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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. A transverse fibular malleolar fracture (1) below the level of the tibiotalar joint space is visible. No fracture is visible at the medial or posterior malleolus. Measurements are normal. The fracture was classified as Weber A, AO-Müller A1.3, Lauge-Hansen SA1. Coronal (c), sagittal (d), and axial (e) proton-density-weighted MR image. The transverse fibula fracture (1) is visible on the coronal and sagittal MR image. The lower border of the ruptured ATIFL (2) lies just across the fibula fracture as can be seen on the sagittal MR image (d). In the 45° oblique image (e) the ATIFL (2) is thickened and avulsed from the fibula. The PTIFL (3) is intact. Ant Anterior, T tibia, F fibula
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Fig5: AP (a) and lateral (b) radiographs. A transverse fibular malleolar fracture (1) below the level of the tibiotalar joint space is visible. No fracture is visible at the medial or posterior malleolus. Measurements are normal. The fracture was classified as Weber A, AO-Müller A1.3, Lauge-Hansen SA1. Coronal (c), sagittal (d), and axial (e) proton-density-weighted MR image. The transverse fibula fracture (1) is visible on the coronal and sagittal MR image. The lower border of the ruptured ATIFL (2) lies just across the fibula fracture as can be seen on the sagittal MR image (d). In the 45° oblique image (e) the ATIFL (2) is thickened and avulsed from the fibula. The PTIFL (3) is intact. Ant Anterior, T tibia, F fibula

Mentions: Underestimation involved three cases in which LH missed a rupture of the anterior syndesmosis. On radiographs, a transverse fibular fracture below the level of the tibiotalar joint space was present, suggesting a supination adduction type 1 (SA1) fracture. MRI showed, in addition to the transverse fibular fracture, injury of the anterior syndesmosis (Fig. 5). This is therefore not compatible with the general statement that the syndesmosis is not involved in supination-adduction injury, which is by definition an infrasyndesmotic injury. Gardner et al. also found 1 case, in a series of 59 patients, with a supination-adduction trauma in which the anterior tibiofibular ligament was ruptured [27]. As the ATIFL runs approximately in a 45° oblique plane from the anterior tibial tubercle to the anterior fibular tubercle and just crosses the anterolateral talar corner, its fibular insertion point lies a little below the level of the tibiotalar joint space [24, 28]. A fibula fracture at this level could therefore result in injury of the ATIFL. This finding could affect treatment outcome, as in the presence of syndesmotic injury a non-weightbearing cast would be the preferred treatment. In case of anterior syndesmotic injury, early weightbearing could result in an elongated healed ATIFL leading to complaints of chronic instability or even early osteoarthritis.Fig. 5


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. A transverse fibular malleolar fracture (1) below the level of the tibiotalar joint space is visible. No fracture is visible at the medial or posterior malleolus. Measurements are normal. The fracture was classified as Weber A, AO-Müller A1.3, Lauge-Hansen SA1. Coronal (c), sagittal (d), and axial (e) proton-density-weighted MR image. The transverse fibula fracture (1) is visible on the coronal and sagittal MR image. The lower border of the ruptured ATIFL (2) lies just across the fibula fracture as can be seen on the sagittal MR image (d). In the 45° oblique image (e) the ATIFL (2) is thickened and avulsed from the fibula. The PTIFL (3) is intact. Ant Anterior, T tibia, F fibula
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Fig5: AP (a) and lateral (b) radiographs. A transverse fibular malleolar fracture (1) below the level of the tibiotalar joint space is visible. No fracture is visible at the medial or posterior malleolus. Measurements are normal. The fracture was classified as Weber A, AO-Müller A1.3, Lauge-Hansen SA1. Coronal (c), sagittal (d), and axial (e) proton-density-weighted MR image. The transverse fibula fracture (1) is visible on the coronal and sagittal MR image. The lower border of the ruptured ATIFL (2) lies just across the fibula fracture as can be seen on the sagittal MR image (d). In the 45° oblique image (e) the ATIFL (2) is thickened and avulsed from the fibula. The PTIFL (3) is intact. Ant Anterior, T tibia, F fibula
Mentions: Underestimation involved three cases in which LH missed a rupture of the anterior syndesmosis. On radiographs, a transverse fibular fracture below the level of the tibiotalar joint space was present, suggesting a supination adduction type 1 (SA1) fracture. MRI showed, in addition to the transverse fibular fracture, injury of the anterior syndesmosis (Fig. 5). This is therefore not compatible with the general statement that the syndesmosis is not involved in supination-adduction injury, which is by definition an infrasyndesmotic injury. Gardner et al. also found 1 case, in a series of 59 patients, with a supination-adduction trauma in which the anterior tibiofibular ligament was ruptured [27]. As the ATIFL runs approximately in a 45° oblique plane from the anterior tibial tubercle to the anterior fibular tubercle and just crosses the anterolateral talar corner, its fibular insertion point lies a little below the level of the tibiotalar joint space [24, 28]. A fibula fracture at this level could therefore result in injury of the ATIFL. This finding could affect treatment outcome, as in the presence of syndesmotic injury a non-weightbearing cast would be the preferred treatment. In case of anterior syndesmotic injury, early weightbearing could result in an elongated healed ATIFL leading to complaints of chronic instability or even early osteoarthritis.Fig. 5

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