Ankle examination

Ankle

Ankle
Lateral view of the human ankle
Latin	articulatio talocruralis
Gray's	subject #95 349
MeSH	Ankle+joint

In human anatomy, the ankle joint is formed where the foot and the leg meet. The ankle, or talocrural joint, is a synovial hinge joint that connects the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus bone in the foot. The articulation between the tibia and the talus bears more weight than between the smaller fibula and the talus.

The term ankle is used to describe structures in the region of the ankle joint proper.

Bones

The bones of the ankle, called tarsal bones, consist of the talus, calcaneus (heel), navicular, cuboid, medial or internal cuneiform, middle cuneiform, and lateral or external cuneiform.

Articulation

The lateral malleolus of the fibula and the medial malleolus of the tibia along with the inferior surface of the distal tibia articulate with three facets of the talus. These surfaces are covered by cartilage.

The anterior talus is wider than the posterior talus. When the foot is dorsiflexed, the wider part of the superior talus moves into the articulating surfaces of the tibia and fibula, creating a more stable joint than when the foot is plantar flexed.

Ligaments

The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament.

The joint is most stable in dorsiflexion and a sprained ankle is more likely to occur when the foot is plantar flexed. This type of injury more frequently occurs at the anterior talofibular ligament, which is also the most commonly injured ligament during inversion sprains.

Name derivation

The word ankle or ancle is common, in various forms, to Germanic languages, probably connected in origin with the Latin "angulus", or Greek "αγκυλος", meaning bent.

Evolution

It has been suggested that dexterous control of toes has been lost in favour of a more precise voluntary control of the ankle joint.

Fractures

Symptoms

Symptoms of an ankle fracture can be similar to those of ankle sprains (pain, hematoma) or there may be an abnormal position, abnormal movement or lack of movement (if there is an accompanying dislocation), or the patient may have heard a crack. There is often concomitant sprains with fractures.

Evaluation

On clinical examination, it is important to evaluate the exact location of the pain, the range of motion and the condition of the nerves and vessels. It is important to palpate the calf bone (fibula) because there may be an associated fracture proximally (Maisonneuve fracture), and to palpate the sole of the foot to look for a Jones fracture at the base of fifth metatarsal (avulsion fracture).

Evaluation of ankle injuries for fracture is done with the Ottawa ankle rules, a set of rules that were developed to minimize unnecessary X-rays. X-rays optimally includes a mortise view, which is an with the foot internally rotated until the lateral malleolus is on the same horizontal plane as the medial malleolus, and a line drawn through both malleoli would be parallel to the tabletop, resulting in a position where there normally is no superimposition of tibia and fibula on each other. It usually requires 10 to 20 degrees of internal rotation.

On X-rays, there can be a fracture of the medial malleolus, the lateral malleolus, or the anterior or posterior margin. If both malleoli are broken, this is called a bimalleolar fracture (some of them are called Pott's fractures). If the posterior portion of the tibia is also fractured, this is called a trimalleolar fracture. Ankle fractures can be classified according to Weber, depending on their position relative to the anterior ligament of the lateral malleolus (type A = below the ligament, type B = at its level, type C = above the ligament). A special form of type C fracture is the Maisonneuve fracture, which involves a spiral fracture of the fibula with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.

Treatment

Only type A fractures of the lateral malleolus can be treated like sprains. All other types require surgery, most often an open reduction and internal fixation (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A cast will be required to immobilize the ankle following surgery. Trimalleolar fractures or those with dislocation have a high risk of developing arthrosis. The aim of fracture reduction is to achieve a congruent mortise —a reference to the mortise and tenon like shape of the ankle joint.

Mechanical instability of the lateral ankle ligaments can be treated by either the Evans Technique or the Broström procedure.

Kiep ankle disorder

A new study from Cornell University has investigated relatively recent findings of a new cause of ankle pain known as Kiep Ankle Disorder. It lasts up to 6 months and can not be treated with surgery. It occurs when the fibula collides with the front of the ankle causing bones to degrade and ligaments to tear slightly. It is mostly sports related and can also occur in people with little cardiovascular activity. It is most common in women between the ages of 14-25 years old.

See also

References

• Anderson, Stephen A.; Calais-Germain, Blandine (1993). Anatomy of Movement. Chicago: Eastland Press. ISBN 0-939616-17-3.
• McKinley, Michael P.; Martini, Frederic; Timmons, Michael J. (2000). Human Anatomy. Englewood Cliffs, N.J: Prentice Hall. ISBN 0-13-010011-0.
• Marieb, Elaine Nicpon (2000). Essentials of Human Anatomy and Physiology. San Francisco: Benjamin Cummings. ISBN 0-8053-4940-5.

External links

• Media related to Ankle at Wikimedia Commons
• "The Ankle". University of Glasgow. 2007. http://www.gla.ac.uk/ibls/US/fab/tutorial/anatomy/anklet.html. Retrieved March 2010.
• Ardizzone, Remy; Valmassy, Ronald L. (October 2005). "How To Diagnose Lateral Ankle Injuries". Podiatry Today. http://www.podiatrytoday.com/article/4627. Retrieved March 2010.
• Haddad, Steven L. (ed). "Foot & Ankle". You orthopaedic connection (American Academy of Orthopaedic Surgeons). http://orthoinfo.aaos.org/menus/foot.cfm. Retrieved March 2010.

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