ORIGINAL ARTICLE
Lack of Displacement of the Fibula Is Not a Confirmation
of Ankle Stability in Supination External Pattern
Ankle Fractures
Amir A. Shahien, MD and Paul Tornetta III, MD
Objectives: To evaluate and compare radiographic findings in
supination external (SE)2 injuries versus stress (+) SE4 injuries.
Design: Retrospective.
Setting: Academic Level 1 trauma center.
Patients: The study included 350 skeletally mature patients at a
single Level 1 trauma center who presented with an isolated, Lauge-
Hansen type supination-external rotation pattern, Weber B lateral
malleolar fracture, OTA/AO 44-B.
Results: We reviewed 350 patients (185 men and 165 women), 18–
95 years of age (avg 45), with isolated SE pattern lateral malleolar
fractures. One hundred nine had SE4 injuries [medial clear space
(MCS) = 8.3 mm]. Two hundred forty-one ankles were stressed;
164 were unstable and 77 were stable (SE2). Avg MCS at presentation
and on stress radiographs was 3.59 mm for the SE2 (no widening) and
3.86 mm and 5.94 mm for the stress (+) SE4 group, respectively. The
fibular displacement for the SE2, stress (+) SE4, and SE4 groups was
1.5 (0–4.5), 3.5 (0–6.6), and 4.1 (0–30.5), respectively. Sixteen of the
77 (20%) SE2 and 24 of the 164 (15%) stress (+) SE4 fractures had no
displacement of the fibula on the lateral view. Similarly, 53 of the 77
(68%) SE2 and 91 of the 164 (55%) stress (+) SE4 had #2 mm of
fibular displacement Fibular displacement of #2 mm on the lateral
radiograph corresponded with 0.69 sensitivity and only 0.37 positive
predictive value for stable ankle mortise on stress examination.
Conclusions: Previous work indicated that patients with an
isolated SE pattern fibula fracture, a normal MCS, and #2 mm of
fibular displacement on the lateral radiograph have a high rate of
ankle stability, with a positive predictive value of approximately
97%. We were unable to confirm this finding because 15% of unsta-
ble ankles had 0 mm and 55% had #2 mm of fibular displacement.
We conclude that stability may not be inferred from a lack of fibular
Accepted for publication April 1, 2021.
From the Department of Orthopaedic Surgery, Boston Medical Center, Boston,
MA.
The authors report no conflict of interest.
Presented in part at the Annual Meeting of the American Academy of
Orthopaedic Surgeons, 2019, Las Vegas, Nevada.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jorthotrauma.com).
Reprints: Amir A. Shahien, MD, Department of Orthopaedic Surgery, Boston
Medical Center, 850 Harrison Avenue, Dowling 2 North, Boston, MA
02118 (e-mail: amir.shahien@bmc.org).
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000002139
J Orthop Trauma  Volume 36, Number 1, January 2022
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
displacement on the lateral view in this population of patients. If
stability is to be determined, it must be tested irrespective of fibular
displacement on the lateral radiograph.
Key Words: ankle fracture, supination-external rotation, external
rotation ankle stress maneuver, SE2 ankle fracture, SE4 ankle frac-
ture, stress-positive SE2 ankle fracture
Level of Evidence: Diagnostic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2022;36:e1–e5)
Initial evaluation of ankle fracture patterns is typically
based on nonweight-bearing, standard ankle radiographs after
lower extremity trauma. Despite proposed classification systems
from the Orthopaedic Trauma Association Committee for
Coding and Classification1 and by Weber and Lauge-
Hansen,2,3 the clinical and prognostic utility of these static radio-
graphs remains inconsistent. Accordingly, stability-based classi-
fication systems have been proposed over the past decade.4
The most common type of ankle fracture, mechanisti-
cally described as a supination-external rotation (SER)
fracture3 and classified as OTA/AO 44-B,1 represents an iso-
lated lateral malleolar fracture with or without widening of the
ankle mortise. There is a consensus opinion that ankle frac-
tures with a stable ankle mortise can be treated nonopera-
tively5; however, dynamic instability on biomechanical
stress is treated based on patients’ choice with bracing, cast-
ing, or surgery. Without radiographic evidence of osseous
injury or suggestion of ligamentous incompetence on the
medial aspect of ankle, an external rotation stress test should
be conducted to test the competence of the deltoid ligament
because medial tenderness, ecchymosis, and swelling are not
predictive of deltoid incompetence (instability).6–8
A recent article concluded that a minimal (#2 mm)
displacement of the fibula on the lateral view of these SER
fractures predicts a stable joint.9 The purpose of our study
was to evaluate and compare radiographic findings of the
posterior diastasis of the fibula on lateral radiographs with
concomitant measurements of medial clear space (MCS)
and other radiographic parameters across the spectrum of
supination-external rotation ankle fractures. Our hypothesis
is that there is not yet a reliable and validated method to
accurately assess dynamic instability on any view of static,
nonweight-bearing ankle radiographs. Accordingly, we
hypothesized that all isolated fibular fractures must be
www.jorthotrauma.com | e1
Shahien and Tornetta
stressed irrespective of fibular displacement on the lateral
radiograph. Specifically, we sought to confirm or reject the
hypothesis that #2 mm of fibular displacement on the pre-
sentation ankle films predicts a stable joint.
METHODS
We retrospectively reviewed the radiographs of 700
consecutive adult patients presenting to an urban Level 1 trauma
center with an ankle fracture between March 2010 and July 2015.
Demographic data including age and sex were collected at the
time of presentation. Standard radiographs included nonweight-
bearing anteroposterior, lateral, and mortise views; tibia films
were taken if no lateral malleolus fracture was seen. Patients with
pathologic fractures, bimalleolar or trimalleolar fractures, or
dislocation of the talus on initial radiographs were also excluded.
Three hundred fifty patients were found to have an
isolated, Lauge-Hansen type SER pattern, Weber B lateral
malleolar fracture, OTA/AO 44-B, and included in the final
analysis. Ankles with an isolated fibula fracture, intact (symmet-
ric) mortise, and no medial widening had the deltoid stressed on
presentation by a resident on-call using a manual external rotation
FIGURE 1. Patient LB, lateral radiograph displaying non-
displaced posterior diastasis on lateral radiograph.
e2 | www.jorthotrauma.com
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 36, Number 1, January 2022
stress test.7 The stress radiographs were obtained in the radiology
suite on a PACS system using regular radiographs as a standard
distance, not fluoroscopy. The stress examination protocol,
detailed by McConnell et al7, involved the on-call resident per-
forming the stress examination, with the leg stabilized in approx-
imately 10 degrees of internal rotation, the ankle in neutral
dorsiflexion, while an external rotation force of approximately
8–10 lb (3.6–4.5 kg) was applied to the ankle. The deltoid stress
test was performed at the time of presentation, and the radio-
graphs were reviewed the following morning by a senior attend-
ing trauma surgeon and then classified in a prospective database.
A single author (A.S.) evaluated the radiographs for each
patient. Using the anteroposterior, mortise, stress, and lateral
radiographs obtained at presentation, the MCS prestress and
poststress and the maximal displacement of the fibular fracture
on the lateral radiographs at presentation were recorded (Figs. 1
and 2, and see Figure, Supplemental Digital Content 1, http://
links.lww.com/JOT/B431). This evaluating author was blinded
to and not involved in the eventual treatment but observed only
the presentation radiographs of the patients.
All radiographs were obtained in the radiography suite using
a standardized distance from the patient and analyzed in the PACS
system. A positive finding on the stress radiograph was defined as
an MCS of .4 mm that was also .1 mm greater than the superior
joint space or any identifiable amount of lateral talar subluxation.
The requirement for the MCS to be .1 mm greater than the
superior joint space was intended to avoid false-positive results
in most individuals who may have an MCS of .4 mm without
subluxation. In these individuals, the superior joint space acts as a
reference. Those with a negative stress view (normal MCS and no
subluxation) were considered SE2 injuries, OTA/AO 44-B1.
These patients were assumed to have a competent deltoid ligament
and were treated nonoperatively with an Aircast stirrup brace
(Aircast, Summit, NJ) full weight-bearing as tolerated. Those with
widened MCS and subluxation at presentation were considered
SE4 injuries, OTA/AO 44-B2, and were offered open reduction
and internal fixation. Patients presenting with an intact mortise
whose ankles subluxated only on stress radiograph were consid-
ered stress (+) SE4 injuries and were treated by patients’ preference
after a discussion of options with the attending physician.10
Measurements made on the mortise view included height
of the distal fibular fracture defined as the lowest point of the
fracture compared with the joint, tibiofibular space defined as the
distance from the lateral incisural line to the medial fibular
cortex, and fibular diastasis defined as the greatest displacement
visible from the lateral aspect of the intact proximal fibula to the
lateral aspect of the distal fragment (see Figure, Supplemental
Digital Content 2, http://links.lww.com/JOT/B432). On the lat-
eral view, we measured the height of the distal and proximal
aspects of the fibular fracture from a level perpendicular to the
talar dome and the maximum visible fibular displacement within
the fracture site (see Figure, Supplemental Digital Content 3,
http://links.lww.com/JOT/B433). The presentation of these data
was approved by the Institutional Review Board.
RESULTS
Three hundred fifty patients were found to have an
isolated, Lauge-Hansen type SER pattern, OTA/AO 44. One
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 36, Number 1, January 2022 Lack of Displacement of the Fibula

was not statistically different. Posterior diastasis on the lat-

eral radiographs was 1.5 6 1.1 mm in the SE2 group and 3.5
6 1.9 mm in the stress-positive SE4 group (P , 0.001)
(Table 1).
Of the 77 ankles that were found to have a stable
mortise, 16 (21%) had a posterior fibular diastasis of 0 mm
and 53 (68%) had a posterior fibular diastasis of # 2 mm. Of
the 164 stress (+) SE4 ankle fractures, 24 (15%) had a pos-
terior fibular diastasis of 0 mm and 91 (55%) had a posterior
fibular diastasis of #2 mm (Tables 2 and 3). The fibular
displacement for the SE2, stress (+) SE4, and SE4 groups
were 1.5 mm (0–4.5), 3.5 mm (0–6.6), and 4.1 mm (0–
30.5), respectively. Fibular displacement of #2 mm on the
lateral radiograph corresponded with 0.69 sensitivity and 0.37
positive predictive value for stable ankle mortise on stress
examination.
Comminution, that is, the number of fibula fracture
parts, was included in this analysis but not found to be
significantly related to stability of fracture. There were 8
patients with greater than 3 fracture fragments; 6 of the 8 were
stress positive (P = 0.67).

DISCUSSION
Patients with stable SE2 ankle fractures can be
managed nonoperatively and predictably result in an aligned
mortise.7,11,12 Conversely, Sanders et al prospectively ran-
domized unstable SE ankle fractures into operative and non-
operative treatment cohorts. Although there was no difference
in functional outcomes at 12 months follow-up, there was a
higher incidence of displacement at union and delayed union
in the nonoperative group when compared with that in the
operative group.13
Accordingly, there is impetus to find noninvasive and
FIGURE 2. Patient LB, prestress mortise (MCS = 3.37 mm). definitive methods for evaluating ankle stability. A recent
article by Nortunen et al indicated that patients with an
hundred eighty-five men and 165 women, 18–95 years of age isolated SE pattern fibula fracture, a normal MCS, and
(avg 45), presented with isolated SE pattern, Weber B lateral #2 mm of fibular displacement on the lateral radiographs
malleolar fractures. The average age at the time of presenta-
tion for women and men was 45 and 44 years, respectively (P
. 0.8). Forty-seven of the 165 (28%) women and 62 of the TABLE 1. Summary Measurements: 241 Ankles
185 (33%) men had ligamentous SE4 injuries. Stable Unstable
One hundred nine patients had SE4 injuries with an
77 164 P
average MCS of 8.3 mm at presentation and tibiofibular space
Sex
of 4.3 mm. Two hundred forty-one ankles presented with an
Men 35 83
intact mortise and required a manual stress examination.
Women 42 81
Manual stress radiographs found 164 to be unstable
Age 48 6 16 45 6 14 0.06
[stress (+) SE4] and 77 to be stable (SE2). There were 35
Mortise radiographs (mm)
men and 42 women with stable ankle fractures with a mean
MCS 3.6 6 0.7 3.8 6 0.9 0.08
age of 49 6 16 years. The average MCS for SE2 ankles with
Tibiofibular clear space 3.2 6 0.9 3.4 6 0.9 0.1
no widening on stress examination was 3.6 6 0.7 mm, and
Lateral diastasis 1.4 6 0.9 1.7 6 1 0.02
the average tibiofibular space was 3.2 6 0.9 mm. There were
Distal fracture height 0.2 6 3.7 0 6 4.5 0.73
83 men and 81 women with a mean age of 45 6 14 years
Lateral radiographs (mm)
with stress-positive SE4 ankles. In these stress-positive
Posterior diastasis 1.5 6 1.1 3.5 6 1.9 ,0.01
unstable ankles, the mean MCS was 3.9 6 0.7 mm prestress
Anterior fracture height 0.1 6 7.6 0.0 6 6.4 0.92
and 5.9 6 1.2 mm poststress. The average tibiofibular space
Posterior fracture height 32.4 6 14 35.5 6 13.1 0.98
for this group was 3.4 6 0.9 mm. The prestress MCS
Fracture line angle 144 6 10.3 146 6 8.4 0.11
between these groups before external rotation examination

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved. www.jorthotrauma.com | e3

Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Shahien and Tornetta
TABLE 2. Intact Mortise Requiring Stress: 241 Ankles
Lateral XR posterior diastasis comparison for stressed ankles
Displacement 0 mm; Displacement .0 mm
SE2 (Stress 16
negative)
SE4 (Stress 24
positive)
Total 40
are uniformly stable.9 We attempted to confirm or reject this
finding in a large prospectively collected database of ankle
fractures. Fifteen percentage of unstable ankles had no dis-
placement and 55% had #2 mm of fibular displacement, rep-
resenting a large number of dynamically unstable ankle
fractures that may have been undertreated if assumed to be
stable (Table 3). In addition, female sex and simple fracture
patterns (2 fragments) were found to be 98% predictive of
ankle mortise stability in a small subset of their study.
Explanation for these criteria were based on the assumption
that younger male patients have better bone density than their
female peers and are more likely to sustain higher-grade liga-
mentous injury preceding fracture of the lateral malleolus.9,14
In our study, we did not find a statistically significant differ-
ence in age at the time of presentation or the percentage of SE4
ligamentous injuries between male and female trauma patients.
Bone density was not evaluated for this study.
LIMITATIONS
To our knowledge, this study included radiographic
evaluation of a larger number of SE ankle fractures than
previously published literature; however, it also has limita-
tions. Radiograph measurements were performed by a single
orthopaedic surgeon, which would likely limit reproducibility
of both sensitivity and the positive predictive value for the
external rotation stress examination. The external rotation
stress examination was performed using a standardized
procedure published in the literature.
All patients were initially classified prospectively at
morning conferences by experienced surgeons. In addition,
the classifications were verified in the clinic by the attending
surgeon in all cases during treatment follow-up before entry
into the trauma database. There was perfect agreement
between the ankle fracture classification of the author
performing measurements for this study and the classification
TABLE 3. Intact Mortise Requiring Stress: 241 Ankles
Lateral XR Posterior Diastasis Comparison for Stressed Ankles
Displacement ,2 mm; Displacement .2 mm
SE2 (Stress 53
negative)
SE4 (Stress 91
positive)
Total 144
e4 | www.jorthotrauma.com
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 36, Number 1, January 2022
61 77
140 164
201 241
of ankle fractures assigned by the senior trauma surgeons at
the time of initial presentation. In addition, there was no direct
correlation with surgical treatment for the stress-positive
ligamentous SE4 ankle fractures, given that stress-positive
SE pattern fibular fractures with minimal MCS widening on
stress examination may be treated in a cast to union with
predictable healing.10
Previously posited criteria for instability include an
MCS of .4 mm, medial tenderness, bruising or swelling,
and a fibular fracture above the syndesmosis.15 Although
some of these criteria, such as level of fibular fracture and
syndesmotic injury, have been confirmed,16 others such as
correlation between the clinical symptom of medial tender-
ness and deltoid ligament injury have not.8,17 Our center’s
experience has also made our surgeons wary of a definitive
measurement cutoff such as 4 mm because a large patient
with an otherwise symmetric mortise and stable ankle would
be deemed unstable and overtreated given the previously
proposed criteria.
Ultimately, our data potentially represented a gradient
of increasing fibular displacement with increasing instabil-
ity. Our data did not support ankle stability being present
with a radiographic cutoff of fibular diastasis of #2 mm on
the lateral radiograph. In fact, no useful parameters were
seen for any measurements that would help to define stabil-
ity for those presenting with intact mortise other than the
stress view.
CONCLUSION
We conclude that stability may not be inferred from a
lack of fibular displacement on the lateral view in this
population of patients. If stability is to be determined, it must
be tested irrespective of fibular displacement on the lateral
radiographs.
24 77
73 164
97 241
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 36, Number 1, January 2022
REFERENCES
1. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification
compendium—2007: Orthopaedic Trauma Association classification,
database and outcomes committee. J Orthop Trauma. 2007;21(10
suppl):S1–S133.
2. Lauge-Hansen N. Ligamentous ankle fractures; diagnosis and treatment.
Acta Chir Scand. 1949;97:544–550.
3. Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-
surgical and experimental-roentgenologic investigations. Arch Surg.
1950;60:957–985.
4. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based
ankle fracture classification system. J Orthop Trauma. 2007;21:307–
315.
5. van Dijk CN, Longo UG, Loppini M, et al. Conservative and surgical
management of acute isolated syndesmotic injuries: ESSKA-AFAS con-
sensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24:
1217–1227.
6. Egol KA, Amirtharajah M, Tejwani NC, et al. Ankle stress test for
predicting the need for surgical fixation of isolated fibular fractures. J
Bone Joint Surg Am. 2004;86-a:2393–2398.
7. McConnell T, Creevy W, Tornetta P III. Stress examination of supina-
tion external rotation-type fibular fractures. J Bone Joint Surg Am. 2004;
86-a:2171–2178.
8. DeAngelis NA, Eskander MS, French BG. Does medial tenderness pre-
dict deep deltoid ligament incompetence in supination-external rotation
type ankle fractures? J Orthop Trauma. 2007;21:244–247.
9. Nortunen S, Leskelä HV, Haapasalo H, et al. Dynamic stress testing is
unnecessary for unimalleolar supination-external rotation ankle fractures
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Lack of Displacement of the Fibula
with minimal fracture displacement on lateral radiographs. J Bone Joint
Surg Am. 2017;99:482–487.
10. Tornetta P. Treatment of the stress positive ligamentous SE4 ankle frac-
ture: incidence of syndesmotic injury and clinical decision making. J
Orthop Trauma. 2012;26:659–661.
11. Marsh JL. Which Lateral Malleolar Fractures Do Not Need an
Operation?: commentary on an article by Simo Nortunen, MD, et al.:
Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-
External Rotation Ankle Fractures with Minimal Fracture Displacement
on Lateral Radiographs. J Bone Joint Surg Am. 2017;99:e28.
12. Marchand LS, Working ZM, Rane AA, et al. Serial radiographs do not
change the clinical course of nonoperative stable OTA/AO 44-B1 ankle
fractures. J Orthop Trauma. 2017;31:264–269.
13. Sanders DW, Tieszer C, Corbett B. Operative versus nonoperative treat-
ment of unstable lateral malleolar fractures: a randomized multicenter
trial. J Orthop Trauma. 2012;26:129–134.
14. Choi Y, Kwon SS, Chung CY, et al. Preoperative radiographic and CT
findings predicting syndesmotic injuries in supination-external rotation-
type Ankle fractures. J Bone Joint Surg Am. 2014;96:1161–1167.
15. Hastie GR, Akhtar S, Butt U, et al. Weightbearing radiographs facilitate
functional treatment of ankle fractures of uncertain stability. J Foot Ankle
Surg. 2015;54:1042–1046.
16. Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous mem-
brane tears to the level of the fibular fracture. J Orthop Trauma. 2004;18:
68–74.
17. Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measure-
ments do not predict syndesmotic injury in ankle fractures: an MRI study.
Clin Orthop Relat Res. 2005:216–221.
www.jorthotrauma.com | e5