Ankle and Foot 47 - Department of Radiology - University of ...

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2212 VII Imaging of the Musculoskeletal System A B C Figure 47-7. Straight sagittal images. Ca, calcaneus; Cu, cuboid; N, navicular; Ta, talus; Ti, tibia. A, Through the lateral hindfoot, profiling the calcaneocuboid joint (CCJ), the ankle joint (AJ), and the posterior facet of the subtalar joint (P-STJ). The brown arrow points to the lateral process of the talus (LPT), and the red arrow points to the anterior process of the calcaneus (APC). Fractures through these pointed bony projections are often difficult to see on radiographs and are typically worked up with CT. B, Through the middle of the hindfoot, profiling the talonavicular joint (TNJ), the ankle joint (AJ), and the posterior facet of the subtalar joint (P-STJ). The middle facet of the subtalar joint (M-STJ) can now be seen. C, Through the medial hindfoot, now profiling the middle facet, above the sustentaculum tali (ST). Straight alignment should normally be present between the talus, navicular, medial cuneiform (1), and first metatarsal (I). A B C D Figure 47-8. Oblique coronal images through the hindfoot, posterior (A) to anterior (D). Ca, calcaneus; Fi, fibula; ST, sustentaculum tali; Ta, talus; Ti, tibia. A, This plane best profiles the posterior facet of the subtalar joint (red arrow). The ankle mortise (yellow line) can be appreciated in the oblique coronal plane but would be better profiled in the mortise coronal plane. B, This oblique slice is just anterior to the ankle joint, where the posterior facet of the subtalar joint is ending (red arrow) and the middle facet is beginning (blue arrow). C, The oblique coronal slices are angled correctly if the middle facet of the subtalar joint (blue arrow) has a horizontal orientation. The cone of soft tissues lateral to the middle facet is the sinus tarsi (asterisk). D, The junction of the hindfoot and midfoot is at the round head of the talus at the talonavicular joint (circle). Ch047-A05375.indd 2212 9/9/2008 5:33:28 PM
47 Ankle and Foot 2213 47 A B C D E Figure 47-9. The 10 ankle tendons are illustrated as colored lines drawn over three-dimensional CT images. A, Anterior view of the anterior tendons: anterior tibial (AT; red), extensor hallucis longus (EHL; green), and extensor digitorum longus (EDL; blue). B, Posterior view of the posterior tendons: Achilles (Ach; light blue) and plantaris (yellow). Also labeled are the medial pole of the navicular (N) and the sustentaculum tali (ST). C, Posterolateral view of the lateral tendons: peroneus brevis (PB; dark purple) inserting into the base of the fifth metatarsal, and peroneus longus (PL; light purple) wrapping under the cuboid. Medial (D) and posterior (E) views of the medial tendons, illustrating the “Tom, Dick, and Harry” mnemonic: the posterior tibial (PT; red) wraps under the medial malleolus and inserts on the medial pole of the navicular (N); the flexor digitorum longus (FDL; blue) runs behind the PT, under N, and out to the second to fifth toes; and the flexor hallucis longus (FHL; green) runs behind the talus, wraps under the sustentaculum tali (ST), crosses under the FDL at the master knot of Henry, and passes between the two great toe sesamoids (white arrows), inserting on the distal phalanx. tendon in axial cross section, except the Achilles tendon. 42 The anterior tendons extend, uncrossed, over the ankle joint and foot (see Fig. 47-9A). The anterior tibial is the most medial of the three anterior tendons. It extends along the medial aspect of the great toe tarsometatarsal joint to insert on the plantar aspect of the base of the first metatarsal and the adjacent medial cuneiform bone. The extensor hallucis longus is the middle of the three anterior tendons, proceeding straight to its insertion at the dorsal base of the great toe distal phalanx. The most lateral of the three anterior ankle tendons is the extensor digitorum longus. At the level of the midfoot, the extensor digitorum longus fans out into four separate tendon slips, which, in turn, proceed along the forefoot to insert at the dorsal bases of the second through fifth middle and distal phalanges. 21,31 Whereas the anterior tibial and extensor digitorum longus tendons can be followed over a series of axial images (see Fig. 47-10), it is common to lose visualization of the extensor hallucis longus tendon as it curves anterior to the midfoot (see Fig. 47-10C). This is in part due to “magic-angle” effects. 7 It is important not to misinterpret this lack of visualization as a rupture of the extensor hallucis longus tendon, a condition that is exceedingly rare. Ch047-A05375.indd 2213 9/9/2008 5:33:31 PM
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