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Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI.

Hermans JJ, Wentink N, Beumer A, Hop WC, Heijboer MP, Moonen AF, Ginai AZ - Skeletal Radiol. (2011)

Bottom Line: When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed.Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling.TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. jjhermans@gmail.com

ABSTRACT

Objective: Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury.

Materials and methods: Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-Müller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI.

Results: The Weber and AO-Müller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47% and a specificity of 100%, and Lauge-Hansen with both a sensitivity and a specificity of 92%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

Conclusion: Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs.

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A schematic drawing of the ankle shows landmarks used for measurements of the different radiologic parameters. L Lateral border of the fibula, M medial border of the fibula, A anterior tibial tubercle, P posterior tibial tubercle, I floor of incisura fibularis, T tibial plafond, S superior point of medial talus, MT medial side of talus, LMM lateral side medial malleolus. AM is tibiofibular overlap (TFO). MI is tibiofibular clear space (TFCS). TS is superior clear space (SCS) and MTLMM is medial clear space (MCS). (Used with permission from A. Beumer, Clin. Orthop. Rel. Res 2004;423:227–234)
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Fig1: A schematic drawing of the ankle shows landmarks used for measurements of the different radiologic parameters. L Lateral border of the fibula, M medial border of the fibula, A anterior tibial tubercle, P posterior tibial tubercle, I floor of incisura fibularis, T tibial plafond, S superior point of medial talus, MT medial side of talus, LMM lateral side medial malleolus. AM is tibiofibular overlap (TFO). MI is tibiofibular clear space (TFCS). TS is superior clear space (SCS) and MTLMM is medial clear space (MCS). (Used with permission from A. Beumer, Clin. Orthop. Rel. Res 2004;423:227–234)

Mentions: Radiographs obtained at presentation included anteroposterior, lateral, and mortise views. The fractures on the radiographs were classified according to the Weber, AO-Müller, and Lauge-Hansen fracture classification systems [5–7]. Both the fracture type and additional measurements of the TFCS, TFO, and MCS/SCS ratio were used to assess possible syndesmotic injury on a radiograph (Fig. 1). The TFCS is the horizontal distance between the posterolateral border, the anterolateral border, or the incisura fibularis of the tibia and the medial border of the fibula. The TFO is the horizontal distance between the medial border of the fibula and the lateral border of the anterior tubercle and was measured at 1 cm above and parallel to the tibial plafond. The MCS is the widest distance between the medial border of the talus and the lateral border of the medial malleolus and was measured 0.5 cm beneath the talar dome, on a line parallel to the superior talar joint surface. The SCS was the vertical distance between the talar dome and the tibial plafond (Fig. 1) [8, 9, 18–22]. A TFCS larger than 6 mm, the absence of tibiofibular overlap (TFO < 0 mm), an MCS/SCS ratio larger than 1, or an MCS larger than 4 mm was considered deviated and indicative for possible syndesmotic injury. The radiographs were blinded for identity and evaluated by a radiologist with 11 years of experience in musculoskeletal radiology (J.H.). For the Weber and AO-Müller fracture classification, expected syndesmotic injury was determined by the fracture type in combination with the measurements. For the Lauge-Hansen fracture classification, expected syndesmotic injury was based on the trauma mechanism deduced from the radiographs.Fig. 1


Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI.

Hermans JJ, Wentink N, Beumer A, Hop WC, Heijboer MP, Moonen AF, Ginai AZ - Skeletal Radiol. (2011)

A schematic drawing of the ankle shows landmarks used for measurements of the different radiologic parameters. L Lateral border of the fibula, M medial border of the fibula, A anterior tibial tubercle, P posterior tibial tubercle, I floor of incisura fibularis, T tibial plafond, S superior point of medial talus, MT medial side of talus, LMM lateral side medial malleolus. AM is tibiofibular overlap (TFO). MI is tibiofibular clear space (TFCS). TS is superior clear space (SCS) and MTLMM is medial clear space (MCS). (Used with permission from A. Beumer, Clin. Orthop. Rel. Res 2004;423:227–234)
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC3368108&req=5

Fig1: A schematic drawing of the ankle shows landmarks used for measurements of the different radiologic parameters. L Lateral border of the fibula, M medial border of the fibula, A anterior tibial tubercle, P posterior tibial tubercle, I floor of incisura fibularis, T tibial plafond, S superior point of medial talus, MT medial side of talus, LMM lateral side medial malleolus. AM is tibiofibular overlap (TFO). MI is tibiofibular clear space (TFCS). TS is superior clear space (SCS) and MTLMM is medial clear space (MCS). (Used with permission from A. Beumer, Clin. Orthop. Rel. Res 2004;423:227–234)
Mentions: Radiographs obtained at presentation included anteroposterior, lateral, and mortise views. The fractures on the radiographs were classified according to the Weber, AO-Müller, and Lauge-Hansen fracture classification systems [5–7]. Both the fracture type and additional measurements of the TFCS, TFO, and MCS/SCS ratio were used to assess possible syndesmotic injury on a radiograph (Fig. 1). The TFCS is the horizontal distance between the posterolateral border, the anterolateral border, or the incisura fibularis of the tibia and the medial border of the fibula. The TFO is the horizontal distance between the medial border of the fibula and the lateral border of the anterior tubercle and was measured at 1 cm above and parallel to the tibial plafond. The MCS is the widest distance between the medial border of the talus and the lateral border of the medial malleolus and was measured 0.5 cm beneath the talar dome, on a line parallel to the superior talar joint surface. The SCS was the vertical distance between the talar dome and the tibial plafond (Fig. 1) [8, 9, 18–22]. A TFCS larger than 6 mm, the absence of tibiofibular overlap (TFO < 0 mm), an MCS/SCS ratio larger than 1, or an MCS larger than 4 mm was considered deviated and indicative for possible syndesmotic injury. The radiographs were blinded for identity and evaluated by a radiologist with 11 years of experience in musculoskeletal radiology (J.H.). For the Weber and AO-Müller fracture classification, expected syndesmotic injury was determined by the fracture type in combination with the measurements. For the Lauge-Hansen fracture classification, expected syndesmotic injury was based on the trauma mechanism deduced from the radiographs.Fig. 1

Bottom Line: When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed.Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling.TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. jjhermans@gmail.com

ABSTRACT

Objective: Owing to the shortcomings of clinical examination and radiographs, injury to the syndesmotic ligaments is often misdiagnosed. When there is no indication requiring that the fractured ankle be operated on, the syndesmosis is not tested intra-operatively, and rupture of this ligamentous complex may be missed. Subsequently the patient is not treated properly leading to chronic complaints such as instability, pain, and swelling. We evaluated three fracture classification methods and radiographic measurements with respect to syndesmotic injury.

Materials and methods: Prospectively the radiographs of 51 consecutive ankle fractures were classified according to Weber, AO-Müller, and Lauge-Hansen. Both the fracture type and additional measurements of the tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and superior clear space (SCS) were used to assess syndesmotic injury. MRI, as standard of reference, was performed to evaluate the integrity of the distal tibiofibular syndesmosis. The sensitivity and specificity for detection of syndesmotic injury with radiography were compared to MRI.

Results: The Weber and AO-Müller fracture classification system, in combination with additional measurements, detected syndesmotic injury with a sensitivity of 47% and a specificity of 100%, and Lauge-Hansen with both a sensitivity and a specificity of 92%. TFCS and TFO did not correlate with syndesmotic injury, and a widened MCS did not correlate with deltoid ligament injury.

Conclusion: Syndesmotic injury as predicted by the Lauge-Hansen fracture classification correlated well with MRI findings. With MRI the extent of syndesmotic injury and therefore fracture stage can be assessed more accurately compared to radiographs.

Show MeSH
Related in: MedlinePlus