 ANNOTATION

When is a simple fracture of the lateral

malleolus not so simple?
HOW TO ASSESS STABILITY, WHICH ONES TO FIX AND THE ROLE
OF THE DELTOID LIGAMENT

N. Gougoulias, Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being
A. Sakellariou recognised that the integrity of the ‘medial column’ is essential for the stability of the
fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are
From Frimley Health pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-
NHS Foundation C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how
Trust, Frimley Park best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external
Hospital, Surrey, rotation (SER) fractures of the lateral malleolus remains controversial.
United Kingdom We provide a rationale as to how to classify SER distal fibular fractures using weight-
bearing radiographs, and how this can help guide the management of these common
injuries.
Cite this article: Bone Joint J 2017;99-B:851–5.

 N. Gougoulias, MD, PhD,
Consultant Orthopaedic Foot &
Ankle Surgeon
 A. Sakellariou, BSc, MBBS
FRCS(Orth), Consultant
Orthopaedic Foot & Ankle
Surgeon
Frimley Health NHS Foundation
Trust, Frimley Park Hospital,
Portsmouth Road, Frimley,
Surrey, GU16 7UJ, UK.
Correspondence should be sent
to N. Gougoulias; email:
gougnik@yahoo.com
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B7.
BJJ-2016-1087.R1 $2.00
Bone Joint J
2017;99-B:851–5.
Lateral malleolar fractures are often described
as “simple”, or “straight forward” and “easy”
to fix.1 However, there is quite a high incidence
of complications after surgical treatment. Up
to 20% of operatively treated distal fibular
fractures will result in damage to the superfi-
cial peroneal nerve,2 or other complications,
including prominent hardware requiring
removal.3 Furthermore, long-term studies
summarised in a systematic review in 2010,4
show that “stability is a key issue” in the man-
agement of isolated Weber type-B fractures of
the distal fibula5,6 resulting from a Lauge-
Hansen supination and external rotation
injury.7 These correspond to the 44-B1 type
fractures according to the Arbeitsgemeinschaft
für Osteosynthesefragen (AO) classification.8
Stable fractures can safely be treated non-
operatively with good or excellent long-term
outcomes.4,9 It is therefore mandatory to iden-
tify the unstable fractures accurately.
The classification of fractures of the
ankle and implications in clinical
practice
Isolated fibular fractures account for approxi-
mately 70% of all fractures involving the
ankle10 and in order to manage these injuries
rationally some understanding of the Lauge-
Hansen classification is essential.7 This classifi-
cation relates the mechanism of injury to the
ligamentous injuries and the patterns of frac-
ture. It was described more than 60 years ago
and at the time of its proposal, strict scientific
criteria and processes for validation had not
been introduced. It was based on observations
and assumptions. Gardner et al11 have
reported that the Lauge-Hansen classification
predicts only about 50% of ligamentous inju-
ries accurately. However, in a more recent
study involving the MRI and intra-operative
findings of 300 fractures of the ankle, the
Lauge-Hansen classification accurately pre-
dicted the ligamentous component of the
injury in 94%.12 Other studies have shown
that this classification does not always predict
the extent of the bony component of the
injury.13,14
It has previously been thought that the integ-
rity of the ‘lateral column’ (fibula) is essential
for providing stability to the ankle mortise.
This was the basis for the Danis-Weber classi-
fication,5,6 which did not take into considera-
tion any damage to the medial structures.
However, later studies have shown that the
medial column, made up of the medial malleo-
lus and deltoid ligament is more important to
the stability of the ankle than the lateral struc-
tures.9 The ankle can, thus, be considered as a
ring. If it breaks in one place it remains stable.
If it breaks in two places it becomes potentially
unstable.8 Therefore, although easy and
descriptive, the Weber classification cannot
guide management for the most common type-
B fractures, as it does not distinguish between
stable and unstable fractures.
The Lauge-Hansen classification takes into
consideration the mechanism of injury causing

VOL. 99-B, No. 7, JULY 2017 851

852 N. GOUGOULIAS, A. SAKELLARIOU
Fig. 1a Fig. 1b
Non-weight-bearing anteroposterior ankle radiographs (a, b) taken on
presentation in the Emergency Department. In the absence of lateral
talar shift and a narrow distance between the medial surface of the talus
and the medial surface of the medial malleolus (medial clear space;
MCS), the deltoid ligament is intact (black arrow). This is described as
supination external rotation stage II (SER-II) fracture (a), according to the
Lauge-Hansen classification. Widening of the MCS, is indicative of rup-
ture of the deltoid ligament (white arrow). This is classified as SER-IV
fracture (b).
the fracture and/or ligamentous injuries as each fracture has
an equivalent ligamentous injury. Most injuries involving
the ankle are the result of rotational forces. When the foot
is supinated, the axial load causes an external rotation
force; the body externally rotates in relation to the supi-
nated foot causing a trans-syndesmotic fibular fracture.
This corresponds to type-B fractures according to the
Weber5,6 and AO8 classifications. When the force ceases on
the lateral side and no further damage is done, two struc-
tures may have been damaged, namely the syndesmotic lig-
aments and the distal fibula. Thus, we describe these
injuries as supination external rotation stage II (SER-II)
fractures. When excessive rotational force is applied, fur-
ther sequential injuries involve a posterior malleolar frac-
ture or, a posterior ligamentous injury (SER-III) and,
sequentially, a medial malleolar fracture (obvious SER-IV)
or injury to the deltoid ligament (potentially occult SER-
IV). When the deltoid ligament is ruptured, lateral talar
shift occurs and the medial clear space, the distance
between the medial malleolus and the medial surface of the
talus (Fig. 1), widens on the anteroposterior radiograph. A
medial clear space of > 4 mm is usually considered to be
abnormal.10
When, on the other hand, an external rotation force is
applied to the pronated foot, the medial structures (the
medial malleolus or the deltoid ligament) will give way
first. As the external rotation force travels to the lateral
side, it can cause disruption of the syndesmosis, a supra-
syndesmotic fibular fracture and, finally, a posterior malle-
olar fracture or injury to the posterior tibiofibular ligament.
So, by definition, a supra-syndesmotic type-C fracture of
the fibula according to the Weber and AO classifications,
indicates a more severe, unstable pattern of injury that usu-
ally requires operative management.10
Thus, the standard view is that bi- and tri-malleolar frac-
tures are clearly unstable as the ring has broken in at least
two places, and so are pronation external rotation (PER)
injuries, resulting in a type-C high fibular fracture. How-
ever, interestingly some authors have shown that supra-
syndesmotic, as well as some bi-malleolar and tri-malleolar
fractures, can be treated functionally in a brace with no
subsequent displacement.15,16 Perhaps pronation-type frac-
tures are less unstable than the classification predicts. Fur-
thermore, if stability of the medial column is key, then the
distinction between SER-II and occult SER-IV fractures
(Fig. 1; no medial malleolar fracture, but possible deep del-
toid rupture) is essential in order to decide the appropriate
management. SER-II fractures are stable and should be
treated non-operatively; but how can we reliably, identify
these stable SER fractures?
Methods used to assess the stability of isolated
SER fractures of the ankle
It has been proposed in the past, that tenderness around the
medial aspect of the ankle, swelling, and/or ecchymosis
indicate damage to the deltoid ligament and thus these frac-
tures should be fixed. The medial tenderness sign has, how-
ever, been shown to be unreliable, as often it is only the
superficial component of the deltoid ligament complex that
is injured causing pain and bruising, while the deep part of
the ligament is intact, providing stability to the ankle.17-19
Therefore, it was felt that one should test the ankle for
dynamic instability and the manual, external rotation stress
test was introduced.20 There are several drawbacks associ-
ated with manual stress radiographs. Are they tolerated by
the patient? Should they be performed under anaesthesia?
How much stress should be applied? Who applies the
stress, a doctor or a radiographer and what are the practical
and logistical issues?
Consequently, the gravity stress (GS) radiograph20 (Fig. 2)
was introduced, in which the patient lies on the side of the
injury, with the lower leg hanging off the edge of the x-ray
table, resulting in gravity causing external rotation, while
an anteroposterior radiograph is taken in order to stand-
ardise testing in external rotation. Although it has been
shown to be tolerated better by patients than the manual
stress test, it was thought that instability and, consequently,
the need for surgery, could be over-emphasised. This was
mainly after weight-bearing radiographs were introduced
as a means of identifying lateral talar shift.3,21,22
At our institution, we have sequentially used all three
methods (manual stress, gravity stress and weight-bearing
radiographs) to identify unstable SER fractures. We found
that when gravity stress radiographs were used, before
2011, 45% of isolated distal fibular SER fractures were
shown to be unstable and were treated operatively. Opera-
tive fixation resulted in an increased rate of further surgery,
including removal of hardware of 12% and an overall rate
THE BONE & JOINT JOURNAL
 WHEN IS A SIMPLE FRACTURE OF THE LATERAL MALLEOLUS NOT SO SIMPLE?
Fig. 2
A gravity stress radiograph showing widening of the
medial clear space, indicating injury of the deltoid liga-
ment (white arrow).
of complications of 20%. When weight-bearing radio-
graphs within seven to ten days of the injury were intro-
duced in 2011, to detect unstable SER fractures, only 3.7%
of these injuries were deemed to be unstable and need sur-
gical treatment. None of the fractures that were deemed to
be stable and treated conservatively required subsequent
surgery.3 Thus, gravity stress testing not only resulted in
over-estimation of the need for surgery but also, in more
complications. These findings confirmed those of others
who reported that surgery was needed in only 3%22 and
10%21 of SER fractures, respectively, when weight-bearing
radiographs were used to assess stability. Patients treated
non-operatively had an excellent clinical outcome. Also, a
recently published Combined Randomised and Observa-
tional Study of Surgery for type-B Ankle Fracture Treat-
ment (CROSSBAT),23 showed that surgical management
for AO type 44-B1 fractures with minimal talar shift
resulted in more complications, without a better outcome
compared with non-surgical management.
Anatomical and biomechanical considerations: the
role of the deltoid ligament
These findings are also partly consistent with two cadaveric
studies. Michelson et al24 studied eight cadaveric specimens
VOL. 99-B, No. 7, JULY 2017
853
having performed an oblique distal fibular osteotomy and
complete transection of the deltoid ligament. Mortise views
were normal, whereas gravity stress views showed talar
shift of > 2 mm and valgus tibio-talar alignment of > 15°.
Stewart et al25 questioned the ability of simulated weight-
bearing radiographs to assess the stability of fractures of
the ankle. They examined 12 cadaveric specimens and pre-
pared three experimental groups: (a) intact ankles, (b)
ankles with a fibular osteotomy and (c) those with fibular
osteotomy and transection of the deltoid ligament. Axial
loading radiographs failed to show any difference in talar
shift with widening of the medial clear space between the
three groups. If we combined the findings of these cadaveric
studies, we would conclude that gravity stress views
detected instability in all, whereas axial loading views
detected instability in none of the ankles. Therefore, one
can argue that axial loading helps reduce an ankle with an
isolated distal fibular fracture, whether the deltoid ligament
is ruptured or not. However, findings in cadavers cannot
necessarily allow conclusions to be drawn about the bio-
mechanics of a fracture in vivo. Furthermore, it could be
argued that a small sample size, as in cadaveric studies, may
not also be such as to allow conclusions to be drawn, given
that in the clinical studies we mentioned earlier,3,22 a small
proportion (< 5%) of ankles were deemed unstable using
weight-bearing radiographs. Nevertheless, if we consider
the findings of all these clinical and cadaveric studies, we
could conclude that, in the vast majority of cases, the axi-
ally loaded or weight-bearing position reduces the ankle
mortise when examining SER fractures. Further laboratory,
cadaveric and clinical studies may shed more light on this
issue.
Why do stress radiographs overestimate the instability of
a fracture? What is different about the small proportion of
SER fractures that present with talar shift only in the
weight-bearing position? No definite explanation can be
given. In this annotation, we have tried to address this by
proposing a theory based on what is already known about
the anatomy and biomechanical properties of the medial
collateral (deltoid) ligament.26,27
This ligament has a superficial and a deep layer. The
superficial layer resists plantar flexion and external rota-
tion of the talus relative to the tibia.26 The deep layer has
anterior and posterior components, the anterior and poste-
rior talo-tibial ligaments (ATTL and PTTL). The posterior
ligament is the strongest and most consistently found in
cadaveric specimens. It is an intra-articular, but extra-
synovial ligament, originating mostly from the posterior
colliculus of the medial malleolus and inserting onto an
oval tubercle on the posteromedial surface of the talus, just
plantar to the articular surface.26 The PTTL is tight when
the foot is plantigrade such as when weight-bearing on a
plantigrade foot, and loose when the foot is plantar
flexed.26 Therefore, a ruptured ATTL, with an intact PTTL,
may have the same effect on stability, allowing lateral shift
of the talus when the foot is in a non-plantigrade position
854 N. GOUGOULIAS, A. SAKELLARIOU
Fig. 3a Fig. 3b
A standard anteroposterior non-weight-bearing radiograph with the
foot plantar flexed, taken on the day of injury (a) showed widening of
the medial clear space (white arrow). A weight-bearing radiograph
when the foot is plantigrade of the same patient (b), a few days later,
showed a congruent joint, thus, potentially a stable fracture. This is
what we classify as a supination external rotation stage IV(A) (‘SER-
IV(A)’) fracture. It can be treated non-operatively, in a below-knee cast
(not a removable boot), allowing weight-bearing as tolerated.
Fig. 4
Weight-bearing radiograph, taken a few days after injury,
showing talar shift (white arrow). This fracture is unstable,
irrespective of the position of the foot. We classify this fracture
as supination external rotation stage IV(B) (‘SER-IV (B)’). Sur-
gical treatment is indicated.
(when the PTTL is loose) as, for example, when presenting
on a non-weight-bearing mortise radiograph, at examina-
tion under anaesthesia or, when performing a gravity stress
radiograph. Thus, a partial rupture of the deltoid ligament
involving the ATTL only, accompanying a SER distal fibu-
lar fracture, may result in widening of the medial clear
space with talar shift, when the foot is not plantigrade, and
the assumption under these circumstances would be that
the fracture was unstable.
Therefore, these characteristics of the deltoid ligament
have the following implications on the classification and
the clinical and diagnostic features:
- when both the superficial and deep components are
intact (SER-II fracture), external rotation forces can be
resisted and stress tests indicate a stable ankle;
- when the superficial component is ruptured, it cannot
resist external rotation which will open the medial clear
space and stress radiographs will indicate instability. This
could be the result of a partial rupture of the deep deltoid
ligament involving only the ATTL;
- when the superficial and ATTL parts of the ligament are
injured, but the PTTL is intact, and a standard non-weight-
bearing radiograph is taken, the foot plantar flexes, the
PTTL becomes loose, does not resist talar shift and the
medial clear space widens (Fig. 3a). If however, the foot is
plantigrade, as on an anteroposterior weight-bearing radio-
graph, the PTTL, if intact, is tight, thereby preventing lateral
translation of the talus and the mortise, as a result, appears
congruent (Fig. 3b). We therefore propose that, a (ligamen-
tous) SER-IV ankle fracture, one without a medial malleolar
fracture, with a ruptured superficial and/or ATTL, but an
intact PTTL, be classified as a ‘SER-IV(A)’ fracture.
With a complete rupture of the superficial and deep com-
ponents (both ATTL and PTTL) of the deltoid ligament, the
medial clear space will open in all positions of the foot, thus
also on weight-bearing radiographs (Fig. 4). This type of
fracture can be classified as SER-IV(B).
Implications on the management of the fracture
SER-II type fractures are stable and can safely be treated
non-operatively in a brace, boot or cast depending on the
patients’ characteristics and the clinicians’ preferences,
allowing early weight-bearing, as tolerated. The intact del-
toid ligament prevents translation of the talus in any posi-
tion of the foot. Thus, immobilisation in a plaster cast or
internal fixation are not mandatory requirements.
SER-IV(A) fractures are potentially unstable because if a
neutral, plantigrade position of the foot is not maintained,
the PTTL will not be tight, thereby potentially allowing the
superficial and ATTL components to heal with lengthening,
resulting in chronic instability and, ultimately, allowing late
talar shift. Thus, they should be treated with immobilisa-
tion in a cast, in a neutral plantigrade position, with
weight-bearing as tolerated. A boot is contra-indicated in
these patients as it can be removed allowing plantar flexion
which increases the chances that the partly torn ligament
will heal with some lengthening, potentially allowing later
talar shift.
SER-IV(B) fractures are always unstable according to
our theory. Thus, we advocate operative fixation. One can
argue, however, that functional bracing may still be possi-
ble for some (occult) SER-IV fractures, based on the find-
ings of studies, referenced earlier.15,16 Prospective
THE BONE & JOINT JOURNAL
 WHEN IS A SIMPLE FRACTURE OF THE LATERAL MALLEOLUS NOT SO SIMPLE?
multicentre studies comparing operative fixation with func-
tional bracing may clarify this issue further.
The above proposed recommendations and algorithm
are consistent with the current British Orthopaedic Associ-
ation Standards for Trauma guidelines, published in August
2016.28
In conclusion, there is no absolute requirement for oper-
ative stabilisation of isolated SER Weber type-B fractures,
as about 90% of them reduce in the weight-bearing posi-
tion and appear stable. They can safely be treated non-
operatively as internal fixation is not without its problems
and complications.2,3 Stress radiographs overestimate the
need for surgery, whereas weight-bearing radiographs per-
formed for these fractures, within ten days of injury, can
identify the stability of the fracture reliably and also, the
potentially unstable 10% which should be considered for
internal fixation. Evidence shows that even when these
potentially unstable fractures are treated non-operatively,
only 2.3% displaced, and this was within the first week.15
The anatomy and biomechanical properties of the del-
toid ligament have important implications for the manage-
ment of isolated SER Weber type-B fractures.
Take home message:
- The vast majority of SER (Weber type-B) ankle fractures are
stable and can be safely treated non-operatively.
- Weight-bearing radiographs can identify unstable fractures.
- The anatomical features and integrity of the deep deltoid ligament play
a crucial role in fracture stability.
Author contributions:
N. Gougoulias: Literature search, Collection and analysis of data, Writing the
paper.
A. Sakellariou: Literature search, Collection and analysis of data, Writing the
paper.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott.
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