The fracture occurs when the foot is dorsiflexed and inverted, as can happen with snowboarding (hence the term "snowboarder fracture")1. At surgery the ankle was found to be unstable and syndesmosis screws were inserted. A lateral malleolus fracture is a type of ankle fracture that occurs when the fibula fractures just above the ankle joint. This woman had a distortion of the ankle and had pain on both medial and lateral side. Stage 1: stable ankle fracture Stage 1 Here a typical avulsion or pull-off fracture of the lateral malleolus. Here another example. Although a fracture of the medial malleolus can be a serious injury, the outlook for recovery is good, and complications are . contusion and small avulsion fracture of the anterior process of the cal- . The patient presented with lateral ankle pain associated with tenderness at the tip of the lateral malleolus. A fracture of the posterior malleolus as an isolated finding is very uncommon. In many cases there is only minimal or no displacement. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. Bone edema around the lateral aspect of the calcaneocuboid joint, without associated lesions of the dorsal . These fractures are easily overlooked because the patients rarely complain of pain in the region of the proximal fibula, since the ankle is most painful. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Ultrasound may be useful for detection, but follow up CT or MRI is necessary to further evaluate the extent of the fracture and the amount of displacement of the fragments 3. Easily missed injuries around the knee. avulsion tip fractures of medial or lateral malleolus . 5. On the lateral projection, an os trigonum can be appreciated. Blue arrow indicates avulsion fracture. So even in a Weber C stage 4 sometimes only a fracture of the medial malleolus will be visible. Lucent line on Mortise view (black arrow) and lateral view. a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint; usually associated with an injury to the medial side This was thought to be an avulsion of the posterior malleolus. Whenever you see such a fracture, you have to look for higher stages of this exorotation injury. Normal radiographs do not rule out a Weber C fracture. unfit for surgery. Alignment has been maintained. Example 1 It is the most common type of ankle fracture and may happen. Since there is no fibula fracture seen on the x-rays of the ankle, there must be a high fibular fracture. 2013;17 (04): 416-28. This should make you consider a tertius fracture. This image shows a small avulsion fracture at the tip of the lateral malleolus (stage 1) and an oblique fracture across the base of the medial malleolus (stage 2). ISBN:B0040SYP2C. Segond tibial condyle fracture: lateral capsular ligament avulsion. 48, No. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails to tear during an injury. So now we start looking for stage 4, which is rupture or avulsion of the posterior syndesmosis. Alignment has been maintained. According to Lauge Hansen we can conclude that this patient first had a rupture of the medial collateral ligaments (stage 1), followed by a rupture of the anterior syndesmosis (stage 2) and a high fibula fracture (stage 3) and finally an avulsion of the posterior malleolus, i.e. Weber-A stage I Stage 1 In any patient with an ankle injury you should always ask yourself the questioncan I exclude a high Weber C fracture or do I need additional imaging. Scroll through the images. In children, a fibula fracture usually requires a short leg cast and six weeks of non-weight bearing. Comminuted fracture. She suffered a sprain of the left ankle one week before. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Several ankle ligaments ensure the static and dynamic stability of the ankle joint, but they are prone to injury due to acute trauma as well as repetitive ankle sprains. Most fractures of the posterior malleolus are part of a complex ankle injury, either Weber B or Weber C. Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. The tertius fracture is stage 3 in Weber B and stage 4 in Weber C (figure). First study the radiographs and then continue with the CT. ISBN:0323072437. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. Always look for higher stages of an exorotation injury. The ankle is the most frequently injured joint. It can be seen as a widening of the lateral masses and loss of congruity with the axis beneath. In this case there is a Weber B fracture with avulsion of the medial malleolus. CAM boot. First study the images and then continue reading. The bright line on the AP-view indicates a large tertius fracture fragment. An ankle avulsion fracture is a bone chip caused by a ligament or tendon that tears away a part of the bone. This combination of findings implicate that the ankle is unstable. 15.19 ). Yellow arrow indicates os subfibulare. Management decisions are based on the interpretation of the AP and lateral X-rays. This is also a Salter-Harris type III fracture. Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. As in most ankle fractures the mechanism is external rotation. Details of type 7 intraepiphyseal injuries and accessory ossicle are . 4. modalities. So we have to look for higher stages. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. Annotated image Stress placed on the bone by a tendon or ligament causes the fracture. By the way.there are two fractures. Radiology. Check for errors and try again. The type of treatment depends on the fracture grade 6: If symptomatic non-union occurs, debridement may be necessary. The lateral side is under extreme tension with stretch on the ligaments which results in an avulsion fracture. The injury can continue to the following: In all these subsequent stages, purely ligamentous injury will not be visible on the radiographs of the ankle. Clinical examination findings are important but less reliable. A lateral malleolus fracture commonly occurs in association with a rolled ankle particularly with significant weight bearing forces. This is called a pull off type of fracture in contrast to a push off type, which is seen as an oblique or vertical fracture. It is amazing, that such a large tertius fragment is so difficult to see on the radiographs. HAWKINS LG. Proper positioning is essential after a type II growth plate fracture. The fracture through the epiphysis is indicated by the blue arrow. According to Lauge-Hansen this is the first stage of a pronation exorotation injury, which results in a Weber C fracture. Type V. 1%. The radiologist decided first to order a CT to find out if there really was a tertius fracture. In the illustration we see the fractures and ligamentous injury on the left and the resulting x-rays on the right. This is generally a stable injury. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the outer ankle. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Morgan M, Hacking C, Hacking C, et al. Study these images carefully and remember the stages of an exorotation injury. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Medial malleolus avulsion fracture. A subtle high fibula fracture is seen (arrow). It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is closed, while the lateral portion is still open leaving it vulnerable to injury. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. Sonographic diagnosis of talar lateral process fracture. Call our Ankle Fracture Line at 833.294.9759 Anatomy of the ankle joint The ankle joint is composed of the tibia, fibula and talus bones. Jibri Z, Mukherjee K, Kamath S et-al. It is actually a Salter-Harris type IV. Crush injury to the physis. Link, Google Scholar; 18 Capps GW, Hayes CW. short-leg AO splint. The lateral malleolus is part of the fibula, one of two bones of the lower leg, which carries about about 10% of your weight. Medial soft tissue swelling and a tertius fracture are both indications of a Weber C or Pronation Exorotation injury. You may have to enlarge the image, turn down the room lights, and adjust the contrast and brightness on your monitor. Maisonneuve fracture) should always be considered a deltoid / medial malleolus injury. This occurs as tendons can bear more load than the bone. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment.10,11 Small nondisplaced avulsion fractures of the tip of the lateral malleolus ( Figure 13-4) are best treated with early mobilization similar to treatment of an ankle sprain. In most cases, people return to normal daily activities within 3 to 4 months. She was referred to the radiology department by her general practitioner. Unable to process the form. Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. The pain was worse with weight-bearing. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Often, x-rays of a child with a type I growth plate fracture will appear normal. Lateral talar process fracture. . The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7000 pages. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-89034. Fractures of the lateral malleolus are the most common type of ankle fracture. Seen with medial malleolus shearing injuries and triplane fractures. In such a case, you have to rule out a Maisonneuve fracture, which is a high Weber C fracture. There is also an avulsion fracture at the tip of the lateral malleolus ( best seen on T1 sequences ), with associated bone marrow edema. Continue with the CT. The size of this fragment depends on the direction of the force (figure). Lateral X-ray Frontal Anteromedial soft tissue swelling. Study the images and then scroll to the next images. Mosby. This small fragment is best seen on the AP view just inside the medial malleolus. At first this looks like a Weber B fracture with an oblique fracture in the fibula as seen on the lateral view (black arrows). Hangman's fracture -- A fracture of C2 (axis) caused by hyperextension of the neck with the force of the occiput and the atlas bearing down on pedicle of C2. Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. 16). The talus (or "ankle bone") connects your leg to your foot. The fracture through the growth plate is only seen on CT. There is a Tillaux fracture due to avulsion of the anterolateral part of the distal tibia by the anterior syndesmosis. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. Since they are generally the result of external rotation and abduction, they are almost always seen in . These are discussed in the next chapter. A lateral malleolus fracture usually requires the person to keep weight off the affected foot for a few weeks. Small ankle joint effusion. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. The small bony chips lateral to the tip of the lateral malleolus represent an avulsion fracture while the well-corticated bony fragment adjacent to the medial aspect of the lateral malleolus tip could be mistaken for fracture if this was not the typical appearance and location for an accessory ossicle - the os subfibulare. Check for errors and try again. Link, Google Scholar; 19 Goldman AB, Pavlov H, Rubenstein D. The bright side is that the majority of lateral malleolus fractures are considered steady ankle fractures and can be treated without surgery. It is important to see your doctor as soon as the accident takes place to prevent more damage. Example 3 2004;24 (4): 1009-27. [3] Also notice the soft tissue swelling on the medial side indicating rupture of the medial collateral ligaments (arrow). Incidental note of os subfibulare and os trigonum. Type I Salter-Harris fractures tend to occur in younger children (5). These Salter-Harris fractures can be easily missed. Lateral malleolus avulsion fracture with os subfibulare. posterior malleolar fracture with < 25% joint involvement or < 2mm step-off. Anterior distal tibial spurring. The injury occurs at the site where a tendon or ligament attaches and happens because the tendon or ligament pulls abruptly and breaks a piece of bone away. These types of fractures may permanently injure the growth plate, requiring later treatment to restore alignment of the limb. Radiology 1986; 159:467-469. Radiology. Isolated lateral malleolus fractures are the most common fracture involving the ankle. 1. 6B 45-year-old woman who felt "ripping" sensation in bottom of her ankle 2 weeks ago. You can enlarge the images by clicking on them. It is actually a Salter-Harris type IV. Lateral malleolus fractures are common in running and . lateral malleolus fracture with talar shift (static or stress view) technique. Study free Radiology flashcards about RAD Pathology created by bre092795 to improve your grades. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. Type V growth plate injuries occur with the growth plate is crushed. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. At that age it is a fracture through the growth plate and is then called a juvenile Tillaux. For acute trauma to the ankle, according to the ACR, radiographs are usually . Almost always the avulsion is seen as a horizontal fracture. Trnka HJ, Zettl R, Ritschl P. Fracture of the anterior superior pro- It is the most common of the ankle joints to fracture. Type IV is a fracture through all three elements of the bone, the growth plate, metaphysis and epiphysis. The patient was treated with immobilization for 4 weeks and anti-inflammatory agents. Often type II growth plate fractures must be repositioned under anesthesia, but healing is usually quick and complications are uncommon. Notice also that the medial epiphysis is already closed, while the lateral portion is still open(blue arrows). You can enlarge the images by clicking on them. Although less common, accessory ossicle of the malleoli is an important differential diagnosis for such injury. Deltoid ligament injuries, be it sprain, tear, or avulsion, are much less common than lateral collateral or syndesmotic injuries. A type II growth plate fracture starts across the growth plate, but the fracture then continues up through the metaphysis. These injuries generally occur when the ankle is either twisted or rolled, frequently with an awkward or unequal action. Continue with the images of the lower leg. There is an avulsion of the lateral malleolus, a Tillaux and a medial malleolar fracture. ADVERTISEMENT: Supporters see fewer/no ads. Study the images and then scroll to the next images. There are two basic types of ankle fractures: 1) High Energy Axial Injuries: Pilon 2) Rotational Injuries: - Malleolar - either medial or lateral - Bimalleolar - both medial and lateral - Trimalleolar - includes posterior malleolus The direction of the force determines the fracture pattern - external rotation, abduction, adduction. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children : a diagnostic accuracy study comparing ultrasonography with radiography. Blue arrow indicates avulsion fracture. This case illustrates the importance of medial soft tissue swelling aswell as the finding of a tertius fracture. Additional x-rays of the lower leg were taken. RadioGraphics 1994; 14:1191-1210. Study the images and then continue reading. As the bone breaks, the part of the bone that is attached to the tendon or ligament pulls away from the rest of the bone. It is important to find these fractures, since a tertius fracture can be the only clue to an unstable ankle injury. It may be an isolated fracture or occur as a component of more complex ankle fractures. Fractures of the ankle, combined experimental-surgical and experimental-roentgenologic investigationsby N. Lauge-Hansen (1948). Check for errors and try again. This juvenile Tillaux is especially seen in young athletes. Before you read this article, you need to understand the classification of ankle fractures and exorotation injuries that were highlighted in Ankle - Fractures 1 and 2. Lateral talar process fracturesor snowboarder fractures are talusfractures that can mimic a lateral ankle sprain. Proper positioning is also essential with type IV growth plate fractures, and surgery may be needed to hold the bone fragments in proper position. Point your toes down as far as they go, then use the other foot on top to apply some pressure to create a stretch on the top of your foot. Notice that there is also a Tillaux fracture. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. There is also a very subtle fracture through the epiphysis. Case Discussion. In 1840 Maisonneuve described a frature of the proximal shaft of the fibula, which was caused by exorotation force applied to the ankle. Type V growth plate fractures carry the most concerning prognosis as bone alignment and length can be affected. Can occur with lateral malleolus fractures, usually SH I or II. Diagnostic guidelines for suspected ankle fracture are from the American College of Radiology. Imaging of the proximal fibula should also be . Procedure: The patient is supine with one leg extended and the other flexed at the knee. An isolated fracture of the medial malleolus, or widening of the ankle joint with no visible fracture seen on ankle X-ray, should raise the suspicion of an associated fracture of the fibula. A lateral malleolus fracture is classified as nondisplaced when the bone fragments are not out of place. J Bone Joint Surg Br. 80 (4), 1998, 684-8. Another Tillaux in a patient with a strange combination of findings. . We will discuss these fractures in a moment. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. Incidental note of os subfibulare and os trigonum. Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. The x-ray shows a subtle Tillaux fracture, which is better appreciated on the CT-images. Usually, you will need to stay off the ankle for several weeks after surgery. A proximal fibular injury (i.e. Anteromedial soft tissue swelling. The alignment is so perfect, that you do not see the fracture on the radiographs. There was an indication for fixing the posterior malleolar fracture, since the fragment involved more than 25% of the articular surface of the distal tibia. In some cases the tertius fractures are easily seen on the x-rays, but frequently they can be difficult to detect. And finally we tend not to look carefully at the epiphysis. were recorded: medial malleolus, lateral malleolus/distal fib-ula, posterior malleolus, talus, calcaneus, navicular, cuboid, . Weber C fractures can be further subclassified as 6. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. 7-32). The diagnosis is made by x-raying the ankle. At physical exam there was some swelling on the medial side and although the patient did not complain of any pain higher in the lower leg, there was some tenderness when the fibula was palpated. The diagnosis of apophyseal separation should be made with caution, since the normal ossific portion of the apophysis may be quite lateral in the cartilaginous mass (Fig. In that case we have the following combination: An isolated tertius fracture on the ankle radiographs indicates the presence of an unstable ankle injury. It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is closed, while the lateral portion is still open leaving it vulnerable to injury. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-31923, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, fractures have been graded by a three point scale, grade 2 fractures may be further subdivided into, cortical disruption of the lateral talar process (best seen with a coronal approach). Stress placed on the bone by a tendon or ligament causes the fracture. So if there is a tertiu sfracture and no sign of a Weber B fracture, then we have to start looking for a high Weber C fracture. Isolated fracture of the posterior malleolus Ankle - Fractures 2 - Fracture mechanism and Radiography. Increased risk of physeal arrest. the 7th character must always be the 7th position of a code. ADVERTISEMENT: Supporters see fewer/no ads. It occurs before the distal tibial epiphysis has completely fused. ( avulsion fracture) Transverse fracture (like our case) Vertical fracture. What is going on here? fluid-sensitive sequences: if an acute injury, there may be bone marrow edema in the lateral process; T1: hypointense fracture line through the lateral process (fracture line and/or cortical step off may be better seen on CT) Ultrasound e.g. Fractures Avulsion fractures are breaks or splits in the bone. Type I - transverse fracture through the growth plate or physis, Type II - fracture through the growth plate and the metaphysis, sparing the epiphysis, Type III - fracture through growth plate and epiphysis, sparing the metaphysis, Type IV - fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis, Type V - compression fracture of the growth plate, Epiphyseal fracture in the sagittal plane, Injury to the growth plate in the axial plane, Metaphyseal fracture in the coronal plane, stage 2: rupture of the anterior syndesmosis, stage 4: rupture of the posterior syndesmosis, stage 1: rupture of the medial collateral ligament stage 2: rupture of the anterior syndesmosis, stage 1: rupture of the medial collateral ligament, which causes the swelling and hematoma, stage 3: high fibular fracture - not visible on the radiographs of the ankle. Simulated avulsion injuries related to these ligaments were created, and the visibility of these structures was assessed. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. J Ultrasound Med. Oblique fracture. There was a trend towards direct xation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03-5.99). A fracture should be suspected when there is soft tissue swelling inferior to the lateral malleolus. Avulsion fractures are breaks or splits in the bone. It is seen when someone's foot hits the ground and a fragment of the posterior malleolus is pushed off by the talus. Copercini M, Bonvin F, Martinoli C et-al. 1 These breaks are the most common type of ankle fracture. The images show an obvious Weber B fracture. Yellow arrow indicates os subfibulare. Surgical Treatment Surgical repair is necessary when a lateral malleolus fracture is displaced. Radiographics. Knowing that this can be the only clue to a high Weber C, additional radiographs were taken. 10) Takakura Y. et al. Put a towel/bandage around your foot and pull it towards you. The ATFL attaches to the distal end of the fibula and the lateral surface of the talus bone, having its center approximately 10 mm above the apex of the lateral malleolus. They are commonly injured in the case of ankle sprains. 2b: >2 mm displacement of fracture fragments; grade 3: cortical avulsion fracture; MRI. ADVERTISEMENT: Supporters see fewer/no ads. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names?. The technician made the standard AP-, Mortise- and lateral view and showed them to the radiologist, who was a little bit puzzled. Frequently missed findings in acute ankle injury. ADVERTISEMENT: Supporters see fewer/no ads. J Bone Joint Surg Am. The use of preperitoneal pelvic packing for unstable pelvic fractures as well as early fracture immobilization with external fixators are paradigm shifts in management. 3, 2009 315 Acta Clin Croat 2010; 49:315-329 Case Report UNRECOGNIZED FRACTURE OF THE POSTEROMEDIAL PROCESS OF THE TALUS - A CASE REPORT AND REVIEW Alignment has been maintained. The avulsion fragment is quite large. So this is the fracture of the metaphysis in the coronal plane. There are three situations in which we should suspect a high Weber C or Maisonneuve fracture: Isolated fracture of the medial malleolus It is the most commonly injured ligament in the ankle. Dimensions and Weight Chassis Engine Type V-Twin cylinder,Liquid cooled,4-stroke,8-Valve,SOHC Displacement 800 cc Bore Stroke 91 61.5 mm Maximum Power 45.0 kW/6750. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone . By Jonathan Cluett, M.D., About.com Guide, Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System. Feel a stretch in the back of your calf. This case demonstrates why a knowledge of common anatomical variants is essential. Unable to process the form. Soft tissue swelling both medial and lateral (red arrows). On the left image the lateral malleolus is pushed off by exorotation of the talus. Campbell's Operative Orthopaedics. Note saucerlike defect in inferior aspect of calcaneus from bone lysis ( curved arrow ). 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