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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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AP (a) and lateral (b) radiographs show an oblique fibula fracture (1), running from anteroinferior to posterosuperior, characteristic of a supination-external rotation injury. The medial malleolus (2) and posterior malleolus (3) are avulsed. AP (c) and lateral (d) radiographs after open reduction and internal fixation without a setscrew. The fracture of the posterior malleolus (3) is visible and not fixated. The fracture was classified as Weber type C, AO-Müller C2.3, Lauge-Hansen SE4. Coronal (e), 45° oblique (f, g), and axial proton-density-weighted (h) MR image. The coronal MRI shows the laterally dislocated talus, with a distal fibula fracture (1) and an avulsion fracture of the medial malleolus (2) attached to a thickened but intact superficial deltoid ligament (4). In f, the ATIFL (5) is ruptured, whereas the PTIFL (6) is intact and attached to an avulsion fracture of the posterolateral malleolus (3). In g, the ruptured interosseous ligament (7) is visible. In h, the fibula fracture (1) runs proximal to the interosseous membrane (8), which has a small tibial avulsion (9) up to this level. Ant Anterior, T tibia, F fibula
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Fig2: AP (a) and lateral (b) radiographs show an oblique fibula fracture (1), running from anteroinferior to posterosuperior, characteristic of a supination-external rotation injury. The medial malleolus (2) and posterior malleolus (3) are avulsed. AP (c) and lateral (d) radiographs after open reduction and internal fixation without a setscrew. The fracture of the posterior malleolus (3) is visible and not fixated. The fracture was classified as Weber type C, AO-Müller C2.3, Lauge-Hansen SE4. Coronal (e), 45° oblique (f, g), and axial proton-density-weighted (h) MR image. The coronal MRI shows the laterally dislocated talus, with a distal fibula fracture (1) and an avulsion fracture of the medial malleolus (2) attached to a thickened but intact superficial deltoid ligament (4). In f, the ATIFL (5) is ruptured, whereas the PTIFL (6) is intact and attached to an avulsion fracture of the posterolateral malleolus (3). In g, the ruptured interosseous ligament (7) is visible. In h, the fibula fracture (1) runs proximal to the interosseous membrane (8), which has a small tibial avulsion (9) up to this level. Ant Anterior, T tibia, F fibula

Mentions: Syndesmotic injury consisted of either a rupture of the distal tibiofibular ligament or an intact tibiofibular ligament with a bony avulsion from either the tibia or fibula. Anteriorly, the distal tibiofibular ligament was ruptured in 27 patients and intact but associated with a fibular avulsion in 8 patients and with a tibial avulsion in 1. On the radiographs, however, only the tibial avulsion and three of eight fibular avulsion fractures were visible. Posteriorly, the distal tibiofibular ligament was ruptured in three patients. An intact ligament associated with an avulsion fracture occurred in 18 patients, but only at the tibia, and was defined as any size of posterior malleolus fracture. The posterior malleolus fracture was not visible on the radiographs in 6/18 patients, although it involved a large posteromedial fragment in 3. Injury of the posterior syndesmosis occurred only in combination with anterior injury (n = 21) (Fig. 2).Fig. 2


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)

AP (a) and lateral (b) radiographs show an oblique fibula fracture (1), running from anteroinferior to posterosuperior, characteristic of a supination-external rotation injury. The medial malleolus (2) and posterior malleolus (3) are avulsed. AP (c) and lateral (d) radiographs after open reduction and internal fixation without a setscrew. The fracture of the posterior malleolus (3) is visible and not fixated. The fracture was classified as Weber type C, AO-Müller C2.3, Lauge-Hansen SE4. Coronal (e), 45° oblique (f, g), and axial proton-density-weighted (h) MR image. The coronal MRI shows the laterally dislocated talus, with a distal fibula fracture (1) and an avulsion fracture of the medial malleolus (2) attached to a thickened but intact superficial deltoid ligament (4). In f, the ATIFL (5) is ruptured, whereas the PTIFL (6) is intact and attached to an avulsion fracture of the posterolateral malleolus (3). In g, the ruptured interosseous ligament (7) is visible. In h, the fibula fracture (1) runs proximal to the interosseous membrane (8), which has a small tibial avulsion (9) up to this level. Ant Anterior, T tibia, F fibula
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Related In: Results  -  Collection

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Fig2: AP (a) and lateral (b) radiographs show an oblique fibula fracture (1), running from anteroinferior to posterosuperior, characteristic of a supination-external rotation injury. The medial malleolus (2) and posterior malleolus (3) are avulsed. AP (c) and lateral (d) radiographs after open reduction and internal fixation without a setscrew. The fracture of the posterior malleolus (3) is visible and not fixated. The fracture was classified as Weber type C, AO-Müller C2.3, Lauge-Hansen SE4. Coronal (e), 45° oblique (f, g), and axial proton-density-weighted (h) MR image. The coronal MRI shows the laterally dislocated talus, with a distal fibula fracture (1) and an avulsion fracture of the medial malleolus (2) attached to a thickened but intact superficial deltoid ligament (4). In f, the ATIFL (5) is ruptured, whereas the PTIFL (6) is intact and attached to an avulsion fracture of the posterolateral malleolus (3). In g, the ruptured interosseous ligament (7) is visible. In h, the fibula fracture (1) runs proximal to the interosseous membrane (8), which has a small tibial avulsion (9) up to this level. Ant Anterior, T tibia, F fibula
Mentions: Syndesmotic injury consisted of either a rupture of the distal tibiofibular ligament or an intact tibiofibular ligament with a bony avulsion from either the tibia or fibula. Anteriorly, the distal tibiofibular ligament was ruptured in 27 patients and intact but associated with a fibular avulsion in 8 patients and with a tibial avulsion in 1. On the radiographs, however, only the tibial avulsion and three of eight fibular avulsion fractures were visible. Posteriorly, the distal tibiofibular ligament was ruptured in three patients. An intact ligament associated with an avulsion fracture occurred in 18 patients, but only at the tibia, and was defined as any size of posterior malleolus fracture. The posterior malleolus fracture was not visible on the radiographs in 6/18 patients, although it involved a large posteromedial fragment in 3. Injury of the posterior syndesmosis occurred only in combination with anterior injury (n = 21) (Fig. 2).Fig. 2

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