Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle.

Seidel, Angela; Krause, Fabian; Weber, Martin (2017). Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle. Foot & ankle international, 38(7), pp. 736-744. Sage 10.1177/1071100717702589

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BACKGROUND Isolated lateral malleolar fractures may result from a supination-external rotation (SER) injury of the ankle. Stable fractures maintain tibiotalar congruence due to competent medial restraints and can be treated nonoperatively with excellent functional results and long-term prognosis. Stability might be assessed with either stress radiographs or weightbearing radiographs. METHODS A consecutive series of patients with closed SER fractures (presumed AO 44-B1) were prospectively enrolled from 2008 to 2015. Patients with clearly unstable fractures (medial clear space more than 7 mm) on the initial nonweightbearing radiograph were excluded and operated on. All other patients were examined with a gravity stress and a weightbearing anteroposterior radiograph. Borderline instability of the fracture was assumed when the medial clear space was 4 to 7 mm. Those were treated nonoperatively. RESULTS Of 104 patients with isolated lateral malleolar fractures of the SER type, 14 patients were treated operatively because of clear instability (displacement) on the initial radiographs. Of the nonoperative patients, 44 patients demonstrated borderline instability on the gravity stress but stability on the weightbearing radiograph ("gravity borderline"); the remaining 46 were stable in both tests ("gravity stable"). At an average follow-up of 23 months, no significant differences were seen in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points gravity-borderline group vs 93 points gravity-unstable group), the Foot Functional Index score (11 vs 10 points), the Short Form 36 (SF-36) physical component (86 vs 85 points), and SF-36 mental component (84 vs 81 points). Radiographically, all fractures had healed with anatomic congruity of the ankle. CONCLUSION Weightbearing radiographs provided a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up. Gravity stress radiographs appear to overrate the need for operative treatment. LEVEL OF EVIDENCE Level III, prospective comparative study.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > Department of Orthopaedic, Plastic and Hand Surgery (DOPH) > Clinic of Orthopaedic Surgery

UniBE Contributor:

Seidel, Angela; Krause, Fabian and Weber, Martin


600 Technology > 610 Medicine & health








Lilianna Bolliger

Date Deposited:

25 Jan 2018 11:13

Last Modified:

05 Nov 2019 05:00

Publisher DOI:


PubMed ID:


Uncontrolled Keywords:

ankle fracture gravity stress radiograph stability assessment weightbearing radiograph





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