Ankle ligament injury: current mephistolessiveur.info Orthopaedics
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. 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”. There are two main sets of ligaments, which originate from each malleolus. The lateral ligament originates from the lateral malleolus (a bony.
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.
The deep peroneal nerve passes under the retinaculum while the superficial peroneal nerve is outside of it. The inferior extensor retinaculum of foot is a Y-shaped structure. Its lateral attachment is on the calcaneus, and the band travels towards the anterior tibia where it is attached and blends with the superior extensor retinaculum.
Along that course, the band divides and another segment attaches to the plantar aponeurosis. The tendons which pass through the superior extensor retinaculum are all sheathed along their paths through the inferior extensor retinaculum and the tendon of the fibularis tertius muscle is also contained within the retinaculum. The flexor retinaculum of foot extends from the medial malleolus to the medical process of the calcaneus, and the following structures in order from medial to lateral: The fibular retinacula hold the tendons of the fibularis longus and fibularis brevis along the lateral aspect of the ankle region.
The superior fibular retinaculum extends from the deep transverse fascia of the leg and lateral malleolus to calcaneous. The inferior fibular retinaculum is a continuous extension from the inferior extensor retinaculum to the calcaneous.
It was hypothesized that muscle spindle feedback from the ankle dorsiflexors played the most substantial role in proprioception relative to other muscular receptors that cross at the ankle joint. All human subjects, in these referenced studies, gave informed consent to participate in these studies. Functional anatomy Stability of the ankle is due to bony configuration of the ankle mortise and talar dome, ligamentous structures, capsule, syndesmosis and the crossing tendons[ 16 ].
Medial and lateral collateral ligaments together with syndesmosis dynamically contribute to biomechanical stability in every step of motion. Lateral collateral ligament complex The lateral collateral ligamentous complex of the ankle joint is composed of the anterior talofibular ligament ATFLthe calcaneofibular ligament CFL and the posterior talofibular ligament PTFL.Ankle Ligaments Anatomy - Everything You Need To Know - Dr. Nabil Ebraheim
Anterior talofibular ligament, which measures nearly 10 mm in length and 2 mm in thickness, is the weakest and the mostly injured part of the lateral collateral ligamentous complex[ 17 ]. The main function of the ATFL is to resist torsion and inversion stresses in a plantar-flexed foot. CFL, which lies between the tip of the fibula and calcaneus, is the only extra-articular component. Its main function is to resist torsion and inversion stresses in a dorsal-flexed foot.
The PTFL plays a role in limiting the posterior movement of the talus and is the strongest component of the lateral ligamentous complex[ 17 ]. Medial collateral ligament complex The deltoid ligament is the only stabiliser of the medial side of the ankle joint. This ligamentous complex is composed of two layers: The superficial layer includes tibionavicular, tibiocalcaneal and posterior talotibial ligaments, whereas the deep layer includes deep anterior talotibial and deep posterior talotibial ligaments.
The deep layer is more important in the aspect of contribution to whole joint stability.
Anatomy of lateral ankle ligaments and their relationship to bony landmarks.
The medial side of the ankle is more stable than the lateral side, so that the strength of the ligamentous complex may even lead to fracture of medial malleolus without rupture of the ligamentous fibres. Syndesmosis Syndesmosis is a complex structure which is composed of four parts in the distal tibiofibular joint. These four components are antero-inferior tibiofibular ligament, postero-inferior tibiofibular ligament, transverse tibiofibular ligament and interosseous membrane.
Synchronised function of these ligamentous structures as distal tibiofibular syndesmosis is crucial for biomechanical stability of the ankle[ 12131920 ]. When the inversion forces occur in a dorsiflexed ankle, primary stabiliser is the CFL and thus, this is the mechanism of injury for the CFL. Deltoid ligament injury is generally due to eversion together with external rotation, and its complete rupture commonly accompanies with fractures of the ankle[ 9 ].
Syndesmotic injuries occur as a result of forced external rotation during dorsiflexion—eversion movement in the ankle. Syndesmotic injury may be in isolation or may be associated with ankle fracture[ 22 ]. Classification The classification of ankle sprains is composed of three grades, which are formed according to pathological anatomy, clinical findings and instability, with increasing severity.
The classification is important in clinical practice to diagnose and choose the appropriate treatment for the patient. Grade I is a stretching injury without any macroscopic tear. It is generally limited to the ATFL injury. Mild swelling, tenderness and minimal difficulty in range of motion ROM characterise the clinical presentation.
Moderate swelling, ecchymosis, antero-lateral tenderness and restriction of ROM are the clinical findings. 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 - Wikipedia
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 ].
- Ankle ligament injury: current concept
- 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 ].
The Ankle Joint
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 ].
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 ].