Ultrasound in Emergency Medicine| Volume 52, ISSUE 5, P707-714, May 2017

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Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament



      Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging.


      Our aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane.


      Magnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted.


      By MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%.


      PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.


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        • Cheng Y.
        • Cai Y.
        • Wang Y.
        Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings.
        Br J Radiol. 2014; 87: 20130406
        • Hua Y.
        • Yang Y.
        • Chen S.
        • Cai Y.
        Ultrasound examination for the diagnosis of chronic anterior talofibular ligament injury.
        Acta Radiol. 2012; 53: 1142-1145
        • Gun C.
        • Unluer E.E.
        • Vandenberk N.
        • Karagoz A.
        • Senturk G.O.
        • Oyar O.
        Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury.
        J Emerg Trauma Shock. 2013; 6: 195-198
        • Oae K.
        • Takao M.
        • Uchio Y.
        • Ochi M.
        Evaluation of anterior talofibular ligament injury with stress radiography, ultrasonography and MR imaging.
        Skeletal Radiol. 2010; 39: 41-47
        • Szczepaniak J.
        • Ciszkowska-Lyson B.
        • Smigielski R.
        • Zdanowicz U.
        Value of ultrasonography in assessment of recent injury of anterior talofibular ligament in children.
        J Ultrason. 2015; 15: 259-266
        • Singh V.
        • Elamvazuthi I.
        • Jeoti V.
        • George J.
        • Swain A.
        • Kumar D.
        Impacting clinical evaluation of anterior talofibular ligament injuries through analysis of ultrasound images.
        Biomed Eng Online. 2016; 15: 13
        • McKeon K.E.
        • Wright R.W.
        • Johnson J.E.
        • McCormick J.J.
        • Klein S.E.
        Vascular anatomy of the tibiofibular syndesmosis.
        J Bone Joint Surg Am. 2012; 94: 931-938
        • Taser F.
        • Shafiq Q.
        • Ebraheim N.A.
        • Yeasting R.A.
        Enlarged perforating branch of peroneal artery and extra crural fascia in close relationship with the tibiofibular syndesmosis.
        Surg Radiol Anat. 2006; 28: 108-111
        • Giebel G.D.
        • Meyer C.
        • Koebke J.
        • Giebel G.
        The arterial supply of the ankle joint and its importance for the operative fracture treatment.
        Surg Radiol Anat. 1997; 19: 231-235
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Fleis J.L.
        • Levin B.
        • Paik M.C.
        Statistical Methods for Rates and Proportions.
        3rd ed. Wiley, New York2003
        • Hallgren K.A.
        Computing inter-rater reliability for observational data: an overview and tutorial.
        Tutor Quant Methods Psychol. 2012; 8: 23-34
        • Robinson P.
        Impingement syndromes of the ankle.
        Eur Radiol. 2007; 17: 3056-3065
        • Chan K.W.
        • Ding B.C.
        • Mroczek K.J.
        Acute and chronic lateral ankle instability in the athlete.
        Bull NYU Hosp Jt Dis. 2011; 69: 17-26
        • Alavekios D.A.
        • Dionysian E.
        • Sodl J.
        • Contreras R.
        • Cho Y.
        • Yian E.H.
        Longitudinal analysis of effects of operator experience on accuracy for ultrasound detection of supraspinatus tears.
        J Shoulder Elbow Surg. 2013; 22: 375-380
        • Latham S.K.
        • Smith T.O.
        The diagnostic test accuracy of ultrasound for the detection of lateral epicondylitis: a systematic review and meta-analysis.
        Orthop Traumatol Surg Res. 2014; 100: 281-286
        • Todsen T.
        • Tolsgaard M.G.
        • Olsen B.H.
        • et al.
        Reliable and valid assessment of point-of-care ultrasonography.
        Ann Surg. 2015; 261: 309-315