Supination-external rotation ankle fractures: analysis of clinical results after syndesmotic screw removal

Background: While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures. Methods: Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis. Results: There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had “good,” and seven had “fair” reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with “good” operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a “fair” operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population. Conclusions: The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with “fair” radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

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Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures

Injury ◽

10.1016/j.injury.2019.05.020 ◽

2019 ◽

Vol 50 (7) ◽

pp. 1382-1387 ◽

Cited By ~ 2

Author(s):

Dong-Il Chun ◽

Jahyung Kim ◽

Yoon Seok Kim ◽

Jae-Ho Cho ◽

Sung-Hun Won ◽

...

Keyword(s):

External Rotation ◽

Fracture Morphology ◽

Lateral Malleolus ◽

Ankle Fractures ◽

Supination External Rotation

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Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture?

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00526 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0052

Author(s):

Sohail Yousaf ◽

Daniel Hay

Keyword(s):

Systematic Review ◽

External Rotation ◽

Weight Bearing ◽

Ankle Fractures ◽

Controlled Trials ◽

Distal Fibula ◽

Fibula Fracture ◽

Stress Radiographs ◽

The Stability ◽

Supination External Rotation

Category: Trauma Introduction/Purpose: Differentiating stable isolated fibula fractures consistent with supination external rotation (SER) II ankle fractures from unstable SER IV fractures is essential in determining the need for surgical stabilisation. Stress radiographs are usually required to assess stability including gravity stress views (GSV) and external rotation views (ER). There is no clear consensus as to which modality is most useful to determine stability in a fracture clinic or emergency setting. In last, few years clinical uncertainty about the reliability has led researcher to focus on weight bearing radiographs (WB) .We aim to review recent literature regarding reliability of WB radiographs to estimate the stability of supination external rotation ankle fractures. Methods: A systematic review of the literature relating to radiological assessment of stability of supination external rotation ankle fractures was conducted according to PRISMA guidelines. The systematic review was prospectively registered with PROSPERO. It involved the following steps: Researching the question-Do weight bearing radiographs estimate the stability of an isolated distal fibula fracture? Setting inclusion and exclusion criteria-All English language articles published in the including any Randomised controlled trials (RCT’s) and cohort studies. Data collection)– A literature search of Medline (PubMed), the Cochrane Bone, Joint, and Muscle Trauma Group trial register, the Cochrane central register of controlled trials, Embase and CINAHL was undertaken. The grey literature was searched. Key terms ‘supination external rotation fracture’, ‘stability’. Other variations to the key words were ‘weight bearing’, “axial load”, ‘stress x-rays’, ‘systematic reviews’ and ‘meta-analysis’. Results: A total of six studies met the inclusion criteria including 601 patients. No previous systematic review on stress radiographs including weight bearing was published. All studies concluded weight bearing radiographs is an easy, pain-free, safe and reliable method to estimate stability of isolated distal fibula fractures. No serious concerns or complications were reported. Conclusion: The evidence base contained many methodological limitations and most of the evidence was either level III or IV, and so any conclusion drawn from the research must be done so with caution. The studies suggest that GSV overestimates the instability which should be assessed with studies should focus on randomized controlled trials with narrow range of clinically useful outcome measures.

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Arthroscopic Reduction and Minimally Invasive Surgery in Supination–External Rotation Ankle Fractures: A Comparative Study With Open Reduction

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2019.03.051 ◽

2019 ◽

Vol 35 (9) ◽

pp. 2671-2683 ◽

Cited By ~ 9

Author(s):

Chao-Ching Chiang ◽

Yun-Hsuan Tzeng ◽

Chien-Fu Jeff Lin ◽

Chien-Shun Wang ◽

Chun-Cheng Lin ◽

...

Keyword(s):

Minimally Invasive Surgery ◽

Minimally Invasive ◽

Comparative Study ◽

Invasive Surgery ◽

Open Reduction ◽

External Rotation ◽

Ankle Fractures ◽

Arthroscopic Reduction ◽

Supination External Rotation

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Ankle Joint Pressure in Supination-External Rotation Injuries: A Dynamic Biomechanic Cadaveric Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00306 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0030

Author(s):

Fabian Krause ◽

Ivan Zderic ◽

Angela Seidel ◽

Boyko Gueorguiev ◽

Marc C. Attinger ◽

...

Keyword(s):

Operative Treatment ◽

Contact Area ◽

Peak Pressure ◽

External Rotation ◽

Clinical Results ◽

Deltoid Ligament ◽

Type Ii ◽

Type Iv ◽

Joint Contact ◽

Supination External Rotation

Category: Ankle; Basic Sciences/Biologics; Trauma Introduction/Purpose: In isolated lateral malleolar fractures of the supination-external rotation (SER) type and competent medial stabilizers (type II and III), non-operative treatment has yielded excellent outcome. With complete rupture of the deltoid ligament (SER type IV) fracture instability increases substantially. The rationale for operative treatment of SER type IV fractures is based upon good clinical results and previous biomechanical studies. A significant reduction of the ankle contact area that however is caused by an artificially forced lateralization of the talus in the ankle mortise has been demonstrated. Presumed resultant elevated joint contact stresses are thought to lead to ankle arthritis in the longterm. Methods: In 12 lower leg specimen SER type injuries were simulated by gradual bony and ligamentous destabilization of the ankle from lateral to medial according to the mechanism of injury as described by Lauge and Hansen. High-resolution pressure sensors placed in the ankle joint recorded tibio-talar pressure changes at physiologic weightbearing (700N) in three positions (plantigrade, 10° dorsiflexion and 20° plantarflexion). Results: With increasing instability changes of the ankle kinematics were seen in SER II and III fractures with the same trend also in SER IV lesions. In the plantigrade position, the medial clear space (MCS) increased significantly from an average of 2.5+-0.4mm (no fracture) to 3.9+-1.1mm (SER type IV fracture). However, the corresponding peak pressure increased only slightly from 2.6+- 0.5 mPa to 3.0+-1.4 mPa on average, and the contact area decreased slightly from 810+-42 mm2 to 735+-27mm2 on average representing a non-significant reduction of only 9% of the contact area (p=0.08) after the deep deltoid ligament was completely dissected.The comparison of the results in plantigrade and plantarflexed position revealed substantial differences for MCS, contact area and center of force. Conclusion: Under physiologic load SER type IV isolated lateral malleolar fracture with completely disrupted deep deltoid ligament led to a significant increase of the MCS, but neither to a significant decrease of the of the joint contact area nor significant increase of peak pressure. Clinical Relevance: The findings of this biomechanical study support the recently reported good clinical results of non-operative treatment of SER type II to IV fractures.

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