Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article

Kwon, John Y.; Cronin, Patrick K.; Velasco, Brian; Chiodo, Christopher P.

doi:10.1177/1071100718768509

Cited by 14 publications

(12 citation statements)

References 65 publications

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“…During axial loading, even in the presence of a partial tear, the talus remains anatomically reduced within normal limits of MCS on WB radiographs. 13 This lends supports to the theory that ankle stability can be thought of as a spectrum rather than simply stable or unstable, and perhaps further validation with higher levels of evidence would be required. Preliminary reports of WB computed tomography have recently been published with promising results.…”

Section: Discussionsupporting

confidence: 58%

“…2,3 The patterns of instability may not be apparent on standard radiographs. 2,3,13,29 Fractures with suspected deltoid ligament injury require careful evaluation and treatment, as inability to maintain anatomical alignment of the ankle has clinical and biomechanical implications with potential for poor outcomes. 6,24 Stable SER fractures can effectively be treated nonoperatively with functional bracing and early mobilization.…”

Section: Introductionmentioning

confidence: 99%

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Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures

Yousaf

Saleh

Ahluwalia

et al. 2019

Foot & Ankle Orthopaedics

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Background: Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a diagnostic dilemma for clinicians. The status of the deep deltoid ligament, the main stabilizer of the ankle joint, is assessed by an increase in medial clear space (MCS) on radiographs. Therefore, these injuries can be either stable or unstable. In recent years, considerable clinical and research efforts have been made to determine ankle stability following SER fracture. The purpose of this systematic review was to evaluate and compare the role of different stress radiograph modalities in assessing stability of the ankle with SER fractures with no obvious talar subluxation on standard radiographs. Methods: The electronic databases MEDLINE, EMBASE, Ovid, Cochrane Central, CINAHL, and Google Scholar were searched from January 2000 to January 2018 to identify literature relating to radiologic assessment of stability of SER ankle fractures. Results: Our literature search revealed 10 peer-reviewed articles that fulfilled inclusion criteria. This yielded a total of 698 patients. The systematic review found 3 broad categories of radiographic investigations in the assessment of ankle joint stability: external rotation (ER) stress radiographs, gravity stress views (GSV), and weightbearing (WB) radiographs. Proponents of WB radiographs have demonstrated how axial load can normalize ankle joint alignment in cases of proven instability. There was a consistently high grade of evidence for using a medial clear space (MCS) value of more than 4 to 5 mm to indicate an unstable ankle following SER fracture. Conclusion: In conclusion, the results of this systematic review support an MCS value of less than 4 to 5 mm as a good indicator of stability, regardless of choice of stress imaging modality. These patients can be allowed early weightbearing with expected good functional outcomes. Recent published literature favors WB stress radiographs as a reliable and safe technique for assessing stability in SER ankle fractures. However, it should be kept in mind that this is based on studies with relatively low grades of evidence. Level of Evidence: Level II, systematic review of variable quality studies.

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Section: Discussionsupporting

confidence: 58%

Section: Introductionmentioning

confidence: 99%

Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures

Yousaf

Saleh

Ahluwalia

et al. 2019

Foot & Ankle Orthopaedics

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“…As previous studies have demonstrated the negative effects of malalignment on the contact area, contact pressures, and the development of arthrosis, short-term assessments are unlikely to predict long-term functional outcomes. 28,29) To the best of our knowledge, this is the first study that compares US findings to those of arthroscopy for patients with isolated lateral malleolar fractures. Our results confirmed that all patients had complete or partial deltoid ligament rupture surgically.…”

Section: Discussionmentioning

confidence: 97%

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

2020

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Ankle fractures are commonly treated orthopedic trauma injuries. There is no doubt about surgical treatment of unstable bimalleolar or trimalleolar ankle fractures. However, treatment of isolated lateral malleolar fractures remains controversial. 1-6) The treatment strategy depends on the stability of the ankle joint. Conceptualizing the ankle joint as a ring, like the pelvis, is helpful in deciding which fractures are stable or unstable. One fracture in the otherwise intact ring is stable. 7) Therefore, pure isolated lateral malleolar fractures are stable. However, combined medial deltoid ligament injury will make the ankle unstable. The deep deltoid ligament is recognized as a primary stabilizer of the ankle. It prevents lateral talar shift and external rotation (ER) of the talus. 6) Given that the inability to maintain anatomic alignment of the mortise has been correlated with poor outcomes, the assessment of stability is critical. Ankle stability has been traditionally assessed through clinical findings and simple radiography. If medial tenderness, swelling, and ecchymosis are present on clinical examination in combination with lateral talar shift on simple radiography, a medial deltoid ligament injury is suspected. However, clinical findings alone are insufficient to determine the status of the medial deltoid ligament; other objective assessment methods are therefore needed. In clinical evaluation of lateral malleolar fractures with medial tenderness, which appear to be stable on plain radiography, stress radiography is used to determine medial deltoid injury and stability of the ankle. The me

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“…Investigators continue to examine the diagnosis and treatment of bimalleolar-equivalent ankle fractures. A recent review by Kwon et al 11 illustrated consensus that accurate assessment of the integrity of the deltoid ligament is important for guiding treatment and optimizing outcomes. There are several commonly utilized techniques to determine ankle instability for the apparent, isolated lateral malleolar fracture.…”

Section: Discussionmentioning

confidence: 99%

Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures

et al. 2020

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Background: In the setting of apparently isolated distal fibula fractures, the gravity stress view (GSV) is a validated method to determine mortise stability. There is currently no published data evaluating whether dynamic muscle activation can reduce an unstable mortise. If patients with instability can overcome gravity, resultant images could yield false-negative results. The goal of this investigation was to determine if patient effort can influence medial clear space (MCS) measurements in proven unstable bimalleolar-equivalent ankle fractures. Methods: Patients presenting with Weber B fibula fractures were assessed for mortise stability using the GSV. If the GSV demonstrated instability based on MCS widening >4 mm, 3 additional views were performed: GSV with an assistant maintaining the ankle in a neutral position; GSV with the patient actively dorsiflexing to neutral; and GSV with the patient actively dorsiflexing and supinating the foot. Twenty-four consecutive patients met inclusion criteria, with a mean age of 48.7 (range, 22-85) years. Fifteen patients (62.5%) were female and 9 (37.5%) were male. The laterality was evenly divided. Results: The mean MCS was 5.8 ± 2.0 6.0 ± 2.6, and 6.2 ± 2.7 mm for the manual assist, active dorsiflexion, and active supination radiograph measurement groups, respectively ( P = .434). Only 5 of 24 subjects had any measurable decrease in their MCS with active supination, with a maximum change of 1.2 mm. The remainder of the patients had an increase in MCS ranging from 0.1 to 4.0 mm. Conclusion: There was no significant difference between measurement states indicating that muscle activation is unlikely to yield a false-negative result on GSV. Mortise instability, secondary to deep deltoid injury in the presence of gravity stress, is unlikely to be actively overcome by dynamic stabilizers, supporting the validity and specificity of the GSV. Level of Evidence: Level III, prospective study.

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Evaluation and Significance of Mortise Instability in Supination External Rotation Fibula Fractures: A Review Article

Abstract: Level V, expert opinion.

Cited by 14 publications

References 65 publications

Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures

Systematic Review of Stress Radiographic Modalities Stability Assessment in Supination External Rotation Ankle Fractures

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

Effect of Muscle Activation on the Gravity Stress View in Unstable Weber B Ankle Fractures

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