Normal Ankle and foot Radiographs by Dr Avinash

X ray ankle and foot radiographs are takent in day by day in radiological work up study done at Smbt medical college nashik. different radiographs are described with Hows its taken? and at what Kv given. refrence taken from YOCHUM Rowe book of radiology.

1. ANKLE, FOOT RADIOGRAPHS AND COMMON PATHOLOGIES BY :- DR AVINASH DAHATRE RADIOLOGY DEPARTMENT

2. ANATOMY OF ANKLE

3. ANKLE JOINT It is Synovial type of hinge joint. Formed by articulation of Tallus with Tibia and Fibula. Function:- plantar flexion and dorsiflexion . Below the true ankle joint second part of ankle is Subtalar joint . Subtalar joint is formed by tallus superiorly and calcaneus below.

4. NORMAL RADIOGRAPHIC VIEWS

5. ANKLE AP VIEW Demonstrate :- Tibia, fibula, talus and ankle joint. KVP :- 55 (50 – 60) Film size :-10x12 inch Grid :- No. Patient position :- Supine. Part position :- Ankle is dorsiflexed so that surface of foot is perpendicular to the film. Centring :- Half way between medial and lateral malleolus . Collimation :- 6x10inch field

6. Articular surface of distal tibia and talar dome should be parallel. Inferior articular surface of tibia called as tibial plafond (ceiling). Growth plate ( physeal scar) oftenly seen parallel to plafond. Lateral malleolus is bulbous toward distal end and has groove called peroneal groove through which peroneal tendon pass. Distance between medial malleolus and medial talar dome and lateral malleolus and lateral talar dome should be same distance.(5mm)

7. COMMON PITFALLS Lack Of Dorsiflexion :- tibiotalar joint space and lateral malleolus will not be visualized b cause of over lap. In case of plaster or cast : Increase Kv by 5 to achieve improved penetration. Demonstration of distal tibia and fibula should be included when symptoms are proximal to ankle.

8. MORTISE VIEW Demonstrate :- Tibia, fibula, talus and ankle joint. KVP :- 55 (50 – 60) Film size :-10x12 inch Grid :- No. Patient position :- Supine. Part position :- Ankle is dorsiflexed so that surface of foot is perpendicular to the film. Lower leg is internally rotated so that intermalleolar line forms angle of 35 degree. Centring :- Half way between medial and lateral malleolus . Collimation :- 6x10inch field

9. The view is called mortise because entire joint space is seen in one view. Demonstration of distal tibio fibular joint separation of 2mm. Measurement of >5 mm indicate diastasis . Lateral and medial malleoli are clearly shown and overlap of distal tibiofibular is reduced. Most imp view for detecting subtle fracture of distal fibula, posterior tibia and talar dome.

10. COMMON PITFALLS Inadequate dorsiflexion :- calcaneus will overlap lateral malleolus . Incorrect medial rotation:- results in overlaping of medial malleolus on medial clear space.

11. ANKLE LATERAL VIEW DEMONSTRATE :-tibia, fibula, ankle joint tallus , calcaneus . KvP :- 55 FILM SIZE:- 8x10 inch PATIENT POSITION:- lateral recumbent. PART POSITION:- Lateral surface of ankle in contact with the film with slightly dorsiflexed . CENTRING :- Given on medial malleolus COLLIMATION :-8x10 inch field.

12. Noted the tibia on tallus . calcaneus is upward. Downward-sloping metatarsal forms the longitudinal arch of foot. Surface of convex talus reciprocal with concave surface of tibial plafond. Talocalcaneal joint is seen in midsection where sinus tarsi is found. Normal trabecular pattern seen on calcaneus that pass upward to subtalar joint.

13. ANATOMY OF FOOT

14. ARCHES OF FOOT MEDIAL LONGITUDENAL ARCH:- Formed by calcaneus , navicular,3 cuneiform bones and 3 metatarsals. LATERAL LONGITUDENAL ARCH:- Formed by lateral calcaneus , cuboid and two metatarsals. TRANSVERSE ARCH:- Form by cuneiform, cuboid and metatarsals bone.

15. X RAY VIEWS

16. FOOT AP VIEW DEMONSTRATE :- Phalanges, cuneiform bones, metatarsals, navicular and cuboid . KvP :- 55 (50-60) FILM SIZE :-10x12 inch. PATIENT POSITION :-Supine with knee flexed, or standing. PART POSITION :-Knee is flexed so that the plantar surface should rest on cassette. CENTRING :- Base of 3 rd metatarsal. COLLIMATION :- 5x12 inch field.

17. Each phalynx has expanded ends which are radiolucent. Expanded distal end of distal phalynx are termed as Ungula tufts . Articulations of tarsometatarsal , cuneiform, and cuboid are not well seen on this view. Tarsometatarsal joint is known as Lisfranc’s joint. The talo navicular and calcaneocuboid joint articulation is known as chopart’s joint.

18. COMMON PITFALLS Uneven exposure:- Wedge filter to be used to prevent overexposure. Toe flexion or extension:- when toes are flexed or extended joint spaced will not be depicted.

19. FOOT LATERAL VIEW DEMONSTRATE :-distal tibia, fibula, tarsals , ankle joint, metatarsal and phalanges. KvP :-55 (50-60) FILM SIZE :- 8x10 inch. PATIENT POSITION :- lateral recumbent or standing. PART POSITION :- affected leg placed in true lateral projection with fifth metatarsal in contact with the film. CENTRING :- At navicular . COLLIMATION :- to the film.

20. Note the position of tibia on tallus . Calcaneus is angle cephalad relative to plane of forefoot and midfoot . Talus, calcaneus , navicular , cuboid are clearly visible and base of fifth metatarsal is well demonstrated. First metatarsal is recognised by shortest, broadest, with largest head. Subtalar joint is visible in midsection with sinus tarsi. Calcaneocuboid joint is visible inferiorly.

21. COMMON PITFALLS FOOT over-rotation:- care must be taken to achieve lateral of foot.

22. FOOT OBLIQUE VIEW DEMONSTRATE :- Phalanges, metatarsal, cuboid , third cuneiform, navicular and distal calcaneus . KvP :-55 FILM SIZE :- 10x12 inch. PATIENT POSITION :-supine with knee flexed or standing. PART POSITION :-begins with knee flexed with foot rest flat on film and leg is rotated medially so that plantar surface of foot forms angle of 35 degree. CENTRING :- to the base of third metatarsal. COLLIMATION :- 5x12 inch field.

23. It is the important view in assesment of lateral foot pain to show cuboid and fifth metatarsal. Joint relationship especially of toes are well appreciated in this plane to show latent dislocations. Clear depiction of cuboid , navicle , 3cuneiform bones and base of adjacent metatarsals. It is the excellent view for detecting bony bridging across joints.

24. COMMON PITFALLS Uneven exposure:- wedge filter can be used. Tube tilt improves tarsometatarsal articulations.

25. CALCANEUS AXIAL VIEW DEMONSTRATE:- Body and posterior calcaneus Tube tilt:- 35-40degree Patient position :- supine with legs extended. Part position:- Foot is dorsiflexed such that plantar surface is perpendicular to Film.

26. LATERAL VIEW OF CALCANEUS DEMONSTRATE:- calcaneus , Tallus , subtalar joints and tendo achilles . Patient position :- Lateral recumbent. Part position:-Lateral side of foot is in contact with the film and plantar surface perpendicular to film. Centring:- Mid calcaneus

27. LATERAL VIEW OF CALCANEUS

28. BOHLER’S ANGLE Angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus in the lateral view. <20 s/o CALCANEAL FRACTURE.

29. COMMON PATHOLOGIES OF ANKLE AND FOOT

30. GOUT Gout  is a crystal arthropathy  due to deposition of monosodium urate crystals in and around the joints. Pathology: Monosodium urate crystals deposition in periarticular soft tissues. The primary risk factor is  hyperuricemia with levels of uric acid (≥7 mg/ dL ) in the blood   Presentation: - Typically in the lower limb and classically affecting the first metatarsophalangeal joint  - monoarticular red, inflamed, swollen joint.

31. Classic marginal erosions (red arrow) Overhanging cortex (blue arrow)

32. Joint effusion (earliest sign) Punched-out lytic bone lesions Preservation of joint space until late stages of the disease Overhanging sclerotic margins Osteonecrosis can be seen.

33. BRODIES ABCESS OF DISTAL TIBIA Chronic intraosseous abscess resulting from incomplete resolution of osteomyelitis. Most common site is distal tibia metaphysis.

34. SYNOVIAL CYST OR GANGLIA Most common around ankle and foot. It is the para-articular fluid filled sac or pouch lined by synovial membrane.

35. ACHILLES TENDINOPATHY Thickening of achilles tendon seen on lateral view of ankle.

36. CALCANEAL APOPHYSITIS or SEVER DISEASE It is the painful inflammation of the apophysis of the  calcaneus . Presents in active young children and adolescents, especially those who enjoy jumping and running sports. 

37. FRACTURES

38. Jones fracture  It is an extra- articular fracture at the base of the fifth metatarsal  bone.

39. Pseudo- jones fracture or a Dancer fracture Avulsion fracture of fifth metatarsal occurs due to forceful inversion of foot.

40. MARCH FRACTURE/STRESS OR FATIGUE FRACTURE Fracture of 2 nd metatarsal due to repititive trauma.

41. PILON FRACTURE A   pilon fracture  is a type of distal tibial fracture involving the tibial plafond

42. Comminuted ,displaced Fracture involves the tibial plafond and the distal tibial articular surface along with fibula.

43. CHOPART’S FRACTURE-DISLOCATION

44. LISFRANC’S FRACTURE  Dislocation of the articulation of the tarsus with the metatarsal bases. Displacement of 2 nd  to 5 th  metatarsals where the 1 st  MTP joint remains congruent.

45. Lovers fracture or Don Juan fracture  or  Casanova   fracture lover's fracture" is derived from the fact that a suitor may jump from great heights while trying to escape from the lover's spouse.

46. Accessory navicular  Large accessory ossicle  that can be present adjacent to the medial side of the  navicular  bone.  first appears in adolescence. more common in female patients.