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Treatment of the Stress Positive Ligamentous SE4 Ankle Fracture: Incidence of Syndesmotic Injury and Clinical Decision Making

Tornetta, Paul III MD*; Axelrad, Thomas W. MD, PhD; Sibai, Tarek A. MD*; Creevy, William R. MD*

doi: 10.1097/BOT.0b013e31825cf39c
Original Article

Objectives: The objective of the study was to review our experience with the treatment of stress positive (+) supination and external pattern injuries using shared decision making with the patients.

Design: Retrospective case review.

Setting: Level 1 trauma center.

Patients: Over a 9-year period, we treated 114 patients (aged 19–76 years, average 43 years) with stress (+) supination and external rotation type fibula fractures, who were included in the present study.

Intervention: X-rays were reviewed, and the medial clear space (MCS) measured on the presentation, stress, and final united radiographs. The decision for surgical or nonsurgical management was made by the patient and surgeon after a discussion of risks/benefits of both. Syndesmotic instability for the operative cases was diagnosed by medial widening and talar subluxation on abduction/external rotation stress after fibular fixation.

Main Outcome Measure: MCS measurement at union.

Results: Of the 114 cases, 54 were definitively treated in a cast, and 60 were treated operatively. Twenty-seven (45%) of the operative cases demonstrated syndesmotic instability on radiographic examination. The MCS on stress examination was statistically different, with greater widening seen for operatively treated patients (4.8 ± 0.5 vs. 6.9 ± 0.86) (P < 0.001). No patient healed with any subluxation on weight bearing x-rays.

Conclusions: Stress (+) SE pattern fibular fractures with minimal MCS widening on stress examination may be treated in a cast to union with predictable healing. In those patients treated operatively, the treating surgeon should be aware of the high rate of syndesmotic injury.

Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedics, Boston University Medical Center, Boston, MA

Department of Orthopaedics, Lake Charles Memorial Hospital, Lake Charles, LA.

Reprints: Thomas W. Axelrad, MD, PhD, 1717 Oak Park Boulevard, 3rd Floor, Lake Charles, LA 70601 (e-mail:

Dr Thomas W. Axelrad is salaried and supported by publication royalties from Wolters Kluwer/Lippincott Williams & Wilkins ( Dr Paul Tornetta III is salaried and supported by publication royalties from Smith & Nephew and Wolters Kluwer/Lippincott Williams & Wilkins; holds the intellectual property rights/patent and royalties from Smith & Nephew; receives consulting fees from Smith & Nephew; and is supported by contracted research with Smith & Nephew. Dr Paul Tornetta III shares ownership interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) with Exploramed. Dr Tarek A. Sibai and Dr William R. Creevy have no financial disclosures or conflicts of interest to declare.

Presented in part at the Annual Meeting of the Orthopaedic Trauma Association, 2010, Baltimore, MD; at the Annual Meeting of the American Academy of Orthopaedic Surgeons, 2011, San Diego, CA; and at the Annual Meeting of the American Orthopaedic Association, June 22-25, 2011, Boston, MA.

Accepted March 16, 2012

© 2012 Lippincott Williams & Wilkins, Inc.