During the normal gait cycle, two seemingly contradictory functional demands are placed on the midtarsal joint complex: flexibility at heel strike—to adapt the weight-bearing foot to unpredictable terrain—followed by rigidity for weight transfer and propulsion into the next step (2). Edema in the dorsal subcutaneous soft tissues overlying the ligament further supports the diagnosis. (b) In contrast, eversion results in distraction at the talonavicular joint with navicular tuberosity avulsion fractures and impaction injury of the calcaneocuboid joint (nutcracker effect) (arrowheads). It is clearly seen on axial MR images as a flat muscle overlying the lateral calcaneocuboid joint. The dorsal calcaneocuboid ligament is often multipartite and subject to anatomic variations (Fig 3). Figure 9b. Cuboid instability, or so-called “cuboid syndrome,” is an important cause of chronic lateral foot pain and is at least in part related to posttraumatic calcaneocuboid instability [11]. Figure 17a. Note the proximity of the adjacent EDB (*). The Calcaneocuboid Joint is formed by the articulation between the calcaneus and the cuboid. Even in the absence of additional fractures, associated ligamentous injuries indicating midtarsal sprain are common and MRI is a useful modality for their detection [5]. Imaging of Chopart (Midtarsal) Joint Complex: Normal Anatomy and Posttraumatic Findings, Pictorial Essay. While there is insufficient high-level evidence proving its efficacy, RICE is commonly and easily employed in the early postsprain setting (35,36). Figure 16b. Although midtarsal sprains most commonly result from ankle inversion, ever-sion injuries are also a possible mechanism. Imaging the Postoperative Knee Meniscus: An Evidence-Based Review, Original Research. Avulsion-related marrow edema can be subtle, but will be found at the dorsal talar head, navicular, or both. Nevertheless, the close proximity of the lateral collateral and midtarsal ligaments and the epidemiologic overlap between midtarsal and lateral collateral ligament sprains, as well as the high incidence of the latter, present a challenge to clinicians evaluating acute inversion-type ankle injuries. As both can occur simultaneously, the better known lateral ankle sprain may dominate the clinical picture, delaying diagnosis and treatment of midtarsal sprains (7,33). Note the offset at the calcaneocuboid joint (yellow arrow). The medioplantar oblique component is best seen on axial ankle or long-axis midfoot planes and has a striated appearance (Fig. Ligaments stabilizing the Chopart joint include the dorsal talonavicular ligament, bifurcate ligament, dorsal calcaneocuboid ligament, short and long plantar ligaments, and spring ligament (3,4). 2B and 2C). Fig. ); Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland (A.H.); and Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.T. Note the offset at the calcaneocuboid joint (yellow arrow). (c) Sagittal PD fat-saturated image shows avulsion of the dorsal talonavicular ligament (curved arrow) and typical plantar talar head contusion (straight arrow). (c) Sagittal PD fat-saturated image shows the avulsion fracture at the navicular attachment of the inferoplantar longitudinal component of the spring ligament (white arrow). Midtarsal sprain with concomitant lateral and medial column fractures in a 47-year-old woman after an inversion injury. (a) Frontal foot radiograph shows an avulsion fracture of the navicular tuberosity (*) and a comminuted impaction fracture of the anterior process of the calcaneus (arrow). Keywords Transligamentous Midtarsal Dislocation, Chopart Joint, Dorsal Talonavicular Ligament, Avulsion Fracture, Dislocation, External Fixation, Calcaneocuboidal Joint, Talo-navicular Joint The normal calcaneonavicular component of the bifurcate ligament is almost always clearly seen; therefore, an absent or indistinct ligament should prompt a higher degree of suspicion for midtarsal sprain. Conversely, an eversion mechanism will cause impaction injuries at the calcaneocuboid joint and medial avulsion fractures, typically at the navicular tuberosity. Chopart joint ligamentous anatomy. (Fig 3a adapted and reprinted, with permission, from reference 21. Related pathology. Ligaments of the Transverse Tarsal Joint Complex: MRI–Anatomic Correlation in Cadavers. 1, 3 April 2020 | RadioGraphics, Vol. Not uncommonly, midtarsal injuries will result in fracture nonunion, usually of the anterior process of the calcaneus. Plantar compressive forces may occur in this injury pattern, but are neither a consistent nor dominant feature. (b) Axial CT image shows the comminuted impaction fracture of the anterior calcaneus (white arrow) and a distraction fracture of the navicular tuberosity (black arrow) related to the eversion mechanism of injury. A torn dorsal talonavicular ligament is present (black arrow). Figure 18a. Original Research. * = extensor digitorum brevis (EDB). Long plantar ligament (curved arrow, C) typically has striated appearance. (A full DICOM image stack is available online. Oblique radiograph (a) and sagittal CT image (b) of the foot show an intra-articular comminuted impaction fracture of the cuboid (arrows). We then present the spectrum of traumatic injuries of the midtarsal joint complex, emphasizing clinical considerations and imaging findings of midtarsal sprains and Chopart fracture-dislocations. As with other joints, osteochondral injuries or intra-articular fractures related to sprain or fracture-dislocations of the Chopart joint will hasten the onset of osteoarthritis. Figure 2a. Avulsion fracture of the anterior calcaneal process in a 47-year-old woman 2 days after an ankle injury. Eversion-related impaction fractures (nutcracker fractures) are seen about the calcaneocuboid joint (oval). In one recent study, calcaneocuboid avulsion fractures were evident in 48% of radiographs and 100% of MR images [5]. (a) Sagittal CT image shows an avulsion fracture at the cuboid attachment of the bifurcate ligament (arrow). Midtarsal fracture-dislocations occur in high-energy lower extremity trauma with an axial loading force and are present in up to 10% of patients with motor vehicle crash polytrauma [24, 25]. Figure 3a. High-energy axial forces transmitted through the foot are universal among Chopart fracture-dislocations, usually occurring with the ankle in inversion. (a) Fractures associated with inversion injuries include avulsion of the anterior process of the calcaneus (arrow) and impaction fractures of the navicular (solid line) and talar head (dotted oval). Midtarsal sprains have been shown in up to 19% of patients presenting for MRI after acute ankle trauma, most commonly in the setting of ankle inversion, and therefore frequently overlap with lateral ankle sprains (5). Comprehensive radiographic evaluation of the midtarsal joint requires anteroposterior (AP), lateral, and oblique views of both the foot and the ankle. Accompanying talus and navicular fractures are often comminuted and impacted and are also frequently underestimated on conventional radiographs. Alternatively, the meniscoid variant protrudes into the calcaneocuboid joint [21, 48]. The joint is surrounded by a fibrous joint capsule lined with synovium, which produces lubricating synovial fluid and nutrients required by the tissues within the joint. The calcaneocuboid joint is best seen on the medioplantar oblique view of the foot, which most reliably demonstrates intra-articular fractures of the cuboid, with as little as 1-mm articular surface step-off along the calcaneocuboid joint (22). Note the proximity of the adjacent EDB (*). 5 and 6). The talus and navicular form the proximal, flexible part of the medial column of the foot, and the calcaneus and cuboid form the proximal, more rigid segment of the lateral column. (c) Axial T1-weighted image shows the striated medioplantar oblique (arrow) and inferoplantar longitudinal (arrowhead) bands of the spring ligament. Midtarsal sprains may affect the supporting ligaments along the talocalcaneonavicular and calcaneocuboid joints. The Chopart joint complex, also known as the midtarsal or transverse tarsal joint, is located Radiologists should be familiar with the normal and abnormal appearances of the Chopart joint complex and the relevant mechanism-specific injury patterns seen at imaging. (b) Axial PD fat-saturated image shows that the fracture (straight black arrow) is related to avulsion of the inferoplantar longitudinal component of the spring ligament (white arrow). Pain persisting beyond a few weeks after conservative therapy or severe pain not controlled by oral nonsteroidal anti-inflammatory drugs should raise suspicion for complicating factors such as fracture, osteochondral injury, or midtarsal sprain (16,32). B, Schematic drawing of spring ligament complex depicts medioplantar oblique (MPO), inferoplantar longitudinal (IPL), and superomedial (SM) components. For example, avulsion fractures of the dorsal talonavicular ligament will often be concomitant with avulsion fracture of the anterior process of the calcaneus and plantar talar head impaction (Figs 7, 11). The dorsal calcaneocuboid and short and long plantar ligaments stabilize the calcaneocuboid joint; the dorsal talonavicu- Concomitant fractures of the anterior calcaneus and talus are common in these injuries, and talar head avascular necrosis is a common posttraumatic sequela [32, 33]. 6A —55-year-old woman who presented for follow-up imaging 3 weeks after falling. 3B). Note typical subfibular soft-tissue swelling (asterisk, A) as secondary sign of calcaneocuboid joint injury. In the setting of ankle inversion, distraction forces produce avulsion fractures along the calcaneocuboid joint and impaction fractures along the talonavicular joint (Fig. Delayed diagnosis of midtarsal sprains may lead to dysfunction, prolonged pain, and instability. Ligaments of the talonavicular joint can be divided into ligaments of the acetabulum pedis (spring ligament and calcaneonavicular component of bifurcate ligament), talocalcaneal ligaments (lateral, medial, and posterior talocalcaneal, interosseous, and cervical ligaments), and dorsal talonavicular ligament (Fig. Because the normal dorsal calcaneocuboid and calcaneocuboid components of the bifurcate ligament may be difficult to detect on MRI, failure to visualize them should not automatically be considered pathologic; secondary signs of ligamentous injury should be sought to support the diagnosis of a sprain. The midtarsal (Chopart) joint complex consists of the talonavicular and calcaneocuboid joints and their stabilizing ligaments. Overall, radiographic detection of midtarsal injuries is thought to be insensitive, missing up to 33% of cases with fractures [44]. Signs of a Chopart joint injury include bony avulsion dorsal calcaneonavicular ligament, bony avulsion fracture of the talar attachment of the talonavicular capsule, and anterior calcaneum process fractures 1.
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