![]() The fractures on the radiographs were classified according to Lauge-Hansen (Table 1) by a radiologist with 11 years experience in musculoskeletal radiology (J.H.). Radiographs obtained at presentation included AP, lateral, and mortise views. Exclusion criteria were associated neurological or vascular injuries, fractures associated with a hindfoot or midfoot fracture, a former trauma of the ankle, contraindications for MRI, and an insufficient knowledge of the Dutch language. Inclusion criteria were an acute ankle fracture that had occurred within 48 h and closure of the growth plates. Written informed consent was obtained, and the study was approved by the institutional review board. In 16 patients the fracture was treated with an open reduction and internal fixation (ORIF), with a setscrew placed in 4 patients. In 24 patients the injury involved the left and in 20 the right ankle. The mean age of the patients was 36 years and ranged from 16 to 61 years 25 were men and 19 were women. In the 44 patients, the fracture distribution according to Lauge-Hansen was 59% supination external rotation (SE), 5% pronation external rotation (PE), 25% supination adduction (SA), 9% pronation adduction (PA), and 2% pronation dorsiflexion (PD). The data were collected and analyzed from 44 consecutive patients with an acute ankle fracture who underwent a radiograph as well as an MRI in both the standard three orthogonal planes and in an additional oblique plane. Therefore, this prospective study evaluated the additional value of an oblique MRI scan plane for assessing the anterior and posterior distal tibiofibular syndesmotic ligaments in patients with an acute ankle fracture. A recent study demonstrated that the anterior and posterior syndesmotic ligaments are better depicted and that the integrity of the ligaments can be better evaluated in an oblique image plane of about 45° when compared to the axial plane. Several studies reported that the most commonly injured and reliably visualized anterior tibiofibular ligament on MRI might not be seen in its entire length on one single transverse image and a partially imaged ligament may be mistaken for a tear despite careful observation of contiguous slices. However, imaging in the axial plane can result in false-positive findings since the anterior and posterior distal tibiofibular ligament run in an oblique plane. The value of MRI in acute and chronic syndesmotic injuries has been described in several articles, and the axial image is known to be the most useful image plane. However, evaluating syndesmotic stability in ankle fractures is still a subject of debate as it is unclear when to stabilize an injured syndesmosis. It is commonly agreed that adequate reduction of ankle fractures reduces late osteoarthritis. In up to 13% of all ankle fractures and in 20% of patients requiring internal fixation, there will be an associated injury to the syndesmosis. Disruption of the distal tibiofibular syndesmosis in ankle fractures is common and usually results from an external rotation injury.
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