The complex extends from the calcaneus to the tarsal navicular. Normal ultrasound images are shown concurrently. (Left side of image is proximal.) (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). 6.3). F = fibula. (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).Download as PowerPointOpen in Image 5-7 Their origins and insertions can be seen in Table 1. (Left side of image is posterior.) 24-year-old man with Weber type B fracture of fibula. (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). Viewer. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). The peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow.Download as PowerPointOpen in Image (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. Lateral ankle ligaments prevent joint damage in varus, inward movement. (Left side of image is posterior.) Drawing illustrates peroneal tendon split and rerouting (Chrisman-Snook procedure). F = fibula, T = talus.Download as PowerPointOpen in Image C = calcaneus. High frequency linear probe. Here is what to look for when assessing for an acute tear of the Calcaneofibular ligament. (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). The peroneal tendons are intact. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). Figure 13b. (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf ,,,Fig 9). Direct anterior TFL repair (Broström procedure) in a 34-year-old man. Figure 4d. The peroneus longus tendon is shown in yellow. F = fibula, PL = adjacent normal peroneus longus tendon. Figure 13b. At radiography and magnetic resonance (MR) imaging, the presence of one or more suture anchors in the region of the anterior talofibular ligament indicates direct ligament repair, whereas a fibular tunnel indicates peroneus brevis tendon rerouting or loop. Peroneus brevis tendon rerouting (Evans procedure) in a 42-year-old woman. Viewer, ACR Appropriateness Criteria ® Chronic Ankle Pain, Postoperative Magnetresonanztomographie des Sprunggelenks, CT and MR Imaging of the Postoperative Ankle and Foot, Diagnostic validity of alternative manual stress radiographic technique detecting subtalar instability with concomitant ankle instability, Soft Tissue Injury to the Ankle: Ligaments, Evaluation of the results of Watson Jones tenodesis in chronic lateral instability of the ankle. Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. Drawing illustrates direct repair of the anterior talofibular (solid arrow) and calcaneofibular (open arrow) ligaments. Longitudinal US image of the fibular diaphysis (F) shows the peroneus brevis tendon (P) entering the proximal end of a fibular tunnel (arrows). Figure 11. The calcaneofibular ligament (CFL) is the middle ligament of the lateral collateral ligament complex of the ankle and stabilizes both the ankle and subtalar joints. 34, No. Viewer. We categorized the more common procedures into four groups: direct lateral ligament repair, peroneus brevis tendon rerouting, peroneus brevis tendon loop, and peroneus brevis tendon split and rerouting. (Left side of image is posterior.) Familiarity with the surgical procedures most commonly used for lateral ankle ligament reconstruction, and with the imaging features of these procedures, is essential for avoiding diagnostic pitfalls and ensuring accurate assessment of the ligament reconstruction. Drawing of the lateral ankle illustrates the normal anterior talofibular ligament (TFL) (straight arrow), calcaneofibular ligament (CFL) (curved arrow), and posterior TFL (arrowhead). Figure 13c. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. One surgical treatment for lateral ankle ligament abnormality involves direct repair of the anterior TFL, and possibly of the CFL if it also is torn (,3). The calcaneofibular ligament is frequently seen as a band of low signal intensity parallel to the lateral calcaneal wall on routine axial MR images obtained with the foot in plantar flexion (,,, Fig 4a). Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).Download as PowerPointOpen in Image (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). Tendons were identified on the basis of their characteristic fibrillar hyperechoic echotexture and ligaments on the basis of their more compact fibrillar hyperechoic echotexture. Use of only one-half of the peroneus brevis tendon allows preservation of the dynamic function of the peroneus brevis muscle (,3). 24, No. Initial management of acute ankle sprain consists of rest, ice, compression, and elevation (the “RICE” regimen), followed by early controlled motion with a functional brace (,3). Findings were classified normal, partial tear, and complete tear. The plantar calcaneonavicular ligament is also known as the spring ligament complex (Figs. (a) Oblique radiograph of the ankle shows a distal fibular tunnel (arrows). CONCLUSION. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. The peroneal tendons are intact. F = fibula, T = talus. This procedure represents a modification of the original Evans procedure, in which the transected peroneus brevis tendon is directly attached to the distal fibula (,3,,5,,7,,8) and is used to reconstruct the anterior TFL (,4). (c) Longitudinal US image shows a portion of the split peroneus brevis tendon (solid arrow) entering the anterior end of the fibular tunnel (open arrow). (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (Left side of image is superior.) Peroneus brevis tendon loop (Lee procedure) in a 22-year-old woman. All available images were then retrospectively reviewed. (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf ,,,Fig 9). Figure 10d. (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). 11 and 24). 163.1). A portion of the split peroneus brevis tendon is seen coursing through a fibular tunnel and is secured to the talus and calcaneus with periosteal flaps before reattachment to the distal portion of the tendon. F = fibula, PL = adjacent normal peroneus longus tendon. The Calcaneofibular ligament is a small lateral ankle ligament that is often torn. (Left side of image is posterior.) talofibular ligament injuries and six of six calcaneofibular ligament injuries. MSK Classifications. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). Viewer. ... at or below the level of anterior talo-fibular ligament or a tear of lateral collateral ligament structures with the anterior talofibular ligament disrupted most often and frequently the calcaneofibular ligament … F = fibula. F = fibula. (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). Direct anterior TFL repair (Broström procedure) in a 34-year-old man. The calcaneofibular ligament (CFL) originates from the distal fibula and passes obliquely and inserts into the peroneal tubercle of the calcaneus. (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). (Left side of image is superior.) (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).Download as PowerPointOpen in Image 5 Laterally, the ankle has three distinct ligaments (Figure 1A) which form the lateral collateral ligament: the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). Figure 10c. C = calcaneus. Artifact from suture material may obscure the tendon at MR imaging but not at US. Similarly, identification of a suture anchor or fibular tunnel at MR imaging provides clues to the surgical procedure used. F = fibula, PL = adjacent normal peroneus longus tendon. (Left side of image is proximal.) Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. In 30% of patients, similar direct repair of the CFL for ligament injury or laxity is also performed (,3). Figure 13c. C = calcaneus, CFL = calcaneofibular ligament, PB = spared half of the peroneus brevis tendon, PL = peroneus longus tendon. Department of Radiology, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea See all articles by this author. This site is intended for Medical Professionals only. One clue at imaging that this procedure has been performed is the presence of an oblique vertical fibular tunnel, which typically courses cephalad in the fibula from anterior to posterior (,,,,,,,,Fig 6a, ,,,,,,,,6b). C = calcaneus. The peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow. Peroneus brevis tendon loop (Lee procedure) in a 22-year-old woman. Anterior Calcaneofibular Ligament (CFL) ultrasound – Technique and Findings. One hundred ninety-five consecutive 3-T ankle MRI studies … At radiography, a fibular tunnel is typically visualized (,,,,,,,Fig 13). Of the ligament injuries detected, 83 had new anterior talofibular ligament injuries. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). Thickened, hyper-intense and ill defined calcaneofibular ligament (Pink arrows). Figure 5. In peroneus brevis tendon split and rerouting, the tendon is split longitudinally, with half of the tendon separated proximally from the intact peroneus brevis muscle-tendon unit (,Fig 12). Peroneus brevis split and rerouting (Chrisman-Snook procedure) in a 19-year-old woman. Calcaneofibular ligament lies deep in relation to peroneal tendons and extends from lateral malleolar tip to trochlear eminence, stabilizing subtalar joint. Direct anterior TFL repair (Broström procedure) in a 34-year-old man. Instead, it is looped around the distal fibula and sutured distally back upon itself. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Good resolution. Figure 10c. F = fibula. Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).Download as PowerPointOpen in Image Figure 11. F = fibula. Findings were classified normal, partial tear, and complete tear. At this site, the calcaneofibular ligament is identified as a compact fibrillar structure between the peroneal tendons and calcaneus ( Fig. Viewer. The ligament is two centimeters long, five millimeters wide, and three millimeters thick. (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). UPCOMING MRI MINI FELLOWSHIPS (Click Below). Note the rerouting of the tendon (red) through a fibular tunnel (dashed lines) with distal reattachment. Fig. The calcaneofibular ligament is a part of the lateral collateral ligament complex. F = fibula, PL = adjacent normal peroneus longus tendon. Viewer. More than 50 procedures or modifications of procedures designed to stabilize the lateral ankle have been described (,4). Figure 13a. The calcaneofibular ligament and the posterior talofibular ligament are usually well seen on coronal MR images (D), and the calcaneofibular ligament can also be visualized on axial images (E), coursing deep to the peroneal tendons. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). (Left side of image is posterior.) The calcaneofibular ligament may become entrapped in calcaneofibular impingement, as it courses from the fibula to the calcaneus (17a). (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. (a, b) Anteroposterior (a) and oblique (b) radiographs of the ankle show a fibular tunnel (arrows). Here is what to look for when assessing for an acute tear of the Calcaneofibular ligament. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). Anatomical landmark to find the CFL are the Peroneal tendons (Blue arrows) with the CFL lying deep to it. Note the rerouting of the tendon (red) through a fibular tunnel (dashed lines) with distal reattachment. Drawing shows rerouting of the peroneus brevis tendon (red) through a fibular tunnel (dashed lines) with proximal reattachment (Evans procedure). (Left side of image is proximal.) Peroneus brevis tendon loop (Lee procedure) in a 47-year-old man. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). ... Radiology 1994; 192:189-194. (d) Longitudinal US image shows the normal anterior TFL with a compact fibrillar echotexture (arrowheads) and echogenic suture material (arrows). Note that the tendons of the peroneus longus and brevis cross the calcaneofibular ligament superficially and these tendons also are stretched with inversion, but are placed in … (b, c) Axial (b) and sagittal (c) T1-weighted MR images show artifact from suture anchors at the distal fibula in the region of the anterior TFL (arrows). (d, e) Transverse US images show one segment of the peroneus brevis tendon loop (arrow in d) lateral to the fibula (F), another segment entering the fibular tunnel (arrowhead), and a distal tendon anastomosis with echogenic suture material (arrow in e).Download as PowerPointOpen in Image As in ,Figure 2, the peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow. Peroneus brevis tendon rerouting (Evans procedure) in a 42-year-old woman. 3 In the neutral position, the CFL courses posteriorly, inferiorly, and … Sequential axial T1-weighted MR images (b obtained inferior to a) show one segment of the peroneus brevis tendon loop lateral to the fibula (arrow in a) and another segment coursing through a fibular tunnel (arrowhead in a) above the level of the tendon anastomosis (arrow in b). Figure 10e. ANKLE, Ankle Ligaments / By Dr Ravi Padmanabhan. 3—Lateral complex: calcaneofibular ligament. F = fibula, T = talus.Download as PowerPointOpen in Image Direct anterior TFL repair (Broström procedure) in a 34-year-old man. Six patients were retrospectively identified as having undergone lateral ligament reconstruction surgery. The surgical procedures were categorized into four groups: direct lateral ligament repair, peroneus brevis tendon rerouting, peroneus brevis tendon loop, and peroneus brevis tendon split and rerouting. (c-g) Axial (c-f) (c most caudal, f most cephalic) and sagittal (g) T1-weighted MR images show the peroneus brevis tendon (solid arrows) coursing through the fibular tunnel. Figure 6b. (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf ,,,Fig 9). Note the normal peroneus longus tendon (arrowheads) and suture artifact at the proximal peroneus brevis tendon reattachment site (open arrow in g).Download as PowerPointOpen in Image In peroneus brevis tendon rerouting, the tendon is transected above the ankle, rerouted in a distal-to-proximal direction through a surgically created tunnel in the fibula, and then reattached at the initial transection site (,Fig 5). (b) Axial computed tomographic scan of the ankle obtained after air-contrast arthrography shows one segment of the peroneus brevis tendon loop lateral to the fibula (arrow) and another segment coursing through the fibular tunnel (arrowhead) (cf ,,,Fig 9). (d) Longitudinal US image shows a segment of the peroneus brevis tendon (solid arrow) between the posterior aspect of the fibular tunnel (open arrow) and the calcaneal periosteal flap (arrowheads). As in ,Figure 2, the peroneus brevis tendon is shown in red and the peroneus longus tendon in yellow.Download as PowerPointOpen in Image (f) Transverse US image of the split segment of the peroneus brevis tendon shows a distal tendon anastomosis (arrows).Download as PowerPointOpen in Image (e) Longitudinal US image shows the peroneus brevis tendon (arrows) exiting the periosteal calcaneal tunnel (arrowheads). Drawing illustrates rerouting of the peroneus brevis tendon (red) through fibular (dashed lines) and talar tunnels with distal reattachment (Watson-Jones procedure). Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman. (a, b) Oblique (a) and lateral (b) radiographs of the ankle show a fibular tunnel (arrows). At MR imaging and US, the rerouted peroneus brevis tendon can be followed proximally from the fifth metatarsal bone and identified entering the osseous tunnel at the fibular tip.The tendon exits more superiorly from the posterior end of the fibular tunnel (,,,,,,,,Fig 6c–,,,,,,,,6g, ,7) and continues cephalad. Peroneus brevis tendon loop (Lee procedure) in a 22-year-old woman. The peroneal tendons are intact. (c) Longitudinal US image shows a segment of the distal peroneus brevis tendon (arrows) entering the fibular tunnel. Peroneus brevis tendon rerouting (Evans procedure) in a 55-year-old woman.

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