![]() ![]() It makes intuitive sense that an injury to the deltoid ligament should cause tenderness over the medial ankle, and that absence of tenderness could rule out an unstable injury without additional radiographs. A stress view is indicated.īut her medial malleolus isn’t tender to exam, How can she have a deltoid injury? As we just learned, there is no way to tell by looking at the above x-ray if the fracture is an isolated injury (ie an SER 2), or if it is associated with an occult deltoid ligament tear (SER 4). You correctly classify this injury as a Dennis-Webber B (the fibular fracture is at the level of the mortise). Although you can safely assume that the injury is unstable, a stress view is still useful to document the degree instability.Īnkle Injury Classification (Schwartz 2008) The fibula breaks after injury to the medial malleolus or deltoid ligament. These injuries are caused by pronation and external rotation. ![]() The quick and easy way to differentiate these two are via stress view of the ankle.Ĭ: In Danis-Webber C the fibula fracture is above the level of the mortise. Because a deltoid ligament injury is not seen on plain radiographs, an unstable injury can appear to be a stable one on a standard (i.e. The fibula breaks first, the next injury (with increasing severity) is either a fracture of the medial malleolus OR a deltoid ligament is tear. In more severe cases the tibia also breaks through the medial malleolus, and once both malleoli are broken the joint becomes unstable and the talus can shift inside the mortise.ī: In Supination External Rotation injury the fibula breaks at the level of the mortise ( Danis-Webber B). Within these two systems most ankle fractures fall into three distinct categories.Ī: In a Supination-Adduction injury the fibula breaks first, with a fracture below the level of the mortise ( Danis-Webber A). Luckily the Danis-Weber classification divides ankle fractures based on the location of the fibular injury compared to the level ankle mortise. The system is a little complicated, and is probably beyond what most of us can memorize for use in everyday practice. The Lauge-Hansen system is based on the underlying forces that cause an individual pattern or injuries, and the order in which they occur. No orthopedic discussion is complete without a fracture-classification system, and I’m going to give you two. How can you tell the difference? Enter the Stress ViewĪnkle Mortise View (Figure from Schwartz 2008) So if you see an isolated lateral malleolar fracture on x-ray, it could be a stable fracture (not much more than an ankle sprain) or an unstable injury that requires a cast and an orthopedist. Some unstable fractures, are obvious on physical exam and radiology, but some can be indistinguishable from stable injuries on initial evaluation.īi-malleolar Equivalent: A fracture of the lateral malleolus can be associated with an injury to the deltoid ligament (which connects the talus and distal tibia and supports the medial aspect of the ankle joint) without a fracture of the medial malleolus itself. ![]() Stable Fractures: Fractures that do not affect the stability of the mortise, like some isolated distal fibular fractures, can often be treated non-operatively in a walking cast/boot and heal without surgery. These injuries generally require surgery, and non-weight-bearing status. They often involve fractures to two or more of the malleolae (Bi-malleolar or tri-malleolar fractures). Unstable Fractures: Fractures that compromise the stability of the MORTISE (formed by the medial and posterior malleolae of the tibia, the lateral malleolus of the fibula and associated ligaments) are considered unstable. ![]() The Emergency Department management of ankle fractures varies greatly between stable and unstable injuries. ![]()
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