Ultrasonography as a Diagnostic Tool in Assessing Deltoid Ligament Injury in Supination External Rotation Fractures of the Ankle

ABSTRACT Objective: To evaluate the frequency of deltoid ligament injury in bimalleolar supination-external rotation type fractures and whether there is a correlation between the size of the fractured medial malleolus and deltoid ligament injury . Methods: Twenty six consecutive patients underwent magnetic resonance exams after clinical and radiographic diagnosis of bimalleolar supination-external rotation type ankle fractures . Results: Thirteen patients (50%) presented deltoid ligament injury associated to bimalleolar ankle fracture. Partial injury was present in seven (26.9%) patients and total injury in six (23.1%). Regarding medial fragment size, the average was 2.88 cm in the absence of deltoid ligament injury. Partial injuries presented 1.93 cm and total 2.1 cm on average . Conclusion: Deltoid ligament injury was present in 50% of bimalleolar ankle fractures. Smaller medial malleolus fragments, especially concerning the anterior colliculus, presented greater association with partial deltoid ligament injuries. Level of Evidence IV, Cross Sectional Study.

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Deltoid ligament injury patterns in external rotation ankle injuries: A cadaveric study

Foot and Ankle Surgery ◽

10.1016/j.fas.2017.07.1120 ◽

2017 ◽

Vol 23 ◽

pp. 26-27

Author(s):

M. Cooper ◽

A. Mait ◽

B. Nie ◽

J.P. Donlon ◽

A. Mane ◽

...

Keyword(s):

External Rotation ◽

Cadaveric Study ◽

Ankle Injuries ◽

Ligament Injury ◽

Deltoid Ligament ◽

Injury Patterns ◽

Deltoid Ligament Injury

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Whether need to repair deltoid ligament injuries in Supination-external Rotation type Ⅳ ankle fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00523 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0052

Author(s):

Yunfeng Yang

Keyword(s):

Scoring System ◽

External Rotation ◽

Ankle Fractures ◽

Ligament Injury ◽

Deltoid Ligament ◽

Ligament Injuries ◽

Clear Space ◽

Significant Difference ◽

Supination External Rotation

Category: Ankle Introduction/Purpose: To evaluate the effect of repairing deltoid ligament in patients with supination-external rotation type? ankle fractures. Methods: Between January 2013 and June 2016, 35 patients of supination-external rotation type? ankle fractures associated with deltoid ligament injury had complete medical records and were included in this study. Among all, 30 cases involved pure deltoid ligament injuries while others also included medial malleolus fractures. All fractures were treated by open reduction and internal fixation. Patients were assigned to the repaired group (21 patients) or the non-repaired group (14 patients) according to whether deltoid ligament injuries were treated during the surgery. No significant difference was found in gender, age, injury pattern, time from injury to operation(P>0.05), which was comparable. Medial clear space, visual analogue scale(VAS) score, and American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hindfoot score(6 months, one year, two years after surgery), Baird-Jackson scoring system and complications were recorded. Results: Thirty-five patients were followed up 21-28months.The mean duration of operation in the repaired group was significantly longer than that of the non-repaired group.Baird-Jackson scoring system: the excellent rate of the repaired group was 90.5% while the non-repaired group was 85.7% . The VAS scores and the medial clear space of preoperative and final follow-up were significantly improved. At the last follow-up,2.85 percent of the patients presented with ankle instability while 8.5 percent of them occured traumatic arthritis. The AOFAS scores at 6, 12, and 24 months after operation were (82.1 ± 6.6; 86.2 ± 5.9; 91.5 ± 5.8) and (78.1 ± 6.5; 83.9 ± 5.6; 90.3 ± 5.6). However, none of them showed significant difference between the two groups (P>0.05). Conclusion: It’s unnecessary to repair the deltoid ligament in patients with supination-external rotation type? ankle fractures when ankle mortise restores after the fractures are fixed.

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Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-020-06308-7 ◽

2020 ◽

Author(s):

Umile Giuseppe Longo ◽

Mattia Loppini ◽

Caterina Fumo ◽

Angela Lanotte ◽

Ugo Trovato ◽

...

Keyword(s):

Ankle Joint ◽

Biomechanical Study ◽

Ligament Injury ◽

Rotational Instability ◽

Deltoid Ligament ◽

Deltoid Ligament Injury

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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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Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures

Foot & Ankle International ◽

10.1177/1071100720962796 ◽

2020 ◽

pp. 107110072096279

Author(s):

D’Ann Arthur ◽

Casey Pyle ◽

Stephen J. Shymon ◽

David Lee ◽

Thomas Harris

Keyword(s):

External Rotation ◽

Open Reduction Internal Fixation ◽

Ankle Fractures ◽

Ligament Injury ◽

Deltoid Ligament ◽

Posterior Tibial Tendon ◽

Level Of Evidence ◽

Radiographic Findings ◽

Type Iv ◽

Retrospective Comparative Study

Background: The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. Methods: A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. Results: Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. Conclusion: Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. Level of Evidence: Level III, retrospective comparative study.

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