The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures

Abstract

Background

Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.

Questions/Purposes

The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures.

Methods

Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation.

Results

Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%).

Conclusion

Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

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References

  1. 1.

    Bauer M, Bergström B, Hemborg A, Sandegård J. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clin Orthop Relat Res. 1985;199:17–27.

    Google Scholar 

  2. 2.

    Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures. Acta Orthop Scand. 1985;56:103–106.

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Boss AP, Hintermann B. Anatomical study of the medial ankle ligament complex. Foot Ankle Int. 2002;23(6):547–553.

    Article  PubMed  Google Scholar 

  4. 4.

    Brink O, Staunstrup H, Sommer J. Stable lateral malleolar fractures treated with aircast ankle brace and DonJoy R.O.M.-Walker brace: a prospective randomized study. Foot Ankle Int. 1996;17:679–684.

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014;96:e62.

    Article  PubMed  Google Scholar 

  6. 6.

    Chen P-Y, Wang T-G, Wang C-L. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. Foot Ankle Int. 2008;29:883–886.

    Article  PubMed  Google Scholar 

  7. 7.

    Cheung Y, Perrich KD, Gui J, Koval KJ, Goodwin DW. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted?, Am J Roentgenol. 2009;192:7–12.

    Article  Google Scholar 

  8. 8.

    Crim J, Longenecker LG. MRI and surgical findings in deltoid ligament tears. Am J Roentgenol. 2015;63–69.

  9. 9.

    de Souza LJ, Gustilo RB, Meyer TJ. Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg Am. 1985;67:1066–1074.

    Article  PubMed  Google Scholar 

  10. 10.

    DeAngelis, NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures?, J Orthop Trauma. 2007;21:244–247.

    Article  PubMed  Google Scholar 

  11. 11.

    den Bekerom MPJ, Mutsaerts ELR, Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: A systematic review of the literature. Arch Orthop Trauma Surg. 2009;129:227–235.

    Article  PubMed  Google Scholar 

  12. 12.

    Earll M, Wayne J, Brodrick C, Vokshoor A, Adelaar R. Contribution of the deltoid ligament to ankle joint contact characteristics: a cadaver study. Foot Ankle Int. 1996;17:317–324.

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Egol K, Amirtharajah M, Tejwani NC, Capla EL, Koval KJ. Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am. 2004;86-A:2393–2398.

    Article  Google Scholar 

  14. 14.

    Femino JE, Vaseenon T, Phistkul P, Tochigi Y, Anderson DD, Amendola A. Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption: a cadaveric study. Foot Ankle Int. 2013;34:251–260.

    Article  PubMed  Google Scholar 

  15. 15.

    Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC. Comparison of manual and gravity stress radiographs for the evaluation of supination-external rotation fibular fractures. J Bone Joint Surg Am. 2007;89:994–999.

    Article  PubMed  Google Scholar 

  16. 16.

    Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? Bone Jt J. 2017;99-B:851–855.

    Article  CAS  Google Scholar 

  17. 17.

    Hastie GR, Akhtar S, Butt U, Baumann A, Barrie JL. Weightbearing radiographs facilitate functional treatment of ankle fractures of uncertain stability. J Foot Ankle Surg. 2015;54(6):1042–1046.

    Article  PubMed  Google Scholar 

  18. 18.

    Henari S, Banks LN, Radiovanovic I, Queally J, Morris S. Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle. Orthopedics. 2011;34(10):e639–e643.

    PubMed  Google Scholar 

  19. 19.

    Hermans JJ, Wentink N, Beumer A, et al. Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol 2012;41:787–801.

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int. 2012;33:92–98.

    Article  PubMed  Google Scholar 

  21. 21.

    Jeong MS, Choi YS, Kim YJ, Kim JS, Young KW, Jung YY. Deltoid ligament in acute ankle injury: MR imaging analysis. Skeletal Radiol. 2014;43:655–663.

    Article  PubMed  Google Scholar 

  22. 22.

    Jones CR, Nunley JA. Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures. J Orthop Trauma. 2015;29:245–249.

    Article  PubMed  Google Scholar 

  23. 23.

    Koval KJ, Egol KA, Cheung Y, Goodwin DW, Spratt KF. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma. 2007;21:449–455.

    Article  PubMed  Google Scholar 

  24. 24.

    Kristensen KD, Hansen T. Closed treatment of ankle fractures. Stage II supination-eversion fractures followed for 20 years. Acta Orthop Scand. 1985;56:107–109.

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957–985.

    Article  CAS  PubMed  Google Scholar 

  26. 26.

    Lauge-Hansen N. Fractures of the ankle. IV. Clinical use of genetic roentgen diagnosis and genetic reduction. AMA Arch Surg. 1952;64:488–500.

    Article  CAS  PubMed  Google Scholar 

  27. 27.

    Lee TH, Jang KS, Choi GW, Jeong CD, Hong SJ, Yoon MA, Kim HJ. The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures. Injury. 2016;47:1581–1585.

    Article  PubMed  Google Scholar 

  28. 28.

    Little MMT, Berkes MB, Schottel PC, et al. Anatomic fixation of supination external rotation type IV equivalent ankle fractures. J Orthop Trauma. 2015;29:250–255.

    Article  PubMed  Google Scholar 

  29. 29.

    McConnell T, Creevy W, Tornetta P. Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am. 2004;86–A:2171–2178.

    Article  Google Scholar 

  30. 30.

    Metitiri O, Ghorbanhoseini M, Zurakowski D, Hochman MG, Nazarian A, Kwon JY. Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int. 2017;38:443–451.

    Article  PubMed  Google Scholar 

  31. 31.

    Michelson JD. Current concepts review fractures about the ankle. J Bone Joint Surg Am. 1995;77:142–152.

    Article  CAS  PubMed  Google Scholar 

  32. 32.

    Michelson JD. Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg. 2003;11:403–412.

    Article  PubMed  Google Scholar 

  33. 33.

    Michelson J, Solocoff D, Waldman B, Kendell K, Ahn U. Ankle fractures. The Lauge-Hansen classification revisited. Clin Orthop Relat Res. 1997;198–205.

  34. 34.

    Michelson JD, Varner KE, Checcone M. Diagnosing deltoid injury in ankle fractures: the gravity stress view. Clin Orthop Relat Res. 2001;178–182.

  35. 35.

    Michelson JD, Hamel AJ, Buczek FL, Sharkey N. Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model. J Bone Joint Surg Am. 2002;84-A:2029–2038.

    Article  Google Scholar 

  36. 36.

    Nortunen S, Lepojärvi S, Savola O, et al. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. J Bone Joint Surg Am. 2014;96:1855–1862.

    Article  PubMed  Google Scholar 

  37. 37.

    Panchani PN, Chappell TM, Moore GD, et al. Anatomic study of the deltoid ligament of the ankle. Foot Ankle Int. 2014;35:916–921.

    Article  PubMed  Google Scholar 

  38. 38.

    Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. II. Clinical studies. Acta Orthop Scand. 1979;50:225–236.

    Article  CAS  PubMed  Google Scholar 

  39. 39.

    Park SS, Kubiak EN, Egol K, Kummer F, Koval KJ. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma. 2006;20:11–18.

    Article  PubMed  Google Scholar 

  40. 40.

    Petrisor B, Poolman R, Koval K, Tornetta P, Bhandari M. Management of displaced ankle fractures. J Orthop Trauma. 2006;20:515–518.

    Article  PubMed  Google Scholar 

  41. 41.

    Phillips W, Schwartz HS, Keller CS, et al. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am. 1985;67:67–78.

    Article  CAS  PubMed  Google Scholar 

  42. 42.

    Port M, McVie JL, Naylor G, Kreibich DN. Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus. J Bone Joint Surg Br. 1996;78:568–572.

    Article  CAS  PubMed  Google Scholar 

  43. 43.

    Rasmussen O, Kromann-Andersen C, Boe S. Deltoid ligament. Functional analysis of the medial collateral ligamentous apparatus of the ankle joint. Acta Orthop Scand. 1983;54:36–44.

    Article  CAS  PubMed  Google Scholar 

  44. 44.

    Salai M, Dudkiewicz I, Novikov I, Amit Y, Chechick A. The epidemic of ankle fractures in the elderly—is surgical treatment warranted?, Arch Orthop Trauma Surg. 2000;120(9):511–513.

    Article  CAS  PubMed  Google Scholar 

  45. 45.

    Sanders DW, Tieszer C, Corbett B. Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial. J Orthop Trauma. 2012;26:129–134.

    Article  PubMed  Google Scholar 

  46. 46.

    Sasse M, Nigg BM, Stefanyshyn DJ. Tibiotalar motion—effect of fibular displacement and deltoid ligament transection: in vitro study. Foot Ankle Int. 1999;20:733–737.

    Article  CAS  PubMed  Google Scholar 

  47. 47.

    Schottel PC, Fabricant PD, Berkes MB, et al. Manual stress ankle radiography has poor ability to predict deep deltoid ligament integrity in a supination external rotation fracture cohort. J Foot Ankle Surg. 2015;54(4):531–535.

    Article  PubMed  Google Scholar 

  48. 48.

    Schottel PC, Baxter J, Gilbert S, Garner MR, Lorich DG. Anatomic ligament repair restores ankle and syndesmotic rotational stability as much as syndesmotic screw fixation. J Orthop Trauma. 2016;30(2):e36–40.

    Article  PubMed  Google Scholar 

  49. 49.

    Stufkens SS, van den Bekerom MPJ, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: A review. Strateg Trauma Limb Reconstr. 2012;7:73–85.

    Article  Google Scholar 

  50. 50.

    Weber M, Burmeister H, Flueckiger G, Krause FG. The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle. Arch Orthop Trauma Surg. 2010;130:693–698.

    Article  PubMed  Google Scholar 

  51. 51.

    Yde J. The Lauge Hansen classification of malleolar fractures. Acta Orthop Scand. 1980;51:181–92.

    Article  CAS  PubMed  Google Scholar 

  52. 52.

    Yde J, Kristensen KD. Ankle fractures. Supination-eversion fractures stage II. Primary and late results of operative and non-operative treatment. Acta Orthop Scand. 1980;51:695–702.

    Article  CAS  PubMed  Google Scholar 

  53. 53.

    Yde J, Kristensen KD. Ankle fractures: supination-eversion fractures of stage IV. Primary and late results of operative and non-operative treatment. Acta Orthop Scand. 1980;51:981–990.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Stephen J. Warner MD, PhD.

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Conflict of Interest

Stephen J. Warner, MD, PhD, Matthew R. Garner, MD, Peter D. Fabricant, MD, MPH, Patrick C. Schottel, MD, Michael L. Loftus, MD, MBA, and Keith D. Hentel, MD, declare that they have no conflicts of interest. David L. Helfet, MD, reports owning stock in FxDevices and OHK Medical Devices and being an unpaid consultant to OHK Medical Devices, Healthpoint Capital, and TriMedics, outside the submitted work. Dean G. Lorich, MD, reported personal fees from DePuy Synthes, outside the submitted work.

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All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

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Level of Evidence: Diagnostic Study: Level III

Dean G. Lorich, MD, died December 10, 2017.

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Warner, S.J., Garner, M.R., Fabricant, P.D. et al. The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures. HSS Jrnl 15, 115–121 (2019). https://doi.org/10.1007/s11420-018-09655-x

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Keywords

  • ankle fracture
  • deltoid
  • stress test
  • magnetic resonance imaging
  • supination-external rotation (SER) ankle fracture