Trauma X-ray - Lower limb
Ankle

Key points

  • Ankle injury may involve bones or ligaments - or a combination of the two
  • The talar dome surface should be carefully viewed following ankle trauma

Three bones form the ankle joint - tibia, fibula and talus. Ankle fractures are usually bony injuries involving the distal tibia (medial malleolus) or distal fibula (lateral malleolus). Occasionally the articular surface of the talus can be injured.

Standard views

Anterior-Posterior (AP) and Lateral. The AP or 'mortise' view is not a true Anterior-Posterior projection but rather at an angle to optimise visualisation of the ankle joint without being overlapped by the fibula.

Ankle anatomy - Normal AP 'mortise'

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Ankle anatomy - Normal AP 'mortise'

  • The weight-bearing portion is formed by the tibial plafond and the talar dome
  • The joint extends into the 'lateral gutter' (1) and the 'medial gutter' (2)
  • The joint is evenly spaced throughout

Ankle anatomy - Normal Lateral

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Ankle anatomy - Normal Lateral

  • Carefully following the bone contour of the tibia and fibula shows the inferior edge of the medial and lateral malleoli

Ankle ligament anatomy

Ankle injuries may involve bones or ligaments in isolation, or a combination of bones and ligaments. X-rays directly visualise bone injury, but understanding of the anatomical position of ligaments is required to appreciate the presence of ligament injuries which are not directly visualised.

Ankle bone and ligament anatomy

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Ankle bone and ligament anatomy

  • The ankle is stabilised by multiple ligaments not visible with X-ray

Ankle injuries

Fractures of the medial or lateral malleoli can lead to ankle joint instability and loss of normal ankle joint alignment. The posterior edge of the distal tibia is sometimes referred to as the 'posterior malleolus'.

Ligamentous injury may also lead to instability of the joint, but this is not always appreciated if there is no displacement.

Lateral malleolar fractures are categorised according to their position in relation to the distal tibiofibular syndesmosis at the level of the ankle joint.

Lateral malleolus fracture - AP

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Lateral malleolus fracture - AP

  • Soft tissue swelling laterally (asterisks)
  • Transverse fracture of fibular tip (Weber A)
  • The ankle joint remains aligned normally

Weber fracture classification

  • Weber A = Distal to ankle joint (this case)
  • Weber B = At level of ankle joint
  • Weber C = Proximal to ankle joint

Bimalleolar fractures - AP

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Bimalleolar fractures - AP

  • Transverse medial malleolus fracture
  • Lateral malleolus fracture - at level of ankle joint (Weber B)
  • Joint widened medially due to lateral displacement of the talus

Trimalleolar fracture - AP and Lateral

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Trimalleolar fracture - AP and Lateral

  • 1 - Medial malleolus fracture
  • 2 - Lateral malleolus fracture - proximal to the ankle and extending up the fibula (Weber C fracture)
  • 3 - Posterior malleolus fracture
  • The joint is unstable and widened anteriorly (arrowheads) and at the distal tibiofibular syndesmosis (asterisk)
  • The talus is displaced posteriorly and laterally along with the medial and lateral malleolus bone fragments

Maisonneuve fractures

A 'Maisonneuve fracture' is a fracture of the proximal fibula associated with injury to the medial side of the ankle and disruption of the distal tibiofibular syndesmosis. The medial ankle injury may be either a visible medial malleolus fracture or an invisible injury of the medial ligaments.

An isolated fracture of the medial malleolus, or widening of the ankle joint with no visible fracture seen on ankle X-ray, should raise the suspicion of an associated fracture of the fibula. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. Imaging of the proximal fibula should also be considered in the setting of any severe ankle injury or if the proximal fibula is tender to palpation.

Maisonneuve fracture - Ankle AP

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Maisonneuve fracture - Ankle AP

  • (Same case as below)
  • 1 - Disruption of the medial ankle joint with small bone avulsion
  • 2 - Disruption of the distal tibio-fibular syndesmosis
  • No fibular fracture is visible at the ankle raising the suspicion of a proximal fibular fracture

Maisonneuve fracture - AP proximal tibia-fibula

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Maisonneuve fracture - AP proximal tibia-fibula

  • (Same case as above)
  • Spiral fracture of the proximal fibula

Osteochondral fractures

Occasionally ankle trauma causes a fracture of the talus bone surface. These 'osteochondral' injuries are often subtle and so this area should be assessed carefully on all post-traumatic ankle X-rays.

Osteochondral fracture

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Osteochondral fracture

  • Loss of the normal talar dome cortex contour due to an osteochondral fracture