Stress examination of supination external rotation-type fibular fractures.

BACKGROUND:
Deltoid incompetence in association with an isolated fibular fracture is assumed to be present if there is medial tenderness, ecchymosis, or substantial swelling. We sought to determine whether these soft-tissue indicators predict deltoid incompetence by comparing such findings with the findings on stress radiographs.

METHODS:
Over a thirty-two-month period, 138 patients who presented acutely with a Weber type-B supination-external rotation (SE) fibular fracture were evaluated for tenderness (in nine locations), ecchymosis, and swelling. Patients who presented with an apparently isolated fibular fracture and an intact ankle mortise (with a medial clear space of < or =4 mm and no talar subluxation) were evaluated with a stress radiograph to determine deltoid competence. Four groups of patients were identified: those who had an SE2 fracture (defined as those who had a stable ankle on the stress radiograph), those who had a stress (+) SE4 fracture (defined as those who had an unstable ankle on the stress radiograph), those who had an SE4 fracture (defined as those who presented with a wide medial clear space), and those who had a bimalleolar fracture. These four groups were compared with regard to tenderness, swelling, and ecchymosis at the time of initial presentation. Patients with SE2 injuries were allowed immediate weight-bearing.

RESULTS:
Of the ninety-seven patients who presented with an isolated fibular fracture and an intact mortise, sixty-one had a stable SE2 injury and thirty-six had an unstable stress (+) SE4 injury. All stable SE2 injuries healed with an intact mortise. Medial tenderness, ecchymosis, and swelling were not predictive of deltoid incompetence (instability).

CONCLUSIONS:
Stress radiographs allow for the accurate diagnosis of deltoid incompetence in patients with Weber type-B SE fibular fractures and no other osseous injury. Soft-tissue indicators are not accurate predictors of instability. If medial tenderness, ecchymosis, and swelling are used as operative indications, in some cases surgery may be performed on stable ankles.