The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 10

Scientific Articles | October 01, 2004

Stress Examination of Supination External Rotation-Type Fibular Fractures

Timothy McConnell, MD¹; William Creevy, MD¹; Paul TornettaIII, MD¹

¹ Boston University Medical Center, 818 Harrison Avenue, Boston, MA 02118. E-mail address for P. Tornetta III: ptornetta@pol.net

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Aircast, Inc. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated..

Investigation performed at Boston University Medical Center, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Oct 01;86(10):2171-2178

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Abstract

Background: Deltoid incompetence in association with an isolated fibular fracture is assumed to be present if there is medial tenderness, ecchymosis, or substantial swelling. We sought to determine whether these soft-tissue indicators predict deltoid incompetence by comparing such findings with the findings on stress radiographs.

Methods: Over a thirty-two-month period, 138 patients who presented acutely with a Weber type-B supination-external rotation (SE) fibular fracture were evaluated for tenderness (in nine locations), ecchymosis, and swelling. Patients who presented with an apparently isolated fibular fracture and an intact ankle mortise (with a medial clear space of =4 mm and no talar subluxation) were evaluated with a stress radiograph to determine deltoid competence. Four groups of patients were identified: those who had an SE2 fracture (defined as those who had a stable ankle on the stress radiograph), those who had a stress (+) SE4 fracture (defined as those who had an unstable ankle on the stress radiograph), those who had an SE4 fracture (defined as those who presented with a wide medial clear space), and those who had a bimalleolar fracture. These four groups were compared with regard to tenderness, swelling, and ecchymosis at the time of initial presentation. Patients with SE2 injuries were allowed immediate weight-bearing.

Results: Of the ninety-seven patients who presented with an isolated fibular fracture and an intact mortise, sixty-one had a stable SE2 injury and thirty-six had an unstable stress (+) SE4 injury. All stable SE2 injuries healed with an intact mortise. Medial tenderness, ecchymosis, and swelling were not predictive of deltoid incompetence (instability).

Conclusions: Stress radiographs allow for the accurate diagnosis of deltoid incompetence in patients with Weber type-B SE fibular fractures and no other osseous injury. Soft-tissue indicators are not accurate predictors of instability. If medial tenderness, ecchymosis, and swelling are used as operative indications, in some cases surgery may be performed on stable ankles.

Level of Evidence: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Indirect ankle fractures are one of the most common injuries seen by orthopaedic surgeons. Several classification schemes have been created for such injuries. The Lauge-Hansen classification is based on experimental, clinical, and radiographic observations¹. In 1966, Weber modified the Denis classification of these fractures on the basis of the radiographic level of the fracture in relation to the tibiotalar joint². There is a large volume of literature promoting both operative and nonoperative treatment of indirect ankle fractures. The outcome after an ankle fracture correlates most closely with the alignment of the ankle mortise at the time of union. Ankle fractures that allow for talar subluxation are considered to be unstable. If no specific contraindication is identified and the ankle is unstable, operative treatment is generally recommended^3-8. Ankle instability exists when talar subluxation is possible. As external rotation is the most common mode of injury, the fibula usually fails first when the foot is in supination¹. If displacement continues, then the medial support is eventually lost by means of a medial malleolar fracture or deep deltoid ligament disruption, resulting in instability^9,10. The subjective findings of medial tenderness, swelling, and ecchymosis have been reported to imply a deltoid ligament injury and have been used as an indication for surgical treatment in the presence of a fibular fracture without a medial malleolar fracture^11-13. The assumption is that tenderness over the deltoid, swelling, or ecchymosis indicates a deltoid rupture and concomitant ankle instability. To our knowledge, this concept has never been confirmed, and it is possible that these findings have led to surgery in patients with stable ankle fractures that could have been treated effectively with functional bracing. If the fibula is fractured by means of an external rotation mechanism and the deep deltoid is competent, then ankle stability is maintained. Numerous authors have demonstrated that isolated, stable Lauge-Hansen type-SE2 lateral malleolar fractures can be treated nonoperatively, with an excellent functional outcome and with no increased risk of arthritis after as much as thirty years of follow-up^4,11-18. The purpose of the present investigation was to study the use of stress radiography for the evaluation of ankle stability in patients who presented with a reduced ankle mortise, a Lauge-Hansen type-SE/Weber type-B lateral malleolar fracture, and no medial malleolar fracture. Additionally, we sought to determine the value of medial joint-line tenderness, swelling, and ecchymosis in predicting instability of the ankle in order to differentiate SE2 from SE4 ankle fractures.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Over a thirty-two-month period, 138 consecutive skeletally mature patients with an acute Weber type-B fracture of the lateral malleolus that fit the criterion of a supination-external rotation (SE) fracture, as described by Lauge-Hansen, were evaluated prospectively^1,2. Standard anteroposterior, lateral, and mortise radiographs of the ankle were made for each patient. A clinical data form was completed at the time of presentation in order to document the mechanism of injury, associated injuries, tenderness, swelling, and ecchymosis. Only patients who presented within twenty-four hours after the injury were included. Soft-tissue swelling and ecchymosis of the medial and lateral aspects of the ankle were graded as none, mild, moderate, or severe. Swelling was graded as mild if the ankle was minimally different from that on the normal (contralateral) side, moderate if it was clearly and easily visible, and severe if it was striking or blisters were present. Ecchymosis was described as mild if it was barely visible, moderate if it was easily seen, and severe if it extended over a large area. Finally, each patient was asked to grade tenderness to moderate palpation of nine locations on a visual analog scale from 0 (no pain) to 10 (severe pain). The locations were posteromedial, medial, and anteromedial to the medial malleolus; posterolateral, lateral, and anterolateral to the fibula; and over the lateral malleolus, over the medial malleolus, and over the anterior joint line.

Patients who presented with a wide medial clear space on the initial radiographs (an indication of instability) were deemed to have a displaced SE4 fracture. These patients did not undergo stress radiography and were managed with open reduction and internal fixation. Patients who presented with a fibular fracture, no other osseous injury, and a reduced ankle mortise (Fig. 1) underwent stress radiography, which was performed by an orthopaedic resident at the time of presentation. The stress radiograph was made with the leg stabilized in approximately 10° of internal rotation in order to obtain an approximate mortise view with the ankle in neutral dorsiflexion while an external rotation force of approximately 8 to 10 lb (3.6 to 4.5 kg) was applied to the ankle (Fig. 2)¹⁹. A standard distance was used for all radiographs. A positive finding on the stress radiograph was defined as a medial clear space of >4 mm that was also >1 mm greater than the superior joint space¹⁹, or any identifiable amount of lateral talar subluxation. The requirement for the medial clear space to be >1 mm greater than the superior joint space was intended to avoid false-positive results in larger individuals, who may have a medial clear space of >4 mm normally. In these individuals, the superior joint space acts as a reference. Patients who had a negative finding on the stress examination were assumed to have a competent deltoid ligament, were considered to have an SE2 fracture (Figs. 3-A and 3-B), and were treated nonoperatively with an Aircast stirrup brace (Aircast, Summit, New Jersey) followed by immediate walking with full weight-bearing as tolerated. Patients who were found to have a positive finding on the stress examination (a medial clear space of >4 mm) were assumed to have an incompetent deltoid ligament, were considered to have a stress (+) SE4 fracture (Fig. 4), and were offered open reduction and internal fixation.

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Fig. 1: Mortise radiograph of the ankle of a patient who presented with a Weber type-B SE fibular fracture and no widening of the medial clear space or talar subluxation.

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Fig. 2: Clinical photograph of the position of the external rotation stress radiograph.

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Figs. 3-A and 3-B: Radiographs of the ankle of a patient with an SE pattern fibular fracture. Fig. 3-A Initial radiograph demonstrating a congruent mortise. Fig. 3-B Stress radiograph demonstrating no widening of the medial clear space or talar subluxation.

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Fig. 4: Stress radiograph of the ankle of a patient who presented with an intact ankle mortise. The superior clear space measures 3 mm, and the medial clear space widens to 6 mm. Talar subluxation is also evident.

A single author (T.M.) evaluated the radiographs for each patient. This author was blinded to the eventual treatment during the evaluation of the initial radiographs as the measurements were performed prior to any surgery. The anteroposterior and mortise radiographs that were made at the time of presentation, the stress radiographs, and the immediate postoperative anteroposterior mortise radiographs were used to measure the syndesmotic distance, the medial clear space, the superior clear space, the lateral clear space, and the fibular displacement. The initial and immediate postoperative lateral radiographs were used to measure the distance from the joint line to the fracture and the amount of fibular displacement. Each measurement was repeated two times for consistency, and no differences were found. Comparisons were made between the groups of patients (those with SE2 fractures, those with stress [+] SE4 fractures, and those with displaced SE4 fractures) as defined by the findings on the initial and stress radiographs. Medial tenderness was categorized as mild (0 to 3), moderate (4, 5, or 6), or severe (7 to 10) for the purpose of statistical analysis. Data on patients with bimalleolar ankle fractures also were included for the comparisons of tenderness, ecchymosis, and swelling, but not for the comparisons of radiographic parameters. Statistical comparisons of the groups were performed with use of the Student t test, with a Bonferroni adjustment for repeated evaluations. The presentation of these data was approved by our Institutional Review Board, but the consent of the individual patients was not obtained.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

During the audit period, 138 patients with a Weber type-B SE fibular fracture presented acutely. Twenty-five had a bimalleolar fracture, and 113 had no other osseous injury. Ninety-seven patients presented with no other osseous injury and a reduced mortise and were evaluated with stress radiographs. Sixty-one (63%) of these ninety-seven patients had a negative result on the stress radiograph, were diagnosed as having an SE2 fracture, and were permitted to bear weight as tolerated in an Aircast stirrup splint. Thirty-six (37%) of the ninety-seven patients were found to have instability, were diagnosed as having a stress (+) SE4 fracture, and were offered open reduction and internal fixation. In the cases of six (6%) of the ninety-seven patients, the initial stress radiographs were not diagnostic because of either the poor quality of the radiographs or an equivocal measurement. In these cases, the measurements were repeated in the operating room with the patient under anesthesia and the data were recorded. Thus, there were twenty-five bimalleolar fractures, sixty-one SE2 fractures, thirty-six stress (+) SE4 fractures, and twenty SE4 fractures.

Eight patients with an SE2 ankle fracture were lost to follow-up, leaving fifty-three patients in whom such fractures were followed to union. All fractures healed without widening of the medial clear space or talar subluxation. The average duration of follow-up was nine months (range, three to twenty months).

Radiographic analysis demonstrated significant differences between the displaced SE4 fractures and the SE2 and stress (+) SE4 fractures with regard to the medial clear space and fibular displacement (p < 0.0001) (Table I). Although not helpful in individual cases, analysis of the radiographs that were made at the time of presentation demonstrated significant differences between the SE2 and stress (+) SE4 fractures with regard to the medial clear space (3.23 compared with 3.73 mm, p = 0.001) and fibular displacement (1.58 compared with 1.94 mm, p = 0.008). In contrast, on the stress radiographs, the medial clear space averaged 3.63 mm for the SE2 fractures and 5.69 mm for the stress (+) SE4 fractures (p < 0.0001).

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TABLE I Radiographic Analysis

	Medial Clear Space (mm)			Fibular Displacement (mm)
	Presentation	Stress Radiograph
SE2 (n = 61)	3.23 ± 0.66	3.63 ± 0.58	1.58 ± 1.07
Stress (+) SE4 (n = 36)	3.73 ± 0.69	5.69 ± 0.99	1.94 ± 1.01
Displaced SE4 (n = 20)	7.13 ± 3.42	—	4.00 ± 2.47

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TABLE I Radiographic Analysis

	Medial Clear Space (mm)			Fibular Displacement (mm)
	Presentation	Stress Radiograph
SE2 (n = 61)	3.23 ± 0.66	3.63 ± 0.58	1.58 ± 1.07
Stress (+) SE4 (n = 36)	3.73 ± 0.69	5.69 ± 0.99	1.94 ± 1.01
Displaced SE4 (n = 20)	7.13 ± 3.42	—	4.00 ± 2.47

The rates of tenderness, swelling, and ecchymosis are presented in Tables II, III, and IV. Severe medial tenderness, defined as tenderness at any of the three positions that were tested adjacent to the medial malleolus, was reported by 24% of the patients with an SE2 fracture, compared with 37% of those with a stress (+) SE4 fracture (Fig. 5). Conversely, 50% of the patients with stress (+) SE4 fracture and 31% of those with a displaced SE4 fracture had only mild tenderness medially (Fig. 5). Table II details the percentages of mild, moderate, and severe tenderness according to specific locations. The positive predictive value of severe tenderness in predicting instability was only 56%. The negative predictive value of no or mild tenderness in predicting a stable ankle was 69%. Severe medial soft-tissue swelling was present in 24%, 35%, and 56% of patients with SE2, stress (+) SE4, and displaced SE4 fractures, respectively (Table III and Fig. 6). Severe medial ecchymosis was present in 5%, 6%, and 19% of patients with SE2, stress (+) SE4, and displaced SE4 fractures, respectively (Table IV and Fig. 7).

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TABLE II Rates of Medial Joint-Line Tenderness

	Anterior	Middle	Posterior
SE2 (n = 61)
Severe	15%	13%	11%
Moderate	13%	20%	13%
Mild	72%	67%	76%
Stress (+) SE4 (n = 36)
Severe	25%	28%	19%
Moderate	25%	22%	22%
Mild	50%	50%	59%
Displaced SE4 (n = 20)
Severe	38%	25%	25%
Moderate	13%	38%	6%
Mild	50%	38%	69%
Bimalleolar (n = 25)
Severe	36%	45%	14%
Moderate	41%	18%	23%
Mild	23%	36%	64%

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TABLE II Rates of Medial Joint-Line Tenderness

	Anterior	Middle	Posterior
SE2 (n = 61)
Severe	15%	13%	11%
Moderate	13%	20%	13%
Mild	72%	67%	76%
Stress (+) SE4 (n = 36)
Severe	25%	28%	19%
Moderate	25%	22%	22%
Mild	50%	50%	59%
Displaced SE4 (n = 20)
Severe	38%	25%	25%
Moderate	13%	38%	6%
Mild	50%	38%	69%
Bimalleolar (n = 25)
Severe	36%	45%	14%
Moderate	41%	18%	23%
Mild	23%	36%	64%

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TABLE III Rates of Swelling

	Mild	Moderate	Severe
Medial
SE2 (n = 61)	38%	37%	24%
Stress (+) SE4 (n = 36)	21%	44%	35%
Displaced SE4 (n = 20)	13%	31%	56%
Bimalleolar (n = 25)	36%	50%	14%
Lateral
SE2 (n = 61)	0%	29%	71%
Stress (+) SE4 (n = 36)	6%	44%	50%
Displaced SE4 (n = 20)	6%	31%	63%
Bimalleolar (n = 25)	23%	68%	9%

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TABLE III Rates of Swelling

	Mild	Moderate	Severe
Medial
SE2 (n = 61)	38%	37%	24%
Stress (+) SE4 (n = 36)	21%	44%	35%
Displaced SE4 (n = 20)	13%	31%	56%
Bimalleolar (n = 25)	36%	50%	14%
Lateral
SE2 (n = 61)	0%	29%	71%
Stress (+) SE4 (n = 36)	6%	44%	50%
Displaced SE4 (n = 20)	6%	31%	63%
Bimalleolar (n = 25)	23%	68%	9%

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TABLE IV Rates of Medial Ecchymosis

	Mild	Moderate	Severe
SE2 (n = 61)	84%	11%	5%
Stress (+) SE4 (n = 36)	72%	22%	6%
Displaced SE4 (n = 20)	56%	25%	19%
Bimalleolar (n = 25)	50%	36%	14%

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TABLE IV Rates of Medial Ecchymosis

	Mild	Moderate	Severe
SE2 (n = 61)	84%	11%	5%
Stress (+) SE4 (n = 36)	72%	22%	6%
Displaced SE4 (n = 20)	56%	25%	19%
Bimalleolar (n = 25)	50%	36%	14%

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Fig. 5: Illustration depicting the percentage of patients with varying degrees of medial tenderness in each group.

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Fig. 6: Illustration depicting the percentage of patients with varying degrees of medial swelling in each group.

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Fig. 7: Illustration depicting the percentage of patients with varying degrees of medial ecchymosis in each group.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Isolated Lauge-Hansen SE type fractures of the lateral malleolus comprise 20% to 40% of all ankle fractures^5,7,20. Many authors have reported that nonoperative treatment is effective for SE2 ankle fractures^{4,11-14,17,18,21-23}. Kristensen and Hansen¹⁷ reported that eighty-nine of ninety-four patients who had received closed treatment of an SE2 fracture without reduction had a good outcome with no radiographic signs of arthrosis after sixteen to twenty-five years of follow-up. They stated, however, that some patients who had an SE4 fracture with an associated injury of the deltoid might have been included erroneously, probably giving less favorable results. Ryd and Bengtsson²¹, in a study of forty-nine patients with SE2 fractures who were managed with an elastic bandage and immediate weight-bearing, reported thirty-nine excellent and no poor outcomes after 1.5 years of follow-up. Such treatment was reported to be associated with less joint stiffness, shorter periods of sick leave, and faster mobilization when compared with cast treatment. No or minimal pain on the medial side of the ankle was a prerequisite for inclusion in that study. Port et al.¹³, in a study of sixty-five patients with SE2 fractures, reported that immediate weight-bearing and mobilization resulted in a shorter period of rehabilitation and a significant improvement in range of motion when compared with immobilization in a plaster cast. However, they excluded patients who had medial tenderness or swelling. Finally, Bauer et al.¹⁵ reported that closed treatment did not result in appreciable arthritis after thirty years of follow-up.

The presence of a deltoid ligament injury in conjunction with a lateral malleolar fracture allows for instability, as demonstrated by talar subluxation. Riede et al.²⁴ demonstrated experimentally that a 2-mm displacement of the lateral malleolus reduced the articular surface contact between the tibia and talus by 50% and therefore increased contact forces. For this reason, in the presence of a deep deltoid ligament injury, an SE-type fibular fracture is classified as an SE4 injury, for which operative treatment has been recommended^{10,11,14,18,23,25}. Until now, no clear method of testing deltoid competence in patients with acute fractures has been validated in a study in which the fractures were followed to union. Most surgeons, as described above, rely on medial tenderness, swelling, or ecchymosis as indicators of deltoid incompetence in patients who present with a reduced ankle mortise. While it is likely that the patient has a soft-tissue injury if these symptoms are present, it may not be a complete deep deltoid injury and the deltoid ligament may not be incompetent. The superficial deltoid ligament, taking its origin from the anterior colliculus, does not contribute to medial stability of the ankle and may be injured by means of a rotational mechanism. In our series, anterior tenderness (over the superficial deltoid) was more common than tenderness in the posterior regions of the medial ligamentous complex.

We examined the ability of a radiographic stress examination to differentiate stable SE2 from unstable SE4 ankle fractures in patients who presented with a Weber type-B SE fibular fracture, no other osseous injury, and a reduced ankle mortise. A negative finding on the stress examination (i.e., a medial clear space of =4 mm) predicted a stable ankle that could be treated with full weight-bearing in a functional brace and that could heal without talar displacement. On the basis of previous reports in the literature, patients in whom the fracture unites with no talar subluxation will predictably do well over the long term^2,13,17,21.

Most importantly, the presence of medial tenderness did not predict deltoid incompetence and the lack of medial tenderness did not predict a stable ankle. There were significant differences between the groups with regard to the measurements of clear space and fibular length on the initial presentation radiographs, but the magnitude of these differences was small and was not helpful for decision-making in individual cases. For example, the average medial clear space was slightly wider in the group with stress (+) SE4 fractures than in the group with SE2 fractures (3.73 compared with 3.23 mm), but all of the measurements were <4 mm. Thus, this small difference was not useful for decision-making in individual cases. Likewise, severe medial tenderness was more common in the group with unstable fractures whereas no tenderness was more common in the group with stable fractures, but tenderness was not helpful for predicting stability in individual cases. The positive predictive values of moderate and severe medial tenderness in predicting instability were only 47%, and the value for severe ecchymosis was only 33%. In contrast, a negative finding on the radiographic stress examination was predictive of stability as all SE2 fractures healed without talar displacement with nonoperative functional treatment.

Other modalities, such as magnetic resonance imaging, may be able to determine the extent of soft-tissue injury in patients with ankle fractures but are more costly and less convenient. The radiographic stress examination was able to determine stability in ninety-one (94%) of the ninety-seven patients who were tested in the emergency room, with the other six patients (6%) having the diagnosis made in the operating room with the same method. It was necessary to repeat the examination in the operating room for the latter six patients because the radiographs that had been made in the emergency room were not of good quality (four patients) or because the stress examination was thought to be less than adequate with respect to pain and the measurements were equivocal (two patients). While we are unable to determine if nonoperative treatment of the stress (+) SE4 fractures would have been effective, we believe that operative treatment is the most predictable way to achieve union with an anatomic ankle mortise and we recommended such treatment to our patients. The limitations of the present study include the difficulty of examining acute injuries and of attempting to quantify swelling and ecchymosis. These issues aside, stress radiographs were able to define which patients would be able to bear weight immediately without risk of subluxation. Medial tenderness, ecchymosis, and swelling were not accurate indicators of deltoid incompetence and, if used as indications for surgery, will result in operative management of patients who have stable ankles.

In conclusion, one must use caution when evaluating the initial radiographs to determine the competency of the deltoid ligament in patients who have a Weber type-B, SE pattern fibular fracture. In the absence of a widened medial clear space, the findings of medial tenderness, ecchymosis, and swelling are not predictive of deep deltoid injury. A stress radiograph is a useful clinical examination that can be used to predict the ability to treat isolated Weber type-B, SE fibular fractures with a functional brace without surgery.

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

NOTE: The authors thank all of the orthopaedic surgery residents at the Boston University Medical Center who helped to care for these patients.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

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Topics

edema ; fracture ; ankle ; ecchymosis ; supination ; weber's test ; fibular fractures ; ankle mortise ; deltoid muscle

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John F. Kragh, Jr., M.D.

Posted on November 17, 2004

Radiographic Indicators of Ankle Instability

Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200

To the Editor:

We thank Egol et al. and McConnell et al. for their fine works on deltoid ankle instability with fibula fractures(1,2). We ask them to consider replying to the ideas herein.

1. Women have smaller radiographic medial clear spaces than men,(3) and the use of an absolute threshold introduces non-random error into measurement of instability. An absolute threshold biases assessment because of patient size.

2. Magnification variability due radiographic technique introduces error when using an absolute distance measurement on radiographs to represent an anatomical distance.

3. The operational definition of instability chosen by Egol et al. and used as an indicator by McConnel et al., that is, a medial clear space >4mm on a radiograph during stress examination without anesthesia, led to some determinations of instability that were difficult to explain(1,2). Unstressed radiographic medial clear spaces are reportedly up to 5.5mm in radiographs without fracture and about 8% are >4mm.(4) In cadaver ankles with fibulas excised in simulation of ankle fracture with an intact deltoid ligament, the medial clear space distance increased up to 2mm from the resting distance when stressed due to deltoid laxity at rest.(5) As 4mm may be too low a threshold at rest and up to 2mm more may be added when stressed with the deltoid ligament intact, then laxity may need more consideration in determining instability thresholds. Some of Egol et al.â€™s patients may have been stressed >4mm yet have had intact superficial and/or deep deltoid ligaments. The 4mm threshold historically is an unstressed threshold, but both recent reports used it as stressed. An explanation of the stressed-unstressed mismatch by the authors may help as these problems with the 4mm absolute threshold may in part explain the difficulties.

4. Radiographic indicators of ankle instability that address these problems may perform better diagnostically. Conceivably, if the medial clear space is divided by the superior clear space to get a relative index of instability, then the problems of patient size bias, magnification error, and the absolute threshold can be mitigated.

John F. Kragh, Jr. M.D. LTC(P), MC, USA

Jon Thompson, M.D. MAJ, MC, USA

1. Egol KA, Amirtharage M, Tejwani NC, Capla EL, Koval KJ. Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg, 86A:2393-405, 2004.

2. McConnell T, Creery W, Tornetta P III. Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg, 86A:2171-8, 2004.

3. Jonsson K. Fredin HO. Cederlund CG. Bauer M. Width of the normal ankle joint. Acta Radiologica: Diagnosis. 25(2):147-9, 1984.

4. Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A. Observer reliability in ankle radiographic measurements, Foot Ankle Int, 18:324-9, 1997.

5. Close JR. Some applications of the functional anatomy of the ankle joint. J Bone Joint Surg, 38A:761-81, 1956.

James D. Michelson

Posted on November 02, 2004

Assessment of the Deltoid Ligament Complex

George Washington University School of Medicine

To the Editor,

I congratulate Drs. McConnell, et al.,(1) on their paper describing a clinical method to evaluate the competence of the deltoid ligament. Since biomechanical ankle instability is determined by the presence of complete medial injury(2-6), assessing the competence of the deltoid complex does, as noted by McConnell, et al., assume primary importance in the treatment of patients with ankle fractures.

It should be noted, however, that previous work(7) provided the underpinning of this study by demonstrating that the ankle is unstable to valgus stress only when the deep and superficial deltoid ligaments are simultaneously injured. In the earlier study, the need for forceful application of stress was avoided by letting gravity provide gentle stress to the ankle, similar to the gravity stress test for ulnar instability of the elbow. This was accomplished by taking a mortise or antero-posterior radiograph of the ankle while it was held horizontal (medial side uppermost) and supported on a pillow. This radiographic technique was shown to be 100% sensitive and 100% specific for deltoid injury in a cadaver model. Although the work of McConnell has added external rotation to the stress view, it essentially provides the companion clinical study to the previous laboratory investigation. As such, it serves to validate the concept of how to assess the competence of the deltoid ligament complex.

This is a significant study that points out the importance of assessing the deltoid ligament complex in the treatment of lateral malleolar ankle fractures. Whether one uses the applied external rotation stress method or the gravity stress method, the authors have done well by emphasizing the need to determine deltoid competence, so as to avoid unnecessary surgery in isolated lateral malleolar fractures (3,4).

Sincerely,

James Michelson, M.D.

Reference List

1. McConnell, T., Creevy, W., and Tornetta, P., III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg. Am. 86-A:2171-2178, 2004.

2. Michelson, J. D., Ahn, U. M., and Helgemo, S. L.: Ankle Motion Following Simulated Supination-External Rotation Fracture. J. Bone. Joint. Surg. [Am]. 78:1024-1031, 1996.

3. Michelson, J. D.: Ankle fractures resulting from rotational injuries. J Am. Acad. Orthop. Surg. 11:403-412, 2003.

4. Michelson, J. D.: Fractures about the ankle. J. Bone Joint Surg. Am. 77:142-152, 1995.

5. Earll, M., Wayne, J., Brodrick, C., Vokshoor, A., and Adelaar, R.: Contribution of the deltoid ligament to ankle joint contact characteristics: a cadaver study. Foot Ankle Int. 17:317-324, 1996.

6. Boden, S. D., Labropoulos, P. A., McCowin, P., Lestini, W. F., and Hurwitz, S. R.: Mechanical considerations for the syndesmosis screw. A cadaver. J. Bone Joint Surg. [Am. ]. 71:1548-1555, 1989.

7. Michelson, J. D., Varner, K. E., and Checcone, M.: Diagnosing deltoid injury in ankle fractures: the gravity stress view. Clin Orthop. 387:178-182, 2001.

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Timothy McConnell, William Creevy, Paul TornettaIII; Stress Examination of Supination External Rotation-Type Fibular Fractures. The Journal of Bone & Joint Surgery. 2004 Oct;86(10):2171-2178.

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