POSTER SECTIONS Coverpage Learning objectives Background Imaging findings OR Procedure details Conclusion Personal information References

2023 ASM / C-164

Radiograph and Computed Tomography for Ankle Trauma: Making an Impactful Report for Surgical Planning

Congress:

2023 ASM

Poster Number:

C-164

Type:

Educational Exhibit

Keywords:

Musculoskeletal bone, Musculoskeletal joint, CT, Plain radiographic studies, Education, Surgery, Education and training, Trauma

Authors:

W. Y. Leung, R. Sendanayake

DOI:

10.26044/ranzcr2023/C-164

DOI-Link:

https://dx.doi.org/10.26044/ranzcr2023/C-164

Learning objectives

To demonstrate different types and patterns of ankle fractures according to mechanisms. To recommend ways for radiologists to provide comprehensive reports with correct lexicon and classification systems tailored for orthopaedic surgeons.

Background

The ankle joint is a seemingly simple but complex articular system that is prone to injury, ranging from soft tissue and ligamentous injury to simple and complex fractures. Ankle fractures have been observed to affect all ages and genders, with a bimodal distribution involving peaks in age group between 51-60 years followed by age 21-30 years [1, 2]. Plain radiographs and non-contrast computed tomography (CT) with multiplanar reformat are two commonly used imaging modalities to detect and assess injury severity to provide critical information and,...

Imaging findings OR Procedure details

Case 1: 53-year-old female, inversion injury to right ankle. Injury Classification: Weber A / Lauge-Hansen supination-adduction stage 1 / AO 44A1.3 fracture. Mechanism: This is an avulsion fracture resulted by adduction force on the supinated foot, which causes substantial tension to the lateral ligaments. Pitfall: medial malleolus can be fractured occasionally, upgrading the fracture to Weber A stage 2 i.e. unstable bimalleolar fracture, see companion case below. Management: Non-operative. This patient was managed in a moonboot with ongoing physiotherapy follow up. [Fig 1] [Fig 2]...

Conclusion

Ankle fractures are complex injuries that involve many osseous and ligamental structures. The use of radiograph and CTs are both important in the accurate diagnosis of ankle trauma. The syndesmotic complex is one of the crucial structures that determines the stability of the intricate joint. With the help of a radiologist’s systematic and thorough reporting, this would aid in the judicious and timely classification of the injury and ultimately guide the most appropriate operative or non-operative management.

Personal information

References

Han S, Wu T, Wen J, et al. Radiographic analysis of adult ankle fractures using combined Danis-Weber and Lauge-Hansen classification systems. Sci Rep. 2020(10):article number 7655. doi: 10.1038/s41598-020-64479-2. Tartaglione J, Rosenbaum A, Abousayed M, DiPreta J. Classifications in Brief: Lauge-Hansen Classification of Ankle Fractures. Clin Orthop Relat Res. 2015 Oct;473(10):3323-8. doi: 10.1007/s11999-015-4306-x. Barbosa P, Bonnaire F, Kojima K. Infrasyndesmotic, medial fracture with lateral fracture/avulsion. AO Surgery Reference. Updated 2015. Accessed July 8 2023. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/infrasyndesmotic-medial-fracture-with-lateral-fracture-avulsion/definition?searchurl=%2fsearchresults#avulsion-of-the-tip-of-the-lateral-malleolus Barbosa P, Bonnaire F, Kojima K. ORIF Transsyndesmotic, posterior, lateral simple,...

$Fig 1: Case 1: Mortise view of radiograph of the right ankle, there is a minimally displaced transverse fracture involving the lateral malleolus of the distal fibula which is below the syndesmosis. There is pronounced soft tissue swelling with normally aligned ankle mortise. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 1: Case 1: Mortise view of radiograph of the right ankle, there is a minimally...

$Fig 2: Case 1: Lateral view of radiograph of the right ankle. The lateral malleolus fracture once again demonstrated, no other fractures identified. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 2: Case 1: Lateral view of radiograph of the right ankle. The lateral malleolus...

$Fig 3: Case 2: AP view of radiograph of the right ankle. There is a vertical fracture to the distal tibia involving the medial malleolus, this fracture extends into the articular surface. There is a non-displaced fracture to the tip of fibular epiphysis. © Department of Radiology, Townsville University Hospital, Australia 2023$

Fig 3: Case 2: AP view of radiograph of the right ankle. There is a vertical fracture...

$Fig 4: Case 2: Mortise view of radiograph of the right ankle. The fracture to the distal tibia involving the medial malleolus is once again demonstrated. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 4: Case 2: Mortise view of radiograph of the right ankle. The fracture to the...

$Fig 5: Case 2: Selected coronal slice of non-contrast CT of the right ankle for surgical planning, revealing a comminuted medial malleolus fracture with approximately 6mm medial displacement and cortical step in the medial aspect, with the inner fragment of the fracture being above the level of the ankle mortise. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 5: Case 2: Selected coronal slice of non-contrast CT of the right ankle for...

$Fig 6: Case 3: Mortise view of radiograph of the left ankle is showing a minimally displaced oblique fracture of the lateral malleolus in the distal fibula, the fracture is on the level of the syndesmosis. There is no talar shift observed. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 6: Case 3: Mortise view of radiograph of the left ankle is showing a minimally...

$Fig 7: Case 3: Lateral view of radiograph of the left ankle, there is no clear fracture line seen to indicate a posterior malleolus fracture, it would be vigilant to suggest a CT if there are clinical concerns. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 7: Case 3: Lateral view of radiograph of the left ankle, there is no clear...

$Fig 8: Case 4: AP view of radiograph of the right ankle, there is widening of the ankle joint mortise with talar shift, in keeping with syndesmotic injury. The “push off” mechanism resulted in an oblique fracture to the distal fibula with posterior-lateral displacement of the distal fragment, this displaced fragment induces tension on the posterior syndesmosis and the avulsion fracture of the posterior malleolus (seen on Figure 9). There is also a transverse avulsion fracture through the medial malleolus. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 8: Case 4: AP view of radiograph of the right ankle, there is widening of the...

$Fig 9: Case 4: Lateral view of radiograph of the right ankle shows the avulsion fracture of the posterior malleolus. The following ligamentous structures are assumed to be injured or ruptured with this fracture mechanism: anterior inferior tibiofibular ligament (AITFL), anterior talofibular ligament (ATFL), posterior inferior tibiofibular ligament (PITFL), transverse tibiofibular ligament (TTFL) and possibly the deltoid ligament. These can be further accessed using ultrasound or magnetic resonance imaging (MRI). © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 9: Case 4: Lateral view of radiograph of the right ankle shows the avulsion...

$Fig 10: Case 4: Selected sagittal slice of non-contrast CT of the right ankle, demonstrating the comminuted intraarticular fracture of the posterior malleolus with posterior displacement of the distal fracture (or the Volkmann’s) fragment. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 10: Case 4: Selected sagittal slice of non-contrast CT of the right ankle,...

$Fig 11: Case 4: Selected axial slice of non-contrast CT of the right ankle, demonstrating the comminuted intraarticular fracture of the posterior malleolus of the distal tibia with posterior displacement of the distal fracture (or the Volkmann’s) fragment. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 11: Case 4: Selected axial slice of non-contrast CT of the right ankle,...

Fig 12: Case 4: Lateral view of weight bearing radiograph of the right ankle 6 weeks...

$Fig 13: Case 5: Mortise view of radiograph of the left ankle, showing an oblique fracture to the distal fibula and a horizontal fracture to the medial malleolus. There is widening of the ankle mortise with lateral displacement of the distal fibula fragment, the talus and medial malleolar fragment. Note the prior surgical fixation to the old fractures to the 2nd to 4th metatarsals. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 13: Case 5: Mortise view of radiograph of the left ankle, showing an oblique...

$Fig 14: Case 5: Lateral view of radiograph of the left ankle, once again demonstrating the oblique fracture of the distal fibula. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 14: Case 5: Lateral view of radiograph of the left ankle, once again demonstrating...

Fig 15: Case 5: Selected axial view of non-contrast CT of the left ankle, which...

Fig 16: Case 5: Mortise view of radiograph of the left ankle post surgical fixation....

$Fig 17: Case 6: AP view of pre-reduction radiograph of the left ankle, which shows the disrupted ankle mortis with oblique comminuted fracture of the distal fibula with multiple displaced and overriding fragments. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 17: Case 6: AP view of pre-reduction radiograph of the left ankle, which shows the...

$Fig 18: Case 6: Selected sagittal slice of post reduction non-contrast CT of the left ankle. The intraarticular fractures of the distal tibia with involvement of the medial and posterior malleolus are shown to be minimally displaced post reduction. The posterior malleolus fracture of this injury mechanism is usually an avulsion type fracture involving the posterior tibial attachment of the PITFL. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 18: Case 6: Selected sagittal slice of post reduction non-contrast CT of the left...

$Fig 19: Case 6: Selected coronal slice of post reduction non-contrast CT of the left ankle. The intraarticular fractures of the distal tibia with involvement of the medial and posterior malleolus are shown to be minimally displaced post reduction. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 19: Case 6: Selected coronal slice of post reduction non-contrast CT of the left...

Fig 20: Case 6: Weight-bearing AP view of radiograph of the left ankle post surgical...

$Fig 21: Case 7: Mortise view of radiograph of the right ankle, which demonstrates an oblique fracture to the mid-lower fibular diaphysis with lateral displacement at the fracture site, making this an unstable Weber C injury at initial glance. Note the significant oedema on the medial malleolus. Under careful review, a fracture involving both medial malleolus and anterior aspect of distal tibia can be appreciated. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 21: Case 7: Mortise view of radiograph of the right ankle, which demonstrates an...

$Fig 22: Case 7: Lateral view of radiograph of the right ankle, the oblique fracture to the mid-lower fibular diaphysis is again demonstrated. The fracture involving both medial malleolus and anterior aspect of distal tibia can be better appreciated on this view. The ankle joint also appears mildly incongruent on this view. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 22: Case 7: Lateral view of radiograph of the right ankle, the oblique fracture to...

$Fig 23: Case 7: Selected coronal slice of non-contrast CT of the right ankle. The oblique medial malleolus fracture is much better visualised on the CT. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 23: Case 7: Selected coronal slice of non-contrast CT of the right ankle. The...

Fig 24: Case 7: Selected sagittal slice of non-contrast CT of the right ankle, the...

Fig 25: Case 7: Mortise view of radiograph of the right ankle post suture-button...

$Fig 26: Case 8: AP view of radiograph of the right ankle, which shows an open dislocation of the right ankle with oblique fracture of the distal fibula just proximal to the tibial plafond with posterior-lateral displacement of the distal fragment. With no evidence of a medial malleolus transverse fracture present, there is presumed disruption of the deltoid ligament. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 26: Case 8: AP view of radiograph of the right ankle, which shows an open...

$Fig 27: Case 8: Lateral view of radiograph of the right ankle, which shows an open dislocation of the right ankle with oblique fracture of the distal fibula just proximal to the tibial plafond with posterior-lateral displacement of the distal fragment. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 27: Case 8: Lateral view of radiograph of the right ankle, which shows an open...

$Fig 28: Case 8: Coronal slice of post reduction non-contrast CT of the right ankle reveals the extensively comminuted nature of the distal fibula fracture at the level of syndesmosis and a displaced comminuted fracture to the posterior malleolus with intraarticular extension. There is ongoing talar shift post reduction. There is significant oedema of the medial tibiotalar region and presence of gas locules. © Department of Radiology, Townsville University Hospital, Australia 2023.$

Fig 28: Case 8: Coronal slice of post reduction non-contrast CT of the right ankle...

Fig 29: Case 8: Sagittal slice of post reduction non-contrast CT of the right ankle...

Fig 30: Case 8: Mortise view of radiograph of right ankle post surgical fixation, the...