Background: Displaced transverse fractures of the medial malleolus are commonly treated with open reduction and internal fixation with two screws or wires. A mortise radiograph is often used to verify the position of the implants relative to the joint space. However, because the medial and lateral talomalleolar spaces are normally not parallel, the mortise projection (which is colinear with the lateral space) does not provide an accurate radiograph of the medial joint space.Methods: In ten cadaveric ankles, two wires were inserted into the medial malleolus, as is done for fixation of a fracture, and the distance of the wires from the joint space was measured on an anteroposterior radiograph, on mortise radiographs made with the foot in 15 and 30 degrees of internal rotation, and on anatomical cross section.Results: The measurement on the anteroposterior radiograph exceeded the anatomical measurement in only two specimens, and the discrepancy was 0.5 millimeter in both instances. Measurement of the osseous thickness between the joint surface and the posterior wire on the mortise radiographs always revealed a lower value than the measurements on the anteroposterior radiograph and the anatomical cross section of the same specimen. There was a false appearance of intra-articular placement of the posterior wire on the 15-degree mortise radiographs of four specimens and on the 30-degree mortise radiographs of eight specimens.Conclusions: These findings demonstrate that the mortise projection provides an oblique radiograph of the medial joint space that can inaccurately reflect the true position of fixation implants in the medial malleolus. Because an anteroposterior radiograph is made with the articular surface of the medial malleolus tangential to the beam, it provides a more accurate representation of implants in the medial malleolus.Clinical Relevance: We recommend the use of an anteroposterior radiograph to properly evaluate the position of implants used in the treatment of transverse fractures of the medial malleolus. This type of radiograph allows a more lateral starting point for insertion of the fixation device, more accurate intraoperative evaluation of the position of the implants, and better fixation of fractures of the medial malleolus.
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