Which of the following images do you feel better shows the injury that has occured at the ankle? Is this image of an adult or adolescent? How can you tell? How would you describe the position used to take this image? What would be some symptoms this patient would have? How would they present to therapy?
I'm no expert, but after reading our great Fundamentals of Musculoskeletal Imaging book, I feel I have more insight into these radiographs than I did at first sight. These images are tricky because only image a shows the true fracture, which is a fracture of the distal posterior tibia. One might be tricked into thinking that this was a fracture of the entire tibia, when in fact the main line you see is the epiphyseal growth plate, with the arrow in picture a, pointing out the tiny fracture of the distal posterior tibia. This leads me to the next question that this image is definitely of an adolescent due to the growth plate being present. I would describe the position used to take this image as a lateral shot as it demonstrates the anterior and posterior aspects of the distal tibia, the lateral relationship of the tibiotalar joint and subtalar joint, the talus and calcaneus. This patient would have increased pain with any dorsi/plantar flexion of the ankle, and would have increased pain with WB as well. They would present to therapy either NWB on crutches or with a significant antalgic gait with protective responses upon moving the ankle joint.
ReplyDeleteOh and I think image A is better than image B, because of the density of the image you can better pick out the small fracture which is commonly missed, where in image B you can not easily visualize this fracture.
ReplyDeleteThis image shows an adolescent with a distal posterior tibial fracture. Age is evident by the epiphyseal plate present. Image A shows a much better picture of the fracture, though the fracture is not evident upon first glance. I also misinterpreted the epiphyseal plate at first as the fracture. Image B doesn't show the clear radiodensty of the space between the tibia and fractured bone like image A does. This appears to be a lateral view as you can see the fibula superimposed behind the tibia and talus, as well as the ariculations between the talus/calcaneous and navicular/cuboids. This patient would have swelling in distal LE, as well as pain with WB and ROM of the ankle. Pt would likely present with some sort of assistive device, as WB would be painful. If the pain was tolerable, the patient would likely have some sort of compensative gait.
ReplyDeleteI think that image A is better able to show the injury that has occurred at the distal tibia because you can see the line of the fracture more clearly. The patient appears to be an adolescent because of the presence of the epiphyseal growth plate. The view appears to be a lateral view because you see the fibula superimposed behind the tibia and you can see the outline of what appears to be the lateral side of the talus and calcaneus with the forefoot extending towards the right side of the image and the posterior (calcaneus indicates) side of the foot towards the left side of the image. Symptoms that you would expect to have with this patient include pain with WB such as walking, running, jumping etc due to the fracture in the weight-bearing tibia, pain with PF and DF. I would expect to see swelling at the distal tibia and talocrural joint especially because it appears to have soft tissue swelling on the image. This person is probably using crutches or has a severe limp due to decreased ability to WB on the affected LE.
ReplyDeleteIt looks like image A gives a better view of the injury and you can more clearly see the fracture of the distal tibia. At first glance I thought image B would give better insight into the injury because of the density but I have to agree with my classmates though and say A shows a clearer picture of the fracture. This image is of an adolescent because of the presence of the epiphyseal growth plate. The position used to take this radiograph was a lateral view. You are able to see the tibia and talus however the fibula appears superimposed behind these structures. You can see part of the calcaneus as well as the subtalar joint. This patient would most likely have pain with all weight bearing activities on the affected side causing an antalgic gait and requiring the use of crutches or limping due to pain. This patient would probably also have swelling, and decreased ROM at the ankle joint.
ReplyDeleteI apologize for the lack of new or ground breaking insight into these images.
ReplyDeleteMy fault on the poor questioning regarding these images! So for a continuation of this post from now on (unless you think that you see something different) will be on what would you think you might include on your differential diagnosis list if you did not have these images? If you think that the actual pathology is not as listed feel free to continue to post on original question!
ReplyDeleteThanks,
RM
Picture A defines the fracture of the anterior distal tibia better than picture B, because in radiograph B the radiographic density is too little, making the image appear too white. This image is of an adolescent because of the appearance of the epiphyseal growth plate and the epiphysis. The radiograph view is lateral, with the central ray directed vertically through the medial malleolus. The patient’s symptoms would be pain with weight bearing and ankle ROM especially dorsiflexion due to compression of the site of the fracture. They would present to physical therapy likely non-weight bearing per physician orders with tenderness to palpation over anterior tibia, edema, decreased ROM and strength. For differential diagnosis without images, I would include the possibility of an ankle sprain.
ReplyDeleteI agree with the previous comments concerning the distal tibia fracture. I also agree this image involves an adolescent due to the epiphyseal growth plate. The patient would most likely present with pain with WB, antalgic gait, pain with dorsiflexion/plantarflexion, decreased AROM, and possibly edema into foot and proximal tib/fib. If the images were not available a differential diagnosis list might contain the following: ankle sprain, ankle fracture (unimalleolar, bimalleolar, trimalleolar,or complex), distal tib/fib syndesmosis injury, talus or calcaneus fracture, contusion, and perhaps compartment syndrome.
ReplyDeleteYou asked what might be a differential diagnosis so if a teenager came into the clinic with swelling on medial ankle with an decreased ability to put wt-bear on the involved foot, I would ask what her current activities were. When she said that she was a dancer I might consider that she could be suffering from a flexor hallicus longus tendinitis. To rule this out I would palpate along the the posterior medial aspect of her ankle, posterior to medial malleolus while flexing the great toe. This could be ruled in if during movement crepitus or clicking were present.
ReplyDeleteI feel that neither of these images gives the whole story of what is going on at the ankle. If “one view is no view” then we really can’t make a conclusive statement off of these images because they are both taken in the medial/lateral plane, and we do not have a 90 degree AP view, or even an oblique view to compare to. This is an adolescent, and we can tell because the epiphyseal plate of the tibia is not fused so this is an adolescent that is younger than 16 to 18 years old. This is a lateral radiograph of the ankle which is generally done in sidelying on the affected limb with the central ray passing vertically through the medial malleolus. Based off of what is in the images above, I would expect this patient to have tenderness to palpation at posterior ankle, pain with extreme active plantarflexion is possible, pain with dorsiflexion stretching, and would probably have difficulty walking or weightbearing through the involved extremity. They would likely present to therapy on crutches in a cam walker. Depending on the severity of the injury, they may be presenting after wearing a long leg cast for 6-8 weeks to allow for healing. I would suspect a distal posterior tibia fracture from image a, but as stated above, would not be able to conclusively state a diagnosis unless a view 90 degrees perpendicular to this one was taken.
ReplyDeleteI believe that Image A shows the injury with teh visible line that indicates the fracture of the tibia. The indication of a visible non-fused epipheseal plate would probably show that this is an adolescent. I would describe this image was taken from a medial to lateral saggital plane view. I think the patient would present with pain with weightbearing and expecially with plantarflexion of the ankle as this would compress the fracture site even more. With out these images I would likely think that this could be an osteophyte formation, Heterotopic ossification into the achilles tendon or could be as simple as an ankle sprain, but I tend to remember the majority of ankle sprains would have pain mainly inferior to the malleolus where ligaments attach and cross the joint.
ReplyDeleteI agree that this is a posterior distal tibia fracture, and is an adolescent as we can see from the radiolucent epiphyseal growth plate. Both radiographs are lateral views, which demonstrates the anterior and posterior aspects of the distal tibia, as well as the talus and calcaneus. I think that (a) is better than (b), because you can visualize the radiolucent fracture line better in (a). This patient would probably be unable to weight bear through the tibia and would have pain with ankle movements. The patient would probably present with significant swelling in and around the ankle and lower leg. Differential diagnosis could include ankle sprain, syndesmosis injury, heterotopic ossification in the Achilles tendon, os trigonum (posterior ankle impingment) syndrome, as well as other fractures of the ankle or foot.
ReplyDeleteAfter first looking at these images I thought everyone was crazy because I did not see a fracture at all. I then decided to click on the image and that enlarged it. From there I could appreciate the distal posterior tib fracture in Image A (lateral view) and I couldn't see a fracture in Image B (lateral view). You can tell these are lateral views due to being able to see the calcaneous, tib/fib, talus and navicular in their respective anatomical position as in viewing the LE from a lateral view. Pt. is an adolescent due to epiphyseal plate not being fused. From these images I would conclude that the patient may not tolerate weight bearing very well and PF would increase pain due to location of fracture. Pt. may be able to weight bear some, so he/she may be able to walk, though if they were having increased pain would most likely present to clinic with crutches and/or possible brace. I would suspect that heel strike and toe off to be the most painful areas of the gait cycle. If images were not present, after taking a thorough subjective exam, I would do some tests and measures. First I would want to rule out ankle sprain with use of Klieger's and Ant Drawer, Thompson test, and MMT. Those all done if subjective hx was acute. For chronic or insidious, I would suspect possible hetertopic ossification or osteophytes and would refer back for imaging if PT tests were inconclusive. For acute trauma the last two would obviously be ruled out.
ReplyDeleteImage A is better than B because it shows the extent of the fracture of the distal posterior tibia due to the radiodensity of the image, both images are lateral views. It is an adolescent secondary to the presence of the epiphyseal plate on the long bone of the tibia. Symptoms would be possible edema, bruising (depending on the MOI), inability to bear weight fully, antalgic gait, and decreased ROM secondary to pain. If these images were not accessible prior to my initial evaluation of the patient, I would include the following differential diagnoses into my working hypothesis depending on the MOI that was provided by the patient history examination: moderate to severe ankle sprain, a distal syndemosis injury, posterior ankle impingement, distal tibial fx, distal fibular fx, calcaneous fx, bimalleolar fx, trimalleolar fx, contusion, or heterotopic ossification.
ReplyDeleteHey Dr. Rob
ReplyDeleteLong time listener, first time posting. I believe that picture A demonstrates an more precise view of a fracture of the pt's tibia. This pt. is an adolescent, evident by his growth plate. It appears this radiograph was taken from a lateral view, as you can see both anterior and posterior aspects of talus and calcaneus. This pt would present with pain to compression over this LE, both longitudinally and axially, as well as be TTP over this general area of the fx. Pt would most likely have been put on non-weight bearing restrictions to promote healing of this fracture, and would either be in a boot or with crutches.
I believe that image A is a better view demonstrating a fracture of the distal tibia because the fracture line is more visible. This is a lateral view with the ability to see the fibula behind the tibia, the talus, and calcaneous. The patient appears to be an adolescent due to the visible non-fused growth plate. The patient would most likely present with pain with weight bearing, pain with DF and PF, decreased ankle ROM, increase in swelling/edema and increase in ankle girth compared to the uninvolved ankle. The patient would most likely be using crutches or walk with an antalgic gait. If I did not have access to these images and needed to rule out other pathologies, I would consider a lateral ankle sprain/strain (depending on the MOI) and utilize the talar tilt test to rule out calcaneofibular ligament injury and the anterior drawer test to rule out the anterior talofibular ligament injury.
ReplyDeleteAfter viewing the two images, I agree with my classmates that image A clearly shows the fracture to the R posterior Tibia where image B does not. This is a lateral view of the ankle due to the ability to view the Tibia closer to the image than the Fibula and the appearance of the Navicular bone. This is also an adolescent due to the presence of the epiphyseal growth plate. I would expect this patient to have pain with WB and with extreme plantar flexion. I would also expect tenderness to palpation over the site of the fracture. The patient would most likely present to the clinic with crutches and a CAM boot if acute. Without the image I would have to rule out achilles tendon pathology, medial ankle sprain, heterotopic ossification or bony osteophytes.
ReplyDeleteBeing 18th to comment on this doesn't leave much for discussion. Adolescent, lateral view, distal tibial fracture, decreased WB, antalgic gait, ROM limitations, etc.
ReplyDeleteTesting for an ankle sprain would be included. Subjective history would probably rule out achilles tendinopathy. A squeeze test may help determine a compartment syndrome or a contusion.
Courtney, I love your style. I feel image A is better because the fracture is better visualized and I feel you have a better feel for how open the growth plate is in the tibia. That being said, definitely an adolescent. This would be a lateral view. This pt would have pn with end range PF, weight bearing, likely gait deviations, TTP of posterior ankle. For diff dx I would rule out ankle sprain, achilles tendonitis, posterior tib tendonitis, heterotopic ossification, impingement secondary to Os trigonum.
ReplyDeleteThis image is of an adolescent due to the open growth plates. Image A shows a posterior distal fracture more clearly than Image B. This patient would present with pain with weight bearing on involved side, tenderness specific to the site of fracture, increased swelling, limited ROM with a possible open end-feel due to pain, and possible bruising. My differential diagnosis would include fractures of either the tibia and/or fibula as well as possible fractures of the talus or calcaneus. Ligamentous testing (talar tilt or anterior drawer test) would be included to rule out possible ankle sprain. Squeeze test to rule out possible syndesmosis pathology. Depending on subjective history and MOI, I would perform a Thompson test to rule out Achilles rupture.
ReplyDeleteI agree with Ryan that I didn't see anything on the images until I enlarged them!It is still difficult to see anything but image A has less object radiodensity that makes fractures more difficult to detect. The lateral view makes it easier to see what is going on with the talus, calcaneus and the relationship of the calcaneus, talus and distal tibia. Image A would make it easier to detect a fracture in the fibula if there was one. The epiphyseal growth plates are evident and that is indicative of an adolescent's ankle.If this patient came to the clinic, he/she would most likely present with swelling, decreased WB on that ankle, pain with movements (AROM,PROM), tenderness with palpation of the posterior ankle. A few other diagnoses that would need to be ruled out would be sprain of the calcaneal ligaments, sprain of achilles tendon, heterotropic ossification. This fracture might have been difficulty do detect without imaging because of the other things that it could be.
ReplyDeleteI agree with the previous posts that image A demonstrates a fracture of the distal posterior tibia, which is not really evident in image B. I also suspect these views are of an adolescent due to the evident epiphyseal plate. Also, this is a lateral view, as the tibia is superimposed on the fibula in these images. A patient would commonly present to the clinic with pain with weight bearing, swelling or ecchymosis as well as limited ROM, with dorsiflexion and plantarflexion. Without these images, differential diagnosis for this patient would include ankle sprain, other possible fractures at or around the ankle, syndesmosis injury, heterotopic ossification, compartment syndrome, and tendonitis.
ReplyDeleteImage A is the better image for viewing the distal tibial fracture as it is difficult to see and is totally missed in image B due to the increased density. This is an image of an adolescent clearly because of the epiphyseal plate that is clearly visible in both images. This is a lateral view of the ankle and you can tell because the fibula appears superimposed behind the tibia. The symptoms that this patient would experience would include pain or inability to weight bear, swelling and possibly bruising, and pain on the outside of the ankle. This patient would more than likely present to therapy either non-weightbearing on crutches or with a limp/antalgic gait pattern. My main differential diagnosis if I didn’t have these images would be a lateral ankle sprain, or fracture of the epiphyseal plate or in the ankle. I would also suspect a possible syndesmosis injury, or heterotropic ossification and all of these would need to be ruled out.
ReplyDeleteImage A is better, no fracture is seen in B. This is an adolescent. I know because I am a genius or because there is an epiphyseal growth plate… either way. It is a lateral view. S/s would be edema, and painful AROM, antalgic gait, tender to palpation at the site of fracture and around the rest of the posterior ankle, and use of an AD/ankle support to WB-ing on the involved foot. DD would include fracture/stress fx of another structure (fibula, different location on tibia, talus, calcaneus, and the tarsals), ankle sprain, achilles sprain/tendonitis/rupture, posterior tibial strain/tendonitis, syndesmosis tear, heterotopic ossification, plantar fasciitis, retrocalcaneal bursitis, or tarsal tunnel syndrome. MOI, age, activity level, specific sport, hx of fractures, beighton’s score, etc. would aid in the differential diagnosis.
ReplyDeleteImage A definitely shows the injury better than Image B does. Due to the clearly visible epiphyseal plate, I would say this image is of an adolescent and is a lateral view. The patient would likely have pain with weight-bearing and ROM, be tender to palpation over the injury site, and have some swelling. They would likely present to PT with an assistive device or antalgic gait. I would assume this patient’s subjective history would lead me to include things such as ankle sprain, syndesmotic injury, different types/locations of fractures, or Achilles injury in my differential diagnosis.
ReplyDelete = decreased.
ReplyDeleteI agree that image A shows the fracture better than image B. I think it would have been helpful to see another view of this injury. This adolescent might present to the clinic with swelling, difficulty weight-bearing, antalgic gait, decreased ROM and strength secondary to pain. Pt would also most likely be tender to palpation over the fracture site. It would be important to rule out ankle sprain, tib/fib syndesmosis injury, possible proximal foot bone fractures, Achilles injury, and possible posterior tibialis strain. This differential diagnosis list would be narrowed significantly after an appropriate and complete subjective history was acquired.
ReplyDeleteI agree with my colleagues, image A shows the fracture of the posterior tibia better than image B. This is a lateral view of an adolescence’s ankle (growth plates are still open). This patient would present to the clinic with swelling and pain with WB, palpation, and ROM. DD may include ankle sprain or partial Achilles rupture with or without avulsion. A good subjective history and understanding of MOI would help one develop a working diagnosis.
ReplyDeleteOk, not really anything new to say as I agree with my classmates, but… image A gives a better view of the fracture, which is difficult to see anyway unless the image is enlarged. This is an image of an adolescent due to the presence of the open growth plate in the distal tibia. This is a lateral radiograph. The patient would probably present with pain, antalgic gait (if they were weight bearing when they present), decreased and painful ROM, and edema. In differential diagnosis, it would be important to include ankle sprain, syndesmosis injury, Achilles tendon pathology, posterior tib pathology, and posterior impingement.
ReplyDeleteI do not believe that either xray gives justice to the injury that occured. They are both not of the highest quality. I would say that A is better than B however due to the ability to see the distal tib fracture more clearly. This is clearly an adolescent due to the epiphyseal plate. The view is a lateral xray due to the superimposed fibula in the xray. I would say this patient would present to the clinic with compensatory gait patten, swelling, decreased ROM, and increased pain. However, all symptoms are patient dependent so it could vary greatly.
ReplyDeleteTo me, I could barely make out the fracture in image B; therefore, I would say image A was better. The epiphyseal plate is apparent which led me to the conclusion that the xray was taken of an adolescent and both views were lateral. The patient would most likely present to the clinic with symptoms of decreased or inability to bear weight through that extremity, pain in ankle with all movements, possible swelling depending on acuity, decreased ROM, and an empty end feel with PROM due to pain that is limiting. I am in agreement with everyone's differential diagnoses and thought there was a thorough review of what to rule in/out.
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