Conclusion

Ankle fractures are a common presentation in emergency departments. While some fractures demonstrate either clear stability or instability based on initial radiographs, Weber B fractures require more diagnostic testing to evaluate the stability of the deltoid and tibiofibular ligaments. Historically, this has been done with manual stress views. However, the clear trend is that gravity and weight-bearing stress radiographs are able to detect unstable ankles at the same rate, utilize less physician resources, and are less painful for patients.

Dr. Noack is a third-year emergency medicine resident at Denver Health Medical Center.

Dr. Tomberg is an emergency physician at Denver Health Medical Center. He works in the ski clinic at the base of Winter Park Ski Area, the Denver Health Emergency Department, the Denver Health Adult Urgent Care Center, and the sports medicine department at Denver Health.

References

1. Fonseca LLD, Nunes IG, Nogueira RR, et al. Reproducibility of the Lauge-Hansen, Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 2017;53(1):101-106.
2. Malek IA, Machani B, Mevcha AM, et al. Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures. J Bone Joint Surg Br. 2006;88(9):1204-1206.
3. van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2009;129(2):227-235.
4. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356-357.
5. Yufit P, Seligson D. Malleolar ankle fractures. A guide to evaluation and treatment. Orthop Trauma. 2010;24(4):286-297.
6. Aiyer AA, Zachwieja EC, Lawrie CM, et al. Management of isolated lateral malleolus fractures. J Am Acad Orthop Surg. 2019;27(2):50-59.
7. Schock HJ, Pinzur M, Manion L, et al. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br. 2007;89(8):1055-1059.
8. Stewart C, Saleem O, Mukherjee DP, et al. Axial load weightbearing radiography in determining lateral malleolus fracture stability: a cadaveric study. Foot Ankle Int. 2012;33(7):548-552.
9. Holmes JR, Acker WB 2nd, Murphy JM, et al. A novel algorithm for isolated Weber B ankle fractures: a retrospective review of 51 nonsurgically treated patients. J Am Acad Orthop Surg. 2016;24(9):645-652.
10. Seidel A, Krause F, Weber M. Weightbearing vs gravity stress radiographs for stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle Int. 2017;38(7):736-744.
11. Dawe EJ, Shafafy R, Quayle J, et al. The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures. Foot Ankle Surg. 2015;21(2):86-90.
12. Nortunen S, Lepojärvi S, Savola O, et al. Stability assessment of the ankle mortise in supination-external rotation-type ankle fractures: lack of additional diagnostic value of MRI. J Bone Joint Surg Am. 2014;96(22):1855-1862.
13. van Leeuwen CAT, Hoffman RPC, Donken CCMA, et al. The diagnosis and treatment of isolated type B fibular fractures: results of a nationwide survey. Injury. 2019;50(2):579-589.
14. Schuberth JM, Collman DR, Rush SM, et al. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg. 2004;43(1):20-29.