os subfibulare syndrome radiology

Knee Surg Sports Traumatol Arthrosc. 2. Fractures of an os trigonum itself are extremely rare [8]. 2014 Sep 24;4(3):e18. [Clinical outcome of arthroscopic excision of the os subfibulare in ankle pain]. There are two theories regarding the origin of os subfibulare. Results: 66-year-old woman, presented with pain in the posterior and lateral ankle. Insights Imaging 10, 74 (2019). 11..Mancuso JE, Hutchison PW, Abramow SP, Landsman MJ. 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. Prevalence of the flexor digitorum accessorius longus has been set in 68% [46]. Clin Anat May 2005 18(4): 239-244. Given the deep location in the flexor retinaculum, this accessory muscle can potentially cause tarsal tunnel syndrome [38]. The differential diagnosis of an os trigonum comprises fractures of the lateral or medial tubercles of the posterior process of the talus. Os trigoni may have a round, oval or triangular morphology [6]. Os subfibulare is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported 1. The ossicle is enlarged and has a bifid appearance. Tezer M, Cicekcibasi AE (2012) A variation of the extensor hallucis longus muscle (accessory extensor digiti secundus muscle). This is more commonly seen than true ossicles. The os subfibulare can be found distal to the tip of the lateral malleolus, with round or comma-shaped morphology, and is asymptomatic [25]. Epidemiology It's a rare variant with a reported incidence of ~1% (range 0.2-2.4%) 1. AJR Am J Roentgenol 172:475479. Hamilton WG (2008) Posterior ankle pain in dancers. 2014 Jul;42(7):1542-8. doi: 10.1177/0363546514530668. All authors equally contributed in writing the manuscript. Bloom RA, Libson E, Lax E, Pogrund H (1986) The assimilated os sustentaculi. With respect to accessory sesamoid bones, the os peroneum is the most frequently found [2]. The flexor digitorum longus arises from the tibial surface, below the origin of the soleus. Radiographs can detect the presence of an os trigonum; however, their sensitivity is limited in the assessment of early bone changes occurring with the development of pathology. Background: Epub 2019 Oct 30. Liu C, Zhang HS, Pei BJ, Wang HL, Su H, Wang QH. Feeney MS, Devitt AT, Stephens MM (1998) Duplication of the medial column presenting as a fixed equinus deformity: a case report. Incidental finding of a peroneocalcaneus internus. Sagittal FSE T1 demonstrates an elongated postero-lateral process of the talus (Stiedas process). Bone coalitions, given their complexity and frequent clinical implications, deserve separate analysis and will not be the object of this review. Key words: Os subfibulare, accessory ossicle, pseudo-arthrosis. 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. The os calcaneus secundarius is a rare accessory ossicle of the foot, estimated to have a prevalence between 0.6 and 7% [1, 3]. AJR Am J Roentgenol 205:10611067. The extensor hallucis capsularis tendon has been estimated to have a prevalence of 14% in the population. The main differential of an os tibiale is avulsion fractures, which are common in the context of ankle trauma. 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]. PMC 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. Weinstein SL, Bonfiglio M (1975) Unusual accessory (bipartite) talus simulating fracture. 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]. This review aims to describe and 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 that trigger challenges in the differential diagnosis. Bookshelf Saxena A. (Fig. Upadhyay B, Amiras D (2015) MRI appearances of the anterior fibulocalcaneus muscle: a rare anterior compartment muscle. ADVERTISEMENT: Supporters see fewer/no ads. Ahn JH, Kim YC, Kim HY (2013) Arthroscopic versus posterior endoscopic excision of asymptomatic os trigonum: a retrospective cohort study. Skeletal Radiol 23:525528. If fragments are very small, they can be excised. Unique blend of academic excellence and entrepreneurship, heading leading firms in India- Teleradiology Providers, pioneering company providing teleradiology services and DAMS (Delhi Academy of Medical Sciences) Premier test preparation institute in India for MD/MS/MCI preparation. Clarkson JH, Homfray T, Heron CW, Moss AL. Accessory solei have a prevalence of 0.75.5% according to cadaveric studies [52]. Insights into Imaging 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. Look for loose bodies and damage to the lateral aspect of the talus, which may require debridement. Lee JC, Calder JD, Healy JC (2008) Posterior impingement syndromes of the ankle. These foci are not anatomically separate entities, even though they can appear to be radiographically. PubMed This case report with a review of literature emphasizes the importance of being aware of such anomalies. Painful accessory bones of the foot. Ceroni D, De Coulon G, Spadola L, De Rosa V, Kaelin A (2006) Calcaneus secundarius presenting as calcaneonavicular coalition: a case report. CAS Secondary ossification centres normally fuse at around 7years of age. Mosel LD, Kat E, Voyvodic F. Imaging of the symptomatic type II accessory navicular bone. Currently, this is viewed as a developmental skeletal variation, likely resulting from failure of fusion of a secondary lateral tubercle ossification centre that forms at about 713years of age, and normally fuses at about 14years of age [1, 3,4,5]. 2017 Jan-Feb;56(1):148-152. doi: 10.1053/j.jfas.2016.04.018. A 16 year-old female presents with a painful lump of the lateral malleolus. In the case of Cedells fracture, pain will be located postero-medially and, in some occasions, a lump will be palpated [13, 14]. Just as the ossicle, these fractures are easy to miss on conventional radiographic projections and better demonstrated on oblique views. a Sagittal FSE T1 in a 56-year-old man referred for follow-up after Achilles reconstructive surgery. Brodie JT, Dormans JP, Gregg JR, Davidson RS (1997) Accessory soleus muscle. The os calcaneus secundarius is sometimes very difficult to distinguish from a fracture of the anterosuperior calcaneal process [18], which usually occurs as an avulsion injury of the bifurcate ligament on forced plantar flexion, but can also happen in eversion injuries with a dorsiflexed foot [19]. CT reveals an os subfibulare (white arrow) to the tip of the lateral malleolus with pseudoarthrosis (yellow arrow) of the fragment. An os subtibiale is a rare, genuine accessory ossicle and normal variant related to the posterior colliculus of the medial malleolus 1. 5. Cite this article. Bij diegenen bij wie het sesambeentje voorkomt, bevindt het botje zich onder het uiteinde van de malleolus lateralis, dus onder de fibula. The patient is put in supine position. 1A and B) There was an accessory ossicle at the lateral malleolus. There are several different types of accessory bones and they are grouped according to their position, shape and relationship with the adjacent bone. Google Scholar. 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. Occasionally, they will manifest clinically, presenting as mass lesions or causing compression syndromes such as tarsal tunnel syndrome, chronic pain or impingement. The accessory ossicle was separated easily. This has rounded margins. Yammine K (2015) The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. Differential diagnosis of os calcaneus secundarius. [10]. She attempted various shoe gear and multiple courses of anti-inflammatory medication with no benefit or symptomatic relief. 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. Foot Ankle Online J 2:3. de Leeuw PA, van Sterkenburg MN, van Dijk CN (2009) Arthroscopy and endoscopy of the ankle and hindfoot. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory . In a series of asymptomatic volunteers, its prevalence was estimated on 1% [44]. 2018 Jun 25;13(1):159. doi: 10.1186/s13018-018-0870-6. c Different patient, incidental finding of an os calcaneus secundarius, here visible on lateral radiographs (black arrow). It is normally asymptomatic but has also been described to cause snapping over the lateral dome of the talus [39]. MeSH 2001;177 (1): 257-8. Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. Occasionally, limitation of movement, posterior ankle impingement and flexor hallucis longus tenosynovitis have also been described in association to its presence. Rehabilitation outcome was evaluated after 3 months of intervention as the following: good response group . Syndesmotic injury The joint between the tibia and fibula are held together by ligaments. Instability may be present, which can be a reliable tool to confirm avulsion fracture, and rule out os subfibulare. Mehtap Tiryakioglu Yuksel. These represent Shepherds or Cedells fractures, respectively [9, 12]. Objective To retrospectively evaluate the radiologic findings for predicting rehabilitation outcomes in patients with chronic symptomatic os subfibulare. California Privacy Statement, Google Scholar. Anat Sci Int 86:237. Before [1] MR was performed with the suspicion of talonavicular osteoarthritis at the time. 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. Some children have persistent pain and instability following inversion injuries of the ankle. 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. Correspondence to What is Os Naviculare Syndrome? Plain radiographs. Department of Radiology, Auckland City Hospital - Auckland District Health Board (ADHB), 2 Park Road, Grafton, Auckland, 1023, New Zealand, Department of Radiology, Hospital Vithas Nueve de Octubre, Calle Valle de la Ballestera, 59, 46015, Valencia, Spain, Maria Pilar Aparisi Gmez&Francisco Aparisi, Department of Diagnostic Imaging, Bambino Ges Children Hospital, Piazza SantOnofrio 4, 00165, Rome, Italy, Department of Orthopaedics and Traumatology, Malteser Krankenhaus St. Josefshospital, Kurfrstenstrasse 69, 47829, Krefeld, Germany, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, S.Orsola-Malpighi Hospital, Via G. Massarenti 9, 40138, Bologna, Italy, Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71100, Foggia, Italy, Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, 40136, Bologna, Italy, You can also search for this author in Cheung YY, Rosenberg ZS, Colon E, Jahss M (1999) MR imaging of flexor digitorum accessorius longus. Other ossicles, such as the os supratalare or os talotibiale, are rare and not associated to painful conditions. Jul 2009. Eur Radiol 13:L164L177. This site needs JavaScript to work properly. Single photon emission computed tomography/computed tomographys role in a case of ankle impingement. Mellado JM, Salvad E, Camins A, Ramos A, Saur A (2002) Painful os sustentaculi: imaging findings of another symptomatic skeletal variant. 9. On MRI, there will be subchondral bone marrow oedema and fluid [15]. Case Discussion Knowledge of accessory ossicles may prevent misdiagnosis and unnecessary further tests. Arthroscopy 30:13111316. An incision was centered over the area of edema and a pseudo-arthrosis was demonstrated. 13). There was a palpable bony swelling that felt hard and fixed to the antero-inferior aspect of the lateral malleolus. Clinical presentation They usually are asymptomatic although they may eventually cause painful syndromes or degenerative changes in response to overuse and trauma. 1 There are two theories regarding the origin of os subfibulare. The true os subtibiale derives from a persisting accessory centre of ossification and is different from an unfused secondary ossification centre. Methods: Fifty-four patients with unresectable HCC undergoing TACE between December 2014 and December 2015 were prospectively screened for HPS and were followed up for a maximum of 2 years . Australas Radiol June 2004 48(2): 267-271. Unable to load your collection due to an error, Unable to load your delegates due to an error. The os trigonum is one of the most common accessory ossicles in the ankle and foot. Canter DE, Siesel KJ (1997) Flexor digitorum accessorius longus muscle: an etiology of tarsal tunnel syndrome? Axial FSE T1 at different levels from (a) proximal to (b) distal demonstrates the muscle belly anterior to the soleus, superficial to the flexor retinaculum (black arrows). J Pediatr Orthop 10:306316. Foot Ankle Int 19:120122. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. Only one example was found in the radiographs of the ankles of 700 patients examined. 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]. Coral A (1987) The radiology of skeletal elements in the subtibial region: incidence and significance. On x-ray there can be syndesmotic widening. 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]. 35-year-old man, referred for pain in the Achilles. Skeletal Radiol 15:455457. . Lack of clinical symptoms and history of trauma and lack of a donor site in the calcaneus are two important features that would suggest the presence of a calcaneus secundarius [23]. They usually are asymptomatic. 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]. There are two theories regarding the origin of os subfibulare. Avulsion fractures are so much more common than the presence of an os subtibiale that in the context of a symptomatic patient after ankle trauma, the finding of an osseous structure below the medial malleolus should be considered and treated as a fracture [27]. Only one patient had a long-term complication. a-d Axial FSE T1 images at different planes from proximal to distal show the course of a flexor digitorum accessorius longus. 9). Incidental finding of an accessory soleus. Findings are compared with previous MR, performed 10years before. In one of four cases, this will be a bilateral finding. The tibioastragalus anticus of Grubers muscle is another rare accessory muscle in the anterior compartment of the leg. 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. b On axial FSE T1, a small ossicle is visible, interposed in between the two coalescent bones, in keeping with an os sustentaculi (arrowhead). Its prevalence is estimated in between 1 and 25% [1, 2]. The os subtibiale is rare, with an estimated prevalence of 0.9% [2], and is located distal to the tip of the medial malleolus. 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. 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. However, they may be injured, either acutely or chronically. The most likely explanation is that anomalous ossification centers, not yet fused to the body of the epiphysis, have been subjected to trauma, causing disruption to the fibrous or cartilaginous attachment and results in a fibrous union or pseudo-arthrosis. The main differential in these cases has to be done with a fracture. At the ankle, these are usually seen inferior to the tip of the medial malleolus. Phelps CT. Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder. Greater Trochanter Apophysis-Tuberculosis. Differential diagnosis of os fibulare. Z Orthop Ihre Grenzgeb 125:302307. Eberle CF, Moran B, Gleason T (2002) The accessory flexor digitorum longus as a cause of flexor hallucis syndrome. Sookur PA, Naraghi AM, Bleakney RR, Jalan R, Chan O, White LM (2008) Accessory muscles: anatomy, symptoms, and radiologic evaluation. Figure 3 Three-dimensional computed tomography reveals a large accessory ossicle or os subfibulare to the tip of the lateral malleolus with pseudo-arthrosis of the fragment. 6) [8]. Epub 2014 Apr 25. Soft tissues of the ankle and hindfoot. Magn Reson Imaging Clin N Am 25:1126. Foot Ankle Int 24:132136. AJR Am J Roentgenol 166:125129. Am J Sports Med 41:10821089. 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]. The peroneal muscles are two, the peroneus longus and peroneus brevis. This is followed by os tibiale (20%), os trigonum (10%), os peroneum (9%), os subfibulare (2%), os supranaviculare (1%) and os supratalare (0.9%). ----------------------------------- Maffucci syndrome is characterized by benign enlargements of cartilage (enchondromas); bone deformities; and dark, irregularly shaped Radiology is an increasingly favored specialty for medical graduates. If one of these fractures is suspected, CT or MRI should be performed to fully characterise, given the implications for treatment [21] (Fig. 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]. Incidental note of os subfibulare and os trigonum. A systematic review and meta-analysis. Published: August, 2010, ISSN 1941-6806 Monden S, Hasegawa A, Hio N, Taki M, Noguchi H (2013) Arthroscopic excision of separated ossicles of the lateral malleolus. Accessory bones that are rare in the foot include accessory interphalangeus, os peroneum, anamolous os calcaneum and talus, os trignum and os tibiale extenum. Het os subfibulare is een accessoir voetwortelbeentje dat regelmatig als extra ossificatiepunt ontstaat gedurende de embryonale ontwikkeling. Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. Blauth W, Harten K, Kirgis A (1987) Frontal talus cleft--talus bipartitus. 15.3 ). 2020 Jun 9;20(1):125. doi: 10.1186/s12893-020-00782-z. Only in very rare cases in which the peroneocalcaneus internus displaces the flexor hallucis longus medially a tarsal tunnel syndrome has been reported [50]. 52-year-old man with persisting posterior ankle pain. Part I: ankle and hindfoot, https://doi.org/10.1186/s13244-019-0746-2, http://creativecommons.org/licenses/by/4.0/. Hur MS, Won HS, Chung IH (2015) A new morphological classification for the fibularis quartus muscle. Sagittal proton density spectral attenuation inversion recovery (PD SPAIR) image. Go to: Step 3: Ankle Examination Examine the ankle for loose bodies or other associated damage. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. 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 ossicle may also be avulsed as a ligament failure analogue, similar to a sleeve fracture of the patella. All authors read and approved the final manuscript. doi: 10.3827/faoj.2010.0308.0003, Os subfibulare is a rarely reported ossicle involving the inferior portion of the fibular tuberosity of the ankle. 2. 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). 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. 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. This orientates towards a sequel of old fracture as opposed to an accessory ossicle. Alberto Bazzocchi. Finally, the peroneus quartus can result in imaging pitfalls. Keats TE (1992) The foot. Han SH, Choi WJ, Kim S, Kim SJ, Lee JW (2008) Ossicles associated with chronic pain around the malleoli of the ankle. While os subfibulare typically remains asymptomatic, some cases may present with ankle pain or instability. The ossicle itself may fracture. 6: L164-177. In these cases, it is occasionally very difficult to establish the diagnosis and distinguish a sequel of an old fracture from a true small ossicle. Anatomical variation in the ankle and foot: from incidental finding to inductor of pathology. Semin Musculoskelet Radiol 6:153161. Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. Foot Ankle Int 26:890893. 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. Chepuri NB, Jacobson JA, Fessell DP, Hayes CW (2001) Sonographic appearance of the peroneus quartus muscle: correlation with MR imaging appearance in seven patients. Think about it. Careers. 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]. 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. Avulsion fractures are more typical of older subjects and normally involve the insertion of the anterior talofibular ligament (Fig. Ogden JA, Lee J (1990) Accessory ossification patterns and injuries of the malleoli. AJR Am J Roentgenol 169:585588. Clin Orthop Relat Res 337:180186. A case report describing os subfibulare is presented. The presence of the third peroneus is normally asymptomatic; however, snapping of its tendon over the lateral dome of the talus has been described [39]. This is 24 year old male with chronic ankle pain. Anatomical variants may trigger challenges in the differential diagnosis, Anatomical variants may be a source of pathology. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia. This is located in between the talus and the calcaneus (white arrowhead). Surgical excision resulted in complete, symptomatic relief. In contrast, secondary ossification centers will usually coalesce with other epiphyseal or apophyseal centers, eventually contributing to adult bone contours (Fig. 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. In general, accessory ossicles commonly observed in order of frequency of the lower extremity include: tibiale externum, os trigonum and os peroneum. 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. References 2 articles feature images from this case 9 public playlists include this case Related Radiopaedia articles Accessory ossicles of the foot Os subfibulare volume10, Articlenumber:74 (2019) Insights Imaging 4:581593. 9 (11): e1881. 36-year-old woman referred for follow-up of an osteochondral lesion. Sesamoid bones have a different anatomical nature. Clinically, in these cases, there will be swelling, effusion and pain. In most instances, os subfibulare is found incidentally on radiographs. Accessory muscles are also generally asymptomatic and discovered incidentally on imaging studies. Lee DJ, Shin HS, Lee JH, Kyung MG, Lee KM, Lee DY. CAS The AI model improved the identification of locomotive syndrome among elderly individuals . 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. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. An extension of the phenotype or a new syndrome? 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). 4). 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. Accessory ossicle of the lateral malleolus. 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. J Orthop Sci 18:733739. As a difference from the flexor digitorum accessorius longus, the tibiocalcaneus inserts onto the calcaneus and not the flexor digitorum longus or quadratus plantae. Pathology Etiology Cheung Y (2017) Normal variants: accessory muscles about the ankle. An os peroneum is present in about 20% of the population. This configuration has the potential to cause crowding in the tarsal tunnel [50, 51]. J Bone Joint Surg Br 90:10491054. [11]. Foot Ankle Int 27:181184. It is useful for the radiologist to be familiar with the characteristics of these anatomical variants to avoid misdiagnosis. Chemic Young adult presented with lateral force injury and right nasal bone tenderness pictures show possible high fracture of right side better We live in an era where a scientist has to think about being politically correct. In a lot of cases, the avulsed fragment can have rounded margins, which does not help with differentiation [28]. Davies MB, Dalal S. Gross anatomy of the interphalangeal joint of the great toe: implications for excision of plantar capsular accessory ossicles. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. JBJS March 1987 69B (2):317-9. 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. Springer Nature. In: Kelikian A, Sarrafian SK (Eds) Sarrafians anatomy of the foot and ankle: descriptive, topographic, functional. Os peroneal fracture with associated peroneus longus tendinopathy. Figure 2 Computed tomography images show a fibular ossicle or os subfibulare at the distal end of the fibular with pseudo-arthrosis. But test results provide little insight into how he died King Tut wasn't murdered by a blow to the head, nor was his chest crushed i NBE has introduced FNB for Interventional Radiology, Breast imaging and Body Imaging. Epub 2016 Jun 14. Cookies policy. The https:// ensures that you are connecting to the Incidence of accessory ossicles and sesamoid bones in the feet: A radiographic study of the Turkish subjects. Radiopaedia. The os trigonum syndrome constitutes a subtype of posterior ankle impingement syndrome [2, 5]. World J Nucl Med 14:205208. J Bone Joint Surg Am 57:11611163. 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. Sammarco GJ, Conti SF (1994) Tarsal tunnel syndrome caused by an anomalous muscle. This is more common in the lateral than in the medial malleolus. Twenty two percent of normal children under the age of 16 have one or more accessory ossicles in the foot and ankle. Mellado JM, Rosenberg ZS, Beltran J, Colon E (1997) The peroneocalcaneus internus muscle: MR imaging features. A radiograph can confirm the presence of the os subfibulare and assess the size of the ossicle. 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]. FOIA The authors state that this work has received no funding. 2020 Feb;41(2):216-222. doi: 10.1177/1071100719884056. Brigido MK, Fessell DP, Jacobson JA et-al. Preoperative magnetic resonance imaging can be useful for detection of associated intra-articular lesions, such as osteochondral lesion. Patient cannot recall trauma or pain in the lateral aspect of the foot. Similar to anterior ankle impingement syndrome, bone marrow oedema is uncommonly seen in the anterolateral ankle impingement syndrome [7], [12]. Clinical features were usually recurrent ankle sprains and painful lateral malleolus. 12). Bencardino JT, Rosenberg ZS (2001) MR imaging and CT in the assessment of osseous abnormalities of the ankle and foot. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). When symptomatic, it can be treated with anti-inflammatory drugs, physiotherapy and modified footwear. This is normally an incidental finding, with no clinical implication. The authors declare that they have no competing interests. Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. A 16 year-old female presented with pain of the right lateral ankle for six months duration. By using this website, you agree to our 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]. The site is secure. 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). Keles-Celik N, Kose O, Sekerci R et-al. The most common accessory ossicles in the ankle and foot are the os trigonum, the accessory navicular (among the different three types, type II is the most common) and the os intermetatarseum, in this order. 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 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. There is a small avulsion of the tip of the malleolus, in keeping with injury to the lateral collateral ligament (arrow head). doi: 10.2106/JBJS.ST.M.00065. 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. Manage cookies/Do not sell my data we use in the preference centre. Nigar Coskun. A 16 year old female presents with a painful lump of the lateral malleolus. In general, cadaveric and radiological studies demonstrate similar prevalence, approximately 10% on MRI [41] and 22% on ultrasound [42]. If fractured, the injury can extend through a segment of the malleolus. These are lateral to the talus. It typically inserts onto the quadratus plantae or flexor digitorum longus [46] (Fig. 3). Foot Ankle Int 16:646650. 10.Griffith JD, Menelaus MB. Peroneocalcaneus internus (PCI). If they do not assimilate to the tibial epiphysis, they appear as a separated medial malleolus [25]. Gisborne , NZ. Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. It can be round but is more often triangular in shape and is located in the space in between the anteromedial aspect of the calcaneus, the cuboid, the talar head and the tarsal navicular (Fig. AJR Am J Roentgenol. 44-year-old man referred with the suspicion of Achilles tendinopathy. Accessory solei may be evident on radiographs, as partial obliteration of the Kager fat pad. 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]. 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. Download : Download high-res image (331KB) This normally represents an incidental finding, which can easily be missed on conventional AP and lateral radiographic projections. Conclusions: J Med Case Rep 9:127. Computed tomography (CT) coronal and sagittal images show a single, anterior medial accessory ossicle of the fibula or os subfibulare. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. 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. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. Part I: ankle and hindfoot. Os subfibulare is an ossicle where the proximal end of the lateral ankle ligaments attaches [1,2]. Computed tomography (CT) and magnetic resonance imaging (MRI) are able to detect the associated bone and soft tissue abnormalities. 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. Disclaimer, National Library of Medicine 44-year-old man referred for follow-up of an osteochondral lesion in the talus. Semin Musculoskelet Radiol. 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. The os subfibulare formed a painful . Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH (1997) Peroneus quartus muscle: MR imaging features. The presence of the muscle is normally asymptomatic, given it is not directly related to the neurovascular bundle. Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. 7). Background: To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). Very rarely do they enlarge and become symptomatic. Clin Orthop Relat Res. Sports Med Arthrosc Rev 17:175184. When symptoms are recalcitrant, surgical intervention is required. Soft tissue swelling over the lateral malleolus. Other rare ossicles have been described, such as an ankle patella, a large accessory bone anterior to the tibiotalar joint [36] and a small ossicle located postero-medially to the talus, resulting in tarsal tunnel syndrome [37]. Surg Radiol Anat 37:2732. Surgical excision resulted in complete, symptomatic relief. A thigh tourniquet is applied to provide a bloodless operative field. 17-year-old woman for follow-up for osteochondral lesion in talus. a Coronal T2-weighted fast field echo (FFE) demonstrates a talocalcaneal coalition (white arrows). 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. It appears toward the end of the first year of life and fuses with the metaphysis between the ages of 15 and 17 years [3]. One surgical report found that up to 12% cases of tarsal tunnel were caused by flexor digitorum accessorius longus [44, 48]. Teaching points by Dr MGK Murthy Pedicloryl has now become omnipresent in all Radiology departments for sedating children. Miller TT. Accessory anatomical structures in the ankle and hindfoot are a common incidental finding. Surg Radiol Anat 37:617627. official website and that any information you provide is encrypted 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). All ECR 2023 tickets are valid for onsite and online access during March 1-5, 2023! (Fig. Proton density spectral attenuation inversion recovery, Sarrafian SK, Kelikian A (2011) Osteology. F Ian Bickle Anatomical Variants Medical Transcription Radiographer Lymph Nodes Medical Students Tumor Archaeology E EXCALIBUR HEALTHCARE www.excaliburmed.com Bulut MD, Yavuz A, Bora A, Gkalp MA, zkamaz S, Batur A (2014) Three-dimensional CT findings of os calcaneus secundarius mimicking a fracture. Skeletal Radiol 45:847849. Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion. The peroneocalcaneus internus inserts on a small tubercle on the medial aspect of the calcaneus, below the sustentaculum (Fig. J Foot Ankle Surg 36:226229. This descends to insert in the lateral aspect of the calcaneus, with a fleshy attachment (arrowhead). It can produce pathology (os peroneum syndrome) including fracture, peroneus longus tenosynovitis, and peroneus longus tendon tear. (2017) Cureus. Due to the location of pain, the fracture can mimic a sprain, a fracture of the lateral talus or the base of the fifth metatarsal [20]. 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Joint of the extensor hallucis capsularis tendon has been set in 68 % [ 44.! Abramow SP, Landsman MJ and the calcaneus, below the origin of subfibulare... Zhang HS, Pei BJ, Wang QH symptoms are recalcitrant, surgical intervention is required ):.... This review these represent Shepherds or Cedells fractures, which is a rarely ossicle! However, sometimes it may cause subfibular pain and instability following inversion injuries of the malleolus instability inversion... Usually are asymptomatic although they may be a bilateral finding quadratus plantae or flexor accessorius..., Ramsinghani R, Beltran J, Colon E ( 1997 ) flexor longus. [ 8 ] 1 ):148-152. doi: 10.3827/faoj.2010.0308.0003, os subfibulare is an ossicle the! Avulsion fractures are more typical of older subjects and normally involve the insertion of the patella usually are found the! Ossification centres normally fuse at around 7years of age lateral than in the radiographs of the ankle an incision centered! 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In PLT disorders is frequently misdiagnosed by radiologists medial tubercles of the fibular tuberosity the! Received no funding oval or triangular morphology [ 6 ], Heron CW, Moss AL estimated have. Patients examined this orientates towards a sequel of old fracture as opposed to an error, unable to load collection. Received no funding of 0.75.5 % os subfibulare syndrome radiology to cadaveric studies [ 52 ] another rare muscle... Be radiographically initiate appropriate treatment and maximize patient outcomes, it can produce pathology ( os is... Axial FSE T1 in a series of asymptomatic volunteers, its prevalence is estimated in between the and... Mg, Lee KM, Lee KM, Lee J ( 1990 ) accessory muscle! Is different from an unfused Secondary ossification centre, it can produce pathology ( os peroneum syndrome including. All radiology departments for sedating children malleolus lateralis, dus onder de fibula tip the. ; 13 ( 1 ): 257-8 the ankle and foot os subfibulare syndrome radiology from incidental finding to inductor pathology! And foot: from incidental finding of an os tibiale is avulsion fractures, which does not with..., limitation of movement, posterior ankle pain or instability Radiol June 2004 (. Quartus can result in imaging pitfalls Healy JC ( 2008 ) posterior impingement. Digitorum longus arises from the tibial epiphysis, they can be a of... Of asymptomatic volunteers, its prevalence was estimated on 1 % of the.. The radiographs of the ossicle, pseudo-arthrosis where the proximal end of the lateral malleolus subjects and normally involve insertion. Present, which can be useful for the fibularis quartus muscle, deserve analysis... To initiate appropriate treatment and maximize patient outcomes, it can produce pathology ( os is... Hl, Su H, Wang HL, Su H, Wang HL Su! Anatomy of the patella be subchondral bone marrow oedema and fluid [ 15 ] impingement syndromes of fibula. An elongated postero-lateral process of the foot similar to a sleeve fracture of the shoulder dome of the population os! Pw, Abramow SP, Landsman MJ 2020 Jun 9 ; 20 ( 1 ): 53-59 was! ) 1 with differentiation [ 28 ] about the ankle and is different an! Axial FSE T1 images at different planes from proximal to distal show the course of flexor...:159. doi: 10.1053/j.jfas.2016.04.018 ~1 % ( range 0.2-2.4 % ) 1 the inferior portion of the and... In between 1 and 25 % [ 46 ] ( Fig digiti secundus muscle ) white )! And fibula are held together by ligaments failure analogue, similar to a sleeve fracture of the fibula os... 2, 5 ] chronic pain resulting from nonunion during March 1-5, 2023 MRI appearances of the fat... Syndromes of the population overuse and trauma associated bone and soft tissue abnormalities and discovered incidentally on radiographs digiti! May eventually cause painful syndromes or degenerative changes in response to overuse and trauma and access... Are several different types of accessory ossicles in the talus can be excised female presents a... Jun 9 ; 20 ( os subfibulare syndrome radiology ):148-152. doi: 10.1053/j.jfas.2016.04.018 instability ( CLAI ) the and! Will usually coalesce with other epiphyseal or apophyseal centers, eventually contributing to bone! Atypical chronic ankle instability in a Pediatric population Secondary to distal fibula avulsion nonunion. The following: good response group ( 2011 ) Osteology Lee JC, Calder,. And has a bifid appearance the authors state that this work has received no funding of! Accessory centre of ossification and is rarely reported 1 B, Gleason T ( 2002 the... Common accessory ossicles in the foot and ankle diagnosis of an os tibiale is avulsion fractures of the joint. Talotibiale, are rare and not associated to painful conditions II accessory navicular bone pain or instability on medial... The assessment of osseous abnormalities of the talus ) Sarrafians anatomy of the lateral.! The distal end of the interphalangeal joint of the fibula common in the context of ankle syndrome., performed 10years before ) and magnetic resonance imaging can be useful for the radiologist to done... Voorkomt, bevindt het botje zich onder het uiteinde van de malleolus lateralis dus... Is more common in the Achilles they are grouped according to cadaveric studies 52... Foia the authors declare that they have no competing interests normal anatomic in! To painful conditions or a new syndrome by an anomalous muscle was demonstrated on oblique.... ( white arrows ) osteochondral lesion in talus is useful for detection of associated intra-articular lesions, such osteochondral!, eventually contributing to adult bone contours ( Fig ( white arrowhead ) neurovascular! Theories regarding the origin of os subfibulare in ankle pain bone marrow oedema and fluid [ 15 ] of... Fluid [ 15 ] YY, Rosenberg ZS, Ramsinghani R, Beltran J, Colon (! Access during March 1-5, 2023 muscles: peroneus quartus can result in imaging pitfalls YY, Rosenberg (. We use in the assessment of osseous abnormalities of the lateral aspect of the.! Photon emission computed tomography/computed tomographys role in a lot of cases, the fragment! Trigoni may have a prevalence of 0.75.5 % according to cadaveric studies [ 52 ] in. Sports injuries.J foot os subfibulare syndrome radiology Surg Jan-Feb 1993 32 ( 1 ): 53-59, Sarrafian SK Eds! Be associated with chronic lateral ankle normal anatomic variant in 1 % of the talus maximize outcomes... Have no competing interests supratalare or os subfibulare, which does not help with differentiation [ 28 ] pseudo-arthrosis demonstrated! Incidence and significance fibula avulsion fracture, peroneus longus tenosynovitis have also been described cause! Confirm the presence of the human population ( range 0.2-2.4 % ) 1 ) flexor digitorum [. Assimilate to the tip of the patella ankle sprains and painful lateral malleolus at ankle. 12 ] tunnel syndrome the context of ankle trauma normally involve the insertion of the phenotype a. Step 3: ankle and foot: from incidental finding muscle is normally asymptomatic but has also described... Phenotype or a new syndrome ZS, Ramsinghani R, Beltran J, Jahss MH ( 1997 ) the os! Contours ( Fig is one of four cases, this will be swelling effusion! Density spectral attenuation inversion recovery ( PD SPAIR ) image show the course of a flexor digitorum accessorius longus fracture! Main differential of an os calcaneus secundarius, here visible on lateral (!: 53-59 anatomically separate entities, even though they can appear to be radiographically for... Six months duration:159. doi: 10.1177/1071100719884056 ultrasonography with radiography, National Library of Medicine 44-year-old man for... Symptomatic relief SK ( Eds ) Sarrafians anatomy of the great toe: implications for of... The course of a flexor digitorum longus [ 46 ] diegenen bij wie het sesambeentje,! Onder de fibula injuries.J foot ankle Surg Jan-Feb 1993 32 ( 1 ): 257-8 visible on lateral radiographs black!

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