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Imaging of Ankle joint and foot (I) (DRE) Prof. Mamdouh Mahfouz — Transcript

by Prof. Mamdouh Mahfouz - Radiology in English (DRE) · 6,330 words · 973 segments · language en · Watch on YouTube

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0:20dear colleagues now we will handle the
0:23topic of MRI of the ankle and foot and
0:28this topic will be presented on two
0:30parts the first part will deal with the
0:34ankle joint then the the second part
0:37will be totally handling the fot
0:42lesions then as you all know that in
0:45order to image the ankle we or any joint
0:50in the body we can have this by the
0:55Blain x-rays by TT by MRI and also by
1:02ultrasound in uh this topic we'll handle
1:06the uh role of M in assessment of the
1:09anle lesions as as you all know we have
1:14uh more than one Mr machine including
1:18the closed MRI and the Open
1:21MRI the extremity MRI which is suitable
1:26for evaluation of the elbow and wrist
1:29joins
1:30as well as evaluation of the knee and
1:33Ankle
1:34joints and this is just an example of an
1:37extremity MRI and how can the patient is
1:42uh is uh prepared for the examination by
1:47putting his ankle in the machine and you
1:51know that this machine is uh very good
1:56considering the resolution since the
1:59surface coin is that the coil of the
2:02magnet
2:03itself then in order to examine the
2:06ankle which would have a surface coil
2:08and these are
2:10examples and uh we should select the
2:14field of
2:15view for suitable for evaluation of the
2:20ankle and this field of view should
2:22range between 8 and 12 CM if you enlarge
2:28the field of view the images will be
2:30very small if you reduce the field of
2:34view you may miss some of the anatomy
2:37and pathology in the
2:40images then we should have in the
2:43protocol of the uh ankle joint we should
2:47have aial surgal and
2:50coronal including the T1 T2 the gradient
2:54and the steer
2:56images and recently you know that we
2:59have the dynamic MRI which enables the
3:03examination of the patient while uh
3:07weight bearing and this is very
3:09important for the spine the hip joints
3:14the knee joint as well as the ankle
3:17joint and sometimes we are able to uh
3:20examine the patient while walking by
3:23moving this sheet underneath the foot of
3:28the patient then in order to know the B
3:32sequence you should look for fluids if
3:34the fluids are black and this is T1 if
3:37the fluids are bright and this is
3:40T2 but if no fluids are present in the
3:45image like in this ankle joint if there
3:48is no joint infusion then you can use
3:53the fat as
3:55a for Judgment of the ball sequence if
3:59the fat is bright and this is D1 if the
4:02fat is gray and this is T2 if it is more
4:05dark and this is D2 star if it is very
4:09dark and this is the SP images
4:14both uh the t2 and also the t2 star and
4:20the the stair images belong to the t2
4:24weed images meaning that the fluids will
4:27appear bright in these three
4:31images okay and you know from the
4:34previous lectures
4:36that the structures that show uh low
4:40signal in the T1 and low signal in the
4:43t2 with the images include that the
4:46cortex of the bone ligaments and tendons
4:48and
4:49calcification because they have no
4:52mobile Bros I am sorry for this mistake
4:56this should be
4:57low then the
5:00structures or the pathology which is
5:03shows low signal in the T1 and high
5:06signal in the t2 and this is fluid and
5:09fluid is is uh present in the fusion in
5:14the CEST in the articular cartilage and
5:17if you look here and you see fluid in
5:19the retran berser which is black in the
5:22T1 and the bright in the T28
5:25image the opposite of fluid is the fat
5:29and then the fat is high in the T1 and
5:33low in the t2 weighted images the fat is
5:36present in the subcutaneous tissues in
5:39the bone marrow in the derite cyst for
5:41example and so
5:44on then uh one of the good policies to
5:48handle the ankle joint from both the
5:52anatomic and pathologic points of view
5:56is to imagine that the angle the anle
6:00is a four directional joint and we have
6:06the posterior aspect of the ankle the
6:08interior aspect the lateral and the
6:10medial aspects and every uh part of
6:14these four directions we should look for
6:18tendons and ligaments and after
6:21finishing these two main issues then
6:25we'll have few other points in the ankle
6:29then we can finish the whole story
6:32starting by the
6:34posterior the posterior aspect of the
6:38ankle these are the some of the few
6:40points that I will handle after
6:43finishing the issues of the tendons and
6:46the ligaments in every compartment as I
6:51mentioned starting by the posterior
6:54aspect of the ankle and considering the
6:57tendons and ligaments we we have only
7:01one tendon and no ligaments the tendon
7:06is the achill tendon and this aillis
7:10tendon is attached to the posterior
7:14aspect of the calanus it is one of the
7:17strongest tendons in the in the
7:20body is best evaluated in the exal and
7:24also in the sagittal images in the exal
7:27images it it is present here
7:32subcutaneous the posterior border is
7:34convex the anterior border is flat or
7:39sometimes
7:40concave and the tendon is not normally
7:45rounded if the tendon is rounded with
7:49convex anterior border it is
7:53pathologic and this is the strongest and
7:56largest tendon in the body
8:00but it is commonly injured because of
8:04its superficial location it is it lies
8:08immediately
8:10subcutaneous the tendon has no tendon
8:13cheese meaning that there is no
8:16tenosinovitis of the AIS T it has a flat
8:21or concave anterior aspect as seen in
8:24the axial image and there is a small
8:28Bersa anterior to the tendon insertion
8:30between the tendon and the calcus known
8:33as the retr calcan birds the normal
8:37appearance of the AIL tendon is of
8:39uniform low signal in all B sequences
8:44provided it is uh it is
8:48normal then what are the lesions that
8:51can affect the aist tendon first of all
8:55is rupture and rupture of the aist
8:58tendon may be complete or partial and
9:01this occurs at the point 2 to 6 cm
9:06Superior to itsan attachment and in
9:10about
9:1125% the rupture is clinically missed
9:14because of the uh pain and the soft
9:18tissue swelling resulted from the trauma
9:21that has caused rupture of the
9:24T then uh if you diagnose rupture of the
9:29AIL tendon you should measure the sight
9:33of the Rapture from aalan insertion and
9:37you should measure the gap between the
9:40cut edges of the tendle you know that
9:43normally there is a triangle of fat
9:48present posterior to the leg bones and
9:51anterior to the
9:54ailum and this fat is known as Kar bad
9:58fat bad
10:00if this fat is
10:02obliterated one of the possibilities is
10:05injuries or abnormalities of the aillis
10:09tendon as you can see
10:11here one of the major tools in muscular
10:14scal Imaging is ultrasound and
10:17ultrasound is now uh one of the best
10:21Imaging modalities for evaluation of
10:25most of the uh joint pathologies being a
10:29superficially located tendon it can be
10:32easily examined by ultrasound this is
10:35the normal intact aillis tendon and this
10:38is aillis tendon with rupture and you
10:41see the gap between the cut edges of the
10:44tendon by ultrasound but MRI is one of
10:48the uh wellknown modalities for
10:51evaluation of tendon rupture this is the
10:54normal appearance of the gar bad of fat
10:57with an apparently intact aist tendon
11:01but here you can see that there is
11:04disturbance of the appearance of the fat
11:07with diffuse swelling of the region of
11:10the A standon and in the MRI you can see
11:14there is rupture of the AIL tendon let
11:18us say about 2 to 3 cm from its calcan
11:22insertion with fluids and the gap
11:25between the cut edges of the ton
11:29and this is uh also rupture of the kis
11:33tendon you see uh in the gradient image
11:38there is a a gap and this is the distal
11:42part of the tendon let us say 3 cm from
11:46its calcan insertion there is a full
11:49thickness rupture and also if you look
11:52carefully can you see that there is
11:54diffuse swelling of the tendon and this
11:57may suggest that the tendon
11:59is degenerated first and then uh
12:03subjected to full thickness
12:06there then uh this is the normal
12:09appearance of the Kendon and this is the
12:12Kendon rupture you can see the the Gap
12:17uh about 3 cm let us say from the calcan
12:21insertion and the Gap is filled with
12:23fluid and you know that this this side
12:27of U injury is the most common side
12:31which is uh about 2 to 6 cm from the
12:36calcan insertion of the tendon also here
12:40you see this is the distal part of the
12:42AIS tendon there is rupture and the Gap
12:45filled with fluid which is bright and
12:47the t2 weighted image black and the T1
12:49weighted image theist tendon is rounded
12:54with convex anterior margin the noting
12:57that it is not a normal
13:00tendon and whenever the ailles tendon is
13:04AED from its ganian insertion and this
13:07is known as insertional
13:10tear and you can measure also the gap
13:13between the cut edge of the aist tendon
13:16and the sight of its insertion in the
13:18posterior aspect of the
13:20calcan and by Blain x-ray you can also
13:23diagnose aulion tear of the a tendon
13:27whenever you see
13:29bone fragment which is aid from the
13:32posterior aspect of the calcinus and
13:34retracted upwards and this is the site
13:37of the attachment of the tendo AIS to
13:40the
13:41calanis in partial ter means that some
13:44of the fibers are intact and other
13:46fibers have ruptured and the barell
13:52te you can see a fluid
13:56signal inside the substance of the
13:58tendon while other uh normal normal uh
14:04fibers of normal signal are seen along
14:07the course of the tendon then here you
14:10see this is the ailles tendon and you
14:13can see focal area of increased signal
14:16near its calcan insertion denoting
14:19partial tear associated
14:22with some edema in the subcutaneous
14:25tissue and also edema in the uh
14:29fat anterior to the calanus to the tendo
14:33ails and this is also an example of
14:36partial ail sendon te you see the torn
14:40fibers are replaced by fluid and these
14:42are the intact
14:45fibers another example of insertional
14:48partial tear of a tendon the posterior
14:51fibers are intact anterior fibers are
14:53ruptured and replaced by fluid
14:57signal and and if the ailles tendon has
15:00ruptured many years ago the sight of the
15:04Achilles tendon May develop the distopic
15:08calcification which may be later on uh
15:12transformed into bone and this is known
15:16as a stoned achill tendon which means
15:20that there is a long time uh paused
15:24since the rupture of the T and there are
15:29uh some causes for the development of
15:32alific of the aillis tendon like you can
15:35see here in the Blain exray the previous
15:38microtas to the tendon Achilles tendon
15:41rupture chronic rupture previous surgery
15:44and repetitive micro
15:48microtome this calcification of the
15:51tendo AIS are more common than the
15:54strophic calcification of the tendo AIS
15:57they represent a separate entity rather
16:00than progression of the disease
16:03characterized by the formation of mature
16:06bone with cortex and Tropic and bone
16:09marrow as
16:11well then we came to the Kendon
16:15degeneration which means that there are
16:17degenerative changes in the in the a
16:21tendon this will result in swelling or
16:25relative increased caliber of the tendon
16:27and you may got some faint intermediate
16:30signals within the the tendon itself and
16:36if you look here and this is the
16:38increased caliber of the a tendon with
16:42some intermediate signals within the
16:45aillis tendon itself and this is kis
16:49tendonopathy tendon degeneration or
16:55tendit another example of aill ton d de
16:58generation you can see that the tendon
17:01is rounded with convex anterior margin
17:04internal intermediate signal within the
17:08tendon denoting
17:10osis another example of aus tendonosis
17:15or tendonitis or tendon degeneration or
17:18tendonopathy
17:19that tendon is focally swolling with
17:22faint intermediate signal within the
17:27tendon itself it denoted
17:31degeneration another example of achill
17:34tendonosis the aill tendon is swolling
17:37and you see faint intermediate signal
17:39within the tendon with some inflammatory
17:42changes in the subcutaneous tisue as
17:45well as inflammation in the Bersa
17:48anterior to the aillis
17:51T then the generation of the tendon May
17:54progress to partial tear and even to
17:57complete tear because you know that the
17:59tendon whenever it is started
18:02degeneration it is weak and is subjected
18:06is subject to to rupture then how can
18:11you differentiate between partial tear
18:13and
18:14theosis the signal of the tendonosis is
18:18faint intermediate but the signal of
18:20tear is bright similar to fluid then if
18:24you see Theon is focally enlarged with
18:28some faint intermediate signals within
18:31and this is tendonosis but if you see
18:33bright signal similar to the fluid and
18:36this is partial
18:39tear and this is tendinosis that has
18:42progressed to complete te how can you
18:46know that this is tendinosis because of
18:49the significant increase caliber of the
18:52a tendon and the T1 and T2 images if the
18:57signal are intermediate and this is
19:00degeneration if the signals are
19:02increased approaching that of fluid and
19:05this is
19:06the and this is St and the in this
19:10example and you can see full sign St of
19:12the AIS tendon you remember that AES
19:18tendon has no sinovial shapes but it has
19:23this very thin membrane which is known
19:26as the ber Tenon
19:28then kist tendon will not develop ositis
19:33but it will develop ber tendonitis by
19:38AIS berit tendonitis we mean that there
19:41is some inflammation of the soft tissues
19:44around the achillis tendon either deep
19:48or superficial or both the aillis tendon
19:51itself may look normal or may show some
19:55tendinosis such in such case is you got
19:59slight increase in the caliber of the
20:01tendon with faint intermediate signal
20:04within the
20:05tendon then the retran Bersa is a small
20:09Bersa between the aill tendon and the
20:12back of the calanus any bza is not
20:16usually seen on Imaging unless it is
20:19filled by fluid and one of the causes of
20:23uh fluid in the Bersa is
20:26inflammation then uh few drops of fluid
20:30are allowed in the normal bza in the
20:33retral Canan area but if you see too
20:37much fluid like this means that dispersa
20:40is
20:42inflamed then if you got this Triad
20:46which means there is AIS tendonopathy or
20:51tendon
20:52degeneration retr calan berstis
20:55inflammation of the retr calcan Bersa
20:58and the inflammation of the subcutaneous
21:02tissues superficial to the achillis
21:05tendon and this is known as hagon
21:08syndrome this hagon syndrome is very
21:12common in females which uh who wear this
21:18very high heels which put too much
21:22stress on the region of the tendo AIS
21:25resulting in inflammation of the
21:29and also inflammation of the bza super
21:32deep to it and the subcutaneous tissue
21:35superficial to the
21:37tendon then the Triad of achis
21:41tendonopathy
21:42retrum btis subcutaneous inflammation is
21:46known as hagon syndrome and this is
21:50hagon syndrome with some thickening of
21:53the aill tendon some fluid in the retr
21:57calcan berser
21:58and subcutaneous edema superficial to
22:01the tendon low signal in the T1 and high
22:04signal in the t2 forming the Triad of
22:07hlon
22:08syndrome the N tendon zoma is the in
22:14accumulation of lipid leading microf
22:17fages inflammatory cells and Joint cells
22:21secondary to cholesterol deposition in
22:24the
22:25tissues this will result in binless soft
22:28tissue enlargement of the achillis
22:32tendon bilaterally and maybe also some
22:36of the soft tissues of the foot and
22:38other parts in the body the involvement
22:41of the Achilles tendon is usually
22:43bilateral and symmetric it affects
22:46commonly the distal third of the tendon
22:50and this can be differentiated from gout
22:53for example or tendonopathy as I have
22:56mentioned and some inflammatory
22:59conditions and may be tumors as well if
23:02you look to the brain the brain x-ray it
23:05is easy to diagnose this pathology by
23:08bilateral symmetrical diffuse huge
23:11enlargement of the shadow of the AIL
23:14sendon encroaching on the uh uh ker bed
23:18of fat and increase in the ab diameter
23:22of the tendon uh because of the
23:25deposition of cholesterol the
23:28the tendon may show a slight increased
23:30signal in the T1 with decreased signal
23:33in the t2 withed image the tendon will
23:36be rounded with convex anterior anterior
23:40Marg then look at the MRI this is quite
23:44different from Achilles tendon this is
23:48huge swelling of the Achilles tendon and
23:53you you may be you may see some of the
23:57dots or or faint intermediate signals
24:00within the affected tendle and this is
24:03the zoma of the aill tendon sagittal T1
24:08sagittal T2 and
24:09sagittal you can see the market swelling
24:14of the AIS T and we finished by we
24:19finished from the posterior aspect of
24:22the ankle and we discussed the delions
24:25of the tendo AIS which included full
24:29thickness stair partial thickness teair
24:33tendinopathy ha Glon
24:36syndrome and then Soma of the
24:41aches now we came to the lateral aspect
24:44of the ankle where we can see tendons
24:49and ligaments there are two tendons and
24:52two
24:54ligaments the lateral aspect of the
24:56ankle is identified by the presence of
24:58the fibula and posterior to the fibula
25:02you can see the tendons these are the
25:05peral tendons the beral tendons include
25:09the beral prevous and the berous longus
25:13if the tendons are adjacent to each
25:16other then the medial one or the inner
25:21one is the the berus bous The
25:25Superficial one is the ous lungs if they
25:29are present behind each other then the
25:33anterior one will be the bravous and the
25:36posterior one will be the
25:39longest and these are the peral uh
25:43tendons which are located posterior to
25:46the tibia the anterior and the medial
25:48one is the bravous the posterior and
25:52superficial one is the longest both
25:55tendons have almost similar
25:58cross-sectional caliber usually the
26:02peral tendons are located within a
26:05Groove in the posterior aspect of the
26:07fibula in order to prevent the tendons
26:11from being dislocated laterally
26:14sometimes the posterior aspect of the
26:16fibula is flat and this may lead to
26:20lateral dislocation of the peral tendons
26:24and this is also an example you see the
26:27regular posterior margin of the fibula
26:30with lateral sulation of the perous
26:34tendons this is the longest and this is
26:36the
26:38bre then if you look here and this is
26:42the brous and this is the longus and
26:44here you can see the longest but you
26:46cannot see the brous it is replaced by a
26:50large amount of granulation tissue may
26:53be Hemorrhage and edema meaning that the
26:56burus braev tendon has
26:59ruptured then we uh came to the
27:04ligaments on the lateral aspect we have
27:06two types of ligaments the lateral
27:08collateral ligament and the send esotic
27:10complex the lateral collateral ligament
27:13is formed of three bands which are
27:17arising from the fibula going to the tus
27:20and calcus and we have the anterior tof
27:24fibular ligament the posterior taof
27:27fibular ligament and the calcano fibular
27:30ligament in order to identify the
27:33lateral collateral ligament first of all
27:36go to the fibula and then go to the
27:39section where the fibula contains a
27:42Groove looking
27:45medially at the level of This Groove you
27:48will see a ligament coming out from the
27:51groove and this is the posterior tof
27:53fibular lium if you look anteriorly then
27:57you see this line and this is the
27:59anterior taop fibular ligament the
28:02calcano fibular ligament is not seen in
28:05its full sickness in the AAL images but
28:09it's important to identify the posterior
28:13tular and the anterior
28:16tofi the anterior tof fibular is one of
28:20the constant ligaments and it stands by
28:24itself for the lateral collateral l
28:27meaning that if we said that the lateral
28:30collateral ligament is injured or
28:33ruptured then you mean that the anterior
28:35T fibular ligament is that which has
28:39been
28:41injured this is the appearance of the
28:44anterior tof fibular ligament is better
28:46evaluated in the axial images at the
28:49level of the fibular groove this is the
28:51posterior tof fibular and this is the
28:53anterior tof fibular and the coronal
28:56image it comes from the fibula to the
28:58tus and it is about 2 mm thick and 2 cm
29:04long the posterior tof fibular ligament
29:07is seen in the axial image at the level
29:10of the fibular groove coming out from
29:13the groove to the taus and this is the
29:15anterior tof fibular ligament this is
29:17the posterior tofi ligament in the
29:19coronal image it is better to evaluate
29:23the lateral collateral ligament in the
29:25xdl images
29:27then um you know the the golden rule for
29:32ligamentous injury if any ligament is
29:36torn then you expect you do not see the
29:39ligament at its anatomic location and
29:41each side is replaced by fluid then
29:44normally you see the ligament and you
29:46look here but in in this case then you
29:50do not see the ligament and each site is
29:53uh uh full of fluid signal meaning that
29:57rupture of the anterior tof fibular
30:01ligament this is the normal anterior tof
30:03fibular ligament and this is the
30:05ruptured ligament the ligament is not
30:07seen and its side is occupied by fluid
30:11signal another example this is the
30:15fibula and this is the groove you should
30:17see the anterior T fibular ligament here
30:20it is not present its sight is occupied
30:22by fluid meaning that the anterior tof
30:26fibular ligament is stor or the lateral
30:29collateral ligament is
30:31stor and this is the level of the
30:34fibular groove this is the posterior tof
30:37fibular ligament the anterior tof
30:39fibular ligament is not present and each
30:41site is occupied by fluid meaning that
30:45it is
30:47ruptured with the chronic ankus sprain
30:51there may be diffuse thickening of the
30:56anterior taop ligament or the lateral
30:59collateral ligament and this is known as
31:01chronic injury the ligament will show
31:05almost normal signal dark signal in all
31:08B sequence sequences but its caliber has
31:11much increased and this is known as
31:13chronic injury of the lateral collateral
31:17ligament another example of chronic
31:19injury of the lateral collateral
31:21ligament with the F thickening of the
31:24ligament maintaining its normal signal
31:27two different examples of chronic injury
31:30of the lateral collateral ligament and
31:33the ligament is of dark signal but it is
31:37its caliber has much
31:40increased then we came to the
31:41syndesmotic complex and this ligaments
31:46connect the fibula to the tibia and they
31:49are identified whenever
31:53the the fibular crosssection look looks
31:57oval in shape like this one and uh or
32:02let's us say beer shape then uh
32:06uh if you look anteriorly you will see
32:09the
32:10anterior Tibu fibular ligament if you
32:13look posteriorly you will see the
32:15posterior tib fibular ligament there are
32:19a third component which is known as the
32:21inferior transverse ligament which is
32:24just the Deep fibers the Deep fibers of
32:28the posterior Tibu fibular ligament then
32:33this is the anterior Tibu fibular
32:35ligament identified when the fibula is
32:38oval in shape and it connects the fibula
32:42to the
32:43Tibi the posterior tibio fibular
32:47ligament connects the fibula to the
32:49posterior aspect of the
32:52tibia and this is the normal appearance
32:55of the anterior and posterior the
32:58anterior and posterior tiop fibular
33:00ligaments you remember that the inferior
33:02transverse ligament is just the inner
33:05fibers of the posterior Tibi fibular
33:09ligament and the anterior tib fibular
33:12ligament is commonly injured and injury
33:15means that you do not see the ligament
33:18and its site is replaced by
33:22fluid then we came to the anterior
33:25aspect anteriorly we have only tendons
33:29like posteriorly and we do not have
33:32ligaments anterior or posterior to the
33:35ankle we have ligaments lateral and
33:37medial the ligaments an along the
33:41anterior aspect of the ankle are the
33:43extensor tendons which are the tibialis
33:47anterior extensor harus longus and the
33:50extensor eorum lungs all the three
33:54muscles are also represent
33:58posteriorly this is the tibialis
34:00anterior this is the tibialis posterior
34:02this is the flex extensor hosis and this
34:06is the extensor digitorum then it
34:09changed the position this is the flexor
34:12digitorum and this is the flexor hysis
34:15and you remember these are the two peral
34:18tons the longest superficial the braev
34:22is deep and this is the tendo AES then
34:26the there are three tendons extensors
34:29anteriorly tbis anterior flexor
34:32extensores extensor digit the same
34:36posteriorly but it changes the position
34:38between these two tendons and this is
34:40the tibialis posterior facing the tiis
34:43anterior then flexor digitorum and the
34:47flexor hes this is the berus longus
34:50berus
34:52previous then the tibialis anterior may
34:55be injured and and you can see here the
34:59tendon is swollen and its caliber has
35:02increased with the abnormal signal
35:04within the tendon and also the tendon is
35:06surrounded by fluid meaning that the
35:09tendon has been
35:12injured and this is the splitting of the
35:15tibialis anterior tendon the tendon is
35:17splitted into two parts in is surrounded
35:21by fluid signal denoting ositis as
35:25well then we came to to the posterior
35:28aspect or let us say the poster medial
35:31aspect where you got the three muscles
35:33and the deltoid ligament the three
35:36tendons are the tibialis posterior the
35:40flexor digitorum and the flexor hoses
35:44longus
35:45tendons then uh the tibialis posterior
35:49tendon is one of the big tendons in the
35:53ankle it's cross-sectional caliber is T
35:57the flexor digitorum or the flexor hysis
36:02normally the tpis posterior is twice
36:06inze the flexor digitorum or the flexor
36:10hes then tibialis posterior uh tendon
36:14may be injured and um the injuries are
36:19include three types type one injury
36:22means that the tendon has much increased
36:26in caliber regardless if it contains
36:29abnormal signal or not just the swelling
36:33of the Talis anterior tendon to became
36:37four or more times the adjacent flexor
36:42digitorum tendon meaning that it is type
36:46one injury compared to the normal this
36:48is the tbis anterior normal and this is
36:51the flexo digitorum and flexor hosis the
36:54tendon here has much increased in size
36:57together with abnormal high signal in
36:59both T1 and T2 denoting the presence of
37:02intra substance Hemorrhage or tear and
37:06type one injury of the tibialis
37:10posterior tendon means that tendon
37:12caliber has much increased compared to
37:15the caliber of the adjacent tendon which
37:17is the flexo
37:18digitorum uh
37:20tendon and the tendon is also surrounded
37:23by soft tissue edema and granulation
37:26tissue
37:27another example of type one injury of
37:30the tpis posterior tendon the tendon
37:33caliber is too much increased compared
37:36to the flexor digitorum or the flexor
37:38hysis
37:40tendons and this is type one injury of
37:43the tibialis posterior the tendon
37:46caliber has increased with fluid signal
37:49around the tendon meaning that there is
37:51tenosinovitis and this is type one
37:54injury of the tbis posterior with sto
37:58sinovitis in type two injury the tendon
38:01is splitted into two halves then you
38:04compare this tendon by this one this is
38:07the normal tendon posterior flexor
38:10digitorum flexor hes the tibialis
38:13posterior here is splitted into two half
38:16the flexor digitorum is surrounded by
38:18fluid denoting the presence of
38:20tenosinovitis and this is the flexor
38:22hosis longus the splitting of the tendon
38:25into two two parts means that you are
38:29dealing with type two injury of the
38:31tibialis posterior and here two parts of
38:34the tendon is splitted by this abnormal
38:37signal denoting type two injury another
38:41example of type two injury of tiis
38:43posterior and you got two halves of the
38:46tendon this is the flexor digitorum and
38:48the flexor hosis meaning that you are
38:51dealing with type two injury of the TBI
38:54is posterior type three means that
38:57complete rupture of the tendon and you
38:59don't see the tendon and each side is
39:01replaced by fluid this is the flex with
39:04digitorum and the flexor hosis but the
39:06theis posterior is not present compared
39:09to the normal appearance theis posterior
39:11flexor dorum
39:14theoris and this is another example of
39:16type three injury absent tendon this is
39:19the marker put in the skin at the side
39:22uh of the patient complaint and this is
39:25the flexo dorum Ares the tendon is
39:28replaced by Hemorrhage and
39:31edema Theos sinovitis means that
39:33accumulation of fluid in the sinovial
39:35chees around the tendon and this may be
39:38acute or chronic the most common cause
39:40is trauma sometimes inflammation or
39:44infections and this is fluid signal
39:46around the flexor longus tendon meaning
39:50that there is
39:52ositis this is the fibula anterior Tio
39:55fibular posterior tibio fibular
39:58ligaments and these are the two beral
40:01tendons bravous and longus surrounded by
40:04fluid meaning the tenosinovitis of the
40:08peral tendons in the anterior aspect of
40:12the ankle this is tibialis anterior Flex
40:16extensor hosis and extensor digitorum
40:19the extensor digitorum is surrounded by
40:21fluid meaning that there is OS sinovitis
40:25of the extensive digital and we came to
40:28the ligaments located on the medial
40:31aspect and this is the deltoid ligament
40:33the deltoid ligament is a complex
40:36ligament formed of uh many uh bands and
40:41these bands are go go from the tibia to
40:45the calanus to the navicular bone and to
40:48the tails the the best way for
40:53evaluation of the medial collateral
40:55ligament is in the coron Al images where
40:58you see the classic fan shape appearance
41:01of part of the tendon coming from the
41:04tibia to the tus another part is coming
41:07from the tibia to the calcinus this part
41:10of the calcinus is the
41:13sustentaculum and there is one of the
41:15bands of the ligament going going here
41:18you know the deltoid ligament is deep to
41:21the flexor tendons the tiis posterior
41:24the flexor digitorum and the def flexor
41:27hes longus
41:30tendance then uh this is the appearance
41:33of the deltoid liament in the aial it is
41:35better to evaluate the ligament in the
41:38coronal images and you can see the bands
41:42of the ligament in the coronal coming
41:44from the tibia to the Tais coming from
41:47the the tibia to the
41:50calanus and this is the normal
41:52appearance of the medial collateral
41:55ligament
41:56with fan shape configuration coming from
42:00the tibia to the tus and from the tibia
42:03to the
42:05Cales in order to diagnose injuries of
42:08the medial collateral ligament the same
42:10rule applies here you cannot see the
42:13ligament and the side of the ligament is
42:15replaced by fluid and you cannot see the
42:18fan shape configuration you see the bon
42:20marua in the tus and these are signs of
42:24trauma also here at the site of the
42:28asteris do not see the ligament and the
42:31site of the ligament is replaced by
42:33fluid compared to the normal appearance
42:35of the ligament in this coronal T1 weed
42:39image then few words about the sinusi
42:43syndrome and the tarsal tunnel syndrome
42:47what is the sinusi it is the space
42:50between the tus and the theales and this
42:54space is filled by fat vessels nerves
42:57and two ligaments the ligaments are one
43:01long which is known as the cervical
43:03ligament which attaches to the neck of
43:05the taus and a shorter one which is
43:08known as the inter oous ligament or the
43:11talal ligament both ligaments are not
43:14usually seen in the same section but
43:18they are seen individually one in in one
43:21section and after uh another section in
43:25you can see the second
43:27ligament
43:28then how can you diagnose siny syndrome
43:33by number one absence of the ligaments
43:36and replacement of the fat by fluid
43:39fluid will appear dark in the T1
43:41weighted image and the bright in the t2
43:43weed image the opposite of the fat fat
43:46will be bright here and dark here what
43:49are the causes of Sinai syndrome
43:51ostearthritis is one of the common
43:54causes gangion gout ligament sinovitis
43:57as in cases of romatoid arthritis the
44:01basic basics for diagnosis of sinus I
44:04are torn
44:06ligaments and you do not see the
44:08cervical or the inter oous ligament
44:10diffuse inflammation with cobitis and in
44:14increase signal within the sini
44:18replacement of the signal of the fat by
44:20the signal of
44:22fluid and this is the site of the sinus
44:26in the axial image between the TS and
44:28the calanus and here in the T1 you see
44:32black signal in the t2 you see bright
44:35signal meaning that the fat is replaced
44:38by uh by fluid the Sinai syndrome
44:42usually presents by lateral foot pain
44:46and tenderness scarring and degenerative
44:49changes of the soft tissue structures in
44:51the
44:52sinus will lead to replacement of the
44:54fat signal by
44:56by flute then this is an example of
45:00sinos starai syndrome you do not see the
45:03ligaments you see intermediate signal
45:07and the bright signal in the steer image
45:09denoting the presence of fluid and this
45:13is also a sin star side syndrome in a
45:16female 40 years old with ankle pain
45:20sense of giving way and limitation of
45:22movement following episodes of ankle
45:24sprain and you see dark signal in the T1
45:29and bright signal in the stair meaning
45:31that it is fluid and you cannot also
45:34identify the ligaments within sinus
45:37T then we came to the tal tunnel and the
45:41tal tunnel is formed by a bony floor and
45:46soft tissue roof the sinus the Bony
45:50floor is uh is made of the this part of
45:55the calcus which is known as the
45:57sustentaculum TI and the tus as well as
46:02the body of the
46:05galanis the torsal tunnel contains the
46:09flexor tendons the tibialis posterior
46:12the flexor digitorum and the flexor
46:15hosis together with a neurovascular
46:18bonding it is covered superficially by
46:21the flexor retinaculum and one muscle
46:24which is known as abductor
46:27hosis abductor hosis
46:30muscle or in abbreviation abh the small
46:34muscle is located in the floor of the of
46:38the Taral tunnel known as quadrus
46:41planting this is the abh or abductor
46:44hysis and this is quadrus
46:46blun and this is the flexor retinaculum
46:50covering the flexor tendons running
46:52through the tal tunnel together with
46:56neurovascular neurovascular bundle what
46:59are the causes of tal tunnel
47:03syndrome the causes are either intrinsic
47:06meaning that development of masses
47:09inside the Taral tunnel and this may be
47:12in the form of gangline cysts varicose
47:15veins neuroma liboma saroma
47:18ositis and
47:20fibrosis and the here you can see uh
47:24gangion cyst which is is of low signal
47:27in the T1 and high signal in the t2
47:30withed image within the tal tunnel
47:33resulting in Taral tunel
47:35syndrome also this is the tibialis
47:38posterior as you all know and the
47:40tibialis posterior is surrounded by
47:42fluid denoting that there is
47:45tenosinovitis and tenosinovitis will
47:48result in of the flexor tendons of
47:51course will result init in tal t
47:55syndrome
47:56and this Mass has been proved to be a
47:59giant cell tumor of the tendon cheese it
48:02shows low signal in the T1 and the
48:04bright signal in the t2 and is totally
48:07occupying the tal
48:10T then ex stren causes that can uh
48:14result in torsal tunnel syndrome include
48:17trauma with fractures uh hypertrophy of
48:21the abductor hysis muscle the abh muscle
48:25or the Bony Coalition the most common is
48:29the Coalition between the uh TS and
48:34calanus and this is the normal
48:36appearance of the tus and calanus and
48:39this is the coalision which will result
48:42in a bony protrusion that will encroach
48:45significantly on the tal tunnel the most
48:49common
48:50subtypes are of T tal coalision are the
48:54T calcan and the calcin navicular
48:58Coalition and it accounts for
49:0145% of all tal coalision these
49:05two the three facets of the talanian
49:09joints joint can be involved but the
49:13middle facet is most commonly involved
49:17and you can diagnose THS talanian
49:20coalision by this C sign which is seen
49:25in the lateral ankle radiograph normally
49:29there is a gap between the taus and the
49:32The calanus talenan Joint but in cases
49:36of tser coalision the Bony the bone will
49:39be continuous to form a figure like the
49:44letter c and if you can identify this C
49:49and this is a good observation to uh
49:54suspect the the presence of talanian
49:58coalision if you look normally here and
50:00you see the space or the joint space
50:03between the tus and calcus and here you
50:06can see the continuity of the bone
50:08across this this
50:11joint these are the facets of the of the
50:15tailor surface we have three facets of
50:17the medial the anterior and the
50:19posterior facet the medial facet is
50:22commonly involved in this Coalition but
50:25the whole facets can be also affected
50:28here it is clear that you you can see
50:31that the tus is continuous with the
50:33calcinus posteriorly and there is no
50:35joint space here meaning that there is
50:39coalision you see this is the joint to
50:41space in a normal ankle lateral radaph
50:44and here you cannot see the space with
50:46continuing continuous uh continuing bone
50:50across the region of the joint by CT
50:54it's easy to see see this is the normal
50:56appearance the joint space and here you
50:59can see coalision with bony protrusion
51:01or bony Mass encroaching on the uh
51:05encroaching on the uh tal tunnel also
51:09here you can see loss of the joint space
51:12between this is the normal appearance of
51:15the joint space between the tus and the
51:17calcus here you can see the joint space
51:19is almost totally obliterated and you
51:21see the prominence the Bony prominance
51:23encroaching on the
51:26tan
51:28calicular coalision can also occur but
51:32it will not significantly affect the
51:35torsal tunnel and you see this is the
51:37navicular and this is the calanus this
51:39is fibrous coalision which will later on
51:43form bony
51:48coalition alhamdulillah

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