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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. Short distal fibula fracture (1) extending from just below to just above the level of the tibiotalar joint line. Measurements are normal. This fracture is classified as Weber type B, AO-Müller type B1.1, and Lauge-Hansen SE2. Coronal (c, d), axial (e) and 45° oblique (f, g, h) proton-density-weighted MR images. The coronal MRI (c, d) shows the fibula fracture (1), a posterolateral osteochondral lesion of the talar dome (2), a normal interosseous ligament (3), a thickened superficial (4), and a normal deep (5) deltoid ligament. On the axial (e) and oblique MR image (f), the transverse ligament (6) is ruptured. The PTIFL (7) appears to be ruptured in the axial plane (e) but is still continuous, although thickened, in the 45° oblique plane (h). The ATIFL (8) is ruptured (g). With the MRI findings, this would change the fracture into an AO-Müller type B1.2, but it would still be Lauge-Hansen SE2. Ant Anterior, Ta talus, T tibia, F fibula
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Fig3: AP (a) and lateral (b) radiographs. Short distal fibula fracture (1) extending from just below to just above the level of the tibiotalar joint line. Measurements are normal. This fracture is classified as Weber type B, AO-Müller type B1.1, and Lauge-Hansen SE2. Coronal (c, d), axial (e) and 45° oblique (f, g, h) proton-density-weighted MR images. The coronal MRI (c, d) shows the fibula fracture (1), a posterolateral osteochondral lesion of the talar dome (2), a normal interosseous ligament (3), a thickened superficial (4), and a normal deep (5) deltoid ligament. On the axial (e) and oblique MR image (f), the transverse ligament (6) is ruptured. The PTIFL (7) appears to be ruptured in the axial plane (e) but is still continuous, although thickened, in the 45° oblique plane (h). The ATIFL (8) is ruptured (g). With the MRI findings, this would change the fracture into an AO-Müller type B1.2, but it would still be Lauge-Hansen SE2. Ant Anterior, Ta talus, T tibia, F fibula

Mentions: The interosseous ligament was injured in seven patients, and in six of seven patients showed intact fascicles with an avulsed periost from its tibial attachment. The interosseous ligament was ruptured in three patients in association with a ruptured anterior syndesmosis and in three patients with a ruptured anterior as well as posterior syndesmosis. In one patient it involved a ruptured interosseous ligament in combination with only a fracture of the medial malleolus. The transverse ligament was completely ruptured in one patient with only anterior syndesmotic injury (Fig. 3) and partially ruptured in another with both anterior and posterior syndesmotic injury.Fig. 3


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. Short distal fibula fracture (1) extending from just below to just above the level of the tibiotalar joint line. Measurements are normal. This fracture is classified as Weber type B, AO-Müller type B1.1, and Lauge-Hansen SE2. Coronal (c, d), axial (e) and 45° oblique (f, g, h) proton-density-weighted MR images. The coronal MRI (c, d) shows the fibula fracture (1), a posterolateral osteochondral lesion of the talar dome (2), a normal interosseous ligament (3), a thickened superficial (4), and a normal deep (5) deltoid ligament. On the axial (e) and oblique MR image (f), the transverse ligament (6) is ruptured. The PTIFL (7) appears to be ruptured in the axial plane (e) but is still continuous, although thickened, in the 45° oblique plane (h). The ATIFL (8) is ruptured (g). With the MRI findings, this would change the fracture into an AO-Müller type B1.2, but it would still be Lauge-Hansen SE2. Ant Anterior, Ta talus, T tibia, F fibula
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Fig3: AP (a) and lateral (b) radiographs. Short distal fibula fracture (1) extending from just below to just above the level of the tibiotalar joint line. Measurements are normal. This fracture is classified as Weber type B, AO-Müller type B1.1, and Lauge-Hansen SE2. Coronal (c, d), axial (e) and 45° oblique (f, g, h) proton-density-weighted MR images. The coronal MRI (c, d) shows the fibula fracture (1), a posterolateral osteochondral lesion of the talar dome (2), a normal interosseous ligament (3), a thickened superficial (4), and a normal deep (5) deltoid ligament. On the axial (e) and oblique MR image (f), the transverse ligament (6) is ruptured. The PTIFL (7) appears to be ruptured in the axial plane (e) but is still continuous, although thickened, in the 45° oblique plane (h). The ATIFL (8) is ruptured (g). With the MRI findings, this would change the fracture into an AO-Müller type B1.2, but it would still be Lauge-Hansen SE2. Ant Anterior, Ta talus, T tibia, F fibula
Mentions: The interosseous ligament was injured in seven patients, and in six of seven patients showed intact fascicles with an avulsed periost from its tibial attachment. The interosseous ligament was ruptured in three patients in association with a ruptured anterior syndesmosis and in three patients with a ruptured anterior as well as posterior syndesmosis. In one patient it involved a ruptured interosseous ligament in combination with only a fracture of the medial malleolus. The transverse ligament was completely ruptured in one patient with only anterior syndesmotic injury (Fig. 3) and partially ruptured in another with both anterior and posterior syndesmotic injury.Fig. 3

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