Deltoid Ligament Injuries Associated With Ankle Fractures

Arguments For and Against Direct Repair

Jesse F. Doty, MD; Burton D. Dunlap, MD; Vinod K. Panchbhavi, MD, FACS; Michael J. Gardner, MD


J Am Acad Orthop Surg. 2021;29(8):e388-e395. 

In This Article

Diagnostic Tools

Multiple methods exist to aid in the diagnosis of deltoid ligament injuries. Physical examination criteria have not proven highly accurate when used alone. Medial swelling, ecchymosis, and tenderness have demonstrated a sensitivity of 57% and a specificity of 59% when delineating stable versus unstable ankle fractures in bimalleolar equivalent ankle fractures.[9] An ankle mortise radiograph demonstrating greater than 4 mm of the MCS is evidence of a medial ligamentous injury, although the degree of tissue discontinuity is not well defined. A normal static MCS is not adequate to exclude a deltoid ligament injury. A dorsiflexion-external rotation stress view has shown to have positive and negative predictive values that approach 100% in diagnosing deltoid ligament injury when using >5 mm as the cutoff for a wide MCS[10] (see Supplemental Digital Content, Image 1, MRI has a higher specificity in diagnosing deltoid ligament injury compared with stress examinations in the scenario of an intact MCS.[11] MRI imaging will reveal ligamentous edema or discontinuity, but the utility in predicting instability requires further correlation with talus translation. In 61 ankles with MRI evidence of deltoid ligament injury, 33 had MCS widening while 28 did not, suggesting that MRI may not accurately predict the need for repair.[12] The ease of use and desire to reduce radiation exposure has led to further utilization of ultrasonography as a diagnostic tool. Ultrasonography demonstrated a sensitivity of 100% and a specificity of 90% in diagnosing deltoid ligament disruptions, when compared with 97% and 100% for gravity stress radiograph.[13]

Growing interest exists in arthroscopic evaluation in the ankle fracture setting. Arthroscopy can also provide useful data on articular reduction, allow for treatment of osteochondral lesions, and provide lavage of inflammatory cytokines. Arthroscopy can delineate partial from complete tears, define the location of the tear, and techniques exist to guide anchor placement and suture management for arthroscopic repair. The ligament is visualized under direct visualization with a small joint scope as the ankle is stressed, or by using a probe to mobilize the tissue directly at the medial malleolus attachment site.[14] A "drive-through" sign can also be used arthroscopically to evaluate the deltoid ligament. This is done by attempting to pass the camera or arthroscopic shaver through the medial ankle gutter between the medial malleolus and talus. Stable ankles with intact deltoid ligament fibers generally preclude the surgeon's ability to successfully "drive-through" this anatomic plane.