Torque application helps to diagnose incomplete syndesmotic injuries using weight-bearing computed tomography images

  • Nicola Krähenbühl
  • Travis L. Bailey
  • Angela P. Presson
  • Chelsea McCarty Allen
  • Heath B. Henninger
  • Charles L. Saltzman
  • Alexej BargEmail author
Scientific Article



Accurate identification of distal tibio-fibular syndesmotic injuries is essential to limit potential deleterious post-traumatic effects. To date, conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) have shown limited utilization. This cadaver study evaluates the utility of weight-bearing CT scans on the assessment of incomplete and more complete syndesmotic injuries.

Materials and methods

Ten male cadavers (tibial plateau to toe-tip) were included. Weight-bearing CTs were taken under four test conditions, with and without torque on the tibia (corresponding to external rotation of the foot and ankle). First, intact ankles (native) underwent imaging. Second, the anterior–inferior tibio-fibular ligament (AITFL) was transected (condition 1). Then, the deltoid ligament (condition 2) was transected, followed by the interosseous membrane (IOM, condition 3). Finally, the posterior–inferior tibio-fibular ligament (PITFL) was transected (condition 4). The medial clear space (MCS), the tibio-fibular clear space (TFCS), and the tibio-fibular overlap (TFO) were assessed on digitally reconstructed radiographs (DRRs), and on axial CT images.


The TFO differentiated isolated AITFL transection from native ankles when torque was applied. Also under torque conditions, the MCS was a useful predictor of an additional deltoid ligament transection, whereas the TFCS identified cadavers in which the PITFL was also transected.


Torque application helps to diagnose incomplete syndesmotic injuries when using weight-bearing CT. The TFO may be useful for identifying incomplete syndesmotic injuries, whereas the MCS and TFCS predict more complete injuries.


Imaging Weight-bearing CT Syndesmotic injury Deltoid ligament injury 



The authors thank Nathan B Davidson, for planning the frame used to hold the specimens in the weight-bearing CT, and Maxwell W Weinberg, who helped to plan the experiments.

Source of funding

This work was supported by a grant from the American Orthopaedic Foot & Ankle Society with funding from the Orthopaedic Foot & Ankle Foundation. N Krähenbühl received a grant from the Swiss National Science Foundation (SNF; grant number P2BSP3_174979).

Compliance with ethical standards

Conflicts of interest

For the remaining authors, no conflicts of interest were declared.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.


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Copyright information

© ISS 2019

Authors and Affiliations

  • Nicola Krähenbühl
    • 1
  • Travis L. Bailey
    • 1
  • Angela P. Presson
    • 2
  • Chelsea McCarty Allen
    • 2
  • Heath B. Henninger
    • 3
  • Charles L. Saltzman
    • 1
  • Alexej Barg
    • 1
    Email author
  1. 1.Department of OrthopaedicsUniversity of UtahSalt Lake CityUSA
  2. 2.Division of Epidemiology, Department of Internal MedicineUniversity of UtahSalt Lake CityUSA
  3. 3.Orthopaedic Research LaboratoryUniversity of UtahSalt Lake CityUSA

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