Step-By-Step Ultrasound Assessment of the Ankle Caitlin Gardiner

Presentation 25 year old male Referral: US assessment of the RIGHT ankle ?ATAF rupture Patient indicates falling off a skateboard 3 weeks ago Lateral ankle pain and swelling Reduction in symptoms Reserved movement

Ultrasound Examination Explained examination to the patient to gain informed consent Patient was positioned supine on the bed with right knee bent A 5-13MHz linear array transducer MSK General preset

Anterior Ankle

Lateral Ankle

Findings Rupture of the ATAF ligament Anterior Joint Effusion A 12*7*3mm ganglion cyst arising from the medial talo-navicular joint Mild tenosynovitis of the peroneal tendons Strain of the calcaneo-fibular ligament

The Anterior Talo-Fibular Ligament Most commonly injurered ligament of the ankle Typically occurs in individuals under 35 years of age, mostly 15-19 years and is sports-related in around 50% of cases (van den Bekerom et al, 2012) Important role in limiting anterior diaplacement of the talus and plantar flexion of the ankle Typically damaged by an inversion injury (Golano et al, 2010) Clinical Presentation Ankle diability Pain and swelling ‘Giving way’ or instability (Golano et al, 2010)

The Anterior Talo-Fibular Ligament The anterior talofibular ligament is composed of two bands, separated by vascular branches of the perforating peroneal artery and lateral malleolar artery The upper band is taut on plantar flexion The inferior band is taut on dorsiflexion Originates at the anterior malleolus and attaches around 10mm proximal to the fibula Overall width of 6-10mm (Golano et al, 2010)

The Anterior Talo-Fibular Ligament Ultrasound Findings Distruption/discontinuation of ligament pattern/hyperechoic bundles- Torn Hypechoic lesion- strain Can be classified as Attachment to fibula Mid-substance Attachment to the talus Relevant as a 5mm margin of remnant from the attachment is required to suture the ligament (Oae et al, 2010). Around 60% of acute ATAF rupture cases showing a tibiotalar effusion (McCarthy et al, 2008)

The Anterior Talo-Fibular Ligament Treatment is typically conservative measure Rest, Ice, Non-steroidal anti-inflammatories Support bandages and immobilisation Physical therapy Interventional is typically only required in profession sports players (van den Bekerom et al, 2012) Imaging Modalities Arthroscopy- Gold Standard MR (93% when compared with Arthoscpy in the ATAF injury) US- easily available, economical and portable. Less reliable (63% when compared to Arthroscopy) (Oae et al, 2010).

Reflection Also use a hockey-stick probe Unfortunately only one hockey-stick probe at the practice and was unavailable at the time of examination Comparison picture of the calcaneo-fibular ligament To highlight the strain of the ligament Assess the type of tear of the ATAF Prior to this assignment I was unaware this is something that can and should be assessed

References Galano P, Vega J, de Leeuw PAJ et al, 2010. Anatomy of the Ankle Ligaments: A pictorial essay. Knee Surg Sports Traumatol Arthesc; 18: 557-569 McCarthy CL, Wilson DJ, Coltman TP, 2008. Anterolateral ankle inmpingement; findings and diagnostic accuracy with ultrasound imaging; 37(209-216). Oae K, Takao M, Uchio Y and Ochi M, 2010. Evaluation of Anterior Talofibular Ligament with stress radiography, ultrasonography and MR imaging. Skeletal Radiol; 39:41-47. Van den Bekerom MPJ, Kerkhoffs GM, McCullum GA et al, 2012. Management of Acute Lateral Ankle Injury in the Atheltete. Knee Surg Sports Traumatol Arthosc; 21(6): 1390-1395