The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle

Abstract

Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations. We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of > 4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10). We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle.

Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature

“…There was no signiWcant diVerence between the gravity and the manual-stress radiograph with regard to mean medial clear space or talar shift measured in association with either fracture pattern [18]. The VAS score for examinations of manual-stress indicated that patients perceived more discomfort than with gravity testing [45]. The main limitation of the gravity-stress radiograph is the inability to control dorsiXexion and plantar Xexion [18].…”

“…An overview is shown in Tables 1 and 2. Three trails investigated medial tenderness [12,16,29]; two studies, ecchymosis [16,29]; two studies, swelling [16,29]; one study, an injury radiograph [46]; six studies, a type of radiographic stress view [12,16,18,29,32,35,45]; one study, the Lauge-Hansen classiWcation [46]; one study, MRI [24]; and one article studied arthroscopy [46] in the evaluation of the deltoid ligament integrity. The publication dates span 6 years; in 2001, Michelson et al [32] was the earliest and in 2007, Koval et al [24] and Schock et al [45] were the most recent publications.…”

“…Schock et al [45] measured a mean MCS of 6.09 mm (4.4-8.1) on gravity-stress radiographs, and 5.81 mm Fig. 1 Gravity-stress radiograph (4.0-8.2) on manual-stress examination (P = 0.63).…”

“…Michelson et al [32] Gravity-stress radiographs were found to reproducibly document destabilizing deltoid ligament damage Schuberth et al [46] Deltoid ligament integrity cannot be reliably predicted by the MCS on injury radiographs and by LH classiWcation Koval et al [24] MRI is more reliable than manual-stress radiographs in evaluating deltoid ligament integrity Schock et al [45] Gravity-stress is as reliable as and more comfortable than of manual-stress radiographs…”

Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice

“…With clinical findings of medial-sided tenderness, swelling or ecchymosis being unreliable in detecting deep deltoid incompetence, 3 there are advocates of proceeding to examination under anaesthesia (EUA), magnetic resonance imaging (MRI), 4 ankle arthroscopy 5 or stress radiographs. 6,7 The early accurate differentiation between a stable SER-II from an unstable SER-IV injury can potentially ease pressure on the already over-burdened fracture clinics and allow earlier return of function.…”