wszyscy pacjenci mieli wykonane badania rtg i usg stawu skokowego do 7 dni od urazu .
w badaniu rtg nie stwierdzono patologii u 129 pacjentw ( 63% ) ; u 24 pacjentw ( 12% ) stwierdzono zamanie awulsyjne kostki bocznej ; u 36 pacjentw ( 17% ) stwierdzono wysik w stawie skokowym grnym .
w badaniu usg nie stwierdzono patologii u 19 pacjentw ( 9% ) ; u 60 pacjentw ( 29% ) stwierdzono zamanie awulsyjne kostki bocznej obejmujce przyczep wizada skokowo - strzakowego przedniego ( atfl ) ; u 34 pacjentw ( 17% ) stwierdzono cakowite zerwanie atfl ; u 51 pacjentw ( 25% ) stwierdzono czciowe uszkodzenia atfl ; inne uszkodzenia stanowiy 19% .
wykonane zabiegi operacyjne rekonstrukcji wizada skokowo - strzakowego przedniego ( 19 ) potwierdziy rozpoznania usg / rtg w 100% .
zerwania awulsyjne atfl , czyli obejmujce przyczep wizada , wystpuj u dzieci modszych ( mediana  8 lat ) .
zerwania cakowite atfl ( na przebiegu wizada , nieobejmujce przyczepu ) wystpuj u dzieci starszych ( mediana  14 lat ) .
ze wzgldu na istotnie ograniczon warto badania rtg w rozpoznaniu patologii stawu skokowego w  wieych urazach skrtnych dzieci badanie wykorzystujce obrazowanie tkanek mikkich  ultrasonograa 
zamania awulsyjne obejmujce przyczep atfl , przewaajce u dzieci modszych , wynikaj z niezakoczonego procesu kostnienia i wymagaj pilnej diagnostyki oraz konsultacji ortopedycznej .
sprain injuries are diagnosed in 6% of young people who practice sports , and the highest risk is associated with the following sports : soccer , rugby , hockey , handball , volleyball , basketball and squash .
most ankle sprain injuries involve the region of the lateral malleolus and its ligament complex ( the lateral ligament complex of the ankle joint ) which consists of three ligaments : anterior talofibular ligament ( atfl ) , calcaneofibular ligament ( cfl ) and posterior talofibular ligament ( ptfl ) .
sprained ankle is a result of the supination movement , i.e. plantar flexion and inversion of the foot .
this structure is a strong ligament and it is an element of the lateral ligament complex of the ankle joint .
it attaches to the distal end of the fibula ; the center of the enthesis is localized approximately 10 mm above the apex of the lateral malleolus .
the talar enthesis of the atfl is localized on the lateral surface of the talus bone ( fig .
when the foot is in the anatomic position , the ligament runs nearly horizontally , but in the plantar flexion , the axis of the ligament is nearly parallel to the long axis of the shin bone .
an injury to the ligament can concern its fibers ( mid - substance complete or partial ligament tear ) or the enthesis . in the latter situation ,
the bony attachment site of the ligament is detached ( avulsion fracture of the fibula ) .
injuries in sprained ankle are assessed by x - ray and ultrasound ( us ) examinations , both of which are commonly available .
the assessment of the degree to which the anterior talofibular ligament is damaged and the evaluation of coexisting injuries are important when planning the treatment .
surgery is indicated , for instance , when the anterior talofibular ligament is torn completely and the patient manifests clinical sings of ankle joint instability or when the ligaments of the ankle joint are damaged with a coexisting osteochondral fracture ( e.g. avulsion fracture of the lateral malleolus with the dislocation of an osteochondral fragment in children ) .
when untreated , sprain injury can lead to joint instability , early degenerative changes and chronic joint pain .
the aim of this paper is to draw attention to the usefulness of the ultrasound examination in the diagnosis of recent sprain injuries of the ankle joint .
the retrospective analysis involved 206 patients ( 113 girls and 93 boys ) who reported to the trauma outpatient clinic with recent ankle joint sprain . the average age of the patients was 10.6 .
all of them were instantly examined with x - ray and us ( within 7 days of sustaining injury ) .
x - ray examinations were conducted with the use of a philips digital diagnost v.2 system with eleva workspot v.2 software .
ultrasound examinations were conducted with the use of a ge voluson e8 system using linear probes sp10 - 16d with the frequency of 718 mhz and an 11 l - d probe with the frequency of 410 mhz .
x - ray examinations of the ankle joint were conducted in three views : a - p , lateral and  mortise view  ( used for the assessment of the width of the tibiofibular syndesmosis and for the optimization of the talocrural joint space imaging ) .
x - ray pictures were assessed by four radiologists experienced in diagnosing conditions within the muscoskeletal system .
ultrasound images were assessed by five radiologists experienced in diagnosing conditions within the muscoskeletal system .
the following signs were assessed in each us examination : the presence of fluid / hematoma in the ankle joint , the image of the synovial membrane and the presence of injuries to the ligaments of the ankle joint : anterior and posterior tibiofibular ligament , anterior talofibular ligament , calcaneofibular ligament , medial ligament , chopart 's joint ligaments ( talonavicular and bifurcate ligament ) , as well as tendons of the peroneus muscles , tibialis muscles , extensor and flexor digitorum longus as well as the region of the epiphyseal cartilage of the fibula and the tuberosity of the fifth metatarsal bone . moreover , bone fragments that could be detached in the mechanism of avulsion were actively searched for .
grade 1 referred to ligament edema / thickening , which results from elastic deformation of its fibers without the loss of their continuity ( commonly known as  stretched 
grade 2 was defined as injury in which some fibers are torn ( edema , blurred fibrillar echotexture , areas of decreased echogenicity ) .
finally , grade 3 referred to complete rupture of the ligament ( edema and ligament thickening , no evidence of fiber continuity , failure of function in a dynamic examination : ligament stumps or torn fibers move away from each other ) .
a hematoma at the site of the ligament can be present for several days after sustaining injury .
avulsion fracture , i.e. injury involving the attachment site , is a specific type of grade 3 damage .
the structure of the ligament itself is usually assessed as normal or as in grade i injuries .
based on the clinical assessment and imaging findings , 19 patients were scheduled for a surgery to repair the anterior talofibular ligament .
x - ray failed to visualize a pathology in 129 children ( 63% ) ( fig .
2 ) . in 24 patients ( 12% ) , avulsion fracture of the lateral malleolus
3 ) , and in 36 cases ( 17% ) , the examinations showed evidence of effusion in the ankle joint or thickening of the soft tissues adjacent to the lateral malleolus ( fig . 4 and 5 ) .
a slight detached bone fragment , separated from the fibular outline , can be seen x - ray picture of the right ankle joint in the ap view .
thickening of the soft tissues adjacent to the lateral malleolus ( arrow ) x - ray picture of the right ankle joint in the lateral view .
radiological evidence of effusion in the talocrural joint ( arrow ) a us examination failed to visualize a pathology in 19 children ( 9% ) ( fig .
6 ; fig . 7 ) . in 60 patients ( 29% ) , avulsion fracture of the lateral malleolus involving the atfl enthesis was found ( fig .
in 34 patients ( 17% ) , the atfl was found completely torn ( fig .
9 ) , i.e. the ligament itself was torn ( not involving the enthesis ) .
partial atfl injury was diagnosed in 51 patients ( 25% ) , and other injuries  in 19% of cases ( fig .
the course of the ligament ( arrows ) and ligament attachment sites ( arrowheads ) .
marked fibrillar structure ; stretched in a resting position avulsion injury of the anterior talofibular ligament at the fibular enthesis .
bone entheses are marked with arrowheads ultrasound image of complete tear of the anterior talofibular ligament .
swollen ligament stumps ( arrows ) bridged by thin scars the surgeries ( 19 ) conducted confirmed the us / x - ray diagnoses in 100% of cases ( fig .
ligament stumps ( arrowheads ) based on the data , it can be concluded that avulsion atfl injuries are usually found in younger children ( median : 8 years of age ) in whom the ligament entheses are partially chondral attachments .
in most cases ( over 60% ) , the result of an x - ray examination was normal  no visible structural changes within the joint , which considerably contrasts with the number of normal ultrasound results ( 9% ) ( fig . 2 and 6 ) .
effusion in the ankle joint or thickened shadow of the soft tissues at the ankle level ( fig .
atfl injuries , both those of the ligament only and those involving the enthesis ( avulsion fractures ) , accounted for 70% of cases . some patients with these injuries were scheduled for a surgery .
it must be observed that in 36 patients , avulsion fracture was occult in x - ray , which accounts for 60% of patients with this injury .
it merely enables one to make conclusions concerning soft tissue injuries based on the presence of joint effusion or soft tissue thickening .
the sensitivity and specificity of both modalities ( x - ray and us ) can be compared only with respect to avulsion injuries when a separated bone fragment is visible in an x - ray picture . 


x - ray 

 us 

 sensitivity 
 40%100% 
  x - ray examinations helped establish the correct diagnosis in 40% of cases with avulsion injury whereas this value reached 100% for a us examination .
the specificity of both methods in detecting avulsion fractures is as follows : 

 x - ray 

 us 

 specificity 
 100%100% 
  all patients without avulsion fracture were diagnosed correctly , i.e. they obtained a negative result both in an x - ray and us examination .
ultrasonography is a valuable method to assess avulsion fractures , tiny fractures due to compression injury as well as coexistent soft tissue injuries in the ankle joint .
ultrasonography , as an inexpensive , easily available and noninvasive method , can be broadly used particularly in pediatric radiology , and its findings can significantly influence the therapeutic process . the final decision concerning the treatment
is made by an orthopedists on the basis of the whole clinical picture , current patient condition and own experience .
however , it is not used routinely to assess recent sprain injuries of the ankle joint in children because of its limited availability and long duration of scanning .
ultrasonography can be useful in the initial assessment of whether patients need an mri examination .
the literature reports demonstrate that us and mri are equally sensitive in detecting ligament injuries in the ankle joint .
x - ray and us examinations are used for the assessment of sprain injuries of the ankle joint in children and should be used as complementary tests in the emergency department .
a us examination of the ankle joint is characterized by greater sensitivity in assessing avulsion injuries .
ultrasonography should be therefore considered the primary modality for the assessment of ligament injuries in the ankle joint since its findings can change the therapeutic process .
authors do not report any financial or personal links with other persons and organizations , which might affect negatively the content of this publication and/or claim authorship rights to this publication .
 introductionsprained ankle is a very common injury in children . 
 proper treatment of ligament injuries enables full recovery . 
 x - ray and us examinations are commonly available diagnostic methods.material and methodstwo hundred and six children ( 113 girls and 93 boys , mean age 10.6 ) with recent ankle joint sprain ( up to 7 days of injury ) were subject to a retrospective analysis . 
 all patients underwent an x - ray and us examination of the ankle joint within 7 days of injury . in 19 patients , 
 anterior talofibular ligament reconstruction was conducted.resultsx-ray failed to visualize a pathology in 129 children ( 63% ) ; in 24 patients ( 12% ) , avulsion fracture of the lateral malleolus was found , and in 36 cases ( 17% ) , effusion in the talocrural joint was detected . 
 ultrasonography failed to visualize a pathology in 19 children ( 9% ) ; in 60 patients ( 29% ) , it showed avulsion fracture of the lateral malleolus involving the attachment of the anterior talofibular ligament ( atfl ) ; in 34 cases ( 17% ) , complete atfl tear was detected , and in 51 patients ( 25% ) , partial atfl injury was found . 
 other injuries constituted 19% . 
 the surgeries conducted to repair the anterior talofibular ligament ( 19 ) confirmed the us / x - ray diagnoses in 100% of cases . 
 avulsion atfl injury , i.e. the one that involves the ligament attachment site , is usually found in younger children ( median : 8 years of age ) . 
 complete atfl tears ( not involving the attachment site ) concern older children ( median : 14 years of age).conclusionssince x - ray is of limited value in diagnosing ankle joint pathologies in recent sprain injuries in children , soft tissue imaging , i.e. ultrasonography , is the basic examination to assess the ligament complex . 
 avulsion fractures , which involve the atfl attachment site and are usually found in younger children , are a consequence of the incomplete ossification and require urgent diagnosis and orthopedic consultation . 