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This is a companion case to our 24-year-old

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professional athlete who's had an inversion

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injury, and in part one of this case vignette

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segment, we were talking about the

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calcaneofibular ligament, which was torn, and the value

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of the coronal projection, which unfortunately

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showed that the subtalar ligaments were injured.

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The medial one, the talocalcaneal

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interosseous ligament, is present.

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The cervical ligament is a fat,

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thick, irregular structure.

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It's torn.

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And the inferior retinaculum and stem

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ligament, also known as the frondiform

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ligament, was torn with blood and fluid

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extravasating into a hematoma, which

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which translates into an ecchymosis on plain film.

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But there's still a little bit

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more in this projection that we can see.

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For instance, we can see the nice, black,

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oblique, well-defined, smooth, non-edematous,

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non-swollen, interosseous membrane.

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So if we have a high ankle component to

1:03

this injury, it is certainly not affecting

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the middle of the tib-fib region.

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The interosseous is totally normal.

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The fact that we have no edema there

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at all means it's highly unlikely the

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anterior tib-fib ligament, the first part

1:18

of the high ankle to tear, will be torn.

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So we're immediately thinking

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low ankle all the way.

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This projection also gives us the medial and

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lateral malleoli and all the individual tubercles.

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You know, if we go anteriorly,

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we hit the region of the Chaput tubercle.

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If we go anteriorly on the fibula, we

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hit the region of the Wagstaffe tubercle.

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And these are all tubercles that may be

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swollen, edematous, and tip us off to high ankle

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abnormalities, which in this case we do not have.

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Let's go now to our axial projection.

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Let's pair them up if we can.

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We've got a, we've got a water-

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weighted image on the left.

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Let's make it a little bigger for you.

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In fact, let's make it really big.

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And a T2-weighted image on the right, which

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is water-weighted, but not as water-weighted

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as its fat-suppressed companion, the PD

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fat suppression spare, special, or spur.

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And let's go right to the heart

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of the matter, the low ankle.

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The structure that is most commonly affected

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in the low ankle, either in its mid-portion

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or as an avulsion from the talar neck,

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is the anterior talofibular ligament, also

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known as the ATFL, also known as the ATAF.

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And it is not attached anymore to the talus.

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It's ruptured.

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Now it has length from bottom to top.

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So let's go top.

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Tib-fib ligament.

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Good.

2:57

Black.

2:59

Smooth.

2:59

Non-edematous.

3:01

Normal interosseous.

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Normal space between the talus and the fibula.

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Let's go down.

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We're starting to get out of the anterior tib-fib.

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And we're getting into the talofibular

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ligament, which now looks a little wavy.

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Top of the talofibular ligament.

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Anteriorly.

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Torn.

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Now in the mid-portion of it.

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Nothing.

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Torn.

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The extensor retinaculum, also torn.

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Let's keep going, shall we?

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A little more posterolaterally.

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Anterior talofibular ligament.

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A little bit attached to the talus.

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Torn.

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Let's keep going.

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A little bit of the ligament.

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Torn.

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Blood.

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Now, what ligament is that?

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That is the calcaneofibular ligament.

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There it is.

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There's the origin of it.

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At the base of the calcaneus.

3:55

Thank you.

3:55

It goes underneath the longus.

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It's wavy.

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It should be a nice, straight

4:00

shot right into the fibula.

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It's torn.

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You worked your way down right into the

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second part of the low ankle rupture.

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Now, when you say low ankle

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sprain, that's a clinical thing.

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So you might say low ankle sprain

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with rupture, or partial tear, or

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full thickness tear of A, B, and C.

4:24

Be very clear.

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In the definition of what you're trying to say.

4:29

Remember, sprain is a clinical word.

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You know, if you say two-part sprain, they want

4:34

to know, well, is it swollen, or is it ruptured?

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Two-part sprain with rupture of

4:39

the anterior talofibular ligament.

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With rupture of the calcaneofibular ligament.

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But not the posterior talofibular ligament,

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which never tears, but always swells.

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In this type of ankle injury, you don't

4:53

tear these unless you dislocate the ankle.

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All right.

4:59

No, we're not done.

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Now we got a checklist.

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Let's go through our checklist to see what

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else we have to say to an experienced,

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high-level foot and ankle orthopedic

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surgeon, podiatrist, or clinician.

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We've already said two ligaments ruptured in the

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low ankle, one spared, high ankle not involved.

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Subtalar space

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involved with two of the

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three major ligaments torn.

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We've described the soft tissue abnormalities.

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What else is simple but relevant?

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Well, we need to see if the peroneus longus,

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and brevis are normal in an inversion injury.

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And they are.

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They're black.

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They're tubular.

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What about their retinaculum?

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Well, the retinaculum is

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injured, but it's still present.

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It's not stretched out.

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It's not displaced.

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So there's a very low-grade

5:57

peroneal retinaculum injury.

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We've already said there's an anterolateral

6:02

extensor retinacular injury, which usually

6:06

occurs right here near the ecchymosis.

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That's not uncommon.

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It's not disturbing.

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We've already commented on the bone injury,

6:14

so that would be part of your checklist.

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And also, a discrete part of your checklist

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is an injury to the osteochondral talar

6:21

dome, which the patient does not have.

6:23

So in your conclusion, when you say ankle

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sprain, ankle sprain, with two-part low ankle

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rupture, including ATFL, anterior talofibular

6:33

ligament, and calcaneofibular ligament, period.

6:37

Number next, no evidence of osteochondral defect.

6:40

No evidence of major lateral retinacular

6:44

injury or peroneus longus or brevis tear.

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No major bone fracture,

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microtrabecular bone injury.

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See the body report for additional

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pertinent negative findings.

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Which, by the way, include all the

6:59

subtalar ligament abnormalities.

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Now that is a serious ankle sprain.

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But this professional athlete,

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back to playing in six weeks.

7:09

Amazing.