AJR 2001; 177:1193
© American Roentgen Ray Society
Trauma Cases from Harborview Medical Center |
Peroneal Tendon Dislocation
CT Diagnosis and Clinical Importance
Ralph T. Ho1,
Doug Smith2 and
Eva Escobedo1
1
Department of Radiology, Harborview Medical Center, University of Washington
School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
2
Department of Orthopaedic Surgery, Harborview Medical Center, University of
Washington School of Medicine, Seattle, WA 98104-2499.
Received January 3, 2001;
accepted after revision March 20, 2001.
Address correspondence to F. A. Mann.
Article
A 59-year-old man sustained a left joint depression-type calcaneal fracture
and associated anterolateral dislocation of the peroneal tendon at the fibular
groove (Figs. 1A and
1B).
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Fig. 1A. —59-year-old man with calcaneal fracture and associated
anterolateral dislocation of peroneal tendon at fibular groove. Axial CT scan
shows that peroneal tendons (arrowheads) are dislocated from
"triangle" (see Fig.
2A). Calcaneal fractures and fibular fractures (arrows)
are also seen.
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Fig. 1B. —59-year-old man with calcaneal fracture and associated
anterolateral dislocation of peroneal tendon at fibular groove. Coronal
reformation shows peroneal tendons dislocated from fibular groove
(arrowheads).
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Fig. 2A. —34-year-old woman with fractures of both bones of distal leg
and nondisplaced navicular fracture. Location of peroneal tendons is normal.
Axial CT scan shows normal position of peroneal tendons in
"triangle," with fibula as anterolateral border
(arrowheads), superior retinaculum as posterolateral border
(small white arrows), and calcaneofibular ligament as anteromedial
border (black arrows). Note navicular fracture (large white
arrow).
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The diagnosis of peroneal tendon injury associated with calcaneal fractures
may influence the treatment of intraarticular fractures
[1]. Restoration of anatomic
location of the peroneal tendons is optimally performed at initial reduction
of the fractures of the calcaneus and fibula, but requires an extended
incision.
Dislocation of the peroneal tendons can result in peroneal tenosynovitis,
which in turn results in lateral ankle pain and difficulty in resisting foot
inversion, as when walking on an uneven surface
[2]. Although dislocations of
the peroneal tendons may occur from other causes (such as calcaneal fractures,
spontaneous dislocation, congenital absence or laxity of the superior peroneal
retinaculum, hypoplastic distal fibula), instability symptoms are particularly
frequent after severe fractures of the calcaneus.
In ankle and foot trauma, associated soft-tissue injuries and peroneal
tendon dislocations are commonly overlooked
[3,
4]. Hindfoot CT reliably shows
peroneal tendon displacements and calcaneofibular anatomy. The peroneal
tendons curve around the lateral aspect of the ankle and are held in position
by a fibroosseous tunnel formed medially by the talofibular and
calcaneofibular ligaments, anteriorly by the fibular groove and superior
peroneal retinaculum, and posteriorly by the retinaculum and calcaneofibular
ligament [2].
We use thin-section CT (1.25 x 1.25 mm axial images scanned in a bone
algorithm with a display field of view of 18 cm) to image the fractured
calcaneus. We also obtain reformations in the coronal and sagittal planes as
an adjunct to preoperative planning, with specific attention to the course of
the foot tendons.
One way of quickly and easily diagnosing whether the peroneal tendon is
dislocated at the fibula is to follow these three easy steps: First, find the
"triangle" on axial CT (Fig.
2A). The peroneal tendon should fit in the triangle formed by the
most posterolateral margin of the distal fibula (anterolateral border),
superior retinaculum (posterolateral border), and the calcaneofibular ligament
(anteromedial border). Second, find the fibular groove, which is typically
best seen on coronal CT (Fig.
2B). The common peroneal tendon sheath should lie within this
groove. Third, look for an infralateral fibular bone avulsion fracture, which
is indicative of retinacular damage or peroneal tendon subluxation
[4].
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Fig. 2B. —34-year-old woman with fractures of both bones of distal leg
and nondisplaced navicular fracture. Location of peroneal tendons is normal.
Coronal reformation shows normal position of peroneal tendons in fibular
groove (arrowheads). Note distal fibular fracture
(arrow).
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Early detection of entrapment or dislocation of peroneal tendons helps
guide surgical planning and approach, and aids the orthopedist in restoring
physiologic anatomy. In the presence of an intraarticular fracture of the
calcaneus, directed search for peroneal tendon injuries at CT evaluation of
the foot may change surgical treatment and reduce the subsequent incidence of
tendon dysfunction [1].
References
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Rosenberg ZS, Feldman F, Singson RD, Price GJ. Peroneal tendon
injury associated with calcaneal fractures: CT findings.
AJR
1987;149:125
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Rosenberg ZS, Feldman F, Singson RD. Peroneal tendon injuries: CT
analysis. Radiology
1986;161:743
-748[Abstract/Free Full Text]
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Bradley SA, Davies AM. Computed tomographic assessment of soft
tissue abnormalities following calcaneal fractures. Br J
Radiol 1992;65:105
-111[Abstract]
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Ebraheim NA, Zeiss J, Skie MC, Jackson WT. Radiological evaluation
of peroneal tendon pathology associated with calcaneal fractures. J
Orthop Trauma 1991;5:365
-369[Medline]
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