Medial insufficiency in postoperative weight-bearing radiographs in supination-external rotation type 4 bimalleolar ankle fractures: is the Lauge-Hansen classification insufficient in predicting medial soft tissue damage?

Year 2021, , 465 - 471, 04.09.2021

Ali Yüce , Mustafa Yerli , Tahsin Olgun Bayraktar Bulent Karslıoglu , Yunus İmren Süleyman Semih Dedeoğlu Mustafa Çağlar Kır , Hakan Gürbüz

https://doi.org/10.18621/eurj.796614

Cited By: 1

Abstract

Objectives: According to the Lauge-Hansen classification, supination external-rotation (SER) type 4 fractures should be accompanied by medial malleolar fracture or deltoid ligament injury. The aim of the study was to investigate medial insufficiency rates in postoperative weight-bearing radiographs in SER type 4 bimalleolar fractures.

Methods: The files of the patients who were operated with the diagnosis of SER type 4 bimalleolar ankle fracture between 2017-2020 were evaluated retrospectively. Thirty-seven cases (15 males and 22 females) were included in the study. The data based on the evaluation of the weight-bearing radiographs of the patients taken in the postoperative 1st year were examined statistically.

Results: The injury mechanism was sports injury in 17 (45.9%) cases, traffic accidents in 8 (21.6%) cases, falling in 9 (24.3%) cases, and falling from height in 3 (8.2%) cases. The preoperative tibiofibular distance was 6.05 ± 1.86 mm, and the postoperative tibiofibular distance was 4.19 ± 0.40 mm (p = 0.001). The preoperative tibiofibular overlap was 5.03 ± 2.93 mm, and the postoperative tibiofibular overlap was 8.62 ± 1.04 mm (p = 0.001). The postoperative medial clear space was 4.11 ± 0.57 mm. Postoperative medial clear space of 5 mm and higher was determined in 7 (18.9%) cases.

Conclusions: In SER type 4 bimalleolar fractures with a large medial malleolar fragment fracture, weight-bearing radiographs may show an increase in medial clear space. This means that a medial malleolar fracture in bimalleolar fractures may be also accompanied by deltoid ligament injury. The Lauge-Hansen classification system may be insufficient to identify a medial ligament injury.

Keywords

bimalleol, fracture, supination-external rotation, Lauge-Hansen, deltoid ligament

References

• 1. Kosuge DD, Mahadevan D, Chandrasenan J, Pugh H. Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice. Ann R Coll Surg Engl 2010;92:689-92.
• 2. 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;21:244-7.
• 3. Tartaglione JP, Rosenbaum AJ, Abousayed M, DiPreta JA. Classifications in brief: Lauge-Hansen classification of ankle fractures. Clin Orthop Relat Res 2015;473:3323-8.
• 4. Warner SJ, Garner MR, Hinds RM, Helfet DL, Lorich DG. Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures. J Orthop Trauma 2015;29:574-8.
• 5. Cabuk H, Celebi F, İmren Y, Dedeoğlu SS, Kır MC, Uyanık AF et al. Compatibility of Lauge-Hansen classification between plain radiographs and magnetic resonance imaging in ankle fractures. J Foot Ankle Surg 2018;57:712-5.
• 6. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The Ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma 2006;20:267-72.
• 7. Tornetta PIII. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am 2000;82:843-8.
• 8. Fukuyama JM, Pires RES, Labronici PJ, Hungria JOS, Decusati RL. Bimalleolar ankle fracture: a simple fracture? Acta Ortop Bras 2017;25:48-51.
• 9. Boszczyk A, Fudalej M, Kwapisz S, Błonski M, Kicinski M, Kordasiewicz B et al. X-ray features to predict ankle fracture mechanism. Forensic Sci Int 2018;291:185-92.
• 10. Warner SJ, Garner MR, Hinds RM, Helfet DL, Lorich DG. Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures. J Orthop Trauma 2015;29:574-8.
• 11. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich, DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 2006;27:788-92.
• 12. Budny AM, Young BA. Analysis of radiographic classifications for rotational ankle fractures. Clin Podiatr Med Surg 2008;25:139-52.
• 13. van den Bekerom MPJ, Mutsaerts ELAR, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 2009;129:227-35.
• 14. Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int 2012;33:92-8.
• 15. Weber M, Burmeister H, Flueckiger G, Krause FG. The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle. Arch Orthop Trauma Surg 2010;130:693-8.
• 16. Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination-external rotation ankle fractures. Clin Orthop Relat Res 2010;468:243-51.
• 17. Krintensen KD, Hansen T. Closed treatment of ankle fractures: stage II fractures followed twenty years. Acta Orthop Scand 1985;56:107-9.