Anatomy of lateral ankle ligaments and their relationship to bony landmarks - Semantic Scholar
Lateral ankle sprain is the most common injury in sport.5,16 Eighty percent of patients will tear their anterior talofibular Background:We describe the topographic anatomy of the lateral ligament complex of width, and bony landmarks of the ligaments Present tech- .. aments and their relationship to bony landmarks. Background: We describe the topographic anatomy of the lateral ligament Anatomy of lateral ankle ligaments and their relationship to bony landmarks. The ligaments of the ankle joint are medial and lateral collateral ligaments. . N A. “Anatomy of lateral ankle ligaments and their relationship to bony landmarks”.
The distal-most aspect of the fibula is called the lateral malleolus. Together, the malleoli, along with their supporting ligaments, stabilize the talus underneath the tibia. Because the motion of the subtalar joint provides a significant contribution to positioning the foot, some authors will describe it as the lower ankle joint, and call the talocrural joint the upper ankle joint. When the foot is plantar flexed, the ankle joint also allows some movements of side to side gliding, rotation, adduction, and abduction.
The mortise is a rectangular socket. The distances between the bones in the ankle are as follows: The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: The deltoid ligament supports the medial side of the joint, and is attached at the medial malleolus of the tibia and connect in four places to the talar shelf of the calcaneuscalcaneonavicular ligamentthe navicular tuberosityand to the medial surface of the talus.
The anterior and posterior talofibular ligaments support the lateral side of the joint from the lateral malleolus of the fibula to the dorsal and ventral ends of the talus.
The calcaneofibular ligament is attached at the lateral malleolus and to the lateral surface of the calcaneus. Though it does not span the ankle joint itself, the syndesmotic ligament makes an important contribution to the stability of the ankle. This ligament spans the syndesmosisi.
An isolated injury to this ligament is often called a high ankle sprain. The bony architecture of the ankle joint is most stable in dorsiflexion.
Thus, a sprained ankle is more likely to occur when the ankle is plantar-flexed, as ligamentous support is more important in this position.
The classic ankle sprain involves the anterior talofibular ligament ATFLwhich is also the most commonly injured ligament during inversion sprains. Another ligament that can be injured in a severe ankle sprain is the calcaneofibular ligament.
Retinacula, tendons and their synovial sheaths, vessels, and nerves[ edit ] A number of tendons pass through the ankle region.
Bands of connective tissue called retinacula singular: It contains the anterior tibial artery and vein and the tendons of the tibialis anterior muscle within its tendon sheath and the unsheathed tendons of extensor hallucis longus and extensor digitorum longus muscles. Diffuse swelling, ecchymosis, tenderness and inability of weight bearing are present with significant instability in the clinical examination.
Syndesmotic injuries are assessed particularly because of its unique biomechanical features and the differences in the treatment approach. These injuries are generally related to the level of distal fibular fracture.
Lesion of the syndesmosis is evident in the half of Weber type B and most of Weber type C distal fibular fractures. Additionally, it is the first anatomic structure to be damaged in supination—eversion and also pronation—eversion injuries according to the Lauge—Hansen classification of ankle fractures. Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilises the ankle joint[ 22 ].
Clinical presentation A detailed history of the incident and a careful physical examination of the patient are the primary steps when evaluating an acute ankle sprain.
Previous history of similar injuries is also important. Acute pain, inability to walk and acute swelling may also be reported by the patient. Clinical tools are used in particular to identify areas of pain and for comparative analysis of mobility and any laxity in ligament testing[ 23 ].
Anatomy of lateral ankle ligaments and their relationship to bony landmarks.
Physical examination of such a patient with acute ankle sprain in routine clinical practice of traumatology should always include inspection of any swelling, ecchymosis or deformity of the ankle, careful palpation to localise the pain and tenderness and evaluation of ROM. Careful palpation of the critical anatomic check-points can provide information to confirm affected structures Figure 1.
A typical walking pattern to protect their ankle and avoid further pain, the patients may adapt the situation. Mild swelling, tenderness and minimal difficulty in ROM characterise the clinical presentation in Grade I injuries. However, diffuse swelling, ecchymosis, tenderness and inability of weight bearing are present with significant instability in the clinical examination of a Grade III injury.
Haemarthrosis may also complicate the clinical presentation. Pain, swelling and tenderness on the medial side of the injured ankle as well as a defect in the soft tissues palpated just distal to medial malleolus may indicate possible deltoid ligament injury.
Syndesmotic injury is also a very important pathology which may be clinically suspected during physical examination. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test[ 22 ].
Check tenderness points according to OAR: On physical examination, the use of stress testing is useful Table 1. Anterior drawer test and talar tilt test are the two provocative tests in physical examination to evaluate any clinical instability.
The anterior drawer test is used to assess the ATFL as it prevents anterior translation of talus under distal tibia. Ten millimetres of displacement in the injured ankle or more than 3 mm of difference in translation compared with healthy side indicates the ATFL tear. The talar tilt test is described as the angle formed by the talar dome and the tibial plafond during forced hindfoot inversion with the tibiotalar joint held in neutral[ 16 ].
The test is generally used as a stress radiograph rather than a physical examination method. Table 1 Summary of the tests applied in physical examination and the anatomic structures that are evaluated Differential diagnosis Differential diagnosis of any ligamentous injury of the ankle includes bony, tendinous or joint pathologies around the ankle.
Fracture of the anterior process of calcaneus, lateral process of talus, base of the fifth metatarsal, osteochondral fracture of the talar dome and dislocation of the subtalar joint should be excluded in such patients.
Additionally, it should be noted that physeal injuries around the ankle in pre-pubertal age group may present with similar clinical findings[ 9 ]. Tendon injuries such as displacement of the peroneus longus and brevis due to torn fibrous retinaculum holding them in proper anatomic localisation, or the rupture of tibialis posterior tendon should also be kept in mind in the differential diagnosis[ 24 ].
Ankle ligament injury: current concept
Diagnostic studies The first step following clinical examination in the assessment of an ankle injury is the standard radiographic imaging to rule out any fracture. Initial radiographic imaging of the ankle joint includes antero-posterior APlateral and mortise view.
There are also radiological tests, weight-bearing plain X-ray stress X-rayalignment of the hindfoot, with a meary view [metal wire circling the heel], arthrosis and dynamic images to confirm and quantify laxity manually, with a Telos device, with patient-controlled varus to identify ligament, tendon and cartilage damages[ 23 ].ankle foot victoryawards.us
AP and mortise views in dorsal-flexed and plantar-flexed ankles may provide information about any possible osteochondral lesions of the talus. Furthermore, oblique foot X-ray should also be obtained in the presence of tenderness on the proximal part of the fifth metatarsal. Although its validity is not clear, stress roentgenographs can be used as a component of diagnostic work-up.
Radiographic findings of syndesmotic injury usually include increased tibiofibular clear space, decreased tibiofibular overlap and increased medial clear space; however, syndesmotic injury may not always be apparent radiographically[ 22 ]. Ultrasound may also be used in the diagnostic work-up of ankle ligament injuries. However, it has two important handicaps: Magnetic resonance imaging MRI is not routinely indicated in acute ankle injuries unless there is a major acute instability.
However, MRI may be very useful in some particular patients with clinically suspected concomitant injuries to establish a differential diagnosis i.
MRI is generally indicated in the presence of chronicity of the complaints following an acute ankle injury, a clinical history of repetitive trauma and complex injuries of the ankle including multiple pathologies. Although they are not routinely included in diagnostic work-up, computerised tomography arthrogram, gadolinium enhanced MRI, magnetic resonance arthrogram or scintigraphy are also the sophisticated imaging techniques, which may be helpful in the assessment of particular patients.
Treatment The first principle of the treatment in such kind of injuries is the prevention[ 16 ]. There are different studies that evaluated the role of methods for avoiding of ankle sprains; however, a consensus that is agreed on has not been established yet in the scientific level, and thus ideal prevention method is still controversial.
Non-surgical measures, including functional rehabilitation, are the management methods of choice for acute injuries[ 1 ].
Combination of rest, ice, compression and elevation RICE is the first treatment in ankle sprains. Grade I and Grade II injuries, which constitute most of the cases, are treated conservatively; however many times, this injury is taken for granted because of the frequency of its presentation[ 6 ].
Conservative treatment of acute ankle injuries is composed of four stages, which are named together as the functional rehabilitation protocol. Its main principle is to improve proprioception as the ROM is maintained during the process of soft tissue healing.
The first stage is the RICE of which the primary aim is to reduce inflammation and soft tissue oedema. The second stage, which aims protection of the injured ligaments during the healing process, includes the application of an ankle splint or bracing for up to 3 weeks.
It is demonstrated that bracing can decrease talar tilt on the roentgenographs[ 29 ]. The third stage, which begins by the end of the 3rd week of the injury, includes controlled isometric and concentric stretching exercises to prevent joint stiffness that may occur due to scar tissue at the healing side.
The final stage of the functional rehabilitation protocol is the one that the patient returns to pre-injury level of full activity by the end of 6—8 weeks of the injury. Strengthening exercises should be continued following regain of a pain-free ankle with a normalised weight-bearing as the pre-injury level.
Treatment of Grade III ankle sprains is controversial.
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In other words, there is no ascertained algorithm for such kind of injuries[ 16 ]. Failed non-surgical management after appropriate rehabilitation is an indication for surgery. Acute surgical repair is generally recommended for high-demand athletes[ 1 ].