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

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2298 VII Imaging of the Musculoskeletal System D E Figure 47-102, cont’d Coronal oblique T1- (D) and fat-suppressed T2-weighted (E) images show that this is an incomplete fracture, beginning from the dorsal cortex (arrowhead) and extending inferiorly in the sagittal plane, but not extending completely to the plantar cortex. A CT scan obtained 2 months later, reformatted using a 6-cm field of view in the oblique coronal (F) and oblique axial (G) planes, reveals that the fracture remains nonunited (arrowhead) and the bones are diffusely osteopenic from the patient’s being non–weight bearing. F G • Calcaneal Stress Fractures Calcaneal stress fractures occur in a characteristic location, arising from the posterior third of the calcaneal tuberosity beginning at the superior cortex a few centimeters anterior to the Achilles insertion, and extending inferiorly and slightly anteriorly, running perpendicular to the trabeculae. When radiographically apparent, these fractures are seen as a white sclerotic line on the lateral view (Fig. 47-104A). On MRI, calcaneal stress fractures are seen as a black line on sagittal T1-weighted images (Fig. 47-104B) surrounded by bone marrow edema on fat-suppressed T2-weighted (Fig. 47-104C) and inversion recovery (Fig. 47-104D) images. Figure 47-105 is a an example of a calcaneal stress fracture that was subtle on initial radiographs and was ultimately imaged using CT, a nuclear medicine bone scan, and MRI. • Plantar Fasciitis Plantar fasciitis is a stress reaction occurring at the origin of the plantar aponeurosis from the calcaneus, typically at the medial calcaneal tubercle. Degenerative changes from repetitive microtrauma in the origin of the plantar fascia cause traction periostitis and microtears, resulting in pain and inflammation. Plantar fasciitis is the most common cause of pain in the inferior aspect of the heel, and the diagnosis is typically made based on clinical symptoms and physical examination revealing tenderness along the medial calcaneal tuberosity. The relationship between plantar fasciitis and heel spurs has never been firmly established. Most patients with plantar fasciitis respond to conservative treatments that include calf stretching, orthoses, nonsteroidal anti-inflammatory medication, ultrasonic therapy, and occasionally casting. Patients with atypical clinical presentations or who fail conservative therapies may benefit from MRI to determine if their pain is indeed related to the plantar fascia or to some other etiology such as a tarsal stress fracture. An MRI of plantar fasciitis reveals edema around the origin of the aponeurosis. The plantar fascia itself may be abnormally thickened, and there may be edema in the underlying calcaneal bone marrow (Fig. 47-106; see Fig. 47-53). • Metatarsal Stress Fractures Metatarsal stress fractures occur at such characteristic locations that some carry eponyms. Jones Fracture. The Jones fracture occurs at the proximal metadiaphysis of the fifth metatarsal and is seen radiographically as a transverse lucency (see Fig. 47-41C). Although Jones fractures can be caused by a single traumatic injury, they are commonly seen as the result of repet- Text continued on p. 2304 Ch047-A05375.indd 2298 9/9/2008 5:35:57 PM
47 Ankle and Foot 2299 47 A B C D E Figure 47-103. Navicular stress fracture in a 20-year-old college decathlete complaining of lateral ankle pain not localized to the navicular. An MRI requested to evaluate the ankle joint found no abnormalities in or around the ankle but revealed abnormal bone marrow signal limited to the navicular. Coronal oblique T1- (A) and fat-suppressed T2-weighted (B) images, just distal to the talonavicular joint, reveal the dark fracture line extending from the dorsal cortex (arrowhead) in a plantar-lateral direction. Serial CT scans using our navicular protocol were ordered to follow the progress of healing. Shown here is the same coronal oblique slice, just distal to the talonavicular joint, from scans taken over a period longer than 1 year. C, The first CT scan, obtained 2 months after the MRI, during which time the patient was non–weight bearing on this foot and using an ultrasonic bone stimulator. The fracture (white arrowhead) is very narrow, with indistinct, noncorticated margins, suggesting that it is healing. D, The second CT scan, obtained 1 month after C, during which time the patient was weight bearing in a boot and using the bone stimulator. The fracture line (gray arrowhead) is much less distinct, consistent with continued interval healing. E, The third CT scan, obtained 3 months after D, during which time the patient resumed his training regimen. The fracture line (dark gray arrowhead) is now barely discernible. F, The final CT scan was obtained 9 months after E, when the patient’s symptoms returned. The fracture (black arrowhead) has recurred along the original fracture lines, which are now wider and more distinct than on the first CT scan (C). F Ch047-A05375.indd 2299 9/9/2008 5:35:59 PM
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Ken L. Schreibman Richard Bruce Ank
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