Volume 3, Case 5
Alson S. Inaba, MD
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
This case consists of 16 ankle radiograph sets. Limited histories will be provided in most of them. When lateral views are shown, the heel is to the left of the image and the toes point toward the right on the image.
18-year old male with an inversion injury.
View Case A.
Interpretation of Case A
AP and lateral views are displayed. The AP view shows a fracture of the lateral cortex of the distal fibula. The lateral view shows an oblilque fracture through the distal fibula. The AP view shows a black crescent in the tibia which is an artifact from poor film handling. There is a slight irregularity of the medial metaphysis of the distal tibia, however, the patient is not tender there.
Impression: Oblique fracture of the distal fibula.
This is a 6-year old male who sustained an inversion injury 6 hours prior to the ED visit. He was initially limping, but he is now walking normally. There is minimal tenderness of the lateral malleolus.
View Case B.
Interpretation of Case B
AP, lateral, and mortise views are displayed. There is a small bony density contiguous with the medial malleolus which is probably a developmental variant in view of his tenderness over the lateral malleolus only. This is very faint, best seen on the AP view and posteriorly (left) on the lateral view. To see it best, turn down the room lights and adjust the brightness and contrast on your monitor.
Impression: Probably normal ankle. Small bony density contiguous with the medial malleolus, probably a developmental variant.
This is a 14-year old male who sustained a twisting injury playing football when he stepped into a hole. He has tenderness over his medial malleolus and is unable to bear weight.
View Case C.
Interpretation of Case C
AP and lateral views are displayed. The AP view shows a very slight lucency above the medial malleolus. It can be seen at the medial edge of the tibial metaphysis just above the physis. The lateral view is positioned such that the heel is on the left and the toes are on the right. This lateral view shows the fracture better along the anterior distal tibia.
Impression: Probable non-displaced medial malleolus (tibial metaphysis) fracture.
14-year old male with an ankle injury.
View Case D.
Interpretation of Case D
AP, mortise, and lateral views are displayed. There is a vertical lucency through the distal tibial epiphysis extending from the physis to the mortise joint space.
Impression: Salter Harris Type III fracture of the distal tibia.
This is a 10-year old male who twisted his ankle skateboarding. He complains of pain over his lateral malleolus. There is tenderness and moderate swelling over the lateral malleolus.
View Case E.
Interpretation of Case E
AP and mortise views are shown here. There are no definite abnormalities on this radiograph. The lucency above the medial malleolus at the medial tibial metaphysis does not represent a fracture since the patient is not tender there.
Impression: Normal ankle radiographs.
However on closer examination of this patient, he is not tender over the tip of the fibula, he is mostly tender over the fibular physis raising the possibility of a non-displaced Salter Harris Type I fracture through the fibular physis. This is a clinical diagnosis, not a radiographic diagnosis. Such injuries should be splinted and followed clinically. For a more in-depth review of the Salter-Harris fracture classifications, refer to Case 18 in Volume 1.
Clinical Impression: Rule out a non-displaced Salter Harris Type I fracture of the distal fibular physis.
A TV set fell on the lower leg of this 18-month old.
View Case F.
Interpretation of Case F.
AP and lateral views are displayed. There are disruptions in the cortices of the distal fibular and tibial metaphyses. These are torus fractures of the distal fibula and tibia. There is a second fracture of the fibula more proximal (upper portion of the image) with a modest degree of medial angulation (i.e., angle points to the medial side) seen best on the AP view.
Impression: Torus fractures of the fibula and tibia. Angulated fracture of the distal fibular diaphysis.
This is an 18-year old male with an ankle inversion injury. He is tender over the distal aspect of the lateral malleolus.
View Case G.
Interpretation of Case G.
AP, mortise, and lateral views are displayed. There is a small bony density adjacent to the tip of the lateral malleolus. This could represent an avulsion fracture of distal fibula or an accessory ossicle. Since clinically he is tender in this area, this probably represents a small avulsion fracture of the tip of the fibula.
Impression: Small avulsion fracture of the distal fibula.
This is a 23-year old male who severely twisted his ankle. He was running and he stepped into a deep hole.
View Case H.
Interpretation of Case H.
AP, mortise, and lateral views are displayed. There is an oblique, slightly displaced fracture of the distal portion of the shaft of the fibula. There may be minimal widening of the medial aspect of the ankle mortise. A small avulsion fracture is noted between the dome of the talus and the medial malleolus. This small fragment is best seen on the AP view just inside the medial malleolus. This may be hard to see. You may have to enlarge the image, turn down the room lights, and adjust the contrast and brightness on your monitor.
Impression: Oblique fracture of the distal fibula and a small avulsion fracture which projects between the medial malleolus and the dome of the talus.
This is an 8-year old male who injured his ankle while skateboarding. He has tenderness over his medial malleolus.
View Case I.
Interpretation of Case I.
AP and mortise views are displayed. There is an irregularity of the tip of the medial malleolus. This may represent a normal developmental variant of ossification. However, it may represent a fracture. A comparison view of his other ankle is needed for confirmation. Since he is tender over his medial malleolus, one must assume that this is a fracture until proven otherwise.
Impression: Irregularity of the tip of the medial malleolus representing a fracture or a normal variant.
This radiograph was copied off a 35mm slide. There was no patient identifying information on the slide so the patient's age and history are not available.
View Case J.
Interpretation of Case J.
AP, mortise, and lateral views are displayed. There is an obvious fracture through the medial malleolus. Note that this fracture is obvious on the mortise view, but very subtle on the AP view. This fracture might have been missed if a mortise view was not obtained.
Impression. Medial malleolus fracture.
Note: This is NOT a Salter-Harris type III fracture since the fracture line does not extend into the physis (growth plate). Salter-Harris fractures, by definition, must involve the physis.
This is a 17-year old male who twisted his ankle during a soccer game. He was initially ambulatory, but he could not bear any weight on his injured ankle the next day. He has tenderness over the lateral aspect of his ankle.
View Case K.
Interpretation of Case K.
AP, mortise, and lateral views are displayed. There is a fracture through the distal fibula. Although the growth plate is almost closed, this is still technically a Salter Harris Type I fracture through the physis. It is radiographically visible because it is slightly displaced as a widening of the physis. It is not easily seen on the AP view, but it is more obvious on the mortise view. This fracture might have been missed if a mortise view was not obtained. A normal closure of the growth plate will sometimes have this appearance. Comparative views or stress views are required to confirm this radiographically.
Impression: Probable distal fibula fracture.
This is a 10-year old male who was struck by a car. He has evident injuries of his head, neck, abdomen, pelvis, and lower extremities. Only his ankle radiographs are displayed here.
View Case L.
Interpretation of Case L.
AP, mortise, and lateral views are displayed. There are obvious comminuted fractures of the distal one-third of his fibula and tibia visible at the top of the image. He may also have a medial malleolus fracture. The medial malleolus fracture is best seen on the AP view. There is a subtle lucency through the end of the medial malleolus. There is an irregularity of the posterior tibia seen best on the lateral view. This lateral view is positioned so that the heel is to the left and the toes are to the right. The posterior metaphysis adjacent to the growth plate appears irregular. This is probably not a fracture. Note that a similar finding is visible on the lateral view in image B [Click on B].
Impression: Comminuted fractures of the distal one-third of the fibula and tibia. Possible medial malleolus fracture.
This is a 3-year old female who sustained an inversion injury while running downhill. She is limping and has tenderness over her lateral malleolus.
View Case M.
Interpretation of Case M.
AP, mortise, and lateral views are displayed. There are no definite bony abnormalities seen on these radiographs. It is possible that he may have a slight distortion of the distal fibular metaphysis (proximal to the physis).
There is some controversy as to whether the distal fibular epiphysis is slightly angulated or if this is a normal appearance. According to our radiology editor, this is not necessarily radiographically abnormal (i.e., a normal fibula can have this appearance)..
On closer examination, her pain is mostly over the fibular physis rather than the tip of the fibula. Because of this, she is suspected as having a Salter Harris Type I fracture through the fibular physis or the fracture of the fibular metaphysis. She is placed in a splint and is followed clinically.
Impression: Probably normal ankle radiographs. Rule out fracture of the fibular metaphysis and/or a Salter Harris Type I fracture of the distal fibular physis.
This is a 13-year old male "sprained" his ankle at a baseball game. There is obvious swelling about the ankle joint.
View Case N.
Interpretation of Case N.
AP, mortise, and lateral views are displayed. There is a vertical lucency through the distal tibial epiphysis extending from the ankle joint to the tibial physis. It does not appear to extend into the metaphysis.
Impression: Salter Harris Type III fracture of the distal tibia.
This is a 9-year old female who fell off a second floor balcony at school, landing on her feet.
View Case O.
Interpretation of Case O.
AP, mortise, and lateral views are displayed. The lateral view also includes her foot. There are multiple lucencies evident in her calcaneus. The tibial physis does not appear to be widened or compressed. There are no definite bony abnormalities of the ankle. However, in addition to being tender over her foot, she is also tender over her medial malleolus. The mechanism of injury suggests the possibility of a Salter Harris Type V fracture of the distal tibial physis. This is often not a radiographic diagnosis, but rather a clinical one based on examination findings and the mechanism of injury. This type of injury may cause a growth arrest in a portion of the growth plate causing a valgus or varus deformity.
Impression: Multiple calcaneal fractures. Rule out Salter Harris Type V fracture of the distal tibia.
This is a 23-year old female college student who twisted her ankle while jogging down a hill. She has swelling and tenderness over her lateral malleolus.
View Case P.
Interpretation of Case P.
AP, mortise, and lateral views are displayed. There is an oblique fracture through the posterolateral aspect of the lateral malleolus. This fracture has occurred through the fused growth plate which remains weaker than the surrounding bone for the next several years following closure. The distal fibular physis usually fuses by age 20 years and the distal tibial physis usually fuses by age 18 years.
Impression: Lateral malleolus fracture.