Skeletal Radiology

, Volume 47, Issue 5, pp 631–648 | Cite as

Imaging in syndesmotic injury: a systematic literature review

  • Nicola Krähenbühl
  • Maxwell W. Weinberg
  • Nathan P. Davidson
  • Megan K. Mills
  • Beat Hintermann
  • Charles L. Saltzman
  • Alexej Barg
Scientific Article



To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis.

Materials and methods

A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality.


The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice.


Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients’ complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.


Syndesmotic injury Imaging Conventional radiographs CT MRI 


Compliance with ethical standards

Conflict of interests

Nicola Krahenbuhl is supported by a grant from the Swiss National Science Foundation (SNF; grant number P2BSP3_174979).


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Copyright information

© ISS 2017

Authors and Affiliations

  • Nicola Krähenbühl
    • 1
  • Maxwell W. Weinberg
    • 1
  • Nathan P. Davidson
    • 1
  • Megan K. Mills
    • 2
  • Beat Hintermann
    • 3
  • Charles L. Saltzman
    • 1
  • Alexej Barg
    • 1
  1. 1.Department of OrthopaedicsUniversity of UtahSalt Lake CityUSA
  2. 2.Department of Radiology and Imaging SciencesUniversity of UtahSalt Lake CityUSA
  3. 3.Department of OrthopaedicsKantonsspital BasellandLiestalSwitzerland

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