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Injury of the Tibiofibular Syndesmosis: Value of MR Imaging for Diagnosis¹

¹ From the Departments of Orthopaedics (K.O., M.T., K.N., Y.U., T.K.) and Radiology (J.I.), Shimane Medical University, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan; and Department of Orthopaedic Surgery, Hiroshima University, Japan (M.O.). Received November 21, 2001; revision requested January 18, 2002; revision received May 10; accepted July 24. Address correspondence to K.O. (e-mail: kazuoae@aioros.ocn.ne.jp).

View larger version (32K): [in a new window]   Figure 1. Anatomy of the distal tibiofibular ligaments (lig). The tibiofibular syndesmosis consists of four ligaments: AITFL, PITFL, transverse tibiofibular ligament, and interosseous tibiofibular ligament. The AITFL is a flat band of fibers running obliquely upward and medially from the anterior surface of the fibula to the anterolateral tubercle of the tibia. The PITFL is the posterior counterpart of the AITFL. It is quadrilateral in shape and smaller than the AITFL. The fibers of the PITFL originate from the posterior border of the lateral malleolus and extend upward and medially to insert into the posterolateral portion of the tibial tubercle.

View larger version (131K): [in a new window]   Figure 2. Anteroposterior radiograph shows measurement in the right ankle. 1 = lateral border of posterior tibial malleolus, 2 = medial border of fibula, 3 = lateral border of anterior tibial tubercle. Syndesmosis A is measured from point A to point B. Syndesmosis B is measured from point B to point C (not shown).

View larger version (96K): [in a new window]   Figure 3. Transverse T1-weighted spin-echo (500/18, 256 x 256 matrix, two signals acquired) (left) and T2-weighted fast spin-echo (4,000/96, 256 x 256 matrix, echo train length of eight, two signals acquired) (right) MR images of left ankle joint depict normal AITFL (top arrowheads) and normal PITFL (bottom arrowheads). The two ligaments have a bandlike appearance. The AITFL originates on the anterior surface of the fibula and is attached to the anterior surface of the tibia. The PITFL originates at the posterior border of the lateral malleolus and extends to the posterolateral tibial tubercle.

View larger version (59K): [in a new window]   Figure 4a. MR imaging and arthroscopic criteria for diagnosis of (a) AITFL and (b) PITFL disruptions. (a, b) T1-weighted spin-echo (500/18, 256 x 256 matrix, two signals acquired) (left) and T2-weighted fast spin-echo (4,000/96, 256 x 256 matrix, echo train length of eight, two signals acquired) (center) MR images. Arthroscopic image (right). Examples of criterion 1, ligament discontinuity (arrowheads in a), and criterion 2, either a wavy or curved ligament contour or nonvisualization of the ligament (arrowheads in b), are shown.

View larger version (61K): [in a new window]   Figure 4b. MR imaging and arthroscopic criteria for diagnosis of (a) AITFL and (b) PITFL disruptions. (a, b) T1-weighted spin-echo (500/18, 256 x 256 matrix, two signals acquired) (left) and T2-weighted fast spin-echo (4,000/96, 256 x 256 matrix, echo train length of eight, two signals acquired) (center) MR images. Arthroscopic image (right). Examples of criterion 1, ligament discontinuity (arrowheads in a), and criterion 2, either a wavy or curved ligament contour or nonvisualization of the ligament (arrowheads in b), are shown.

View larger version (77K): [in a new window]   Figure 5. Arthroscopic images of a normal ankle depict the AITFL (left) and the PITFL (right) as bandlike structures. The AITFL (left arrowhead) can be seen from the anteromedial portal, and the PITFL (right arrowhead) can be seen from the anterolateral portal.

View larger version (64K): [in a new window]   Figure 6. False-positive case of AITFL disruption. Transverse T1-weighted spin-echo (500/18, 256 x 256 matrix, two signals acquired) (left) and T2-weighted fast spin-echo (4,000/96, 256 x 256 matrix, echo train length of eight, two signals acquired) (center) MR images show an injured left ankle joint. The AITFL (arrowheads) appears to be striated and discontinuous owing to a high-signal-intensity area in the bundle of the ligament. However, the arthroscopic findings (right) from the anteromedial portal show a normal AITFL (arrowhead), although it seems to be multifascicular.

View larger version (55K): [in a new window]   Figure 7. False-positive case of PITFL disruption. Transverse T1-weighted spin-echo (500/18, 256 x 256 matrix, two signals acquired) (left) and T2-weighted fast spin-echo (4,000/96, 256 x 256 matrix, echo train length of eight, two signals acquired) (center) MR images show that the PITFL (arrowheads) is discontinuous. However, the arthroscopic findings (right) from the anterolateral portal show a normal PITFL (arrowhead).