Table 1.
Predicted syndesmotic injury based on three fracture classification systems and measurements on X-ray. Findings at MRI regarding the anterior (ATIFL) and posterior tibiofibular ligament (PTIFL), transverse ligament, interosseous membrane and ligament, deep and superficial deltoid ligament are presented, together with the type of treatment
| X-ray | MRI | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Fracture classificationc | Measurementsd | Syndesmosis injurye | Syndesmose | |||||||||||||||||||||||
| No. | Age (years) | Sex | MRIa | Sideb | WE | AO | LH | TFCS | TFO | MCS | SCS | WE | AO | LH | Injuryf | ATIFLg | AvAnth | Injuryf | PTIFLg | AvPosh | IOLi | TRLi | IOMj | De ∆i | Su ∆i | ORk |
| 1 | 24 | M | 0 | R | C | C.2.3 | SE4 | 4.3 | 11.9 | 5.7 | 3.9 | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 2 | 0 | 3 | 1 | 1 | 1 |
| 2 | 48 | F | 0 | L | C | * | SE3 | 4.6 | 3.8 | 1.7 | 3.6 | 1 | 0 | 3 | 1 | 3 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 |
| 3 | 33 | M | 0 | L | * | * | SE1-PE2 | 5.7 | 6.3 | 3.3 | 4.4 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 3 | 0 | 0 | 2 | 0 | 0 | 2 | 1 |
| 4 | 26 | M | 0 | R | B | B.1.1 | SE2 | 5.1 | 5.9 | 1.7 | 3.4 | 0 | 0 | 1 | 1 | 3 | 0 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 |
| 5 | 39 | M | 0 | L | B | B.1.2 | SE2 | 6.3 | 5.7 | 4.7 | 3.8 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 1 |
| 6 | 26 | M | 0 | R | B | B.1.2 | SE2 | 6.5 | 0.0 | 7.9 | 5.9 | 1 | 1 | 1 | 1 | 3 | 0 | 1 | 1 | 1 | 1 | 1 | * | 1 | 3 | 1 |
| 7 | 41 | F | 0 | L | C | C.1.2 | SE4 | 3.2 | 7.5 | 1.7 | 3.2 | 1 | 1 | 3 | 1 | 3 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | 0 |
| 8 | 58 | F | 0 | R | C | C.2.2 | SE4 | 3.6 | 4.4 | 3.4 | 5.3 | 1 | 1 | 3 | 1 | 1 | 2 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 0 |
| 9 | 48 | M | 0 | R | A | A.1.3 | SA1 | 3.4 | 7.1 | 2.3 | 3.3 | 0 | 0 | 0 | 1 | 1 | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| 10 | 17 | F | 0 | L | * | * | PD2 | 4.4 | 5.6 | 2.8 | 2.8 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 |
| 11 | 57 | F | 0 | L | A | A.1.3 | SA1 | 3.3 | 5.3 | 2.1 | 3.1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| 12 | 22 | M | 0 | R | A | A.1.2 | SA1 | 4.9 | 8.0 | 1.9 | 2.7 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| 13 | 41 | M | 0 | L | B | B.1.1 | SE2 | 2.8 | 7.6 | 2.1 | 2.9 | 0 | 0 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 14 | 23 | M | 0 | L | B | * | SE3 | 4.5 | 3.2 | 1.3 | 3.1 | 1 | 0 | 3 | 1 | 3 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 3 | 3 | 1 |
| 15 | 48 | M | 0 | L | B | B.2.2 | SE4 | 5.7 | 9.8 | 3.1 | 2.9 | 1 | 1 | 3 | 1 | 3 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 |
| 16 | 21 | M | 0 | R | C | C.2.3 | PE4 | 11.6 | 0.0 | * | * | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 0 | 1 | 4 | 1 | 3 | 1 | 0 | 2 |
| 17 | 51 | M | 0 | R | B | B.3.2 | SE4 | * | 0.0 | * | * | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 |
| 18 | 41 | M | 0 | R | B | B.1.1 | SE2 | 4.0 | 12.8 | 3.8 | 4.6 | 0 | 0 | 1 | 1 | 3 | 0 | 1 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 0 |
| 19 | 58 | F | 0 | L | A | A.1.2 | SA1 | 4.4 | 3.7 | 1.7 | 2.4 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 20 | 58 | M | 0 | L | B | * | SE4 | 3.9 | 9.6 | 2.5 | 2.7 | 0 | 0 | 3 | 1 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 0 |
| 21 | 20 | F | 1 | R | B | B.2.1 | SE4 | 2.5 | 0.0 | 12.7 | 2.9 | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 3 | 3 | 1 |
| 22 | 18 | F | 0 | R | B | B.1.1 | SE2 | 6.0 | 2.6 | 2.7 | 2.9 | 0 | 0 | 1 | 1 | 3 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 1 | 0 |
| 23 | 55 | M | 0 | L | * | * | PA1-PE1 | 4.8 | 4.2 | 2.5 | 2.9 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 4 | 0 | 0 | 0 | 0 | 0 |
| 24 | 25 | F | 0 | L | B | B.1.2 | SE2 | 5.1 | 6.0 | 3.8 | 3.0 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 0 | 3 | 0 | 0 | 1 | 0 |
| 25 | 53 | F | 0 | L | C | C.2.2 | PA3 | 9.8 | 0.0 | 2.5 | 2.9 | 1 | 1 | 3 | 1 | 0 | 2 | 1 | 3 | 0 | 1 | 1 | 0 | 0 | 1 | 2 |
| 26 | 62 | F | 0 | L | B | B.1.2 | SE2 | 4.1 | 10.4 | 2.3 | 2.2 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| 27 | 33 | F | 0 | R | B | B.1.1 | SE2 | 4.6 | 3.3 | 3.1 | 3.4 | 0 | 0 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 28 | 52 | F | 1 | R | C | C.3.3 | PE4 | 7.7 | 0.0 | 3.5 | 5.0 | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 3 | 0 | 1 | 1 | 0 | 2 | 3 | 2 |
| 29 | 48 | M | 1 | L | B | * | SE3 | 6.9 | 3.0 | 4.6 | 5.0 | 1 | 1 | 3 | 1 | 1 | 2 | 0 | 1 | 0 | 4 | 1 | 1 | 2 | 2 | 0 |
| 30 | 29 | M | 0 | R | * | * | PA1 | 2.9 | 2.8 | 2.2 | 4.1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 2 | 3 | 0 |
| 31 | 58 | M | 1 | L | B | B.3.2 | SE4 | * | * | * | * | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 2 | 1 | 1 | 1 | 1 | 1 |
| 32 | 28 | F | 0 | R | A | A.1.2 | SA1 | 5.3 | 3.6 | 2.5 | 3.9 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 33 | 27 | F | 0 | R | B | B.1.1 | SE2 | 4.0 | 3.2 | 3.3 | 3.1 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 |
| 34 | 27 | M | 0 | L | B | B.3.3 | SE4 | 5.4 | 4.5 | 3.7 | 3.0 | 1 | 1 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 0 | 0 | 1 | 0 | 0 | 1 |
| 35 | 56 | F | 0 | L | A | A.1.2 | SA1 | 3.8 | 6.9 | 2.4 | 2.6 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 36 | 56 | M | 0 | R | C | C.1.1 | SE2 | 2.5 | 9.4 | 2.7 | 4.3 | 1 | 1 | 1 | 1 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 37 | 16 | F | 0 | L | A | A.2.2 | SA2 | 3.9 | 5.4 | 3.1 | 3.2 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| 38 | 18 | M | 0 | R | C | * | SE3 | 4.6 | 4.9 | 2.6 | 5.0 | 1 | 0 | 3 | 1 | 3 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 3 | 3 | 2 |
| 39 | 53 | F | 0 | L | B | B.1.1 | SE2 | 3.9 | 3.7 | 2.6 | 3.1 | 0 | 0 | 1 | 1 | 3 | 0 | 1 | 0 | 1 | 4 | 0 | 0 | 1 | 1 | 0 |
| 40 | 51 | F | 0 | R | B | B.1.1 | SE2 | 3.5 | 3.7 | 2.3 | 2.9 | 0 | 0 | 1 | 1 | 0 | 2 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 0 |
| 41 | 56 | M | 1 | L | B | B.1.2 | SE2 | 0.8 | 3.1 | 7.8 | 2.6 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 1 | 0 | 4 | 0 | 1 | 1 | 2 | 1 |
| 42 | 27 | F | 0 | L | A | A.1.1 | SA1 | 5.1 | 0.6 | 2.3 | 3.0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| 43 | 18 | M | 1 | R | C | C.1.3 | PE4 | 6.2 | 1.4 | 2.7 | 3.5 | 1 | 1 | 3 | 1 | 1 | 0 | 1 | 0 | 1 | 4 | 0 | 0 | 0 | 0 | 2 |
| 44 | 30 | F | 0 | L | * | * | PA1-PE1 | 5.0 | 4.4 | 2.1 | 3.8 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 45 | 27 | M | 0 | R | C | C3.3 | PE4 | 4.3 | 2.1 | 4.0 | 4.3 | 1 | 1 | 3 | 1 | 3 | 0 | 0 | 2 | 0 | 3 | 0 | 2 | 3 | 3 | 2 |
| 46 | 20 | M | 0 | R | A | A1.2 | SA1 | 5.1 | 6.2 | 2.9 | 4.8 | 0 | 0 | 0 | 1 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 47 | 61 | F | 0 | L | B | B3.3 | PA3 | 3.0 | 4.5 | 2.1 | 3.0 | 0 | 0 | 3 | 1 | 3 | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 |
| 48 | 36 | M | 0 | L | A | A1.2 | SA1 | 3.9 | 8.1 | 2.1 | 3.6 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| 49 | 17 | M | 0 | R | * | * | * | 4.1 | 1.4 | 2.5 | 2.8 | 0 | 0 | 0 | 1 | 3 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| 50 | 22 | F | 0 | R | B | B.1.2 | SE2 | 7.1 | 0.0 | 2.3 | 2.4 | 1 | 1 | 1 | 1 | 3 | 0 | 0 | 2 | 0 | 0 | 0 | 1 | 0 | 0 | 0 |
| 51 | 17 | M | 0 | L | A | A.1.3 | SA1 | 2.4 | 6.9 | 3.2 | 4.0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 |
aMRI: 0 performed before treatment, 1 performed postoperatively
bSide of ankle fracture: R right, L left
cFracture classification: WE Weber, AO AO-Müller, LH Lauge Hansen
dX-ray measurements: TFCS tibiofibular clear space (normal value TFCS ≤ 6 mm), TFO tibiofibular overlap (normal value TFO > 0 mm), MCS medial clear space, SCS superior clear space (normal value MCS ≤ 4 mm or MCS/SCS ≤ 1)
eSyndesmosis injury based on X-ray and measurements for WE and AO: 0 no injury, 1 injury; for LH based on trauma mechanism deduced from X-ray: 0 no injury, 1 anterior injury, 2 posterior injury, 3 anterior and posterior injury
fSyndesmosis injury anterior or posterior on MRI (i.e., ruptured tibiofibular ligament or intact tibiofibular ligament with an avulsion fracture): 0 no injury, 1 injury
gATIFL and PTIFL: 0 normal tibiofibular ligament, 1 thickened tibiofibular ligament, 2 possibly ruptured tibiofibular ligament, 3 ruptured tibiofibular ligament
hAvulsion fracture anterior (AvAnt) or posterior (AvPos): 0 no avulsion, 1 tibial avulsion, 2 fibular avulsion
iInterosseous ligament (IOL), transverse ligament (TRL), deep deltoid ligament (De ∆), and superficial deltoid ligament (Su ∆): 0 normal, 1 thickened, 2 partially ruptured, 3 completely ruptured
jInterosseous membrane (IOM): 0 normal, 1 rupture of membrane higher than fibula fracture, 2 rupture of membrane at the same level as fibula fracture, 3 rupture of membrane lower than fibula fracture
kOperation (OR): 0 no ORIF, 1 ORIF without setscrew, 2 ORIF with setscrew