EL-MINIA MED., BULL., VOL. 17, NO. 1, JAN., 2006
Fouad
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INCIDENCE AND CLINICAL SIGNIFICANCE OF BONE BRUISE OF THE
TALUS AFTER SIMPLE SUPINATION INJURY OF THE ANKLE
By
Mohammed Mohammed Fouad
Department of Orthopaedic Surgery,
El-Minia Faculty of Medicine
ABSTRACT:
We used MRI to study a series of 42 patients with inversion injuries of the
ankle, with persistent painful, swelling, ankle joint for 2 months after the injury. MRI
showed bone bruise at the talar bone in 12 patients, with an incidence of 28.6%.
Analysis of the results with clinical symptoms and signs was done. The bone bruise
at the talar bone after ankle injury not associated with ligamentous injury is common.
Our aim of the study was to determine the incidence and clinical significance of bone
bruises in the simple supination injury of the ankle. It has been estimated that
regardless of the treatment about 30% of patients with injuries of the ankle ligaments
have residual symptoms such as pain and swelling or a sense of irritability¹. Absence
of the associated ankle ligaments injury with persistent symptoms of pain and
swelling arouse the suspicious of one possible factor of injury to the bones of the
ankle. Conventional radiographic techniques are limited in providing bone marrow
characterization and therefore the diagnosis of bone bruising is essentially based on
MRI findings. The articular cartilage may appear to be intact² and such a lesions may
represent elastic deformation of the cartilage with haemorrhage and disruption of the
trabecular bone³.
KEY WORDS:
Bone brouise
Ankel sprain
department with soft bandage for less
than 3 weeks (83.3%). In 8 patients
the injury occurred at work (75%), and
2 at sport (16.6%). The female patients
were 2 patients and male patients were
10 patients.
PATIENTS AND METHODS:
Between January 2001 and
May 2003, we received 42 patients
with ankle sprain and no fracture
visible on standard radiographs, with
history of pain and swelling at the
sprained ankle for more than 8 weeks
duration after receiving the trauma, all
the patients went for MRI study of the
injured ankle, we set 12 patients
(28.6%) with positive MRI signs of
bone bruise at the talar dome, we
excluded patients of the alcoholism or
rheumatoid arthritis. The age range of
the 12 patients with positive MRI signs
of the talar bone bruise of 22 to 51
years, with the mean age of 28.8 years.
The complaints of patients
were; persistent pain at the injured
ankle for 11 (91.6%) patients, swelling
at the ankle for 9 (75.0%) patients and
pain associated with swelling was 11
patients (91.6%). No instability of the
ankle was recorded.
The clinical signs were; lateral
ankle swelling in 7 (58.3%) patients,
tenderness at the ankle in 9 (75.0%)
patients, and combined ankle swelling
and tenderness at the injured ankle in
10 (83.3%) patients.
The rate among those with
single injury was 8 patients (75%), 10
patients were treated in the casualty
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Fouad
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Imaging Methods:
Conventional radiographs were
used to exclude fractures. MRI used
under supervision and interpretion of
the results by MRI specialist. Used T1
– weighted spin – echo (SE) images
and T2 – weighted images for the 42
presented patients.
The anterior
talofibular (ATF) and calcaneofibular
(CF) ligaments were imaged on axial
planes tilted parallel to the long axes of
the ligaments. Only injured ankle was
imaged.
independent values, significance value
was considered when P>0.001.
RESULTS:
Incidence of bone bruises:
There were a bone bruise in 12
patients, an incidence of 28.6%, this
incidence was not associated with ATF
ligament or CF ligament injury. There
were 10 bruises in the medial tibial
dome, and 2 in the lateral part of the
talar dome.
Clinical significance V bone bruise:
We found significance differences
between complaints of pain 11 patients
(91.6%), swelling (ankle effusion) 19
patients (75.0%), and combined pain
and swelling 11 patients (91.6%).
Clinical signs of tenderness, swelling,
and combined tenderness and swelling
were statistically significant related to
the presence of talar bone bruise (table
II). (figure 3,4).
A radiologist analyzed the
images without clinical data. Injuries
to ATF and CF ligaments were
recorded, and soft-tissue swelling and
joint effusion were recorded. Bone
bruise was diagnosed according to a
method modified by Mink and
Deutch4: stage O was normal, stage 1
was a bone bruise and stage II was an
osteochondral fracture. Only stage 1
bone bruise was recorded in this study
for the recorded 12 patients. An ATF
and CF ligaments injury and an
osteochondral fracture were excluded
(figure 1, 2)
All 12 patients went for below
knee cast with advice for non-weight
bearing for 8 – 10 weeks. 8 patients
had
complete
recovery
from
symptoms, 4 patients was advised for
another options of the treatment, 11
patients showed absence of the MR
image signs of the bone bruise, one
patient had sclerotic subchondral bone
sclerosis of the talar dome; suggestive
the development of the avascular
necrosis of the talus.
Clinical evaluation and image
evaluation with MR image at 3 months
after the first evaluation, using the
same criteria. Follow-up range 3 to 20
months with the mean 11.4 months.
Details of the patients table 1
Statistical Analysis: Using the chisquared test and the t-test for
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Fouad
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Table 1: Details of the patients
No. of patients received
No of patients with bone bruise
Male patients
Female patients
Injury (Supination injury)
Single
Repetitive
Age range years
Mean age years
Treatment at casualty department
Soft bandage
Posterior slap cast
* P = 0.0031
42
12
10
2
83.3%
*
83.3%
*
8
4
22 – 51
28.8
10
2
Table II: Bone Bruise related to Symptoms and Signs
No. of patient received
No. of patients with bone bruise
Symptoms V bone bruise :
Pain
Swelling
Comb/Pain Swelling
42
12
Signs V bone bruise :
Tenderness
Swelling ankle effusions
Combined Tenderness/ankle effusion
11
9
11
91.6%
75.0%
91.6%
*
*
*
9
7
10
75.0%
58.3%
83.3%
*
*
*
* P = 0.0035
Figure I:- AP-Lateral Conventional X-ray showed
no signs of Bone Bruise.
84
28.6%
EL-MINIA MED., BULL., VOL. 17, NO. 1, JAN., 2006
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Figure II(a): T1 Spin-echo : with axial views
Figure II(b): T2 Spin –echo: Showed no associated ligamentous
(ATF) and CF injuries
Figure III (a): Saggittal and cronal images of the Talar dome bruise
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Figure III(b): Saggittal and cronal STIR images of the Talar dome bruise
Figur III(c): STIR View showed Talar Bone Bruise
Figure IV(a) : STIR for the same Ankle Figure (I to V) after 6 Weeks
B.K. cast Showed improved signs of the bone bruise
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Figure IV(b) : STIR for the same Ankle Figure (I to V) after 6 Weeks B.K. cast
Showed improved signs of the bone bruise
Figure IV(c): STIR for the same Ankle Figure (I to V) after 2 months B.K cast
Showed no signs of the bone bruise
is essentially based on MRI findings.
The subcortical epiphyeal marrow
cavity consists of cancellous bone that
usually demonstrates fatty marrow at
all ages. The normal marrow signal on
MRI parallels that of subcutaneous fat,
being high on conventional T1 –
weighted and intermediate on T2 –
weighed spin echo sequences. A
typical bone bruise appears as an area
of signal loss within the marrow on T1
images and high signal intensity on T2
images, as a result of water content of
the injured marrow. With the short T1
inversion recovery (“STIR”) imaging
in which the signal from normal
medullary fat is markedly suppressed
and hence bone bruises are highlighted
with increased intensity [figure 5].
DISCUSSION :
Increasing use of magnetic
resonance imaging in the investigation
of acute ankle and joint injuries in
recent years has altered clinicians to
phenomenon of bone bruising³,4.
Mink4 was the first to identify
bone bruising as a distinct entity in
1987 and several authors since then
have subsequently attempted to
classify the lesions5,6,7. Some confusion exists between the distinction of
bone bruises which only involve the
marrow, and “occult” fractures, undetected on conventional X-rays, which
are similar on MRI but breach the
adjacent cortex or osteochondral
surface. The diagnosis of bone bruising
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The prevalence of bone bruises
is still largely unknown. Lynch et al(7).
retrospectively studied the MR images
of 434 consecutive patients referred for
evaluation of acute knee injury and
found of incidence of 20%, of which
77% had associated anterior cruciate
rupture. Many authors had focused
their attention on population of ACL
injuries and shown a high association
with bone bruises4,8,,9.
is immobilization¹³. This disagreeing
with study reports by Alanen et al(¹º)
and Zanett et al.,¹¹, that bone bruises of
the ankle have a different course from
those in the knee. At the ankle, they
seem to be non-specific in association
with sprains, and do not require
treatment. While bone bruising is being
increasing recognized, little is known
about to short-term resolution, clinical
symptoms and long-term prognosis,
larger prospective studies with serial
MR imaging are necessary to determine the exact pattern, as this may
alter our clinical management. If these
lesions represent trabecular fractures
and occult articular cartilage damage
as suggested by Johnson’s histological
study14, should we advo-cate protected
weight-bearing until the lesion has
resolved radiolo-gically ? it is also
important to identify any distinct
clinical symptoms, specially pain,
which may be asso-ciated with these
lesions. Selective scanning based on
parameters of suspicion would be a
useful adjunct and may obviate the
need for more aggressive investigation
“e.g. arthro-scopy” in some situations.
We conclude that bone bruises in the
ankle are common in uncomplicated
injuries, and have clinical significance.
While the literature to date has
focused on the prevalence and
characteristic patterns of bone bruising
associated with ACL injuries, little is
known about to possible association
with other “non-bony” and “nonligamentous” ankle injuries. Alanen et
al.,¹º reported an incidence of bone
bruising of 27.0% associate with 95
patients with inversion injuries of the
ankle joint, agreeing with our study as
reported incidence of 28.6% associated
with 42 ankle joint sprain, agreeing
with previous studies which showed
incidence of 21.0% and 40.0%¹¹,¹².
Most of the bruises were in the talus,
typically in the medial part, this
agreeing with study results reported by
Nishmura et al.,¹². Our findings
showed bone bruises of the talus were
not associated with ligamentous injury
this disagreeing with other study
reports¹º,¹². Our study had insufficient
statistical power to allow definite
conclusions. We found statistical
differences in the clinical signs and
patients symptoms of pain, tenderness
and presence of ankle joint effusion
either combined or single finding with
the positive MR imaging signs of the
talar bone bruise, the treatment with
below the knee cast with advice of
non-weight bearing for 6 – 8 weeks
seemed to be sufficient for clinical
improvement, and MRI signs of the
bone bruises. This agreeing with study
reported by Bohndorf who suggested
the treatment of choice for bone bruise
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injuries. Am J Sport Med 1993; 21
(2): 220-3.
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‫الكدمات العظمية فى حاالت وجودها وأهميتها اإلكلينيكية‬
‫المصاحبة لجرح مفصل الكاحل‬
‫محمد محمد فؤاد‬
‫قسم جراحة العظام – كلية طب المنيا‬
‫ حالة إصابة جرح بسيط للمفصل الكامل (إلتواء) مع شكوى المرضى‬42 ‫أجريت هذه الدراسة على‬
‫بألم مستمر مزمن ألكثر من شهرين ووجود تورم بالكاحل المصاب – لم تظهر األشعة العادية وجود أى‬
.‫ظواهر غير طبيعية باألشعة االعتيادية بدراسة الحاالت المصابة باألشعة المغناطيسية لكل الحاالت‬
‫ بالمائة أظهرت منها األشعة المغناطيسية وجود كدمات بالعظم الكلسى‬28,6 ‫ حالة بواقع‬12 ‫تم عزل‬
.)‫(الكاحل‬
.‫لم تظهر األشعة المغناطيسية وجود أى حالة تمزق باألربطة للكاحل المصاب مصاحبة لكدم العظم‬
‫تم عمل الدراسات التحليلية للدراسة ووجود ارتباط لوجود األلم مع التورم وعالقة ملحوظة لوجود‬
.‫الكدم العظمى‬
‫الهدف من الدراسة إظهار العالقة األكلينيكية على وجود الكدم العظمى فى المرضى الذين أصيبوا‬
.‫بالتواء بسيط بالكاحل‬
89