ORIGINAL ARTICLE

Treatment of the Stress Positive Ligamentous SE4 Ankle

Fracture: Incidence of Syndesmotic Injury and Clinical
Decision Making
Paul Tornetta, III, MD,* Thomas W. Axelrad, MD, PhD, Tarek A. Sibai, MD,*
and William R. Creevy, MD*

Objectives: The objective of the study was to review our experience

with the treatment of stress positive (+) supination and external pattern
injuries using shared decision making with the patients.

Design: Retrospective case review.

Setting: Level 1 trauma center.
Patients: Over a 9-year period, we treated 114 patients (aged 19
76 years, average 43 years) with stress (+) supination and external
rotation type bula fractures, who were included in the present study.

Intervention: X-rays were reviewed, and the medial clear space

(MCS) measured on the presentation, stress, and nal united radiographs. The decision for surgical or nonsurgical management was
made by the patient and surgeon after a discussion of risks/benets
of both. Syndesmotic instability for the operative cases was diagnosed by medial widening and talar subluxation on abduction/
external rotation stress after bular xation.
Main Outcome Measure: MCS measurement at union.
Results: Of the 114 cases, 54 were denitively treated in a cast, and
60 were treated operatively. Twenty-seven (45%) of the operative
cases demonstrated syndesmotic instability on radiographic examination. The MCS on stress examination was statistically different,
with greater widening seen for operatively treated patients (4.8 0.5
vs. 6.9 0.86) (P , 0.001). No patient healed with any subluxation
on weight bearing x-rays.
Accepted for publication March 16, 2012.
From the *Department of Orthopaedics, Boston University Medical Center,
Boston, MA; and Department of Orthopaedics, Lake Charles Memorial
Hospital, Lake Charles, LA.
Dr Thomas W. Axelrad is salaried and supported by publication royalties from
Wolters Kluwer/Lippincott Williams & Wilkins (www.rockwoodadults
fractures.com). Dr Paul Tornetta III is salaried and supported by publication
royalties from Smith & Nephew and Wolters Kluwer/Lippincott Williams &
Wilkins; holds the intellectual property rights/patent and royalties from Smith &
Nephew; receives consulting fees from Smith & Nephew; and is supported by
contracted research with Smith & Nephew. Dr Paul Tornetta III shares ownership interest (stocks, stock options, or other ownership interest excluding
diversied mutual funds) with Exploramed. Dr Tarek A. Sibai and Dr William
R. Creevy have no nancial disclosures or conicts of interest to declare.
Presented in part at the Annual Meeting of the Orthopaedic Trauma Association,
2010, Baltimore, MD; at the Annual Meeting of the American Academy of
Orthopaedic Surgeons, 2011, San Diego, CA; and at the Annual Meeting of
the American Orthopaedic Association, June 22-25, 2011, Boston, MA.
Reprints: Thomas W. Axelrad, MD, PhD, 1717 Oak Park Boulevard, 3rd
Floor, Lake Charles, LA 70601 (e-mail: lc.ortho.trauma@gmail.com).
Copyright 2012 by Lippincott Williams & Wilkins

J Orthop Trauma  Volume 26, Number 11, November 2012

Conclusions: Stress (+) SE pattern bular fractures with minimal

MCS widening on stress examination may be treated in a cast to union
with predictable healing. In those patients treated operatively, the treating surgeon should be aware of the high rate of syndesmotic injury.
Key Words: stress positive, SE4 ankle fracture, cast treatment,
conservative management

Level of Evidence: Therapeutic Level III. See Instructions

for Authors for a complete description of levels of evidence.
(J Orthop Trauma 2012;26:659661)

INTRODUCTION
Ankle fractures are common injuries that are the result
of varying mechanisms. Still, the high degree of variability in
patterns and unpredictable extent of soft tissue injury have
made the treatment for many of these injuries controversial.
One such area of debate is in the treatment of supination and
external (SE) rotation pattern, Weber B ankle fractures that
present with a well-aligned mortise but demonstrate instability on stress examination, by either manual stress or gravity
stress radiographs. Specically, Weber B injuries are bular
fractures at the level of the joint line, and the SE pattern refers
to direction of the force and the position of the foot at the time
of injury. We refer to these injuries as stress positive (+) SE4
fractures. The decision to operate may be based on patient
factors as well as the degree of displacement or degree of
instability or widening on the stress examination. Additionally,
although other ligamentous equivalent SE4 Weber B ankle
fractures have a reported incidence of syndesmotic injury of
19%40%, the rate of syndesmotic incompetence in stress (+)
SE4 ankle fractures has not been evaluated. Our objective was
to report our experience with the treatment of stress (+) SE
pattern injuries using shared decision making with the patients
and determine if the patients healed in a reduced position.

PATIENTS AND METHODS

All patients treated over a 9-year period were identied
from a prospectively collected trauma database. A total of 114
patients (aged 1976 years, mean 43 years) with stress (+)
isolated SE type Weber B bula fractures were identied.
Men comprised 65% of the patients. The mechanism of injury
was a twist and fall in 83% (94) of the patients, motor vehicle
accident in 6% (7), a fall from heights in 4% (5), and unable to
www.jorthotrauma.com |

659

Tornetta et al

J Orthop Trauma  Volume 26, Number 11, November 2012

be determined in the remaining 8 patients. In those patients in

whom an SE type Weber B bula fracture was identied and
the talus was reduced within the ankle mortise, a manual stress
examination was performed as described previously.1 Briey,
the examination was performed with the ankle in neutral exion with a manual abduction-external rotational force of 810
lbs (3.64.5 kg). The orthopaedic resident on call, who was
trained on the techniques of the stress examination by the
attending trauma surgeon, performed all stress examinations.
A fracture was considered stress (+) if there was widening of
the medial clear space (MCS) greater than 4 mm and at least 1
mm greater than the superior joint space, or if talar subluxation
occurred. A senior trauma surgeon made all classications prospectively and a single author reviewed all images specically
for this study. MCS was measured on the presentation, stress,
casted, and nal follow-up radiographs. Additionally, the lateral injury and casted lms were used to assess the amount of
fracture displacement of the distal bula in relation to the
proximal bula. All measurements were made on 2 separate
occasions to ensure consistency of the values.
All patients were casted after the nding of a positive
stress radiograph, with post casting lms taken to assess
reduction. The treatment plan for stress (+) fractures was made
by one of the two full-time orthopaedic trauma surgeons after
a discussion of surgical versus nonsurgical options with each
patient. Syndesmotic instability for the operative cases was
diagnosed by medial widening and/or talar subluxation on stress
examination after bular xation.2 Syndesmotic xation was
performed for any elicited subluxation on Cotton and/or external rotation stress radiography in the operating room.3 The Cotton test is a direct test for syndesmotic instability and involves
manual lateral displacement of the reduced bula, whereas the
external rotation stress examination is an indirect test that places
a force on the talus that will demonstrate widening with syndesmotic injury. All patients were followed until radiographic
and clinical healing had occurred. All patients had nal lms
obtained after union with the ankle in a neutral position.

Factors contributing to the use of multiple screws included

patient factors, such as diabetes mellitus (1 patient), concern for
patient noncompliance (1 patient), and bone quality (3 patients).
The fracture pattern was the reason for multiple syndesmotic
screws in the remaining 3 patients.
The radiographic measurements are reported for the
3 treatment groups: cast, Open Reduction Internal Fixation
with a stable syndesmosis, and ORIF with unstable syndesmosis requiring one or more syndesmotic screws. Measurements
of the radiographs were done on the PACS system, and the
reviewer was blinded to the nal treatment. The same reviewer
repeated measurements on 2 separate occasions with no
statistically signicant differences noted (P = 0.95). There
was no difference in the MCS measurements among the 3
groups on the presentation radiographs. There was a signicant
difference in the measurements of the MCS on the stress radiograph between the casted and operative patients (P , 0.001)
(Table 1). Additionally, the range of widening for the patients
treated operatively was 5.1515.3, whereas the range for those
treated in a cast was 3.925.9. The postreduction casted lms
also demonstrated that patients treated nonoperatively had signicantly less MCS displacement than patients treated surgically with or without syndesmotic injuries (P = 0.007) and (P =
0.044), respectively. Although these differences where small as
a whole, they suggest that greater widening on stress examination results in a decreased ability to maintain the mortise
reduced in a cast. We further found that the difference in
MCS widening from presentation and stress examination was
greater in the operatively treated group compared with the
casted group (2.6 vs 4.3). The nding of an increasing MCS
after stress examination was supported by similar ndings
of an increased MCS after casting. All patients went on to
heal without evidence of subluxation, and there was no difference in the MCS among the groups at union.

RESULTS
Patients identied from the trauma database were followed until radiographic union, with no patients lost to followup before the achievement of union. Fifty-four (47%) patients
were denitively treated in a cast (6 weeks Non-Weight Bearing,
then Weight Bearing As Tolerated in brace), while the remaining
60 patients were treated operatively. Twenty-seven (45%) of the
operative cases demonstrated syndesmotic instability after
xation of the bular fracture and were treated with syndesmotic
screws. Twenty of these patients received a single syndesmotic
screw, with the remaining patients receiving 2 or 3 screws.

DISCUSSION
The stress examination requires radiation exposure to
the examiner and can be painful to the patient. Some have
proposed a gravity stress test, however, others argue that the
foot is not controlled during this procedure and can falsely
increase the MCS as a result of plantar exion and the
variations in talar anatomy.4,5 Regardless, treatment of these
injuries can vary from closed reduction and casting to open
reduction and internal xation, with the ideal treatment being
unknown for fractures that are well reduced in a cast.
Several reasons exist for the variations in treatments,
including concerns about the competency of the ligaments
about the medial and lateral aspects of the ankle. It is thought
that a stress (+) ankle fracture must have an injury to the deep

TABLE 1. Radiographic Findings

Treatment

Initial MCS
(mm)

Stress MCS
(mm)

MCS Casted
(mm)

Initial Fibular Displacement

(mm)

United MCS
(mm)

2.6 0.4
2.6 0.4
2.9 0.4

4.8 0.5
6.3 0.9
7.6 2.2

2.8 0.7
3.1 0.7
3.2 0.6

1.7 1
2.6 1.2
3.1 1.7

2.5 0.5
2.4 0.3
2.5 0.4

Cast (54)
ORIF, syndesmosis stable (33)
ORIF, syndesmosis unstable
(27)

660

| www.jorthotrauma.com

2012 Lippincott Williams & Wilkins

J Orthop Trauma  Volume 26, Number 11, November 2012

portion of deltoid ligament, however, studies using magnetic

resonance imaging (MRI) have found that these injuries may
be only partial in nature.6,7 Koval et al. reviewed the results
of 19 patients with widening of the MCS, who were treated
nonoperatively after MRI showed only partial deltoid injuries.
All patients healed without evidence of widening or arthrosis.
Fifteen patients were seen at 1-year follow-up, with 14 of the
15 patients stating they would have the same treatment again.
One concern with this study is that patients without medial
tenderness were not subjected to a stress examination and
were excluded from the study. Tenderness has also been
shown to be a poor predictor of deltoid injury, with regard
to both positive and negative predictive values.1,8
With regard to the syndesmotic ligament, it has been
suggested that measurements of plain lms and the level of the
bular fracture are poor at predicting these injuries.9,10 Stress
examination of Weber B fractures would not be able to assess
the competency of the syndesmosis given that the attachments
are above the level of the fracture. MRI studies have shown that
there is a large variation in the amount of disruption that occurs.
We have previously reported on incidence of syndesmotic injury
in displaced ligamentous SE4 type fractures to be 39%.2 Interestingly, we found a similar incidence in this group of stress (+)
injuries in patients who went on to have surgical xation. The
patients who demonstrated syndesmotic instability after bular
xation had a greater degree of ankle instability based on the
MCS on initial stress testing, such that these patients had
a greater displacement (6.3 9 vs 7.9 2.2, P , 0.05). This
is a previously unreported nding, and its implications are
unknown. None of the patients who were treated in a cast
developed MCS widening or syndesmotic instability at union.
When we review the decision making for each patient, it
would seem that part of the judgment used in the discussion
with the patient was the amount of talar subluxation seen
on the stress examination and the degree of posterior bular
displacement, with more unstable injuries being treated
operatively. Although the patients all ultimately made these
decisions, this process was undoubtedly guided by the impression of the injury by the surgeon. Based on the incidence of
syndesmotic instability found in this group, it is likely reasonable to offer surgery to patients who have greater degrees of
instability on their initial stress radiograph, or who are not
anatomically aligned in the postreduction cast. This method
of treatment yielded 100% union with no subluxation at nal
follow-up for any patient while avoiding the surgical risk in
about half of the study group.
There are several limitations with our study, including
its retrospective nature and the lack of clinical follow-up
with functional outcome scores. Although we lack functional
outcome scores at follow-up, we were able to obtain lms at
union for all patients. This is likely because of a combination
of factors, including our treatment protocol of maintaining
solid berglass cast until clinical and bony union and the
lack of alternative treatment options in this largely indigent
population. None of the patients demonstrated instability with
this stress maneuver. It is our belief that a stable and reduced
ankle mortise at the time of union has the greatest predictive
value for long-term outcomes.
2012 Lippincott Williams & Wilkins

Treatment of Stress Positive SE Pattern Injuries

FIGURE 1. Patient treated with closed reduction and casting.

Presentation film in (A) with stress radiograph shown in (B).
Final weight bearing films at union (C).

Our results show that patients with an intact ankle

mortise, minimal MCS displacement on stress radiographs,
and minimal bular displacement on initial lateral radiographs can be successfully treated closed in a cast (Fig. 1). An
exact number with regard to the amount of MCS displacement is difcult to ascertain from this data, although widening
or 5 mm or less in our series showed predictable healing
when offered cast treatment. This is consistent with the data
presented by Yang et al. in which patients with less than
5 mm of displacement on stress examination and treated in
a cast had an average OlerudMolander ankle score of 89 at
nal follow-up.11 As we do not have a protocol that includes
MRI studies on patients with these types of injuries, it is
impossible to determine the extent of ligamentous injury in
these patients. However, based on previous studies that found
no correlation between the extent of MCS widening and the
severity of deep deltoid injury, our results would suggest that
these injuries heal regardless of severity as long as a the mortise is reduced and maintained by surgical or cast treatment.
REFERENCES
1. McConnell T, Creevy W, Tornetta P III. Stress examination of supination external rotation-type bular fractures. J Bone Joint Surg Am.
2004;86-A:21712178.
2. Stark E, Tornetta P III, Creevy WR. Syndesmotic instability in Weber B
ankle fractures: a clinical evaluation. J Orthop Trauma. 2007;21:643646.
3. Mizel MS. Technique tip: a revised method of the Cotton test for intraoperative evaluation of syndesmotic injuries. Foot Ankle Int. 2003;24:8687.
4. Michelson JD, Varner KE, Checcone M. Diagnosing deltoid injury in ankle
fractures: the gravity stress view. Clin Orthop Relat Res. 2001;(387):178182.
5. Park SS, Kubiak EN, Egol KA, et al. Stress radiographs after ankle
fracture: the effect of ankle position and deltoid ligament status on
medial clear space measurements. J Orthop Trauma. 2006;20:1118.
6. Koval KJ, Egol KA, Cheung Y, et al. Does a positive ankle stress test
indicate the need for operative treatment after lateral malleolus fracture?
A preliminary report. J Orthop Trauma. 2007;21:449455.
7. Cheung Y, Perrich KD, Gui J, et al. MRI of isolated distal bular fractures with widened medial clear space on stressed radiographs: which
ligaments are interrupted? AJR Am J Roentgenol. 2009;192:W7W12.
8. DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation
type ankle fractures? J Orthop Trauma. 2007;21:244247.
9. Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous
membrane tears to the level of the bular fracture. J Orthop Trauma.
2004;18:6874.
10. Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study.
Clin Orthop Relat Res. 2005;(436):216221.
11. Yang E, Wu Y, Dorcil J. Surgical versus nonsurgical treatment of the
SE4-equivalent ankle fracture: a retrospective functional outcome study.
Orthopedics. 2011;34:271.

www.jorthotrauma.com |

661