Semin Musculoskelet Radiol 12:154169. Knee Surg Sports Traumatol Arthrosc. It is useful for the radiologist to be familiar with the characteristics of these anatomical variants to avoid misdiagnosis. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. In most cases, the peroneus quartus arises from the peroneus brevis, but it can arise from the peroneus longus and fibula as well. J Foot Surg Jan-Feb 1991 30(1): 52-55. Bone coalitions, given their complexity and frequent clinical implications, deserve separate analysis and will not be the object of this review. The tendon normally runs along the extensor digitorum longus tendon and inserts on the dorsal surface of the shaft of the fifth metatarsal. Part of the anterior talar fibular ligament was sutured to the lateral malleolus. [7]. The os subfibulare is a normal anatomic variant that represents either an unfused accessory ossification centre or a supernumerary bone [1]. Would you like email updates of new search results? Repetitive plantar flexion is a continuous requirement in activities such as ballet, basketball or soccer [5, 7]. The accessory soleus normally arises from the anterior surface of the soleus, partially sharing the soleus origin, and descends antero-medially to the Achilles, superficial to the flexor retinaculum, to insert on either the Achilles or the calcaneus, on the superior or medial surface, with a tendinous or a fleshy insertion. 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. Foot Ankle Int 16:646650. Lee JC, Calder JD, Healy JC (2008) Posterior impingement syndromes of the ankle. Objective: To provide a novel MRI classification system for the symptomatic type II os naviculare by creating a standardized grading of associated bone marrow edema (BME) and correlating with patient symptoms. a Sagittal FSE T1 in a 56-year-old man referred for follow-up after Achilles reconstructive surgery. Os subfibulare is an accessory ossicle that lies at the tip of the lateral malleolus of the ankle and is rarely reported 1. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. This accessory muscle can be used for tendon transfer or graft. A number of anatomical variations can be found in the ankle and hindfoot. 3 Liberson F. Os acromiale: a contested anomaly. Background: 7. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. 1 There are two theories regarding the origin of os subfibulare. Madhuri V, Poonnoose PM, Lurstep W (2009) Accesory os subtibiale: a case report of misdiagnosed fracture. 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. Keles-Celik N, Kose O, Sekerci R et-al. Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. 2) Three-dimensional images show the ossicle with a local pseudo-arthrosis of the large os subfibulare along the distal anterior edge of the lateral malleolus. Mellado JM, Ramos A, Salvad E, Camins A, Dans M, Saur A (2003) Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. Radiopaedia. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Accessory anatomical structures in the ankle and hindfoot are a common incidental finding. These foci are not anatomically separate entities, even though they can appear to be radiographically. 2019 Sep;27(9):2774-2780. doi: 10.1007/s00167-018-5055-7. In one of four cases, this will be a bilateral finding. 3). Injury to the synchondrosis is one of the causes of symptomatic os trigonum. An incision was centered over the area of edema and a pseudo-arthrosis was demonstrated. MR was performed with the suspicion of talonavicular osteoarthritis at the time. Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. 4. This site needs JavaScript to work properly. Jan-Feb 1982 (162): 112-118. Magn Reson Imaging Clin N Am 25:1126. Fig. 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. An extension of the phenotype or a new . Other ossicles, such as the os supratalare or os talotibiale, are rare and not associated to painful conditions. Objective To retrospectively evaluate the radiologic findings for predicting rehabilitation outcomes in patients with chronic symptomatic os subfibulare. Accessory soleus. 3. Accessory bones that are rare in the foot include accessory interphalangeus, os peroneum, anamolous os calcaneum and talus, os trignum and os tibiale extenum. (Fig. In the absence of an os peroneum, a fibrocartilaginous nodule can be found in the same region. Here is my attempt to explain the charm of this branch. Foot Ankle Int 19:120122. Note the hyperintense band of fluid between the os trigonum and the posterior aspect of the talus, in keeping with disruption of the synchondrosis (white arrow). Rehabilitation outcome was evaluated after 3 months of intervention as the following: good response group . https://doi.org/10.1186/s13244-019-0746-2, DOI: https://doi.org/10.1186/s13244-019-0746-2. (2017) Cureus. Terms and Conditions, Semin Musculoskelet Radiol. Skeletal Radiol 31:5356. 2001;177 (1): 257-8. Only one patient had a long-term complication. They are commonly separated from the tip of the lateral malleolus and are totally asymptomatic. 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. Bulut MD, Yavuz A, Bora A, Gkalp MA, zkamaz S, Batur A (2014) Three-dimensional CT findings of os calcaneus secundarius mimicking a fracture. All fees in EUR; 20% VAT included This represents an accessory joint between the bony projections at the sustentaculum tali and the adjacent talus. 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. Saxena A. Epidemiology It is a very common anatomical variant, seen in up to 26% of feet 1. One year post-operatively, the patient was noted to be totally asymptomatic. Epub 2019 Oct 30. Short- to Medium-term Outcomes After a Modified Brostrm Repair for Lateral Ankle Instability With Immediate Postoperative Weightbearing. Surgical management of chronic lateral ankle instability: a meta-analysis. Mellado JM, Ramos A, Salvado E, Camins A, Danus M, Sauri A. Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis.Eur Radiol Dec 2003 Suppl. Phelps CT. Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder. Syndesmotic injury The joint between the tibia and fibula are held together by ligaments. 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. The authors declare that they have no competing interests. MeSH Berkowitz Y, Mushtaq N, Amiras D (2016) MRI of the tibioastragalus anticus of Gruber muscle: a rare accessory muscle and normal anatomical variant. There are several different types of accessory bones and they are grouped according to their position, shape and relationship with the adjacent bone. Accessory tali are extremely rare, with only a few case reports [34]. Radiology. Accessibility 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. Miller TT (2002) Painful accessory bones of the foot. When this is markedly prominent, the same mechanism of plantar flexion described above [2, 11] causes similar pathology in the surrounding anatomical elements (Fig. Computed tomography (CT) coronal and sagittal images show a single, anterior medial accessory ossicle of the fibula or os subfibulare. At the ankle, these are usually seen inferior to the tip of the medial malleolus. Differential diagnosis Miller TT. The Foot and Ankle Online Journal, 2010, on Os Subfibulare: A case report of painful fibular accessory ossicle, Management of an open crush fracture to the foot from a lawnmower injury: A case report, The clinical and patient centered outcomes following surgical correction of tailors bunion in an acute hospital based podiatric surgery service, Fluoroquinolone-induced Achilles tendinopathy A case report and management recommendations, Reconstruction of an Achilles rupture with 12 cm defect utilizing Achilles tendon allograft and calcaneal bone block: A case report, Congenital amniotic band constriction of the proximal tibia: A Yucatan project case report, Distal lower extremity manifestations in spina bifida patients of the Yucatan Peninsula: A 24-year retrospective case series, Management of a dislocated talar dome fracture with ankle arthrodiastasis and open reduction internal fixation: A case report, A case of recurrent hyperostotic macrodactyly. They are seen as subdivisions of existing bones or free elements in the vicinity of the normal bone structures. In general, cadaveric and radiological studies demonstrate similar prevalence, approximately 10% on MRI [41] and 22% on ultrasound [42]. Epub 2016 Jun 14. AJR Am J Roentgenol 205:612618. Tezer M, Cicekcibasi AE (2012) A variation of the extensor hallucis longus muscle (accessory extensor digiti secundus muscle). Z Orthop Ihre Grenzgeb 125:302307. The mean age of the patients was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing a mean delay in diagnosis and treatment of 3.2 years. volume10, Articlenumber:74 (2019) 40-year-old man, incidental finding of a small os supratalare (white arrow), as well as an os trigonum. The accessory ossicle is at the anterior medial portion of the malleolus giving it a bifid appearance. Foot Ankle Int 27:181184. Clinically, in these cases, there will be swelling, effusion and pain. 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. Os peroneal fracture with associated peroneus longus tendinopathy. The true os subtibiale derives from a persisting accessory centre of ossification and is different from an unfused secondary ossification centre. Accessory muscles can occasionally represent an incidental finding on radiographs, but are mainly incidentally noted on MRI and CT. 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]. Incidence of accessory ossicles and sesamoid bones in the feet: A radiographic study of the Turkish subjects. Think about it. Weinstein SL, Bonfiglio M (1975) Unusual accessory (bipartite) talus simulating fracture. A third peroneus can be found with a prevalence of up to 95% in cadaveric studies [38]. Bookshelf Stiedas process. a 17-year-old man referred with the suspicion of peroneal tenosynovitis. This is 24 year old male with chronic ankle pain. There was no evidence of instability or locking of the ankle joint. She attempted various shoe gear and multiple courses of anti-inflammatory medication with no benefit or symptomatic relief. These are lateral to the talus. 8). FOIA Surgical excision resulted in complete, symptomatic relief. Conclusions: Peroneocalcaneus internus (PCI). In most instances, os subfibulare is found incidentally on radiographs. Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. Matthews S (2012) Fractures of the talus. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory . Oblique views will demonstrate its presence. Single photon emission computed tomography/computed tomographys role in a case of ankle impingement. Occasionally, they will manifest clinically, presenting as mass lesions or causing compression syndromes such as tarsal tunnel syndrome, chronic pain or impingement. Skeletal Radiol 15:455457. Clin Orthop Relat Res 337:180186. Go to: Step 3: Ankle Examination Examine the ankle for loose bodies or other associated damage. Radiology 1994; 193:255-257. Chokkappan K, Srinivasan S, Subramanian M, Kannivelu A (2015) Os trigonum sheer incidental or quite significant? Krause JO, Rouse AM (1995) Accessory calcaneus: a case report and literature review. A radiograph can confirm the presence of the os subfibulare and assess the size of the ossicle. The flexor hallucis longus is used as a landmark for the medial margin of safety in arthroscopic surgery [44]. In the cases of fracture, besides from the background of trauma that may suggest it, on CT or MRI assessment, the edges will be irregular, not corticated and comminution is possible [2]. Radiology 202:745750. F Ian Bickle Anatomical Variants Medical Transcription Radiographer Lymph Nodes Medical Students Tumor Archaeology E EXCALIBUR HEALTHCARE www.excaliburmed.com Skeletal Radiol 2018 47:553562. The tendon courses beneath the flexor retinaculum, through the tarsal tunnel, superficial to the neurovascular bundle (posterior tibial artery and nerve). Os subfibulare can cause impingement on the anterior talofibular ligament, producing anterolateral ankle impingement ( Figure 5, A and B). Since symptoms were recalcitrant, exploration and removal of the ossicle was performed. When present, it is usually located at the calcaneocuboid joint, in the region of wrap-around just before the cuboid tunnel8. Google Scholar. Its tendon normally joins the Achilles tendon. Case Rep Radiol 2014:537062. The tendon is deep to the tibialis anterior and extensor hallucis longus tendon [59]. Methods: Most accessory ossicles will represent an incidental finding on radiographs. Liu C, Zhang HS, Pei BJ, Wang HL, Su H, Wang QH. 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]. The patient is put in supine position. Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. 2. The flexor digitorum longus arises from the tibial surface, below the origin of the soleus. There are two theories regarding the origin of os subfibulare. A very interesting feature of this accessory muscle is that it can be used on ankle surgery to repair retinaculum injuries [38]. On MRI images, the presence of bone marrow oedema in both aspects of the synchondrosis, fluid within or joint effusion, or signs of soft tissue involvement, such as oedema in surrounding structures or tenosynovitis of the flexor hallucis longus, will be indicative of os trigonum syndrome [6] (Fig. Dr. Sethi is Editor-in-Chief of Internet Journal of Radiology. Review June 2002 6(2):153-161. 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. Foot Ankle Int. The ankle, subtalar and forefoot range of motion was within normal limits. Mellado JM, Rosenberg ZS, Beltran J, Colon E (1997) The peroneocalcaneus internus muscle: MR imaging features. Sports Med Arthrosc Rev 17:175184. Nigar Coskun. 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. 2. The main differential of an os tibiale is avulsion fractures, which are common in the context of ankle trauma. 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. 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. (Fig. Kinoshita M, Okuda R, Morikawa J, Abe M (2003) Tarsal tunnel syndrome associated with an accessory muscle. Just as with the previously seen ossicles, the diagnosis can be established with the clinical background, and the typical irregularity of margins of fracture and no cortication described [22]. c Sagittal plane CT reconstruction with soft tissue algorithm in the same patient also allows visualisation of the muscle, extending to insert in the calcaneus (black arrowhead). There are two theories regarding the origin of os subfibulare. 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. Takakura Y, Yamaguchi S, Akagi R, Kamegaya M, Kimura S, Tanaka H, Yasui T. BMC Musculoskelet Disord. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. AJR Am J Roentgenol. Sweed TA, Ali SA, Choudhary S (2016) Tarsal tunnel syndrome secondary to an unreported ossicle of the talus: a case report. On x-ray there can be syndesmotic widening. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gaillard F, Baba Y, Saber M, et al. Open the capsule to directly visualize the articular surface. Provided by the Springer Nature SharedIt content-sharing initiative. Os trigoni may have a round, oval or triangular morphology [6]. There was a palpable bony swelling that felt hard and fixed to the antero-inferior aspect of the lateral malleolus. Article. An ossicle may also be avulsed as a ligament failure analogue, similar to a sleeve fracture of the patella. Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. The muscle arises from the lower third of the anterolateral tibia and interosseous membrane and inserts onto the anterolateral aspect of the neck of the talus. Os Subfibulare Definition small piece of bone adjacent to inferior fibula Epidemiology incidence 1-2% of population Pathoanatomy may represent avulsion fx of ATFL that secondarily ossifies or accessory ossification center Presentation symptoms may be asymptomatic may have ankle pain (symptomatic os subfibulare) The os calcaneus secundarius is a rare accessory ossicle of the foot, estimated to have a prevalence between 0.6 and 7% [1, 3]. Yammine K (2015) The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. Clinical examination revealed a visible swelling 2cm by 2cm over the lateral malleolus. Some children have persistent pain and instability following inversion injuries of the ankle. Accessory muscles are also generally asymptomatic and discovered incidentally on imaging studies. Cheung YY, Rosenberg ZS, Ramsinghani R, Beltran J, Jahss MH (1997) Peroneus quartus muscle: MR imaging features. Differential diagnosis of os fibulare. Powered by, Pediatric imaging and Sedation (Pedicloryl). 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. Petrera M, Dwyer T, Theodoropoulos JS, Ogilvie-Harris DJ. Greater Trochanter Apophysis-Tuberculosis. The presence of oedema on MRI confirms the presence of acute fracture [21]. World J Nucl Med 14:205208. Sagittal FSE T1 demonstrates an elongated postero-lateral process of the talus (Stiedas process). Anatomical variation in the ankle and foot: from incidental finding to inductor of pathology. The peroneus accessorius arises from the peroneus brevis to insert onto the peroneus longus, and the peroneus digiti minimi arises from the peroneus brevis and inserts onto the head of the fifth metatarsal and base of the first phalanx [38, 40]. [1] Insights Imaging 10, 74 (2019). 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. On MRI, there will be subchondral bone marrow oedema and fluid [15]. Foot Ankle Int 24:132136. An os supratalare is an accessory ossicle of the foot located at the superior aspect of the talar head or neck. Computed tomography (CT) and magnetic resonance imaging (MRI) are able to detect the associated bone and soft tissue abnormalities. Anat Sci Int 87:111114. sharing sensitive information, make sure youre on a federal J Foot Ankle Surg. The peroneocalcaneus internus inserts on a small tubercle on the medial aspect of the calcaneus, below the sustentaculum (Fig. a AP radiograph in a 67-year-old woman, history of inversion injury. Fluoroscopically guided injection of lidocaine into the synchondrosis was used as a diagnostic test in the past to accurately determine the cause for symptoms [5, 6]. Lack of history of trauma, clinical symptoms and absence of a potential site of origin for a fracture fragment in the adjacent bones would favour the existence of an ossicle [8] (Fig. Background: To determine the prevalence and prognostic impact of hepatopulmonary syndrome (HPS) in patients with unresectable hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). 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