Cite This Article

Sharon, M. Dixon, C. Tomesch, A. Twist and Shout: A Stressed Out Ankle. Ortho Pearls. July 17, 2024; Available: https://www.orthoempearls.com/articles/twist-and-shout-a-stressed-out-ankle

What is your diagnosis?

This is a lateral malleolus fracture Weber type B. You can see an oblique fracture line in the distal fibula extending to the level of the ankle mortise. 

• Pearl: Weber B fracture can be either stable or unstable depending on the integrity of the ankle syndesmosis and particularly the deltoid ligament. Management is conservative for stable fractures and typically surgical for unstable fractures highlighting the importance of differentiating the two. 

Image 2. A/P film of right ankle with oblique fracture through the lateral malleolus. Case courtesy of Alborz Jahangiri, Radiopaedia.org, rID: 46843. Author’s own annotation. 

What are stress view x-rays of the ankle and how can they be used?

The AP stress view of the ankle is a specialized view that can be used to assess the integrity of the syndesmosis and the deltoid ligament [1]. This view can be helpful in patients who have indeterminate AP films of the ankle, but clinically are highly suspicious of an unstable  fracture. 

What are the techniques to perform an x-ray with stress views?

Acquiring plain films of the ankle in a stress view can be done either with manual external rotation or gravity. With manual external rotation, the patient can either be supine or sitting upright with their leg straightened on the table. The goal is to have the leg with internal rotation of about 15-20 degrees. An additional set of hands is required to rotate the ankle into supination and external rotation while the technician shoots the film. With the gravity-assisted view, the ankle should be hanging over an edge, usually the patient’s gurney. The patient can either lay on the gurney in a lateral decubitus position on the ipsilateral side of the ankle of concern or be sitting in a chair. This naturally allows gravity to place the ankle into supination and external rotation without manual positioning [2]. You can see a video of how to obtain these images here.  

• Pearl: Either technique will most likely cause the patient a significant amount of pain, thus requiring pain management prior to attempting these specialized films. 

What is the management and disposition in the ED?

If the stress ankle views show less than 4-5mm of medial clear space widening, these can be considered stable fractures. These patients can typically be weight bearing as tolerated and can be placed in a CAM boot. For our patient above, her stress views were normal though she may benefit from pain management and a brief time in a short leg posterior splint given her inability to ambulate after her fall. 

However, if the stress ankle images show greater than 4-5 mm displacement or the presence of talar shift, these are considered unstable and typically surgical repair with Orthopedics is indicated [4]. A short leg posterior splint with the ankle at 90 degrees can be placed in the ED after reduction if significant displacement is present. 

Do you need an urgent ED Orthopedics consult?

If a patient’s fracture is considered stable on the stress views, these can be managed outpatient with Orthopedics follow up in clinic. Encourage the patient to participate in early mobilization with weight bearing as tolerated and provide outpatient pain management relief. Depending on your institutional practices and culture, unstable fractures might warrant an orthopedics consult in the ED for more expedited outpatient management. If your orthopedic colleagues are amentable, it is perfectly acceptable to make the patient non-weight bearing in a posterior short leg splint with stirrup for outpatient follow-up without an orthopedics consult in the ED.