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Preoperative Radiographic and CT Findings Predicting Syndesmotic Injuries in Supination-External Rotation-Type Ankle Fractures

Choi, Young MD; Kwon, Soon-Sun PhD; Chung, Chin Youb MD, PhD; Park, Moon Seok MD, PhD; Lee, Seung Yeol MD; Lee, Kyoung Min MD, PhD

Journal of Bone & Joint Surgery - American Volume: 16 July 2014 - Volume 96 - Issue 14 - p 1161–1167
doi: 10.2106/JBJS.M.00709
Scientific Articles
Supplementary Content

Background: The Lauge-Hansen classification system does not provide sufficient data related to syndesmotic injuries in supination-external rotation (SER)-type ankle fractures. The aim of the present study was to investigate factors helpful for the preoperative detection of syndesmotic injuries in SER-type ankle fractures using radiographs and computed tomography (CT).

Methods: A cohort of 191 consecutive patients (104 male and eighty-seven female patients with a mean age [and standard deviation] of 50.7 ± 16.4 years) with SER-type ankle fractures who had undergone operative treatment were included. Preoperative ankle radiographs and CT imaging scans were made for all patients, and clinical data, including age, sex, and mechanism of injury (high or low-energy trauma), were collected. Patients were divided into two groups: the stable syndesmotic group and the unstable syndesmotic group, with a positive intraoperative lateral stress test leading to syndesmotic screw fixation. Fracture height, fracture length, medial joint space, extent of fracture, and bone attenuation were measured on radiographs and CT images and were compared between the groups. Binary logistic regression analysis was performed to identify the factors that significantly contributed to unstable syndesmotic injuries. Receiver operating characteristic curves were calculated, and cutoff values were suggested to predict unstable syndesmotic injuries on preoperative imaging measurements.

Results: Of the 191 patents with a SER-type ankle fracture, thirty-eight (19.9%) had a concurrent unstable syndesmotic injury. Age, sex, mechanism of injury, fracture height, medial joint space, and bone attenuation were significantly different between the two groups. In the binary logistic analysis, fracture height, medial joint space, and bone attenuation were found to be significant factors contributing to unstable syndesmotic injuries. The cutoff values for predicting unstable syndesmotic injuries were a fracture height of >3 mm and a medial joint space of >4.9 mm on CT scans, and a fracture height of >7 mm and medial joint space of >4.5 mm on radiographs.

Conclusions: Fracture height, medial joint space, and bone attenuation were useful factors for the preoperative detection of unstable syndesmotic injuries in SER-type ankle fractures.

Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery (Y.C., C.Y.C., M.S.P., S.Y.L. and K.M.L.) and Biomedical Research Institute (S.-S.K.), Seoul National University Bundang Hospital, 300 Gumi-Dong, Bundang-Gu, Sungnam, Kyungki 463-707, South Korea. E-mail address for K.M. Lee:

Copyright 2014 by The Journal of Bone and Joint Surgery, Incorporated
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