Ankle Xray QBank

Board Prep and Comprehension Testing

A 32-year-old female sustains the injury shown here. What is the most reliable method to evaluate the competence of the deltoid ligament?

a. Medial ankle tendernessb. Medial ankle ecchymosisc. Squeeze testd. Stress radiography of the anklee. Canal view radiograph

Fracture: Weber B Stage 4• Lateral swelling (ATFL injury)• Oblique fibular fx• Medial clear space widened >4mm

Injury Pattern: Supination, exorotation

Answer: DDeltoid ligament (medial structure) evaluation is important for therapeutic reasons, as medial sided instability will portend a poor prognosis if treated nonoperatively. The physical exam is a poor indicator of medial ankle injury.

References:1. McConnell T, Creevy W, Tornetta P 3rd. Stress examination of supination external

rotation-type fibular fractures. J Bone Joint Surg Am. 2004 Oct;86-A(10):2171-8. PMID:15466725 (Link to Abstract)

2. Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC Jr. Comparison of manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures. J Bone Joint Surg Am. 2007 May;89(5):994-9. PMID:17473136 (Link to Abstract)

An 18-year-old football player presents to the emergency department after sustaining an ankle injury. What is the next step in his management?

A. ER reduction, splint, d/c to f/uB. Splint in position of comfort and d/cC. Prep for emergent surgeryD. ER reduction, splint, admit for urgent

surgeryE. Have him walk on home

Fracture: Weber C Stage 3• Medial malleolar avulsion fx• Transverse fibular fx above

syndesmosis• Syndesmotic widening, lateral clear

space >5mm

Injury Pattern: Pronation, exorotation

Answer: DThis is a fracture-dislocation w/ evidence of skin tenting (red circle) by the distal tibia. Urgent ER reduction is therefore indicated to minimize tissue necrosis and given the degree of syndesmotic injury, OR fixation is required

References:1. Zalavras C, Thordarson D: Ankle syndesmotic injury. J Am Acad Orthop Surg

2007;15:330-339 PMID:17548882 (Link to Abstract) 2. Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD (eds):

Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090

A 29yo M was playing basketball when he went to pivot and “rolled his ankle”. He was initially unable to walk at the time of injury but is now toe touching. Xrays are taken and you appropriately analyze the fibula. Your next step in management is…

A. Evaluate the medial malleolus for a secondary impact fracture

B. Obtain knee films to rule out a Maissoneuvre fracture

C. Call Ortho for surgical pre-opD. Apply a post-mold splint and refer for

Ortho follow up in 1 weekE. Apply an air cast and encourage early

ambulation

Fracture: None• This is an example of an os sub-

fibulare (see next page for more examples)

Injury Pattern: Supination, adduction

Answer: EAnswer A is reasonable to rule out any secondary impact fracture to the medial tibia or talus, but without obvious fracture pattern or ATFL injury, the likelihood of a Weber A2 fracture is low. The mechanism is not appropriate for syndesomtic injury or Maissoneuvre mechanism, so knee films are not indicated. Basic strain/sprain care is all that is required.

References:1. Browner, BD, Jupiter JB, Levine AM, Trafton, PG, eds. Skeletal Trauma.

Philadelphia, PA; WB Saunders, 2003: 2325-2330.

Os sub-tibiale and os trigonum (of the lateral talus) commonly mistaken for fractures…

• Note the lack of fibular cortical disruption

• Each os is uncorticated

A 45yo M was walking his St. Bernard when it suddenly took off running after a cat, pulling him to the ground and has been unable to ambulate since. How will you manage this patient?

A. Walking boot and ambulate as tolerated

B. Ace wrap, ice, elevation, NSAIDs and early weight bearing

C. Post mold, crutches, NWB status and ortho f/u

D. There is no injury, comfort care only

E. Call Ortho for immediate OR

Answer: C

Without more views, it is difficult to tell if this is a Weber B or C, but we certainly know it is not a Weber A because the posterior malleolus is involved.

Because the posterior malleolus is involved, we know that it is an eversion injury and it would be imperative to image the fibula up to the knee to search for a possible Maissoneuvre.

Note how easily missed this fracture is as it can easily be misinterpreted as the fibular shadow unless closely interrogated.

Without knowing anything about this patient, would you be able to predict the fracture pattern?

A. Pronation eversionB. Pronation abductionC. Supination exorotationD. Supination adductionE. Supination inversion

Answer: D

Aside from being almost assuredly painful, this is a Weber A or supination (aka inversion) adduction (heel up, ankle up) injury.

We see the fibular fracture (arrow) below the level of the mortise. Additionally we see the medial malleolus is fractured (lightning), making this a Weber A type 2.

Most Weber A fractures are type 1 and do not require surgery. However, if the medial malleolus is involved (as in this case), surgery is likely required.

There is also a marked dislocation, so this will need reduction and post-mold w/ stirrup and strict NWB status.

Which ligament is likely NOT ruptured in this patient?

A. Anterior talofibular ligament (ATFL)

B. Deltoid ligamentC. Posterior talofibular ligament

(PTFL)D. Poster tibiofibular ligamentE. Calcaneofibular ligament

Answer: B

The fracture pattern is a Weber C (either 3 or 4, depending on if the posterior malleolus is intact or not).

First we see the spiral fibular fracture above the mortise (red arrow), pathognomonic for a pronation-exorotation (or Weber C) injury. The first ligament injured is the ATFL and commonly the PTFL is involved as well.

Secondly, note the syndesmotic widening (blue arrow) and therefore disruption.

The medial malleolus is sheared off (circle), so the deltoid ligament is likely intact.

Lastly, note the high fibular fracture (that could have been missed.

What is this patient’s disposition?

A. Home w/ an Ace wrap?B. Home w/ an air cast and WBAT?C. Home w/ an air cast and NWB until f/u?D. Post-mold w/ stirrup, crutches, o/p f/u?E. Straight to OR?

Answer: C

Isolated medial malleolar fractures often have good outcomes with conservative measures. You should have the patient maintain non-weight bearing status (NWBS) until their ortho f/u and inform them that they will likely be casted for 4-6 weeks.

Reference:

Conservative treatment of isolated fractures of the medial malleolus D. Herscovici, Jr, DO; J. M. Scaduto, ARNP; A. Infante, DO, Florida Orthopaedic Institute, 13020 Telecom Parkway, Temple Terrace, Florida 33637, USA.

How many fractures did this patient sustain?A. OneB. Two C. ThreeD. FourE. Five

Answer: A

The spiral fibular avulsion fracture (outlined) at the level of the mortise (Weber B) is the only apparent fracture, the tibial abnormality is likely physeal scarring (arrow).

This 13yo F was climbing a tree when she jumped down approximately 8 feet and landed on her feet. She is complaining of severe pain to her plantar foot and heel. What is your plan of management for this patient?

A. Ortho referral for possible surgeryB. Splint, NWBS and f/u w/ PMDC. Aircast and WBAT D. Reassurance and discharge to homeE. Amputation

Answer: D

This is a calcaneal physis, not an avulsion fracture. The pt likely has some plantar fascial irritation and strain from the fall, but there is no evidence of fracture. Note the lack of cortication of the fragment. Another indirect way of teasing out if this is a fracture or physis is to draw lines to approximate the edges. If the extra bone looks like it couldn’t fit on the underlying area perfectly, it’s likely not a fracture. In this case, the fragment looks well aligned with the outer margins of the calcaneus.

By what mechanism did this patient likely injury himself?A. Suppination, exorotation injuryB. Shin strike onto a hard surfaceC. There is no fractureD. Pronation, exorotation injuryE. Fall from height

Answer: E

Pilon fractures most commonly occur as a result of axial loading and special mortise views such as this should be obtained to thoroughly evaluate the plafond.

This patient should be splinted, given crutches, instructed on NWBS and referred to orthopedics for definitive management. This patient will not likely require surgery given that they are young in age (note the many ossification centers).

Which Weber class does this injury represent?

A. Weber A2B. Weber B2C. Weber C1D. Weber C2E. Weber C3

Answer: E

First, the spiral fibular fracture above the mortise (red arrow) identifies this as a Weber C.

Second, the tibiofibular overlap is widened (green arrow), indicating ATFL disruption.

Third, the medial malleolus is avulsed, making this more severe than a Weber B.

If the posterior malleolus is fractured on the lateral film, this would become a C4

This patient slipped on the curb and currently only has lateral malleolar tenderness, therefore you DO NOT need to obtain knee films to assess the proximal fibula?

A. TrueB. False

Answer: False

The spiral fracture above the mortise makes this a Weber C which are the only fracture patterns that commonly cause the Maissoneuvre fracture.

The lack of medial malleolar swelling and pain is less worrisome, but isolated severe spiral fractures often are not found in isolation.

You are a community EP working in Montana when a 24yo M comes in after “just missing” a “killer jump” on his skateboard. You immediately recognize the fracture type, and you plan on…

A. Apply a fiberglass splint, strict NWBS w/ crutches and Ortho f/u in 3-5 days

B. Call Ortho to discuss the case for possible OR pinning during this admission

C. Aircast and toe-touch weight bearing with follow up in 1-2 weeks

D. Doing nothing, these commonly heal without any intervention

E. Asking the patient for a copy of the video he shot of him eating it

Answer: B

This is as severe as they come, Weber C4. The spiral fibular fracture above the mortise (blue arrow) makes this a class C, the anterior supratalar widening of the joint space (green arrow) indicates ligamentous disruption and the posterior malleolar fracture (circle) makes this a C4.

Ortho might have you splint and have the patient follow up in the office tomorrow for surgery, but most likely they will want to stabilize this sooner rather than later, but either way, the patient should not leave without Ortho knowing about this patient.