative measures are unsuccessful.


Freiberg Infraction


Freiberg infraction is a disorder that most commonly involves the second or third metatarsal heads [5,155]. The etiology is likely multifactorial. However, acute or repetitive trauma is commonly associated. The condition is most common in adolescent females and is also associated with use of high-heeled shoes [5,186]. The condition results in fragmentation, collapse, and fissuring of the metatarsal head.


Radiographs are usually diagnostic and useful for staging Freiberg infraction (Fig. 3-130) [155]. However, when indicated, MR imaging is useful to confirm the diagnosis and exclude other conditions such as synovitis [155]. In the latter, intravenous gadolinium may be useful to detect early synovial changes [14]. Synovitis, like osteonecrosis, also more commonly involves the second metatarsophalangeal joint [155].




 

FIGURE 3-130 Freiberg Infraction. AP radiograph demonstrating fragmentation of the second metatarsal epiphysis (arrow).


Management of patients with Freiberg infraction can be complex and is based on symptom duration, associated local and systemic disorders, and staging. Staging is based on image features [155].




  • Stage I: fissuring of the epiphysis
  • Stage II: central articular depression with soft tissue support intact
  • Stage III: central depression with medial and lateral marginal projections
  • Stage IV: fracture with central portion becoming a loose body and medial and lateral marginal projections
  • Stage V: fattening and deformity of the metatarsal head with loss of joint space

Conservative treatment is recommended for Stages I and II as changes may resolve spontaneously (Fig. 3-131) [95,105,155]. Stages IV and V require surgical intervention. Multiple procedures have been used over the years. Approaches include debridement, wedge or shortening osteotomies, core decompression, resection arthroplasty, and joint replacement [95,105,155].




 


 


 

FIGURE 3-131 Conservative management of Freiberg infraction. A) Oblique radiograph demonstrating central depression of the head and a small lateral projection (arrow) (Stage III). AP (B) and oblique (C) images 6 years later demonstrate slight joint space narrowing with a small fragment (arrow in B) along the lateral joint line.


Hallux Rigidus


Hallux rigidus is a syndrome related to degenerative changes of the first metatarsophalangeal articulation resulting in cartilage loss, joint space narrowing and prominent osteophytes, particularly dorsally (Fig. 3-132). There is also restricted motion in the joint [45,86]. Hallux rigidus is second only in frequency to hallux valgus [45]. Coughlin and Shurnas [45] reported that this condition is bilateral in 80% of patients. Some reports demonstrate a male and others a female predominance.




 


 

FIGURE 3-132 Hallux rigidus. AP (A) and lateral (B) radiographs demonstrating advanced hallux rigidus with marked loss of joint space, no hallux valgus and prominent dorsal osteophytes with fragmentation (arrow) and soft tissue swelling.


Hallux rigidus usually results from chronic trauma. Athletes involved in track and football are commonly affected [86]. Most patients present with pain, commonly more marked over the dorsal aspect of the joint. Physical examination reveals restricted motion, prominence, and tenderness over the dorsal aspect of the first metatarsophalangeal joint. Pain is exaggerated with dorsiflexion of the first toe [45,74,94].


Joint space narrowing without hallux valgus deformity may be the only radiographic finding initially. In more advanced cases, there is marked loss of joint space, subchondral cysts, and marginal and prominent dorsal osteophytes on the dorsum of the first metatarsal head (Fig. 3-132) [74]. MR imaging features have also been described [157]. Loss of articular cartilage and marrow edema are more clearly demonstrated (Fig. 3-133). However, imaging beyond radiographs is usually not required to diagnose and manage hallux rigidus.




 


 


 

FIGURE 3-133 Hallux rigidus. T1-weighted axial and sagittal (A,B) and T2-weighted (C) sagittal images demonstrate joint space narrowing with prominent osteophytes on the dorsum of the first metatarsal head and proximal phalanx (arrows). There is also a joint effusion and subchondral marrow edema.


Treatment of early hallux rigidus may be successful using changes in footwear or joint injections. However, in more advanced cases, surgical intervention is more effective [157]. Treatment options will be more completely reviewed in Chapter 10.


Morton Neuroma


Morton neuromas are not true neoplasms, but are composed of fibrous tissue and neural degeneration resulting in a mass near the transverse metatarsal ligament (Fig. 3-134) [5]. These lesions occur based on chronic compression of the digital nerves against the intermetatarsal ligament. Morton neuromas may also be the result of compression of the nerve by adventitial bursae [5,186]. The lesions tend to occur more frequently in females using high-heeled footwear [5]. The most common site is between the third and fourth metatarsal heads [5]. Patients present with pain under the metatarsal heads. The pain is often referred to the toes [5,11]. Morton neuromas may be incidental findings as up to 33% may not present with clinical symptoms [11].




 


 


 

FIGURE 3-134 Morton neuroma. Axial T1- (A) and postcontrast fatsuppressed T1- (B) weighted images demonstrating neuromas between the second and third and third and fourth metatarsal bases. C) Illustration of the location of Morton’s neuromas and intermetatarsal bursae with relation to the transverse metatarsal ligament.


In patients with Morton neuroma, radiographs may show separation of the metatarsal heads. However, this finding is nonspecific and most radiographs are normal. Detection of Morton neuromas can be accomplished with ultrasound or MR imaging [2,14,155,182]. MR images demonstrate a focal soft tissue mass at the plantar between the metatarsal heads below the level of the transverse metatarsal ligament (Fig. 3-134). The lesion is usually equal or slightly greater than muscle density on T1-weighted images and mixed low and high-signal on T2-weighted sequences. Neuromas enhance following intravenous gadolinium. However, the enhancement pattern may not be uniform (Fig. 3-134B) [5,14,182]. Patients may be placed in the prone or supine positions to evaluate the forefoot on MRI. We usually use the supine position, though the prone position reduces motion artifact. Weishaupt et al. [181] reported superior results when the prone position was used to evaluate Morton neuromas.


Conservative treatment is usually used initially. This may include ultrasound-guided steroid injections which are much more successful than non-image-guided injections. When conservative treatment fails surgical intervention is indicated. Neuromas will also be discussed in Chapter 6.


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CHAPTER 4
Fractures/Dislocations


 

Thomas H. Berquist


 


INTRODUCTION


Foot and ankle fractures present a common problem for orthopaedic surgeons, emergency room physicians, family practice physicians, and radiologists. Appropriate use of imaging techniques is important in today’s cost-conscious environment. For example, 10% of emergency department visits are due to ankle sprains [3]. Do imaging procedures need to be ordered in all cases? Clinical algorithms have been developed in an attempt to reduce unnecessary imaging of foot and ankle injuries [2,4,5,13,15,16,29]. The Ottawa ankle rules were instituted to reduce costs of ankle radiographs. Ninety percent of ankle injuries are imaged with radiographs, but the fracture detection yield is less than 15% [2,15,29]. Application of the Ottawa ankle rules (pain over one or both malleoli and one or more of the following: (i) patient 55 years old or older; (ii) inability to bear weight; and (iii) bone tenderness at malleolar tip) before ordering radiographs may reduce costs in treating ankle injuries by 16% to 22% [15,29]. In addition, the American College of Radiology provides appropriateness criteria for which views and modalities should be used in patients with suspected foot and/or ankle injuries. Ankle images should include anteroposterior (AP), lateral, and mortise views; and AP, lateral, and oblique views should be obtained for foot injuries [1].


Radiographs or computed radiography (CR) images remain an effective screening tool for foot and ankle fractures. However, detection of subtle fractures, especially in children, complex fracture patterns, and evaluating the extent of soft tissue injury is more difficult. Additional imaging with CT or MR may be required in the acute setting or when the patients’ symptoms do not respond to treatment [3,9,14]. Haapamaki et al. [9] reported that the three most commonly overlooked fractures in the ankle were posterior and medial malleoli and juvenile Tillaux fractures. They also noted sensitivity for radiographs to be 87% for talar fractures, but only 25% to 33% for midfoot fractures. Lisfranc injuries were missed on radiographs in 24% of cases. These injuries were easily appreciated using CT [9]. Lohman et al. [14] reported improved detection of physeal fractures with MR imaging.


It is essential for those interpreting images to be aware of the manner in which various fractures and soft tissue injuries present, so that the images can be correctly and thoroughly evaluated and additional studies selected when appropriate [3,9,14]. Soft tissue changes may be the only clue to a subtle fracture or ligament rupture. Soft tissue swelling, obliteration of the fat planes or pre-Achilles fat triangle, and the presence of an effusion can be useful in identifying the location of subtle fractures or soft tissue injuries. These findings assist with selecting the next imaging modality to completely evaluate the injuries (Fig. 4-1, also see Fig. 2-3) [23,25,28].




 

FIGURE 4-1 Lateral radiograph of the ankle demonstrating a large joint effusion with anterior and posterior capsular distention (arrows).


It is also important to understand the clinical significance of certain fracture patterns. Fractures may be complete (involve both cortices) or incomplete (one cortex fractured). The latter are more common in children. Fractures may be comminuted (multiple fragments) or compound (open) [3,12,23].


Terms other than complete or incomplete are also used in describing fractures. Avulsion fractures occur at the insertion of ligaments or tendons. Compression is a term usually reserved for vertebral fractures, but it can also be used to describe talar or calcaneal fractures [23]. Pathologic fractures involve bone with underlying abnormality such as osteoporosis or neoplasm. Stress fractures occur in normal bone that is exposed to unusual stress. The metatarsals in military recruits and the tibia and fibula in long-distance runners are commonly involved [3,25]. An insufficiency fracture is a category of stress fracture that occurs in abnormal bone under normal stress. This may occur in a patient with rheumatoid arthritis who becomes active too soon after joint arthroplasty [3,20]. Certain eponyms have been applied to many injuries about the foot and ankle [6–8,18,19,21,25,27]. These terms are frequently used and it is important to understand what they imply. However, eponyms can be confusing and inaccurately used (Figs. 4-2 to 4-15) [3,24,26]. For example, the Jone fracture (Table 4-1) was originally described as a fracture of the proximal fifth metatarsal. However, radiographs were so poor at that time that the fracture site was not clear. Today, the term Jones fracture (see Fig. 4-2) is commonly used to describe a fracture distal to the tuberosity, a condition that is more difficult to treat than a tuberosity fracture [3,10,11,24,26,25]. Today’s approach to proximal fifth metatarsal fractures will be discussed more completely in the Midfoot and Forefoot Injuries section of this chapter. The most commonly used eponyms are summarized in Table 4-1 (Figs. 4-2 to 4-15).



 

A systematic approach should be used when describing the imaging features of a fracture or fracture dislocation so the injury is completely assessed [3,25]. Eponyms can be confusing and should not be used without describing the associated fractures and soft tissue injury. The time, date, and views or imaging technique should be described first. This method makes it easier to keep examinations in chronologic order. This is followed by a general description of the fracture location, orientation (transverse, oblique, spiral), degree of displacement, angulation, and alignment (see Fig. 4-1). Angulation can be described using the direction of the distal fragment or the apex of the fragments [3,16]. I prefer the latter method of describing angulation (Fig. 4-16) [3]. Articular involvement, including the degree of separation or articular irregularity and the percentage of the articular surface involved, should be described. Soft tissue injury should also be carefully described (see Fig. 4-1) [3,22].




 


 

FIGURE 4-2 A) United Jones fracture (arrow). B) Typical proximal avulsion fracture (arrow) with intra-articular extension for comparison.




 

FIGURE 4-3 Mortise view of the ankle demonstrating a comminuted talar neck fracture (arrow).




 

FIGURE 4-4 AP view of the midfoot demonstrating a talonavicular fracture dislocation.




 

FIGURE 4-5 Cotton fracture. AP (A) and lateral (B) radiographs demonstrate a medial malleolar fracture (arrow) and displaced posterior tibial fracture (arrow, lateral view, B). Note the high fibular fracture (upper arrow) in A.




 


 

FIGURE 4-6 Dupuytren’s fracture. A) High fibular fracture with deltoid ligament rupture (black arrow). B) Low fibular fracture (arrow) with rupture of the tibiofibular ligaments (open arrow) and a medial malleolar fracture (arrow).




 

FIGURE 4-7 Illustration of LeFort’s fracture.




 

FIGURE 4-8 AP radiograph of the foot demonstrating widening of the space between the first and second metatarsal bases (vertical arrow) with displacement of the lesser metatarsals laterally (right horizontal arrow) and the medial cuneiform and first metatarsal medially (left horizontal arrow).




 


 

FIGURE 4-9 Maisonneuve fracture. A) AP ankle radiograph demonstrating a medial malleolar avulsion (arrow). B) Lateral view of the upper leg demonstrates an oblique fibular fracture (arrow).




 


 

FIGURE 4-10 March fracture. Sagittal T1 (A) and axial contrast enhanced fat suppressed T1-weighted (B) images demonstrating a stress fracture (arrow) of the second metatarsal.




 

FIGURE 4-11 Pott’s fracture. Fracture of the fibula 2 to 3 in. above the joint with talar shift and medial malleolar avulsion.




 

FIGURE 4-12 Sagittal CT image demonstrating a fracture of the posterolateral talar tubercle (arrow).




 

FIGURE 4-13 AP radiograph of the ankle demonstrating juvenile Tillaux fracture (arrows).




 

FIGURE 4-14 AP radiograph of the foot demonstrating a torus fracture at the first metatarsal base (arrow).




 


 

FIGURE 4-15 AP (A) and lateral (B) radiographs demonstrate a triplane fracture. The fracture looks like a Salter–Harris III fracture on the AP view and a Type II on the lateral view.




 

FIGURE 4-16 Illustration of fractures and descriptive terms. A) Undisplaced complete fracture with normal alignment. No angulation or shortening. B) Impacted fracture with trabecular compression. Minimal shortening with no angulation. C) Distracted fracture with separation of fragments but normal alignment and no angulation. D) Complete fracture with medial displacement of the distal fragment or 34° of lateral angulation. E) Complete fracture with dorsal displacement and no angulation. F) Complete fracture with no apposition. One sees shortening and 34° of lateral angulation.


After the interpretation of available images, one should suggest further techniques that may assist in more clearly defining the injury. Postreduction (closed or open) images should be clearly labeled chronologically because more than one film may be taken during manipulation (Fig. 4-17). Position of fragments should be carefully assessed using the same process applied to the original diagnostic studies. Joint space evaluation or failure to reduce a fracture with usual methods may indicate soft tissue interposition or osteochondral fragments, which prevent good position and alignment of fragments. Generally, these changes are evident to the physician reducing the fracture. If noted, after reduction, one should suggest the best technique to demonstrate the problem [22,23].




 


 


 


 


 


 


 


 

FIGURE 4-17 Radiographs from initial diagnosis through treatment and healing of a metatarsal fracture. Initial interpretation: AP (A) and lateral (B) views of the left foot demonstrate a comminuted oblique fracture of the distal fifth metatarsal diaphysis (arrow). There is dorsomedial displacement of the major distal fragment and slight shortening (note the line on metatarsal heads). Films taken with traction show improvement in length with the change in traction between image 1 (C) and 2 (D). Postreduction AP (E) and lateral (F) views show that reduction is maintained. There is a small medial fragment (arrow). Cast immobilization. AP (G) and lateral (H) views 5 months after injury show that the fracture has healed with slight angular deformity. Shortening of the fifth metatarsal (lines on metatarsal leads) persist.


Discussion of specific foot and ankle fractures and fracture dislocations is most easily accomplished by using anatomic regions. Therefore, ankle, hindfoot, midfoot, and forefoot injuries are discussed separately. Both adult and pediatric disorders are included.


ANKLE FRACTURES


Ankle fractures may be simple or complex with associated ligament ruptures [40,56]. The latter are more common in adults. Generally, fractures in patients older than 15 to 16 years of age are classified and treated using adult criteria. For discussion purposes, it is more effective to review adult and pediatric ankle injuries separately.


Pediatric Fractures


The appearance of ankle fractures in children depends on the age (growth plate development), relationship of the ligaments with the epiphysis, and the mechanism of injury [32,41,45,60,64]. Distal diaphyseal and metaphyseal fractures are frequently incomplete. In most cases, there is a posterior cortical break with buckling (torus fracture) of the anterior cortex above the growth plate (Figs. 4-18 and 4-19) [41]. Fractures of the distal tibia and fibula frequently involve the growth plates (Fig. 4-20). The distal tibia epiphysis is the second most common site for growth plate fracture [61]. In Roger’s series [68], 25% of 188 physeal injuries involved the distal tibia or fibula. Physeal fractures can result in growth or articular deformity if proper diagnosis and treatment are not implemented [52,73,77].


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