By Anthony G. Martin

Summary

Fifty-three patients with ankle fractures presenting to a trauma clinic at a busy district general hospital were used for this study. All subjects sustained fibular fractures at the syndesmosis without demonstrable medial instability or mortice incongruity. All cases were collected consecutively. Radiographs and case notes were studied for each patient. All fractures were categorized as Weber B (Pratique de l'osteosynthese. Les fractures malleolaires [1949]) without medial malleolar fracture. Data collected included the number of radiographs taken per patient and clinic reviews until discharge. Duration of immobilization was recorded as well as weight-bearing status.

None of the 53 fractures showed any change in position following serial radiology. No patient underwent manipulation or internal fixation of the fracture. For Weber B fractures there was an average of six radiographs and 4.3 clinic reviews until discharge. There was a median time of 5.7 weeks spent in plaster immobilization for these fractures. We conclude that once the decision is made to treat Weber B fractures as stable injuries they do not require regular review and serial radiographs. They require only one initial radiograph. Significant reductions in the number of trauma clinic consultations can be achieved as well as a national cost saving in the order of a half million pounds for the x-rays alone.

Background

There is no doubt that trans- syndesmotic, Weber B-type fractures can be unstable fractures. Medial deltoid ligament competence is important for there to be a stable fracture configuration. Such signs as medial tenderness or bruising and radiological evidence of pathological talar shift or tilt can be useful in deciding whether the deltoid ligament is ruptured. If there is no injury to the deltoid ligament, then it is. :aid to be a stable injury (Cedell, 1985; Kristensen & Hansen, 1985) (see Figure One). The implications are that the ankle mortice is likely to remain congruent during the subsequent period of immobilization of the ankle. In the author's experience, there is a reluctance amongst trauma surgeons to reflect this fact in their fracture management. This means that regular patient review and radiological investigations are requested. It is not the aim of this study to establish which Weber B fractures should be treated conservatively. However, if conservative management is implemented, we hypothesize that as long as there is initial mortice congruency and minimal medial tenderness, then the fracture positioning does not alter throughout the duration of treatment.

Figure One. Stable Weber B injury. Medial deep deltoid ligament intact. (1) Fractured fibular with anterior talofibular ligament (ATFL) intact. (2) With ATLF ruptured