The Diagnostic Accuracy of Radiographs and Magnetic Resonance Imaging in Predicting Deltoid Ligament Ruptures in Ankle Fractures

  • Stephen J. WarnerEmail author
  • Matthew R. Garner
  • Peter D. Fabricant
  • Patrick C. Schottel
  • Michael L. Loftus
  • Keith D. Hentel
  • David L. Helfet
  • Dean G. Lorich
Original Article



Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.


The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures.


Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation.


Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%).


Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.


ankle fracture deltoid stress test magnetic resonance imaging supination-external rotation (SER) ankle fracture 


Compliance with Ethical Standards

Conflict of Interest

Stephen J. Warner, MD, PhD, Matthew R. Garner, MD, Peter D. Fabricant, MD, MPH, Patrick C. Schottel, MD, Michael L. Loftus, MD, MBA, and Keith D. Hentel, MD, declare that they have no conflicts of interest. David L. Helfet, MD, reports owning stock in FxDevices and OHK Medical Devices and being an unpaid consultant to OHK Medical Devices, Healthpoint Capital, and TriMedics, outside the submitted work. Dean G. Lorich, MD, reported personal fees from DePuy Synthes, outside the submitted work.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

11420_2018_9655_MOESM1_ESM.pdf (1.2 mb)
ESM 1 (PDF 1224 kb)


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Copyright information

© Hospital for Special Surgery 2019

Authors and Affiliations

  • Stephen J. Warner
    • 1
  • Matthew R. Garner
    • 2
  • Peter D. Fabricant
    • 3
  • Patrick C. Schottel
    • 4
  • Michael L. Loftus
    • 5
  • Keith D. Hentel
    • 5
  • David L. Helfet
    • 3
  • Dean G. Lorich
    • 3
  1. 1.University of Texas Health Science Center at HoustonHoustonUSA
  2. 2.Pennsylvania State UniversityHersheyUSA
  3. 3.Hospital for Special SurgeryNew YorkUSA
  4. 4.University of VermontBurlingtonUSA
  5. 5.Weill Cornell Medical CollegeNew York Presbyterian HospitalNew YorkUSA

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