A Case Based Review of Anatomy and Associated Pathology * Familiarize radiologists with common accessory ossicles of the foot and the anatomic variants. * Discuss relevant pathology associated with accessory ossicles, such as trauma and pain ETT gelato * Provide imaging review of various pathological conditions associated with accessory ossicles.Accessory Ossicle See eR cca ossification centers. + Usually small, ound, well corticated and can be bipartite or multipartite + Incidentally present around a joint with no definite known function, however, can Cet a eae + Usually congenital, although, can result from trauma or degenerative disease Most commonly described accessory ossicles inthe foot are os trigonui, os peroneum and os naviculare, * Other less frequently seen ossicles include os intermetatarseum, os Pre en heearete etttee en oem ic ee Sea Pan v Os trigonum Location: Round or triangular shaped, located fee ca olm Coma Re] OCeT RS -(a keel NTC Ae) a -Riele UTaNeife (aT Sa ao) Can be a source of ankle pain due to posterior ankle impingement syndrome. Can lead to misinterpretation as a fracture of the lateral process of talus (Shepherd fracture) aac ROR e ea eee MULale (een Ric(eev Ly due to trauma. Pay veS and is embedded within the peroneus longus tendon, eC eerie Often bilateral, in 60% of the cases, and canbe bipartite. een amg ars ee ead ease ah Reece cate CUE peroneum syndrome (discussed later) or displacement (indirect sign of Ce ee oe USCOs peroneum Accessory navicular ( Os navicularum or Os tibiale externum) Location: Posterior to the posteromedial tuberosity of the tarsal navicular bone and often contains a broad attachement site for posterior tibialis tendon lTiXeife (ato ay ara Tete] ele. ae More common in females and first occurs in adolescence. Incidental finding on radiographs; however, can be a cause of medial foot pain due to os Wee) ae eel @ PanPee Olam MAUI LS ides accessory navicular bones into three types: ee aoe ea eaOs intermetatarseum Location: Between base of the first and second filet Le Leto Oval, round or linear and may resemble a favre anal Ta Mbt TT 1 Titeife(aTo sae Can be a cause of midfoot pain, best seen as osseous edema on MRI. Based on the location, can be mistaken for a fracture of second metatarsal or Lisfranc injury. Lack of donor site, soft tissue swelling can be of eriee-Tare lamar om egOs vesalianum Location: Proximal to the base of the fifth eae Ley ROL Ua AULA Reale el eea Ue le) tendon and may articulate with the cuboid. Incidence: 0.1-7%. elt M ee RL Cola secondary ossification center and the fifth ie LeLet]| Rarely symptomatic, but can be a cause of lateral foot pain, requiring surgical excision. Can be misinterpreted as a fifth metatarsal fracture, similar to os peroneum. eg Pan Os vesalianum* Location: Between the anteromedial aspect of the calcaneus, the cuboid, the talar head and Pues Ie * Incidence: 0.6-7%. * Usually not associated with any clinically significant pathology; however, can be mistaken for a fracture of the anterior process of the calcaneus. Pan @* Medial cuneiform is divided horizontally by a synchondrosis, creating a dorsal and plantar St * Incidence: 0.1% * Rarely symptomatic, but, can be mistaken for a fracture or can be a source of traumatic or nontraumatic foot pain.Rare 1% incidence. No clinical significance. eRe ene See eee acess CeO RCN Eau Ree me ate ale significance. omic clei See R CRC CMC Rema CeO acura feral Same eC e ma OR tLe) Se clefoeen Pee ea een Pee ery See eet eS ee ad eae a Red edema (white arrow) with adjacent edema inthe posterior talus and posterior calcaneus (arrowheads) eres eeee cunt city arrow), consistent with Os Peter ea Os trigonum Syndrome Posterior ankle impingement syndrome attributed to os tigonum, De ec ee ead eo ace tes ‘Sean with repetitive plantar flexion (ballet dancers, basketball players, football co See eae eos pees Coe ee ce Oe ae ees CT: fracture or fragmentation and degeneration at the synchondrosis, Dee ee ec ene aC Ln o e ind/or tenosynovitis anhPn netroots Dee etd Ce See eres Cee es ee Coe eee ee tee) Sees Pee ed een es Pen octal tee aha) tae ci ene en Set) nas Painful os peroneum syndrome + Spectrum of one or more of the following findings; Sen eee eee ea a Se = Chronic os peroneum fracture or diastasis of a multipartite os Peroneum with callus formation, resulting in a stenosing peroneus eee ST ga eke Coe eae ee nag Cece scot Te fe ee ee eee Cee ieee ae eee ca ue Ci peroneum during tendon excursion MRI: intrinsic osseous signal abnormality in the os peroneum and Bel tea terete tte tionone ER Loan ety post fall eee ens eee ee eee eee eek) edema within the synchondrosis eta tera Painful Accessory Navicular re eeu eee aon POR Se eet ent ee mato Lyell Nee eed eR Cu Ue ur rut eer synchondrosis from the posterior tibial tendon leads to disruption Prete et neater teres Meee eset ace CT: degeneration at the synchondrosis, abnormal osseous density. NY ee Veet ec a ee Cees Pt at eee een eens htc enc caeones Ce Cece) eee is CO esct ee eee! intermetatarseum (arrow) with pee sted Painful Os intermetatarseum * Caused by compression of the superficial nerves by os intermetatarseum. * Patients present with dorsal foot pain and/or la eee ite ae Te Ree intermetatarsal interspace. Symptoms are worse with jumping or standing.Parla * lrregular margins, not well corticated. Samal ls Romolo ele Some C4 Samal iela\a festa Eee ea eee ft Coe ed ae tel Caer mead ban mee ade] Suelo mule * No donor site appreciated. Samal is0)a\aer Penns foot pain Sagittal and short axis PD fat suppressed MR images of the foot Cee eo ae cay (arrow) and surrounding osseous Peete eres fee Ct lee al Aya * Can result from advanced degenerative changes secondary to altered biomechanics. * Can result from direct trauma.Sc Rea ee Ree me Ree eee! ee ee sree cea LL tea) Paienresteccz) Fulwadhva U, Parker R. Symptomatic Bipartite Medial Cuneiform. App! Radi De een eure ere a eee eee eee eet aeerEE TET? Cre es nr eae cd ae Pee Trias Cece er é eee eee td Se eee @ ann