Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme

BACKGROUND

The primary aim of this study was to evaluate the true incidence of osteochondral lesions on the talar dome by location and by morphologic characteristics on MRI. Because no universally accepted localization system for talar dome osteochondral lesions currently exists, we established a novel, nine-zone anatomical grid system on the talar dome for an accurate depiction of lesion location.

METHODS

We assigned nine zones to the talar dome articular surface in an equal 3 x 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all nine zones being equal in surface area. Two observers reviewed MRI examinations of 428 ankles in 424 patients (211 males and 213 females; mean age 43 years; age range 6 to 85 years) with reported osteochondral talar lesions. We recorded the frequency of involvement and size of lesion for each zone. Statistical analyses were performed using ANOVA and Scheffe tests.

RESULTS

Four hundred and twenty-eight lesions were identified on MRI. The medial talar dome was more frequently involved (n = 269, 62%) than the lateral talar dome (n = 143, 34%). In the AP direction, the mid talar dome (equator) was much more frequently involved (n = 345, 80%) than the anterior (n = 25, 6%) or posterior (n = 58, 14%) thirds of the talar dome. Zone 4 (medial and mid) was most frequently involved (n = 227, 53%), and zone 6 (lateral and mid) was second most frequently involved (n=110, 26%). Lesions in the medial third of the talar dome were significantly larger in surface area involvement and deeper than those at the lateral talar dome.

CONCLUSIONS

Our established nine-grid scheme is a useful tool for localizing and characterizing osteochondral talar lesions, which are most frequently located in zone 4 at the medial talar dome, and second most in zone 6 at the lateral talar dome near its equator. Medial talar dome lesions are not only more common but are larger in surface area and in depth than lateral lesions. Posteromedial and anterolateral lesions rarely were found.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings

BACKGROUND

The objective of the present study was to assess the utility of magnetic resonance imaging for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional magnetic resonance imaging is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard.

METHODS

Magnetic resonance images of twenty-one feet in twenty patients (ten women and ten men with a mean age of 33.6 years [range, twenty to fifty-six years]) were evaluated with regard to the integrity of the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal-metatarsal ligaments, and the medial-middle cuneiform ligament. Furthermore, the presence of fluid along the first metatarsal base and the presence of fractures also were evaluated. Radiographic observations were compared with intraoperative findings with respect to the stability of the Lisfranc joint, and logistic regression was used to find the best predictors of Lisfranc joint instability.

RESULTS

Intraoperatively, seventeen unstable and four stable Lisfranc joints were identified. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and positive predictive value of 94%, 75%, and 94%, respectively. Nineteen (90%) of the twenty-one Lisfranc joint complexes were correctly classified on magnetic resonance imaging; in one case an intraoperatively stable Lisfranc joint complex was interpreted as unstable on magnetic resonance imaging, and in another case an intraoperatively unstable Lisfranc joint complex was interpreted as stable on magnetic resonance imaging. The majority (eighteen) of the twenty-one feet demonstrated disruption of the second plantar tarsal-metatarsal ligament, which had little clinical correlation with instability.

CONCLUSIONS

Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended. The appearance of a normal ligament is suggestive of a stable midfoot, and documentation of its integrity may obviate the need for a manual stress radiographic evaluation under anesthesia for a patient with equivocal clinical and radiographic examinations.

Osteochondral lesions of the distal tibial plafond: localization and morphologic characteristics with an anatomical grid

BACKGROUND

The aim of this study was to evaluate the incidence and morphologic characteristics of osteochondral lesions of the distal tibial plafond (OLTP) by location and morphologic characteristics on MRI.

MATERIAL AND METHODS

We assigned 9 zones to the distal tibial plafond articular surface in an equal 3 x 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all 9 zones being equal in surface area. Two observers reviewed MRI examinations of 38 patients (12 males and 26 females; mean age, 38.7 years; age range, 10 to 68 years) with reported OLTPs. We recorded the frequency of involvement and size of lesion for each zone. A chart review was performed.

RESULTS

Of the 38 OLTP found in this study, 14 (37%) of the lesions were on the medial tibial plafond [zones 1, 4 and 7] and 11 (29%) involved the lateral tibial plafond [zones 3, 6 and 9]; 13 lesions (34%) localized to the center third of the plafond [zones 2, 5 and 8]. Nine of the lesions (24%) were on the anterior tibial plafond [zones 1, 2 and 3], 15 lesions (39%) predominately involved the posterior plafond [zones 7, 8 and 9], and 14 lesions (37%) localized to the central third of the plafond [zones 4, 5 and 6]. The medial central tibial plafond was most frequently involved site with 8 of the 38 (21%) lesions located there; the posterior medial tibial plafond was second most frequently involved with six of the 38 lesions (16%). Six of 38 ankles had both a talar osteochondral lesion and an OLTP. Of these, only one was a ;kissing' lesion. Chart review revealed that all subjects had ankle pain at time of MRI examination.

CONCLUSION

We conclude that osteochondral lesions of the distal tibial plafond must be considered in the differential diagnosis of patients with symptomatic ankles and that no location had a significantly higher incidence.

Artificial Intelligence in Radiology: Current Technology and Future Directions

Artificial intelligence (AI) has been heralded as the next big wave in the computing revolution and touted as a transformative technology for many industries including health care. In radiology, considerable excitement and anxiety are associated with the promise of AI and its potential to disrupt the practice of the radiologist. Radiology has often served as the gateway for medical technological advancements, and AI will likely be no different. We present a brief overview of AI advancements that have driven recent interest, offer a review of the current literature, and examine the most likely ways that AI will change radiology in the coming years.

Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study

BACKGROUND

The incidence of failed rotator cuff repairs remains high, especially in the setting of massive tears or revision repairs. The purpose of this study was to evaluate patient outcomes and repair integrity after augmentation with the repair patch, a poly-l-lactide synthetic polymer.

METHODS

Sixteen consecutive patients with massive or recurrent rotator cuff tears underwent open repair with synthetic poly-l-lactide patch augmentation. Two patients required the patch to bridge defects, and 1 patient retore after a motor vehicle accident and had revision surgery at another institution. The 13 remaining patients were retrospectively evaluated from 1.2 to 1.7 years (average, 1.5 years) after surgery by PENN, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation scores. Magnetic resonance imaging was used to examine the integrity of the repair at a minimum of 1 year of follow-up.

RESULTS

The mean age was 57.3 years (42-68 years). Five patients (38%) had an intact rotator cuff at the time of follow-up. The remaining patients (62%) had full-thickness tears. PENN scores significantly improved from a preoperative score of 50.9 to 77.6 (P < .005). American Shoulder and Elbow Surgeons scores significantly improved from 32.8 to 74.2 (P = .0001). Single Assessment Numeric Evaluation scores at latest follow-up were 76.2.

CONCLUSION

Poly-l-lactide repair patch augmentation of massive and recurrent large to massive rotator cuff tears demonstrates significant improvement in shoulder outcome measures for this difficult population, despite a retear rate of 62%. Further investigation with larger, prospective long-term studies is needed to determine whether this technique provides a true benefit compared with traditional, nonaugmented repair.

Review of MRI technique and imaging findings in athletic pubalgia and the "sports hernia"

The clinical syndrome of athletic pubalgia has prematurely ended many promising athletic careers, has made many active, fitness conscious adults more sedentary, and has served as a diagnostic and therapeutic conundrum for innumerable trainers and physicians worldwide for decades. This diagnosis actually arises from one or more lesions within a spectrum of musculoskeletal and visceral injuries. In recent years, MRI has helped define many of these syndromes, and has proven to be both sensitive and specific for numerous potential causes of athletic pubalgia. This text will provide a comprehensive, up to date review of expected and sometimes unexpected MRI findings in the setting of athletic pubalgia, and will delineate an imaging algorithm and MRI protocol to help guide radiologists and other clinicians dealing with refractory, activity related groin pain in an otherwise young, healthy patient. There is still more to be learned about prevention and treatment plans for athletic pubalgia lesions, but accurate diagnosis should be much less nebulous and difficult with the use of MRI as a primary imaging modality.

Frequency, imaging findings, risk factors, and long-term sequelae of distal clavicular osteolysis in young patients

OBJECTIVE

Atraumatic distal clavicular osteolysis (DCO) has been described in adult male weightlifters. Our purpose was to investigate the frequency, magnetic resonance imaging (MRI) characteristics, risk factors, and long-term sequelae of DCO in young patients.

MATERIALS AND METHODS

Individuals with atraumatic DCO were identified in a retrospective review of 1,432 consecutive MRI shoulder reports in patients between 13 and 19 years of age. MRI findings of DCO, association with athletic activity, short-term clinical outcome after 3-6 months, and long-term clinical and MRI outcome after 2 years were analyzed. A pre-MRI questionnaire assessed the patients' athletic history including overhead activity and weightlifting.

RESULTS

At a mean age of 15.9 years, 6.5 % (93/1432) of patients had atraumatic DCO, and 24 % were females. The combination of an overhead sport (basketball, volleyball, tennis, swimming) and supplemental weight training was a risk factor for DCO (odds ratio = 38, p = 0.01). Ninety-three percent of patients responded to conservative therapy. On follow-up imaging, 71 % of DCO patients had acromioclavicular (AC) joint osteoarthritis (vs. 35 % in controls, p = 0.006); 79 % had flattening of the distal clavicle and interval widening of the AC joint to a mean of 5.0 mm (compared to 2.4 mm in controls, p < 0.001). Severity of DCO edema was associated with pain (p < 0.02) at initial presentation and with AC joint osteoarthritis (p = 0.004) on follow-up.

CONCLUSION

In athletic teenagers, the combination of weightlifting and overhead activity is a risk factor for atraumatic DCO, and females are affected in 24 %. Long-term sequelae include widening of the AC joint and AC joint osteoarthritis.

Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice

Magnetic resonance imaging (MRI) has become the standard imaging modality for activity-related groin pain. Lesions, including rectus abdominis/adductor aponeurosis injury and osteitis pubis, can be accurately identified and delineated in patients with clinical conditions termed athletic pubalgia, core injury, and sports hernia. A dedicated noncontrast athletic pubalgia MRI protocol is easy to implement and should be available at musculoskeletal MR imaging centers. This article will review pubic anatomy, imaging considerations, specific lesions, and common MRI findings encountered in the setting of musculoskeletal groin pain.

Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the Foot and Ankle

BACKGROUND

Abnormalities of the peroneal tendons can frequently be identified on routine MRI of the foot and ankle. Previous studies in the orthopedic literature have discussed the prevalence of abnormal MRI findings in asymptomatic patients, most notably with regards to the spine and shoulder. The purpose of this study was to determine the prevalence of abnormal findings of the peroneal tendons on MRI in asymptomatic individuals.

METHODS

We retrospectively reviewed all foot and ankle MRIs from 2 independent time periods that were either performed or reviewed at our institution. Studies were excluded if performed on patients with documented inversion injuries, ankle sprains, or lateral ankle trauma. A total of 294 (of 617) MRIs were eligible for inclusion in this study. A single attending musculoskeletal radiologist reviewed each MRI. Pathologies of the peroneal tendons included tendinosis, tenosynovitis, acute tears, chronic tears, and tendon splits. Additionally, the primary pathology encountered on each MRI was noted. The mean age of the MRIs included in this study was 46.8 years (range 9-82) with 155 females and 139 males.

RESULTS

The most commonly occurring primary pathology was Achilles tendinosis/tears (86), followed by posterior tibial tendon dysfunction (43). With regards to the peroneal tendons, 103 of the 294 (35%) MRIs demonstrated some pathology.

CONCLUSION

The results of this study demonstrated that a sizeable percentage of asymptomatic individuals could have peroneal tendon pathology on MRI of the foot and ankle. This study can have important clinical implications for when patients present with concerning MRI findings that do not correlate clinically. Physicians providing musculoskeletal care can counsel and reassure patients who present with peroneal pathology on MRI but an absence of clinical findings.

LEVEL OF EVIDENCE

Level IV, case series.

Bone stress injury of the ankle in professional ballet dancers seen on MRI

Background

Ballet Dancers have been shown to have a relatively high incidence of stress fractures of the foot and ankle. It was our objective to examine MR imaging patterns of bone marrow edema (BME) in the ankles of high performance professional ballet dancers, to evaluate clinical relevance.

Methods

MR Imaging was performed on 12 ankles of 11 active professional ballet dancers (6 female, 5 male; mean age 24 years, range 19 to 32). Individuals were imaged on a 0.2 T or 1.5 T MRI units. Images were evaluated by two musculoskeletal radiologists and one orthopaedic surgeon in consensus for location and pattern of bone marrow edema. In order to control for recognized sources of bone marrow edema, images were also reviewed for presence of osseous, ligamentous, tendinous and cartilage injuries. Statistical analysis was performed to assess the strength of the correlation between bone marrow edema and ankle pain.

Results

Bone marrow edema was seen only in the talus, and was a common finding, observed in nine of the twelve ankles imaged (75%) and was associated with pain in all cases. On fluid-sensitive sequences, bone marrow edema was ill-defined and centered in the talar neck or body, although in three cases it extended to the talar dome. No apparent gender predilection was noted. No occult stress fracture could be diagnosed. A moderately strong correlation (phi = 0.77, p= 0.0054) was found between edema and pain in the study population.

Conclusion

Bone marrow edema seems to be a specific MRI finding in the talus of professional ballet dancers, likely related to biomechanical stress reactions, due to their frequently performed unique maneuvers. Clinically, this condition may indicate a sign of a bone stress injury of the ankle.

MRI findings in the subchondral bone marrow: a discussion of conditions including transient osteoporosis, transient bone marrow edema syndrome, SONK, and shifting bone marrow edema of the knee

Bone marrow edema signal can be seen in many settings ranging from trauma and arthritis to less common conditions including transient osteoporosis, transient bone marrow edema syndrome, true osteonecrosis, spontaneous osteonecrosis, and shifting bone marrow edema. Terms such as spontaneous osteonecrosis of the knee (SONK) appear frequently in the radiology and orthopedics literature but are rarely described on true, histologic basis. This article reviews the less frequently encountered and less well understood entities and explores their potential pathophysiologies and significance.

Spectrum of MRI findings in clinical athletic pubalgia

Athletic pubalgia is a frequently encountered syndrome for clinicians who treat active patients participating in a wide variety of athletic endeavors worldwide. Pathologies associated with this clinical scenario span anatomically from the pubic symphysis to the hip and include a myriad of poorly understood and incompletely described musculoskeletal entities, many of which are centered about the pubic symphysis and its tendinous attachments. In this article, we discuss the relevant anatomy and pathophysiology for the most frequently encountered of these disorders, using magnetic resonance (MR) images as a guide. We describe an MR imaging protocol tailored to clinical athletic pubalgia. We then review reproducible MRI patterns of pathology about the pubic symphysis, the rectus abdominis/adductor aponeurosis and the inguinal ring, as well as a group of clinically confounding entities remote from the symphysis but visible by MRI.

A specific bone marrow edema around the foot and ankle following trauma and immobilization therapy: pattern description and potential clinical relevance

BACKGROUND

We describe a characteristic pattern of bone marrow edema about the foot and ankle seen by MRI in patients who have undergone recent immobilization therapy and investigate potential etiologies as well as possible clinical significance.

METHODS

Three reviewers retrospectively evaluated 52 ankle MRI examinations in 18 patients with abnormal signals compatible with bone marrow edema who had been treated with various types and durations of immobilization of the lower limb after traumatic injury. Bone marrow edema patterns were characterized by distribution, extent, location, and interval evolution or resolution on subsequent followup MRI examination. These MRI findings were then correlated with clinical history, symptomatology and treatment regimens.

RESULTS

All patients had a characteristic pattern of bone marrow edema about the foot and ankle predominating in subchondral, subcortical, and subenthesial locations. The occurrence of this edema pattern was most often noted on MRI within the first 12 weeks after completion of immobilization therapy or resumption of partial or full weightbearing and did not correlate well with new symptomatology or pain. In patients with protracted imaging followup, the bone marrow edema ultimately resolved and was not associated with reported setbacks in recovery course or unexpected delays in restoration of function. All MRI examinations performed more than 18 weeks after the immobilization period showed resolution or stabilization of bone marrow signal, with no continued evolution. No patient had a clinical picture suspicious for reflex sympathetic dystrophy.

CONCLUSIONS

A distinctive pattern of bone marrow edema on MRI of the foot and ankle can be seen on MRI after a variety of weightbearing and nonweightbearing immobilization therapies. This pattern has a consistent appearance on MRI and does not seem to be related to clinical symptomatology. At present, no substantial conclusions can be made regarding the etiology of this phenomenon. However, these bone marrow signal alterations should not mandate further imaging or a change in therapy on the basis of MRI findings alone.

Imaging sports injuries of the foot and ankle

The complexity of foot and ankle anatomy and function is unique in the musculoskeletal system. Understanding the complex anatomy alone is a daunting task, not to mention transferring that understanding to the two-dimensional planes encountered on imaging studies. When evaluating sports injuries in the foot and ankle, the interpreting radiologist must take into account the type of activity, vector of stress, and inherent characteristics of the involved structures. A strong working relationship with the health care providers managing patient care, ideally orthopedists, is essential. But in this age of decreasing specialization and increasing availability of imaging resources, the interpreting radiologist must use all available tools for clinical investigation. When interpreting an ankle or foot MR imaging, one finding should trigger a search for the next finding along a logical pathway of injury evolution. Bone marrow edema patterns are guides to tendon and ligament failure. And a clinical syndrome without correlative imaging diagnosis should call attention to potential alternative diagnoses. As the number of MR imaging studies performed continues to increase and MR technology continues to improve, we expect further advancements in MR evaluation of foot and ankle injury. We hope to continue to work closely with our referring orthopedists in this arena to improve our diagnostic skills and our understanding of foot and ankle injury.

Magnetic resonance imaging findings in bipartite medial cuneiform - a potential pitfall in diagnosis of midfoot injuries: a case series

Introduction

The bipartite medial cuneiform is an uncommon developmental osseous variant in the midfoot. To our knowledge, Magnetic Resonance Imaging (MRI) characteristics of a non-symptomatic bipartite medial cuneiform have not been described in the orthopaedic literature. It is important for orthopaedic foot and ankle surgeons, musculoskeletal radiologists, and for podiatrists to identify this osseous variant as it may be mistakenly diagnosed as a fracture or not recognized as a source of non-traumatic or traumatic foot pain, which may sometimes even require surgical treatment.

Case presentations

In this report, we describe the characteristics of three cases of bipartite medial cuneiform on Magnetic Resonance Imaging and contrast its appearance to that of a medial cuneiform fracture.

Conclusion

A bipartite medial cuneiform is a rare developmental anomaly of the midfoot and may be the source of midfoot pain. Knowledge about its characteristic appearance on magnetic resonance imaging is important because it is a potential pitfall in diagnosis of midfoot injuries.

Incidence and morphologic characteristics of benign calcaneal cystic lesions on MRI

BACKGROUND

Since we have frequently noted osseous cyst-like lesions within the calcaneus on MRI studies, we sought to systematically evaluate this finding to determine the incidence and morphologic characteristics on MRI.

METHODS

Three observers blinded to age evaluated 198 MRIs of the ankle (74 males, 124 females; mean age 47 years, range 13 to 99 years), recording the presence and size of calcaneal cyst-like foci. Statistical analysis was performed to determine if there was an association with age. Additionally, MRI of 12 ankles precontrast and postcontrast were reviewed for the presence of blood vessels in the calcaneus corresponding to the location of the cyst-like lesions and 24 ankle MR arthrograms were reviewed to evaluate communication of the cyst with the adjacent joint.

RESULTS

Of the 198 ankle MRI examinations, 81 (40%) had hyperintense foci, all within the mid-calcaneal body. The size ranged from 0.01 cm(2) to 2.47 cm(2), with a mean size of 0.36 cm(2) (+/- 0.45 cm(2)). Thirty-seven (46%) were linear or elongated, whereas 44 (54%) were ovoid or round. Seven of the 81 foci (8.6% or 3.5% of the total population) were 1 cm(2) or larger. There was no significant association of patient age and presence (p = 0.49) or size (p = 0.48) of the focus. Location of the cyst-like foci, which often are ovoid or linear, corresponds to penetrating microvessels on precontrast and postcontrast MRI. One MR arthrogram showed communication of a cyst-like focus and the subtalar joint.

CONCLUSIONS

Calcaneal lesions are relatively common incidental findings on MRI. These lesions appear to represent intraosseous ganglion cysts that arise from the anterior margin of the posterior facet of the subtalar joint in the anatomical neighborhood where vessels penetrate the superior calcaneal cortex. The lesions can vary is size; however, there is no correlation between patient age and lesion size and no significant association between age and presence of these foci.

Three-dimensional magnetic resonance imaging analysis of hip morphology in the assessment of femoral acetabular impingement

AIM

To determine a possible association between femoral-acetabular impingement (FAI) volume and the development of labral tear using a three-dimensional (3D) model reconstruction of the acetabulum and the femoral head.

MATERIALS AND METHODS

Magnetic resonance arthrography images of the hip in 42 patients with pain and suspected labral tear were acquired using a 1.5T MRI machine. Using 3D analysis software, outlines of the acetabular cup and femoral head were drawn and 3D reconstruction obtained. To control for differences in patient size, ratios of acetabulum : femoral head volume (AFV) and acetabulum : femoral head surface area (AFA) were used for analysis. The association between volume of acetabulum : femoral head and FAI was investigated using ANOVA analysis.

RESULTS

There were 19 men and 23 women with a mean age of 39 years (range 18-78 years). The average AFV was 0.64 (range 0.37-1.05, SD 0.16) and AFA was 0.73 (range 0.36-1.26, SD 0.23). Herniation pit was significantly associated with a small AFV.

CONCLUSION

Femoral neck herniation pits are associated with a low AFV. Gross volume and surface area ratios do not appear to correlate with labral tears or cartilage loss. This technique will enable more advanced analysis of morphological variations associated with FAI.

ACR Appropriateness Criteria acute trauma to the ankle

Acute ankle injuries are frequently diagnosed and treated in emergency departments and outpatient clinics. Recent evidence-based clinical treatment guidelines and systematic review of economic analyses support the use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation of patients meeting the criteria of the Ottawa ankle rules. Cross-sectional imaging has a limited secondary role primarily as a tool for preoperative planning and as a problem-solving technique in patients with persistent symptoms and suspected of having occult fractures. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.