The diagnosis and treatment of deltoid ligament lesions in supination–external rotation ankle fractures: a review

Abstract

The supination–external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.

Gravity Stress Radiographs and the Effect of Ankle Position on Deltoid Ligament Integrity and Medial Clear Space Measurements

“…The primary function is to restrict the shifting of the talus into valgus, for it to translate anterolaterally, or to externally rotate. 12,18,37,[40][41][42][43] This was seen in our results as well, with the mean medial clear space at both plantarflexion and neutral being 3.78 and 4.33 mm, respectively (Table 2 and Fig. 10,12,19,[32][33][34][35][36][37] The deltoid ligament consists of a superficial layer and a deep layer.…”

“…10,12,19,[32][33][34][35][36][37] The deltoid ligament consists of a superficial layer and a deep layer. The primary function is to restrict the shifting of the talus into valgus, for it to translate anterolaterally, or to externally rotate.…”

The Ligament Anatomy of the Deltoid Complex of the Ankle: A Qualitative and Quantitative Anatomical Study

“…The superficial and deep layers of the deltoid ligament can consist of up to six individual ligamentous bands 6,[21][22][23][24][25][26] . The prevalence of the individual ligamentous bands is variable among individuals, and there is no consensus as to which bands are constant or variable.…”

Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle

“…Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle fixation (8)(9)(10). Of all the methods that have been used to diagnose instability and investigate deltoid ligament integrity (clinical examination, weight-bearing radiographs, stress radiography, magnetic resonance imaging (MRI), arthroscopy, ultrasound), none have been shown to be costeffective, rapid, reliable, and easy to use (8,10,11).…”