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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 a distal fibula fracture (1). Measurements are normal. The coronal proton-density-weighted MR image (c) also shows the fibula fracture (1). The axial proton-density-weighted MR image (d) is just below the level of the fibula fracture and demonstrates the rupture of the ATIFL (2). The fascicles of the PTIFL (3) are a little thickened but intact. This is a Weber type B, AO-Müller type B1.1, Lauge-Hansen SE2 fracture with normal measurements but with anterior syndesmotic injury. Ant Anterior, T tibia, F fibula
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Fig4: AP (a) and lateral (b) radiographs show a distal fibula fracture (1). Measurements are normal. The coronal proton-density-weighted MR image (c) also shows the fibula fracture (1). The axial proton-density-weighted MR image (d) is just below the level of the fibula fracture and demonstrates the rupture of the ATIFL (2). The fascicles of the PTIFL (3) are a little thickened but intact. This is a Weber type B, AO-Müller type B1.1, Lauge-Hansen SE2 fracture with normal measurements but with anterior syndesmotic injury. Ant Anterior, T tibia, F fibula

Mentions: In 33 patients with normal measurements on radiographs, MRI showed absence of syndesmotic injury in 13 cases, consisting of 9 patients with a Weber type A and 4 patients with an unclassifiable fracture (Table 2). In the remaining 20 patients with normal measurements, anterior syndesmotic injury was present in 9 (Fig. 4), and both anterior and posterior syndesmotic injury in 11 patients. Syndesmotic injury was defined as either a rupture of the tibiofibular ligament or an intact tibiofibular ligament attached to an avulsion fracture. The measurements were normal in 2 patients with a Weber type A, or AO-Müller A1.2 and A1.3 fracture, with only anterior syndesmotic injury, and in 10 patients with a Weber type B (3 with only anterior and 7 with anterior and posterior injury), or 7 with a AO-Müller B1.1 fracture (3 with only anterior and 4 with anterior and posterior injury) and 1 AO-Müller B3.3 fracture (anterior and posterior injury). The measurements were also normal in six patients with a Weber type C fracture, with only anterior syndesmotic injury present in three and both anterior and posterior injury in another three cases, and in four patients with an AO-Müller type C fracture, three with anterior and one with both anterior and posterior injury. Two fractures that could not be classified by Weber and six that could not be classified by AO-Müller also showed syndesmotic injury.Table 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 a distal fibula fracture (1). Measurements are normal. The coronal proton-density-weighted MR image (c) also shows the fibula fracture (1). The axial proton-density-weighted MR image (d) is just below the level of the fibula fracture and demonstrates the rupture of the ATIFL (2). The fascicles of the PTIFL (3) are a little thickened but intact. This is a Weber type B, AO-Müller type B1.1, Lauge-Hansen SE2 fracture with normal measurements but with anterior syndesmotic injury. Ant Anterior, T tibia, F fibula
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Fig4: AP (a) and lateral (b) radiographs show a distal fibula fracture (1). Measurements are normal. The coronal proton-density-weighted MR image (c) also shows the fibula fracture (1). The axial proton-density-weighted MR image (d) is just below the level of the fibula fracture and demonstrates the rupture of the ATIFL (2). The fascicles of the PTIFL (3) are a little thickened but intact. This is a Weber type B, AO-Müller type B1.1, Lauge-Hansen SE2 fracture with normal measurements but with anterior syndesmotic injury. Ant Anterior, T tibia, F fibula
Mentions: In 33 patients with normal measurements on radiographs, MRI showed absence of syndesmotic injury in 13 cases, consisting of 9 patients with a Weber type A and 4 patients with an unclassifiable fracture (Table 2). In the remaining 20 patients with normal measurements, anterior syndesmotic injury was present in 9 (Fig. 4), and both anterior and posterior syndesmotic injury in 11 patients. Syndesmotic injury was defined as either a rupture of the tibiofibular ligament or an intact tibiofibular ligament attached to an avulsion fracture. The measurements were normal in 2 patients with a Weber type A, or AO-Müller A1.2 and A1.3 fracture, with only anterior syndesmotic injury, and in 10 patients with a Weber type B (3 with only anterior and 7 with anterior and posterior injury), or 7 with a AO-Müller B1.1 fracture (3 with only anterior and 4 with anterior and posterior injury) and 1 AO-Müller B3.3 fracture (anterior and posterior injury). The measurements were also normal in six patients with a Weber type C fracture, with only anterior syndesmotic injury present in three and both anterior and posterior injury in another three cases, and in four patients with an AO-Müller type C fracture, three with anterior and one with both anterior and posterior injury. Two fractures that could not be classified by Weber and six that could not be classified by AO-Müller also showed syndesmotic injury.Table 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