Ankle X-ray Interpretation

geekymedics.com/ankle-x-ray-interpretation

Dr Swabirah Rassool 22 February 2021

Introduction
The ankle is a hinge joint formed by three bones: the tibia, the fibula and the talus.

Proximally, the joint comprises the medial malleolus (the distal end of the tibia), the
tibial plafond and the lateral malleolus (the distal end of the fibula) which collectively
form a rectangular socket called the mortise into which fits the talar dome distally.

This comes from the similarity to the mortise and tenon joint used in carpentry to create
stable connections (Figure 1).

Figure 1. A mortise and tenon joint in carpentry 1

Further reinforcement of the ankle joint is provided by a strong fibrous complex between
the distal tibia and fibula called the syndesmosis, and the medial (or deltoid) and
lateral ligaments which arise from the medial and lateral malleolus respectively.

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The ankle joint allows dorsiflexion and plantarflexion and is one of the weight-bearing
joints. For more information, see the Geeky Medics guides to the bones of the lower limb
and the bones of the foot.

Figure 2. Mortise radiograph of the left ankle

showing the bones and ligaments (added in
yellow) of the ankle joint.2

Principles of ankle X-ray interpretation

Demographics

Begin by checking that you are looking at the correct radiograph of the correct patient.

It is important to confirm the following details:

Patient details (name, date of birth, unique identification number)

Date and time the radiograph was taken
Correct side (right vs. left)

Views

In the United Kingdom, two views of the ankle joint are routinely performed:

Mortise view: this is a modified anteroposterior (AP) view of the ankle in 10-20°
internal rotation so that the medial and lateral malleoli are in the same horizontal
plane and joint visualisation is optimised
Lateral view

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In some cases, a weight-bearing or a stress radiograph (gravity stress or manual
stress) may also be required.

Consider additional views such as a full-length tibia/fibula radiograph and imaging of the
joint above and below (i.e. a knee and a foot radiograph) to rule out additional fractures.

Comparison
Comparison to previous radiographs, if available, can be especially useful when
interpreting radiographs.

Asymptomatic contralateral sides are not routinely radiographed, however,§ if a recent or

old image of the contralateral side is available, these may also be compared as the
skeletal system is generally symmetrical and could therefore act as a reference point.

You might also be interested in our OSCE Flashcard Collection which contains over
2000 flashcards that cover clinical examination, procedures, communication skills
and data interpretation.

Interpreting an ankle X-ray

Use a methodical approach such as ABCs to look at a radiograph.

Adequacy

Ideally, you should be able to see at least the distal third of the tibia and fibula and the
talus on the mortise view and in addition to those, you should be able to see the
calcaneum and the base of the 5th metatarsal on the lateral view.

Penetration is adequate if you can clearly distinguish between bones and soft tissues.

Look out for artefacts.

Bones
In both views, trace the cortical outline of all the bones visible on the radiograph. On the
mortise view, trace the mortise and the talar dome surface. On the lateral view, assess
the medial, lateral and posterior malleoli, the calcaneum and the base of the fifth
metatarsal.

A loss in bone or joint alignment may be a result of a fracture, joint subluxation (partial
dislocation) or dislocation. Note any other abnormalities such as osteophytes or
calluses.

Look at the internal architecture of the bone (e.g. a thinner cortex and an increased
bone lucency indicate osteopenia or osteoporosis). A fracture in an abnormal bone is
termed a pathological fracture.

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Beware of normal developmental variants such as accessory ossicles which may be
mistaken for fractures.

Figure 3. Lateral view of the ankle tracing the

outline of the tibia (green), fibula (red), talus
(dark red), calcaneum (blue) and base of 5th
metatarsal (orange). Note the os trigonum (red
circle) which is an accessory ossicle of the foot
and a normal variant.3

Cartilages (joint involvement)

Assess the joint space on the mortise view. A loss of joint space may be due to a loss of
cartilage and is commonly seen in conditions such as osteoarthritis. Joint widening may
be due to fracture or dislocation.

Look at the medial clear space. This is the widest distance between the medial border of
the talar bone and the lateral border of the medial malleolus. It should be approximately
equal to the superior clear space (the distance between the articular surfaces of the
tibia and the talus).

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 Figure 4. Mortise view of a normal left ankle
joint. Note how the medial clear space (green
line) is comparable to the superior clear space
(pink line). Note the tibiofibular overlap (yellow
circle).2

Widening of the medial clear space (i.e. lateral talar shift) suggests syndesmosis
disruption and therefore joint instability.

A loss of tibiofibular overlap also suggests syndesmosis injury.

Joint widening with no obvious fracture on the ankle radiograph may also indicate a more
proximal fracture such as a Maisonneuve fracture (this is a combination of an unstable
ankle due to a ligamentous and/or bony injury together with a proximal fibular fracture). In
these situations, consider asking for additional X-rays.

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 Figure 5a. Mortise view of an incongruent left
ankle joint. There is a widening of the medial clear
space (green circle) and lateral talar shift. The
superior clear space (pink oval) is asymmetrical
along its own length and the medial and superior
clear spaces are no longer comparable. The
tibiofibular overlap is reduced (yellow circle). No
obvious fracture is visible.2

Figure 5b. Same case as Figure 5A. AP

radiograph of the left tibia/fibula showing a
minimally displaced comminuted fracture through
the mid-shaft of the fibula.2

Soft tissues

Carefully inspect the soft tissues, as this can provide helpful information. For example,
soft tissue swelling or a joint effusion may sometimes indicate the presence of a subtle
fracture.

Describing a fracture on an ankle radiograph

When describing an ankle X-ray, use the following structure:

Details of the radiograph and the patient

Site of fracture: which bone, which part of the bone, left or right
Type of fracture (e.g. transverse, oblique, spiral)
Simple or comminuted

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 Displacement and angulation of the distal fracture fragment in relation to the
proximal fracture fragment
Intra-articular or extra-articular (i.e. Does the fracture line extend into a joint?)

Classification of ankle fractures

Anatomical descriptors of ankle fractures include (but are not limited to):

Isolated medial malleolus fracture

Isolated lateral malleolus fracture
Bimalleolar fracture (medial + lateral malleoli fractures)
Trimalleolar fracture (medial + lateral + posterior malleoli fractures)

Lateral malleolus fractures can be further classified, as per the Danis-Weber

classification (commonly referred to as just the Weber classification), into:

Type A: below the syndesmosis

Type B: at the level of the syndesmosis
Type C: above the syndesmosis

Figures 6. Mortise and lateral views of

the right ankle. On the mortise view,
there is a minimally displaced
transverse fracture extending through
the distal aspect of the fibula (Weber A
type fracture) with adjacent soft tissue
swelling.2

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 Figure 7. Mortise view of the right ankle
joint – there is an oblique fracture
extending through the distal third of the
fibula at the level of the syndesmosis
(Weber B type fracture) with adjacent
soft tissue swelling (red arrow) and
lateral talar shift (green circle).2

Figure 8. This mortise radiograph

shows a bimalleolar fracture of the right
ankle. There is a comminuted fracture of
the distal fibula above the level of the
syndesmosis (Weber C) with valgus
angulation of the distal fragment. There
is also a simple transverse fracture of
the right medial malleolus. The ankle
joint is subluxed. A lateral view is
required to assess for total joint
dislocation and to exclude a posterior
malleolus fracture which would then
indicate a trimalleolar fracture.2

Tips for ankle X-ray interpretation

Familiarise yourself with normal radiographs of the ankle, so that you are able to
recognise when things don’t look quite right.

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 If you spot an abnormality on a radiograph, continue to examine the entire area
visible before stopping in order not to miss any further abnormalities.
Fractures can sometimes be very subtle; carefully examine the patient and correlate
imaging with clinical findings.
If in doubt, always ask for senior input.

Reviewer

Mr Jack Turnbull

Trauma & Orthopaedics Registrar

Editor

Dr Chris Jefferies

References
1. Adapted by author. Diagram of a mortise (on left) and tenon joint. Licence: [CC BY-
SA].
2. Department of Trauma & Orthopaedics, Lancashire Teaching Hospitals NHS
Foundation Trust. Adapted by author.
3. Hellerhoff, adapted by author. Os trigonum. Licence: [CC BY-SA].

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