os subfibulare syndrome radiology

Article JBJS March 1987 69B (2):317-9. ECR 2023 Registration Fees All ECR 2023 registration fees include access to our Best of ECR 2022 On-demand Package " which will be exclusively available in your personal ESR account after registration has been completed. Sammarco GJ, Henning C (2007) Peroneus tertius muscle as a cause of snapping and ankle pain: a case report. Clinical presentation It is almost always asymptomatic although some cases reported dorsal hindfoot pain with a bump 4. Skeletal Radiol 23:525528. Because ankle trauma is the most common indication for radiological examination of the ankle, the accessory ossicle can be mistaken by a fracture [26]. Os subfibulare is a separated ossicle at the tip of the lateral malleolus and inferior portion of the fibular tuberosity of the ankle which is rarely reported. Background: To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Acta Chir Orthop Traumatol Cechoslov 79:8083. As a difference from the flexor digitorum accessorius longus, the tibiocalcaneus inserts onto the calcaneus and not the flexor digitorum longus or quadratus plantae. Phelps CT. Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder. The os trigonum is normally an incidental finding, with no associated pathology. The flexor hallucis longus is used as a landmark for the medial margin of safety in arthroscopic surgery [44]. 1 Trainee house surgeon, Wellington Medical School, New Zealand. 3). J Med Case Rep 9:127. 2). Separated ossicles at the tip of the lateral malleolus, the condition known as os subfibulare, are sometimes a cause of ankle pain. Clarkson JH, Homfray T, Heron CW, Moss AL. The precise cause of symptoms in patients is conjectural. Materials and methods 38 patients with chronic lateral ankle pain and os subfibulare underwent a standardized rehabilitation program. A variant of the os has been called the assimilated os sustentaculi. Patient was referred for radiographs with the suspicion of Achilles tendinopathy in the contralateral leg. This is more common in the lateral than in the medial malleolus. Diagram of the location of the most common accessory bones around the ankle and hindfoot. Sagittal proton density spectral attenuation inversion recovery (PD SPAIR) image. Matthews S (2012) Fractures of the talus. Epub 2014 Apr 25. 3). Interstitial Lung Disease Series-Part 1- Usual Interstitial pneumonia, King Tut's CT scan rules out violent death, NBE introduces fellowships for Radiology Subspecialization, Posterior Cruciate Ligament Avulsion Injury-MRI. The https:// ensures that you are connecting to the In the cases of Shepherds fracture, there will be postero-lateral tenderness with pain on movement of the subtalar joint and with passive movement of the flexor hallucis longus. Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare. Accessory ossicle of the lateral malleolus. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. Similar to the os subtibiale, this represents persistence of an accessory ossification centre, as opposed to an unfused secondary ossification centre, which is more commonly found. 8. J Bone Joint Surg Am 76:13081314. It is useful for the radiologist to be familiar with the characteristics of these anatomical variants to avoid misdiagnosis. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. Arthroscopy 30:13111316. Accessory solei may be evident on radiographs, as partial obliteration of the Kager fat pad. It has been speculated that the os may incorporate to the sustentaculum when growth finishes, and this represents a fused variant of the condition [15, 16]. Feeney MS, Devitt AT, Stephens MM (1998) Duplication of the medial column presenting as a fixed equinus deformity: a case report. A recent review of 46 studies reported an overall prevalence of 16% [43]. 8). This orientates towards a sequel of old fracture as opposed to an accessory ossicle. 2014 Sep 24;4(3):e18. PubMed Sobel M, Levy ME, Bohne WH (1990) Congenital variations of the peroneus quartus muscle: an anatomic study. Note how the os trigonum is intimately related to the flexor hallucis longus (arrowhead). The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients treated operatively for symptomatic avulsion injuries or a symptomatic os subfibulare. Very rarely do they enlarge and become symptomatic. In a series of asymptomatic volunteers, its prevalence was estimated on 1% [44]. Case presentation includes radiographic and computed tomography findings with discussion of various accessory ossicles and their respective incidence in the lower extremity. It is usually asymptomatic but can become inflamed causing Os Naviculare Syndrome. Manage cookies/Do not sell my data we use in the preference centre. 8600 Rockville Pike There is subtle subchondral bone marrow oedema in the process and in the posterior aspect of the distal tibia (thin white arrows), indicative of mechanical overload. and transmitted securely. size, shape and location of os subfibulare, anterior talofibular ligament abnormality and attachment to the os subfibulare, interposition of fluid signal intensity between the os subfibulare and the fibula, and bone marrow edema in the os subfibulare on radiographs and mri were evaluated by two radiologists blinded to rehabilitation outcomes and J Emerg Med 17:305309. Yu JS, Resnick D (1994) MR imaging of the accessory soleus muscle appearance in six patients and a review of the literature. Most accessory ossicles will represent an incidental finding on radiographs. The main differential is avulsion fractures of the distal fibula. All authors read and approved the final manuscript. They are commonly separated from the tip of the lateral malleolus and are totally asymptomatic. The os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. They functionally represent components of a gliding mechanism and are at least partially embedded in tendons, reducing friction and protecting the tendon structure [1, 2]. 12). 66-year-old woman, presented with pain in the posterior and lateral ankle. Anat Sci Int 86:237. 2019. Clin Orthop Relat Res. What is Os Naviculare Syndrome? [11]. CAS 24-year-old man, history of ankle sprain and persisting pain in the lateral and posterior aspect of the ankle. The Foot and Ankle Online Journal, 2010, on Os Subfibulare: A case report of painful fibular accessory ossicle, Management of an open crush fracture to the foot from a lawnmower injury: A case report, The clinical and patient centered outcomes following surgical correction of tailors bunion in an acute hospital based podiatric surgery service, Fluoroquinolone-induced Achilles tendinopathy A case report and management recommendations, Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report, Congenital amniotic band constriction of the proximal tibia: A Yucatan project case report, Distal lower extremity manifestations in spina bifida patients of the Yucatan Peninsula: A 24-year retrospective case series, Management of a dislocated talar dome fracture with ankle arthrodiastasis and open reduction internal fixation: A case report, A case of recurrent hyperostotic macrodactyly. Proton density spectral attenuation inversion recovery, Sarrafian SK, Kelikian A (2011) Osteology. Mellado JM, Rosenberg ZS, Beltran J, Colon E (1997) The peroneocalcaneus internus muscle: MR imaging features. 2. Key words: Os subtibiale, accessory bones foot, medial malleolus Differential diagnosis of os calcaneus secundarius. An accessory, distal focus of epiphyseal ossification may develop in either malleolus. These represent Shepherds or Cedells fractures, respectively [9, 12]. Key words: Os subfibulare, accessory ossicle, pseudo-arthrosis. Karasick D, Schweitzer ME (1996) The os trigonum syndrome: imaging features. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessory anatomical structures in the ankle and foot usually represent incidental imaging findings; however, they may also eventually represent a source of pathology, such as painful syndromes, degenerative changes, be the subject of overuse and trauma or appear as masses and cause compression syndromes or impingement. Boyd N, Brock H, Meier A, Miller R, Mlady G, Firoozbakhsh K (2006) Extensor hallucis capsularis: frequency and identification on MRI. os sustentaculum os intermetatarseum (between the 1st and second metatarsal) os subfibulare: historically, this has been considered to be an accessory ossicle located just below the ditsal fibular epiphysis; it is distinguished from a fracture by its smooth borders, and by the fact that a fracture will preferentially involve the physis; The os sustentaculi represents a very rare skeletal variant of the ankle and foot region, with a prevalence that has been estimated in 0.30.4% [1, 3]. 2) Three-dimensional images show the ossicle with a local pseudo-arthrosis of the large os subfibulare along the distal anterior edge of the lateral malleolus. Griffith, et al., reported three children with symptomatic os subfibulare. 7). 3. The os subfibulare can be found distal to the tip of the lateral malleolus, with round or comma-shaped morphology, and is asymptomatic [25]. Peroneus quartus. Insights into Imaging The tibiocalcaneus is a rare accessory muscle, with only a few radiology reports [44, 54]. In cases where pathology in relation to the presence of these structures is suspected, detailed clinical correlation and careful assessment with MRI and CT plays a very important role. Het os subfibulare is een accessoir voetwortelbeentje dat regelmatig als extra ossificatiepunt ontstaat gedurende de embryonale ontwikkeling. Surg Radiol Anat 37:617627. Accessory muscles can occasionally represent an incidental finding on radiographs, but are mainly incidentally noted on MRI and CT. Clin Sports Med 27:263277. When symptoms are recalcitrant, surgical intervention is required. Accessory soleus. Bone coalitions, given their complexity and frequent clinical implications, deserve separate analysis and will not be the object of this review. At the ankle, these are usually seen inferior to the tip of the medial malleolus. 10). Berkowitz Y, Mushtaq N, Amiras D (2016) MRI of the tibioastragalus anticus of Gruber muscle: a rare accessory muscle and normal anatomical variant. Most of the ossicle is located anterior to the lower end of the fibula and coincides with the footprint of the anterior talofibular ligament (ATFL). Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. These are typical of inversion injuries of the ankle. Davies MB, Dalal S. Gross anatomy of the interphalangeal joint of the great toe: implications for excision of plantar capsular accessory ossicles. Skeletal Radiol 31:5356. [9], The majority of os subfibulare are small. It has been described arising from the medial tibia and inserting on the medial calcaneus, similarly to a subtype of accessory soleus, with the difference that the tibiocalcaneus is located deep in the flexor retinaculum. [7]. This last term is the one generally used for accessory peroneal muscles in the postero-lateral aspect of the leg [40]. 17-year-old woman for follow-up for osteochondral lesion in talus. Besides from the background of trauma, typical features of a fracture such as irregular interfaces and no cortication help to establish the diagnosis on radiographs and CT. Associated bone marrow and soft tissue oedema typically associated to the presence of fractures will be seen on MRI [2]. Upadhyay B, Amiras D (2015) MRI appearances of the anterior fibulocalcaneus muscle: a rare anterior compartment muscle. [Clinical outcome of arthroscopic excision of the os subfibulare in ankle pain]. We report four cases of symptomatic os subfibulare in four children about 9 years old. 4. Os calcaneus secundarius. A small rounded structure could have already represented a sequel of avulsion injury but was described as an ossicle in the absence of acute trauma. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. Background: 10.Griffith JD, Menelaus MB. Cite this article. A very interesting feature of this accessory muscle is that it can be used on ankle surgery to repair retinaculum injuries [38]. 1A and B) There was an accessory ossicle at the lateral malleolus. Before Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. Full-text available. In cases when non-union has occurred, the fragments are usually resected [14]. The peroneal muscles are two, the peroneus longus and peroneus brevis. statement and 3. Teaching points by Dr MGK Murthy Pedicloryl has now become omnipresent in all Radiology departments for sedating children. This descends to insert in the lateral aspect of the calcaneus, with a fleshy attachment (arrowhead). [1-6] Os peroneum can fracture following an inversion and may mimic sport injury. Metin . There are two theories regarding the origin of os subfibulare. This site needs JavaScript to work properly. Suhana E, Das S (2011) Accessory extensor digiti secundus muscle: some interesting facts. It is normally asymptomatic, but in some cases, it can cause crowding in the retinaculum, leading to subluxation of the peroneal tendons or tears due to friction. Repetitive plantar flexion is a continuous requirement in activities such as ballet, basketball or soccer [5, 7]. This is located in between the talus and the calcaneus (white arrowhead). a 17-year-old man referred with the suspicion of peroneal tenosynovitis. This represents an accessory joint between the bony projections at the sustentaculum tali and the adjacent talus. Greater Trochanter Apophysis-Tuberculosis. All ECR 2023 tickets are valid for onsite and online access during March 1-5, 2023! Cheung YY, Rosenberg ZS, Colon E, Jahss M (1999) MR imaging of flexor digitorum accessorius longus. Part of MRI and CT are more sensitive and specific, and in the case of MRI, intrinsic muscular changes and relations with adjacent structures can be evaluated to investigate the aforementioned associated pathologies [44, 53]. An extension of the phenotype or a new syndrome? J Foot Ankle Surg. Most of them represent developmental abnormalities that constitute incidental radiographic findings [1]. He has also been an invited faculty member at various conferences, including Teleradiology in IRIA 2008 and 2011, Hospital Build Middle East, Congress of the Brain Tumor Radiology in Neuro-oncology Society. Catel-Manzke syndrome: a case report of a female with severely malformed hands and feet. doi: 10.2106/JBJS.ST.M.00065. 15.3 ). Similar to anterior ankle impingement syndrome, bone marrow oedema is uncommonly seen in the anterolateral ankle impingement syndrome [7], [12]. Coral A (1987) The radiology of skeletal elements in the subtibial region: incidence and significance. In most instances, os subfibulare is found incidentally on radiographs. A number of anatomical variations can be found in the ankle and hindfoot. [8] The accessory ossicles most commonly observed, in order of frequency, are the tibiale externum, os trigonum and os peroneum. These occur when there is a direct impact on a supinated foot and are frequently seen in association with severely comminute intraarticular calcaneal fractures, although they can also be found isolated. In the absence of an os peroneum, a fibrocartilaginous nodule can be found in the same region. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia. It is estimated to be present in ~7% of adults 1. There was no evidence of instability or locking of the ankle joint. Coronal FSE T1 in two slices, from (d) posterior to (e) anterior in the same patient nicely depicts the PCI tendon (black arrow) parallel to the flexor hallucis longus (white arrow), descending to insert into the calcaneus, below the sustentaculum (black arrowhead), more medial than the flexor hallucis longus (white arrowhead). Epub 2016 Jun 14. J Orthop Surg Res. A 16 year-old female presented with pain of the right lateral ankle for six months duration. Fractures of an os trigonum itself are extremely rare [8]. Medial to this, there is a small ossified body (black arrow). 1. Incidental note of os subfibulare and os trigonum. 4). All symptoms were relieved by excision of the ossicle and reconstitution of the collateral ligament. These include accessory ossicles, additional sesamoid bones, variations in number and configuration of sesamoid bones, coalitions, bipartitions and variants in the soft tissues, such as accessory muscles. Peterson JJ, Bancroft LW. A third peroneus muscle and tendon located in the anterior compartment is a common finding that can be found with a prevalence of up to 95% in cadaveric studies [38]. Chandoga I, Vajczikov S (2012) Talus partitus. 6.Ogden JA. AJR Am J Roentgenol. One year post-operatively, the patient was noted to be totally asymptomatic. The .gov means its official. There are two theories regarding the origin of os subfibulare. Epub 2019 Oct 30. Miller TT (2002) Painful accessory bones of the foot. After unsuccessful nonoperative treatment, all patients underwent excision of the osseous fragments, anatomic reconstruction of the anterior talofibular ligament with use of drill holes through the lateral malleolus, and a modified Brostrm procedure. Accessory bones that are rare in the foot include accessory interphalangeus, os peroneum, anamolous os calcaneum and talus, os trignum and os tibiale extenum. Symptomatic os talus secundarius: a case report and review of the literature. The ankle, subtalar and forefoot range of motion was within normal limits. This case report with a review of literature emphasizes the importance of being aware of such anomalies. Prevalence is difficult to set. 6 Os subfibulare is sometimes a cause of ankle pain, in which case it is called symptomatic os subfibulare. On CT images, irregularity and sclerosis, or changes related to degenerative change on the articular surfaces of the synchondrosis, may be present as a result of chronic stress and abnormal movement [10]. Since symptoms were recalcitrant, exploration and removal of the ossicle was performed. Accessory anatomical structures in the ankle and hindfoot are a common incidental finding. California Privacy Statement, The accessory tendon of the peroneus quartus, separated by a tissue plane from the other peroneal tendons, can be mistaken for a tear, but distinguishing it becomes easy by following the tendon to its own independent muscle belly [42]. b Axial FSE T1 demonstrates the ossicle located in the space between the talus and calcaneus, articulating with the anterior process of the calcaneus (only partially seen) and the tarsal navicular (white arrow). 9 (11): e1881. The main differential is avulsion fractures of the distal fibula. Powered by, Pediatric imaging and Sedation (Pedicloryl). a-d Axial FSE T1 images at different planes from proximal to distal show the course of a flexor digitorum accessorius longus. The tibioastragalus anticus of Grubers muscle is another rare accessory muscle in the anterior compartment of the leg. A case report describing os subfibulare is presented. Oblique views will demonstrate its presence. Wiegerinck JI, Vroemen JC, van Dongen TH, Sierevelt IN, Maas M, van Dijk CN (2014) The posterior impingement view: an alternative conventional projection to detect bony posterior ankle impingement. In general, cadaveric and radiological studies demonstrate similar prevalence, approximately 10% on MRI [41] and 22% on ultrasound [42]. Alignment has been maintained. In a recent retrospective study by Yun et al., it was found that coexisting intraarticular talocalcaneal coalition was observed in 11 of 13 patients with extraarticular talocalcaneal coalition with os sustentaculi, suggesting that the os sustentaculi is a component of extraarticular talocalcaneal coalitions and thus related to the presence of symptoms [17]. Robbins MI, Wilson MG, Sella EJ (1999) MR imaging of anterosuperior calcaneal process fractures. AJR Am J Roentgenol 205:10611067. When this is markedly prominent, the same mechanism of plantar flexion described above [2, 11] causes similar pathology in the surrounding anatomical elements (Fig. Look for loose bodies and damage to the lateral aspect of the talus, which may require debridement. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. Download : Download high-res image (331KB) 2020 Apr 28;21(1):276. doi: 10.1186/s12891-020-03287-1. Os subfibulare can cause impingement on the anterior talofibular ligament, producing anterolateral ankle impingement ( Figure 5, A and B). Its tendon normally joins the Achilles tendon. Os peroneal fracture with associated peroneus longus tendinopathy. Unable to load your collection due to an error, Unable to load your delegates due to an error. Os subfibulare is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported 1. The accessory muscle inserts in the quadratus plantae (white arrows). Accessibility Z Orthop Ihre Grenzgeb 125:302307. A rare associated problem with the presence of a peroneocalcaneus internus is the possibility to fail to recognise this separately from the flexor hallucis longus in arthroscopy (mistaking it with the flexor hallucis longus tendon), which may lead to an altered surgical approach, and potential injury to the neurovascular bundle. Salekzamani Y, Shakeri-Bavil A, Nezami N, Houshyar Y (2009) Ankle patella: a report of a large accessory bone in the ankle: a case report. [1] Radiology 1994; 193:255-257. Other possible causes of posterior impingement are related to the morphology of the lateral tubercle of posterior process of the talus (also called Stieda process). J Foot Ankle Surg 45:2527. She attempted various shoe gear and multiple courses of anti-inflammatory medication with no benefit or symptomatic relief. In contrast, secondary ossification centers will usually coalesce with other epiphyseal or apophyseal centers, eventually contributing to adult bone contours (Fig. 2020. Tezer M, Cicekcibasi AE (2012) A variation of the extensor hallucis longus muscle (accessory extensor digiti secundus muscle). The peroneocalcaneus internus muscle is a rare accessory muscle. This is followed by os tibiale (20%), os trigonum (10%), os peroneum (9%), os subfibulare (2%), os supranaviculare (1%) and os supratalare (0.9%). Clin Anat May 2005 18(4): 239-244. Article The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. It tends to be noted if there is an increase in muscle mass and activity, and sometimes, there is associated pain, triggered by exercise, that could be explained by the increase of intrafascial pressure or insufficient blood supply [52, 53]. Avulsion fractures are more typical of older subjects and normally involve the insertion of the anterior talofibular ligament (Fig. There was a palpable bony swelling that felt hard and fixed to the antero-inferior aspect of the lateral malleolus. The tendon is medial and posterior to the brevis and longus peroneal tendons. These are lateral to the talus. Here is my attempt to explain the charm of this branch. Os subfibulare is an ossicle where the proximal end of the lateral ankle ligaments attaches [1,2]. Gisborne Hospital, Ormond Road. Differential diagnosis includes fractures of the sustentaculum tali, which are also rare. J Orthop Sci 18:733739. As an incidental finding, an os calcaneum secundarium was noted. Mellado JM, Ramos A, Salvad E, Camins A, Dans M, Saur A (2003) Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. It can be multiple and bilateral and is usually asymptomatic [24]. The most common insertion is on the calcaneus, known as peroneocalcaneus externum, with a prevalence of 7991% [44]. Accessory tali have also been described in association with a partial duplication of the medial column of the foot, in the reported case causing fixed pes equinus deformity [35]. Clin Dysmorphol Oct 2004 13(4):237-240. Mellado JM, Salvad E, Camins A, Ramos A, Saur A (2002) Painful os sustentaculi: imaging findings of another symptomatic skeletal variant. Clinically, they manifest with tenderness in this location, which lies anterior and inferior to the anterior talofibular ligament. This is more commonly seen than true ossicles. Clinical presentation and surgical treatment of distal fibular non-union with talus chondral lesions in a pediatric patient: a case report. Unable to process the form. a Lateral and (b) AP projection of the ankle and hindfoot: 1os trigonum, 2os sustentaculi, 3os calcaneus secundarius, 4os subtibiale, 5os subfibulare, 6os supratalare, 7os talotibiale, 8talus secundarius. CT reveals an os subfibulare (white arrow) to the tip of the lateral malleolus with pseudoarthrosis (yellow arrow) of the fragment. MR was performed with the suspicion of talonavicular osteoarthritis at the time. The authors state that this work has received no funding. Nwawka OK, Hayashi D, Diaz LE et al (2013) Sesamoids and accessory ossicles of the foot: anatomical variability and related pathology. Mehtap Tiryakioglu Yuksel. It is more commonly bilateral and seen in males. Anatomical variants may trigger challenges in the differential diagnosis, Anatomical variants may be a source of pathology. ILD is one of the most difficult topics for the residents to understand. These avulsions, if not adequately diagnosed and treated, may progress to delayed union, nonunion, or a chronically painful ankle. There are several different types of accessory bones and they are grouped according to their position, shape and relationship with the adjacent bone. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-7648, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":7648,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/os-peroneum/questions/2548?lang=us"}, Case 11: in a case of avulsion fracture 5th metatarsal styloid, Avulsion fracture of the 5th metatarsal styloid (Pseudo-Jones), Iselin disease: traction apophysitis base of the 5th metatarsal, Apophysis of 5th metatarsal (illustration), posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. Only in very rare cases in which the peroneocalcaneus internus displaces the flexor hallucis longus medially a tarsal tunnel syndrome has been reported [50]. Foot Ankle Int 24:132136. The os trigonum (plural: os trigona) is one of the ossicles of the foot and can be mistaken for a fracture. The flexor digitorum accessorius longus can arise from any structure in the posterior compartment but is seen to arise more frequently from the medial margin of the tibia or from the lateral aspect of the fibula distal to the origin of the flexor hallucis longus. The muscle arises from the anterior aspect of the distal fibula and the extensor digitorum longus muscle, with the tendon normally running along the extensor digitorum longus tendon and inserting on the dorsal surface of the shaft of the fifth metatarsal. AJR Am J Roentgenol 172:475479. Our aim with this review is to illustrate the imaging findings related to the presence of accessory ossicles and muscles in the ankle and hindfoot through different techniques, with special attention to those variants that associate factors of clinical relevance or, in the case of the ossicles, that would pose a challenge in the differential with fractures. The tendon normally runs along the extensor digitorum longus tendon and inserts on the dorsal surface of the shaft of the fifth metatarsal. Bij diegenen bij wie het sesambeentje voorkomt, bevindt het botje zich onder het uiteinde van de malleolus lateralis, dus onder de fibula. Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. This is a chest CT image of a young male with fever, recurrent cough. Review June 2002 6(2):153-161. This tendon may be useful in the cases in which grafting is needed for reconstruction, especially in cases of hallux dysfunction [55]. Differential diagnosis of os fibulare. The presence of this accessory muscle has also been associated to flexor hallucis longus tenosynovitis [49]. Figure 1 The anterior posterior (A) and Oblique (B) radiograph showing a large accessory ossicle or os subfibulare to the tip of the right lateral malleolus. The os subfibulare is a rounded shaped ossicle with well corticated margins different from the fragment of a fracture that has a sharp fracture margin without sclerosis. The accessory ossicle was separated easily. Ahn JH, Kim YC, Kim HY (2013) Arthroscopic versus posterior endoscopic excision of asymptomatic os trigonum: a retrospective cohort study. The ossicle is enlarged and has a bifid appearance. On MRI, there will be subchondral bone marrow oedema and fluid [15]. Differential diagnosis (Fig. The 2016 World Health Organization Classification of Tumors of the Central Nervo All contents copyrights with Sumer Sethi. The presence of oedema on MRI confirms the presence of acute fracture [21]. CAS He has a keen interest in Web 2.0 technologies and in maintaining his famous radiology blog, which has been featured in multiple international journals. 2. Radiographics 28:481499. Secondary ossification centres normally fuse at around 7years of age. Jul 2009. Careers. In the case of Cedells fracture, pain will be located postero-medially and, in some occasions, a lump will be palpated [13, 14]. Foot Ankle Int 23:5155. b On axial FSE T1, the bone fragment is elongated and has irregular margins (black arrow). Google Scholar. An accessory soleus may present as a soft tissue mass in the postero-medial aspect of the ankle. Surgical excision resulted in complete, symptomatic relief. Keats TE (1992) The foot. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. Accessory muscles are also generally asymptomatic and discovered incidentally on imaging studies. Normally, the secondary center of ossification of the lateral malleolus appears during the first year of life, and fuses with the shaft at 15 years. Several rare accessory bones in the hindfoot have been described, such as an accessory calcaneus, by Krause and Rouse [30], and bipartite configurations of the talus that can be mistaken by fractures [31,32,33]. The patient is put in supine position. This review has illustrated the imaging findings related to the presence of accessory ossicles and muscles in the ankle and foot through different techniques and the potential clinical implications related to their existence, highlighting the importance of each technique in the diagnosis and assessment of related pathology. Mosby-Year book, St Louis. This accessory muscle can be used for tendon transfer or graft. Foot Ankle 11:8189. sharing sensitive information, make sure youre on a federal They run posteriorly to the lateral malleolus, the brevis more anterior than the longus. They usually are asymptomatic. c Reconstructed coronal CT image in the same patient, demonstrating the os sustentaculi (arrowhead), in close relation with the sustentaculum tali. The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. Computed tomography (CT) coronal and sagittal images show a single, anterior medial accessory ossicle of the fibula or os subfibulare. While os subfibulare . Short- to Medium-term Outcomes After a Modified Brostrm Repair for Lateral Ankle Instability With Immediate Postoperative Weightbearing. Occasionally, limitation of movement, posterior ankle impingement and flexor hallucis longus tenosynovitis have also been described in association to its presence. In these cases of repetitive trauma, there can be involvement of the soft tissues, which results in irritation manifested as local synovitis, flexor hallucis longus (FHL) tenosynovitis or entrapment. A thigh tourniquet is applied to provide a bloodless operative field. The ossicle is located under the tip of the lateral malleolus [2]. A talocalcaneal bony bridge at the posterior aspect of the sustentaculum can represent fusion of the os with both bones, calcaneum and talus, effectively constituting a subtalar coalition (Fig. Bloom RA, Libson E, Lax E, Pogrund H (1986) The assimilated os sustentaculi. Madhuri V, Poonnoose PM, Lurstep W (2009) Accesory os subtibiale: a case report of misdiagnosed fracture. HHS Vulnerability Disclosure, Help a Sagittal FSE T1 incidentally demonstrates a small ossified body present in the typical location of an os calcaneus secundarius (white arrow). Go to: Step 3: Ankle Examination Examine the ankle for loose bodies or other associated damage. An official website of the United States government. Soft tissue swelling over the lateral malleolus. Findings are compared with previous MR, performed 10years before. Am J Sports Med. When symptoms persist, surgical excision and repair of collateral ligament is indicated. An extension of the phenotype or a new . government site. Note also the presence of an os trigonum. Case Discussion Knowledge of accessory ossicles may prevent misdiagnosis and unnecessary further tests. Accessory tali are extremely rare, with only a few case reports [34]. It corresponds to a defect in contour of the calcaneus. Chepuri NB, Jacobson JA, Fessell DP, Hayes CW (2001) Sonographic appearance of the peroneus quartus muscle: correlation with MR imaging appearance in seven patients. Accepted: July, 2010 The peroneocalcaneus internus inserts on a small tubercle on the medial aspect of the calcaneus, below the sustentaculum (Fig. Tsuruta T, Shiokawa Y, Kato A, Matsumoto T, Yamazoe Y, Oike T, Sugiyama T, Saito M. [Radiological study of the accessory skeletal elements in the foot and ankle (authors transl)]Nippon Seikeigeka Gakkai Zasshi April 1981 55(4): 357-370. It can be mistaken with a flexor digitorum accessorius longus, but its location posterior to the flexor hallucis longus, as opposed to the neurovascular bundle, and its insertion on the calcaneus, as opposed to the flexor digitorum longus or quadratus plantae, help on distinction [38]. When symptomatic, it can be treated with anti-inflammatory drugs, physiotherapy and modified footwear. Disclaimer, National Library of Medicine Figure 2 Computed tomography images show a fibular ossicle or os subfibulare at the distal end of the fibular with pseudo-arthrosis. An os supratalare is an accessory ossicle of the foot located at the superior aspect of the talar head or neck. Objective To retrospectively evaluate the radiologic findings for predicting rehabilitation outcomes in patients with chronic symptomatic os subfibulare. Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. Foot Ankle Int 16:646650. Radiology. This is 24 year old male with chronic ankle pain. Emerg Nurse 22:2732. In summary, symptomatic os fibulare is extremely rare. The os subtibiale is rare, with an estimated prevalence of 0.9% [2], and is located distal to the tip of the medial malleolus. The os subfibulare formed a painful . Published: August, 2010, ISSN 1941-6806 b Axial fast spin-echo T1 (FSE T1) better depicts the presence of foci of subchondral bone oedema and subchondral bone cysts in both aspects of the synchondrosis (white arrows). Given the much higher prevalence of distal fibular injuries due to inversion trauma, some authors actually blanket any ossified structure adjacent to the lateral malleolus as the result of an avulsion fracture, which might have happened remotely in time [2, 29]. MeSH AJR Am J Roentgenol 169:585588. The peroneus accessorius arises from the peroneus brevis to insert onto the peroneus longus, and the peroneus digiti minimi arises from the peroneus brevis and inserts onto the head of the fifth metatarsal and base of the first phalanx [38, 40]. It sits posterior to the talus on the lateral foot radiograph and represents a failure of fusion of the lateral tubercle of the posterior process. a Coronal T2-weighted fast field echo (FFE) demonstrates a talocalcaneal coalition (white arrows). 1 It is a result of an unfused accessory ossification center or an avulsion fracture of the anterior talofibular ligament.1, 2 Avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension on the anterior talofibular ligament attached to . Foot Ankle Int 26:890893. A systematic review and meta-analysis. Yun SJ, Jin W, Kim GY et al (2015) A different type of talocalcaneal coalition with os sustentaculum: the continued necessity of revision of classification. Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. In one of four cases, this will be a bilateral finding. It is connected to the lateral tubercle of the posterior process of the talus by a fibrocartilaginous synchondrosis and in close vicinity to the flexor hallucis longus tendon [6]. It is where there is a spiral fracture of the proximal fibula along with ankle instability. Twenty two percent of normal children under the age of 16 have one or more accessory ossicles in the foot and ankle. Other rare accessory muscles have been described in the anterior compartment of the leg, with tendons parallel to the extensors, such as the anterior fibulocalcaneus [56], which originates in the fibula and peroneus tertius and inserts in the calcaneus, potentially causing pain due to impingement, and a variation of the extensor hallucis longus, as an accessory extensor digiti secundus [57, 58], which originates with the extensor hallucis longus, runs parallel to it and inserts in medial phalanx of the second digit. Clin Orthop Relat Res 337:180186. Aparisi Gmez, M., Aparisi, F., Bartoloni, A. et al. Syndesmotic injury The joint between the tibia and fibula are held together by ligaments. World J Nucl Med 14:205208. Google Scholar. Sweed TA, Ali SA, Choudhary S (2016) Tarsal tunnel syndrome secondary to an unreported ossicle of the talus: a case report. 5. by Vasu Pai MS, D[Orth], National board [Orth], FICMR, FRACS, MCh[Orth]1, The Foot and Ankle Online Journal 3 (8): 3. 9). Radiopaedia. An Os Naviculare is an accessory bone that is a common genetic variant. In the tarsal tunnel, the tendon or low-lying fibres of the muscle can create a compromise of space, and so the presence of a flexor digitorum accessorius longus has been linked to tarsal tunnel syndrome [47]. 1. Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. The differential diagnosis of an os trigonum comprises fractures of the lateral or medial tubercles of the posterior process of the talus. 11..Mancuso JE, Hutchison PW, Abramow SP, Landsman MJ. (2017) Cureus. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gaillard F, Baba Y, Saber M, et al. Knee Surg Sports Traumatol Arthrosc. Its prevalence is estimated in between 1 and 25% [1, 2]. Morphological Characteristics of Os Subfibulare Related to Failure of Conservative Treatment of Chronic Lateral Ankle Instability. Summers A (2015) Accessory ossicles and sesamoid bones: recognition and treatment. Australas Radiol June 2004 48(2): 267-271. Think about it. Shands AR Jr. Accessory bones of foot: x-ray study of feet of 1,054 patients. In most cases, the peroneus quartus arises from the peroneus brevis, but it can arise from the peroneus longus and fibula as well. Google Scholar. A radiograph can confirm the presence of the os subfibulare and assess the size of the ossicle. Results: One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. When present, it is usually located at the calcaneocuboid joint, in the region of wrap-around just before the cuboid tunnel8. Accessory Ossicles of the Foot and Ankle: Disorders and a Review of the Literature. Foot Ankle Online J 2:3. de Leeuw PA, van Sterkenburg MN, van Dijk CN (2009) Arthroscopy and endoscopy of the ankle and hindfoot. Sports Med Arthrosc Rev 17:175184. Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. volume10, Articlenumber:74 (2019) Clinically, in these cases, there will be swelling, effusion and pain. Incidental finding of an accessory soleus. There are a number of other accessory peroneal muscles, with names such as peroneus accessorius, peroneocalcaneus externum, peroneus digiti minimis and peroneus quartus. Address correspondence to: Vasu Pai MS, D[orth], National board [Orth], FICMR, FRACS, MCh[Orth]. The AI model improved the identification of locomotive syndrome among elderly individuals . PMC Other ossicles, such as the os supratalare or os talotibiale, are rare and not associated to painful conditions. Surg Radiol Anat 37:2732. 2001;177 (1): 257-8. It typically inserts onto the quadratus plantae or flexor digitorum longus [46] (Fig. WHO brain tumour classification has been updated in 2016. 11). Symptoms of os trigonum syndrome may result from all the situations mentioned above and consist of chronic or recurrent pain with stiffness, soft tissue swelling and tenderness to palpation in the postero-lateral aspect [8]. Blauth W, Harten K, Kirgis A (1987) Frontal talus cleft--talus bipartitus. JBJS Essent Surg Tech. This normally represents an incidental finding, which can easily be missed on conventional AP and lateral radiographic projections. Injury to the synchondrosis is one of the causes of symptomatic os trigonum. An os peroneum is a small accessory bone of the foot located at the lateral plantar aspect of the cuboid within the substance of the peroneus longus tendon as it arches around the cuboid. a Sagittal FSE T1 in a 56-year-old man referred for follow-up after Achilles reconstructive surgery. 7. In some cases, it may cause compression of the posterior tibial nerve, and associated tarsal tunnel syndrome has been described in cases in which the accessory soleus inserts onto the medial calcaneus. Year-Old female presented with pain in the postero-lateral aspect of the leg [ 40 ] from. Region: incidence and significance is useful for the residents to understand ankle Disorders... Bony swelling that felt hard and fixed to the synchondrosis is one of the ankle and usually... 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