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

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2284 VII Imaging of the Musculoskeletal System Figure 47-90. Subtle Lisfranc dislocation in a 56- year-old, nondiabetic patient who mis-stepped from a high curb and landed awkwardly, injuring the foot. A, Initial radiograph shows the fracture off the base of the second metatarsal (arrow). The alignment of the Lisfranc joint is relatively maintained. Because of the degree of soft tissue swelling, the patient was initially treated with a boot. B, Axial CT scan obtained 5 days later showed the second metatarsal fracture to be essentially nondisplaced and the first and second tarsometatarsal joints to be in anatomic alignment. When the soft tissue swelling subsided 4 days later, the boot was exchanged for a cast. C, Postcasting anteroposterior radiograph reveals that there is lateral displacement of the first (white arrow) and second (black arrow) metatarsals. Because this demonstrated that the Lisfranc joint was not stable, 3 days later the patient was taken to the operating room for open reduction and internal fixation (D). A B C D subcortical sclerosis, and subcortical round lucencies called geodes—are typically well seen radiographically. But some joints, such as the ankle and subtalar joints, can be difficult to profile radiographically, and in such cases CT should be well able to demonstrate all these osteoarthritic changes (Fig. 47-91). • Rheumatoid Arthritis For rheumatoid arthritis, we prefer MRI to CT when crosssectional imaging is required. MRI after the administration of intravenous contrast well demonstrates abnormally vas- cularized synovium and thickened pannus (see Fig. 47-55) as well as small cortical erosions before they become radiographically apparent. • Gout Gout is uric acid crystal deposition arthropathy with a predilection for the foot, particularly the first metatarsophalangeal joint. The cortical erosions caused by gout form slowly and can take as long as a decade to be manifest radiographically. These erosions are classically described as being well circumscribed with sharp overhanging edges. The diagnosis of gout is confirmed when an aspirate of Ch047-A05375.indd 2284 9/9/2008 5:35:35 PM
47 Ankle and Foot 2285 47 A Figure 47-91. CT scan of osteoarthritis in a 71-yearold patient. A, Axial scan through the tops of both ankle joints demonstrates nonuniform narrowing of the medial ankle mortise bilaterally (black arrows). Many small geodes with well-circumscribed, corticated margins (black arrowheads) are seen in both talar domes. B, Coronal scan demonstrates nonuniform narrowing medially in both mortises (black arrows), subcortical geodes (black arrowheads), and subcortical sclerosis (white arrowheads). C, Sagittal scan demonstrates nonuniform joint space narrowing (black arrows) as well as a small anterior osteophyte (white arrow). B C Ch047-A05375.indd 2285 9/9/2008 5:35:37 PM
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