Effectiveness of Standalone Weight-bearing Radiographs in Guiding the Management of Supination External Rotation Type Isolated Lateral Malleolar Fractures in Indian Population: A Prospective Clinical Study
Singaravadivelu Vaidyanathan, Vignesh Murali, Aju Bosco
Citation Information :
Vaidyanathan S, Murali V, Bosco A. Effectiveness of Standalone Weight-bearing Radiographs in Guiding the Management of Supination External Rotation Type Isolated Lateral Malleolar Fractures in Indian Population: A Prospective Clinical Study. 2022; 4 (1):29-34.
Aim and objective: To assess the effectiveness of standalone weight-bearing radiographs (WBR) in guiding the management of Supination External Rotation (SER), type of isolated lateral malleolar fractures in Indian population.
Materials and methods: In a prospective study involving 19 consecutive patients with SER type of isolated lateral malleolar fractures, stability of the ankle was assessed using both WBR and external rotation stress radiographs. The decision toward conservative or surgical management was made solely on the assessment of ankle stability on WBR alone. Fractures with a medial clear space of <5 mm were deemed stable and managed conservatively (full weight-bearing in cast), while unstable ones were managed surgically (with open reduction and fibular plating). Periodic follow-up was done to assess radiological union and functional outcomes using the American Orthopaedic Foot and Ankle Society (AOFAS) score. Patient\'s pain score visual analogue scale (VAS) and compliance was assessed during radiographic assessment.
Results: Based on WBR alone, 17/19 (89.5%) fractures were found to be stable and treated conservatively, while 2/19 (10.5%) fractures were unstable and managed surgically. The mean AOFAS score in the conservative group [92.9 ± 3.4 (excellent)] and surgical group [91.5 ± 1.5 (excellent)] were comparable at latest follow-up. Complete radiological union was seen at 8.8 ± 1.9 (range, 8–14) weeks in 82% (14/17), while delayed union (union taking place >8 weeks) was seen in three patients in the conservative group. Four patients (21%), who would have been operated had external rotation stress views been used in decision making, were managed conservatively with successful clinical outcome and excellent AOFAS scores. Patient compliance was good with WBR as compared to external rotation stress radiographs.
Conclusion: Standalone WBR are feasible, and reliable in detecting injury of the deep deltoid ligament and the consequent instability of the tibiotalar joint, in Weber type B fractures. They are associated with better patient compliance.
Clinical significance: Standalone WBR serve as a useful guide in decision making between conservative and surgical treatment, in SER type isolated lateral malleolar fractures.
Daly PJ, Fitzgerald RH, Melton LJ, et al. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 1987;58(5):539–544. DOI: 10.3109/17453678709146395
Jensen SL, Andresen BK, Mencke S, et al. Epidemiology of ankle fractures: a prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand 1998;69(1):48–50. DOI: 10.3109/17453679809002356
Court-Brown CM, McBirnie J. Adult ankle fractures-an increasing problem? Acta Orthop 1998;69(1):43–47. DOI: 10.3109/17453679809002355
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(6):981–990. DOI: 10.3109/17453678008990904
Gougoulias N, Khanna A, Sakellariou A, et al. Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res 2010;468(1):243–251. DOI: 10.1007/s11999-009-0988-2
Sanders DW, Tieszer C, Corbett B. Operative versus nonoperative treatment of unstable lateral malleolar fractures. J Orthop Trauma 2012;26(3):129–134. DOI: 10.1097/BOT.0b013e3182460837
Redfern DJ, Sauve PS, Sakellariou A. Investigation of incidence of superficial peroneal nerve injury following ankle fracture. Foot Ankle Int 2003;24(10):771–774. DOI: 10.1177/107110070302401006
Dawe EJC, Shafafy R, Quayle J, et al. The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures. Foot Ankle Surg 2015;21(2):86–90. DOI: 10.1016/j.fas.2014.09.01
Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma 2007;21(5): 307–315. DOI: 10.1097/BOT.0b013e318059aea3
Hak DJ, Egol KA, Gardner MJ, et al. The “not so simple” ankle fracture: avoiding problems and pitfalls to improve patient outcomes. Instr Course Lect 2011;60:73–88. PMID: 21553763.
Michelsen JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg Am 1996;78(7):1024–1031. DOI: 10.2106/00004623-199607000-00006
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(4):244–247. DOI: 10.1097/BOT.0b013e3180413835
Koval KJ, Egol KA, Cheung Y, et al. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma 2007;21(7):449–455. DOI: 10.1097/BOT.0b013e31812eed25
Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? Bone Joint J 2017;99-B(7):851–855. DOI: 10.1302/0301-620X.99B7.BJJ-2016-1087.R1
Weber M, Burmeister H, Flueckiger G, et al. The use of weightbearing radiographs to assess the stability of supination- external rotation fractures of the ankle. Arch Orthop Trauma Surg 2010;130(5):693–698. DOI: 10.1007/s00402-010-1051-1
Hoshino CM, Nomoto EK, Norheim EP, et al. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int 2012;33(2):92–98. DOI: 10.3113/FAI.2012.0092
Schock HJ, Pinzur M, Manion L, et al. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89(8):1055–1059. DOI: 10.1302/0301-620X.89B8.19134
Seidel A, Krause F, Weber M. Weightbearing vs gravity stress radiographs for stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle Int 2017;38(7):736–744. DOI: 10.1177/1071100717702589
McConnell T, Creevy W, Tornetta 3rd P. Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86(10):2171–2178. DOI: 10.2106/00004623-200410000-00007
Anderson SA, Li X, Franklin P, et al. Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int 2008;29(12):1184–1188. DOI: 10.3113/FAI.2008.1184
Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures. Acta Orthop Scand 1985;56(2):103–106. DOI: 10.3109/17453678508994329
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(4):695–702. DOI: 10.3109/17453678008990863
McKenna PB, O'shea K, Burke T. Less is more: lag screw only fixation of lateral malleolar fractures. Int Orthop 2007;31(4):497–502. DOI: 10.1007/s00264-006-0216-6
Mittal R, Harris IA, Adie S, et al. Surgery for type B ankle fracture treatment: a Combined Randomised and Observational Study (CROSSBAT). BMJ Open 2017;7:e013298. DOI: 10.1136/bmjopen- 2016-013298
Holmes JR, Acker WB II, Murphy JM, et al. A novel algorithm for isolated Weber B ankle fractures: a retrospective review of 51 nonsurgically treated patients. J Am Acad Orthop Surg 2016;24(9):645–652. DOI: 10.5435/JAAOS-D-16-00085
Finnan R, Funk L, Pinzur MS, et al. Health related quality of life in patients with supination-external rotation stage IV ankle fractures. Foot Ankle Int 2005;26(12):1038–1041. DOI: 10.1177/107110070502601207