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The Fibular Fleck Sign with Peroneal Tendon Dislocation

2024; Radiological Society of North America; Volume: 311; Issue: 2 Linguagem: Inglês

10.1148/radiol.232932

1527-1315

Matthias Eberhard, Petra Heil,

Foot and Ankle Surgery

HomeRadiologyVol. 311, No. 2 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyThe Fibular Fleck Sign with Peroneal Tendon DislocationMatthias Eberhard , Petra HeilMatthias Eberhard , Petra HeilAuthor AffiliationsFrom the Departments of Radiology (M.E.) and Orthopaedic Surgery (P.H.), Spital Interlaken, Spitäler Frutigen Meiringen Interlaken, Unterseen, Switzerland; and Department of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E.).Address correspondence to M.E. (email: [email protected]).Matthias Eberhard Petra HeilPublished Online:May 21 2024https://doi.org/10.1148/radiol.232932MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In A 56-year-old female patient presented at the emergency department after supination trauma of the left ankle while hiking. She heard a "crack" when twisting her ankle, followed by immediate pain.Radiography of the left ankle showed a small fleck sign (Fig 1A), indicating a distal fibular bony avulsion of the superior peroneal retinaculum (SPR). The SPR is the primary restraint to dislocation of the peroneal tendons from the fibular groove. All anatomic variants of the SPR have a common origin in the periosteum on the posterolateral ridge of the fibula, while the insertion of the SPR is variable. According to the Oden classification, type III injuries consist of a bony avulsion of the SPR at its attachment to the distal fibula, allowing the peroneal tendons to dislocate (Fig 2) (1). Spectral CT confirmed the small bony avulsion and showed acute anterior dislocation of the peroneus brevis tendon (Fig 1B, 1C).Figure 1: Images in a 56-year-old female patient presenting to the emergency department after a supination trauma of the left ankle. (A) Anteroposterior radiograph of the left ankle shows a lateral malleolar fleck sign (circle), indicating bony avulsion of the superior peroneal retinaculum (the radiograph is magnified to highlight the fragment). (B) Axial calcium-suppressed spectral CT image highlights the anterior dislocation of the peroneus brevis tendon (arrow). (C) Lateral volume rendering of the soft tissue CT image depicts both the lateral malleolar fleck sign (circle) and the anterior dislocation of the peroneus brevis tendon (arrow). (D) Lateral intraoperative photograph confirms the diagnosis of anterior dislocation of the peroneus brevis tendon (arrow).Figure 1:Download as PowerPointFigure 2: (A) Axial calcium-suppressed spectral CT image overlaid with a schematic illustration of the small fibular fleck fracture. The image shows a type III injury, consisting of a bony avulsion (red) of the superior peroneal retinaculum (orange) at its attachment to the distal fibula (fibula, blue; origin of the fragment, red). The peroneus brevis tendon (pb, green) is luxated (arrow), whereas the peroneus longus tendon (pl, green) remains in the fibular grove. The fibulotalocalcaneal ligament is shown in yellow. (B) The same image as A without annotations.Figure 2:Download as PowerPointUsing a lateral approach, the peroneus brevis tendon was surgically reduced from its anterior dislocation (Fig 1D) into the retromalleolar groove, and the SPR was reattached with three intraosseous sutures.Lateral malleolar bony fleck has a likelihood of 84% for concomitant peroneal tendon dislocation (2). Therefore, correct diagnosis of SPR avulsion may help identify patients requiring surgical reduction of peroneal tendons to avoid chronic peroneal tendon instability.Disclosures of conflicts of interest: M.E. Payment for speakers bureau from Siemens Healthineers. P.H. No relevant relationships.References1. Oden RR. Tendon injuries about the ankle resulting from skiing. Clin Orthop Relat Res 1987;(216):63–69. Medline, Google Scholar2. Toussaint RJ, Lin D, Ehrlichman LK, Ellington JK, Strasser N, Kwon JY. Peroneal tendon displacement accompanying intra-articular calcaneal fractures. J Bone Joint Surg Am 2014;96(4):310–315. Crossref, Medline, Google ScholarArticle HistoryReceived: Nov 13 2023Revision requested: Dec 18 2023Revision received: Feb 14 2024Accepted: Feb 23 2024Published online: May 21 2024 FiguresReferencesRelatedDetailsRecommended Articles CT and MR Imaging of the Postoperative Ankle and FootRadioGraphics2016Volume: 36Issue: 6pp. 1828-1848Hindfoot Fractures: Injury Patterns and Relevant Imaging FindingsRadioGraphics2022Volume: 42Issue: 3pp. 661-682Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging PrimerRadioGraphics2018Volume: 39Issue: 1pp. 136-152Layered Approach to the Anterior Knee: Normal Anatomy and Disorders Associated with Anterior Knee PainRadioGraphics2018Volume: 38Issue: 7pp. 2069-2101Acute Fractures and Dislocations of the Ankle and Foot in ChildrenRadioGraphics2020Volume: 40Issue: 3pp. 754-774See More RSNA Education Exhibits Acute Ankle Tendon Tears, Dislocations And Associated LesionsDigital Posters2021Musculoskeletal Ultrasound: No Pain, No Gain - A Compilation of Techniques and LesionsDigital Posters2022Fractures of the Hindfoot: Patterns of Injury and Relevant FindingsDigital Posters2020 RSNA Case Collection Peroneus Brevis Split TearRSNA Case Collection2021Painful Os peroneum syndromeRSNA Case Collection2021Transient patellar dislocationRSNA Case Collection2020 Vol. 311, No. 2 Metrics Altmetric Score PDF download