This document provides several case studies and radiographs related to ankle injuries for medical board preparation. It discusses the fracture patterns, likely ligament injuries, and appropriate management for each case. For example, one case shows a severe Weber C4 ankle fracture and states the orthopedist would likely want to surgically stabilize the injury soon rather than have the patient follow up later in the office. The document emphasizes analyzing radiographs to determine fracture classification and developing a treatment plan based on injury severity and mechanism.

1. Ankle Xray QBank
Board Prep and Comprehension
Testing

2. A 32-year-old female sustains the injury shown
here. What is the most reliable method to
evaluate the competence of the deltoid
ligament?
a. Medial ankle tenderness
b. Medial ankle ecchymosis
c. Squeeze test
d. Stress radiography of the ankle
e. Canal view radiograph

3. Fracture: Weber B Stage 4
• Lateral swelling (ATFL injury)
• Oblique fibular fx
• Medial clear space widened >4mm
Injury Pattern: Supination, exorotation
Answer: D
Deltoid ligament (medial structure) evaluation
is important for therapeutic reasons, as medial
sided instability will portend a poor prognosis
if treated nonoperatively. The physical exam is
a poor indicator of medial ankle injury.
References:
1. McConnell T, Creevy W, Tornetta P 3rd. Stress examination of supination
external rotation-type fibular fractures. J Bone Joint Surg Am. 2004 Oct;86-
A(10):2171-8. PMID:15466725 (Link to Abstract)
2. Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC Jr. Comparison of manual and
gravity stress radiographs for the evaluation of supination-external rotation
fibular fractures. J Bone Joint Surg Am. 2007 May;89(5):994-9. PMID:17473136
(Link to Abstract)

4. An 18-year-old football player presents to
the emergency department after
sustaining an ankle injury. What is the
next step in his management?
A. ER reduction, splint, d/c to f/u
B. Splint in position of comfort and d/c
C. Prep for emergent surgery
D. ER reduction, splint, admit for urgent
surgery
E. Have him walk on home

5. Fracture: Weber C Stage 3
• Medial malleolar avulsion fx
• Transverse fibular fx above
syndesmosis
• Syndesmotic widening, lateral clear
space >5mm
Injury Pattern: Pronation, exorotation
Answer: D
This is a fracture-dislocation w/ evidence of
skin tenting (red circle) by the distal tibia.
Urgent ER reduction is therefore indicated
to minimize tissue necrosis and given the
degree of syndesmotic injury, OR fixation is
required
References:
1. Zalavras C, Thordarson D: Ankle syndesmotic injury. J Am Acad Orthop Surg
2007;15:330-339 PMID:17548882 (Link to Abstract)
2. Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD (eds):
Rockwood and Green’s Fractures in Adults, ed 5.
Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 2001-2090

6. A 29yo M was playing basketball when
he went to pivot and “rolled his ankle”.
He was initially unable to walk at the
time of injury but is now toe touching.
Xrays are taken and you appropriately
analyze the fibula. Your next step in
management is…
A. Evaluate the medial malleolus for a
secondary impact fracture
B. Obtain knee films to rule out a
Maissoneuvre fracture
C. Call Ortho for surgical pre-op
D. Apply a post-mold splint and refer for
Ortho follow up in 1 week
E. Apply an air cast and encourage early
ambulation

7. Fracture: None
• This is an example of an os sub-
fibulare (see next page for more
examples)
Injury Pattern: Supination, adduction
Answer: E
Answer A is reasonable to rule out any
secondary impact fracture to the medial
tibia or talus, but without obvious fracture
pattern or ATFL injury, the likelihood of a
Weber A2 fracture is low. The mechanism is
not appropriate for syndesomtic injury or
Maissoneuvre mechanism, so knee films are
not indicated. Basic strain/sprain care is all
that is required.
References:
1. Browner, BD, Jupiter JB, Levine AM, Trafton, PG, eds. Skeletal Trauma.
Philadelphia, PA; WB Saunders, 2003: 2325-2330.

8. Os sub-tibiale and os
trigonum (of the
lateral talus)
commonly mistaken
for fractures…
• Note the lack of
fibular cortical
disruption
• Each os is
uncorticated

9. A 45yo M was walking his St.
Bernard when it suddenly took off
running after a cat, pulling him to
the ground and has been unable
to ambulate since. How will you
manage this patient?
A. Walking boot and ambulate as
tolerated
B. Ace
wrap, ice, elevation, NSAIDs
and early weight bearing
C. Post mold, crutches, NWB
status and ortho f/u
D. There is no injury, comfort
care only
E. Call Ortho for immediate OR

10. Answer: C
Without more views, it is difficult to
tell if this is a Weber B or C, but we
certainly know it is not a Weber A
because the posterior malleolus is
involved.
Because the posterior malleolus is
involved, we know that it is an
eversion injury and it would be
imperative to image the fibula up to
the knee to search for a possible
Maissoneuvre.
Note how easily missed this fracture is
as it can easily be misinterpreted as
the fibular shadow unless closely
interrogated.

11. Without knowing anything about
this patient, would you be able to
predict the fracture pattern?
A. Pronation eversion
B. Pronation abduction
C. Supination exorotation
D. Supination adduction
E. Supination inversion

12. Answer: D
Aside from being almost assuredly
painful, this is a Weber A or supination
(aka inversion) adduction (heel
up, ankle up) injury.
We see the fibular fracture (arrow)
below the level of the mortise.
Additionally we see the medial
malleolus is fractured
(lightning), making this a Weber A type
2.
Most Weber A fractures are type 1 and
do not require surgery. However, if the
medial malleolus is involved (as in this
case), surgery is likely required.
There is also a marked dislocation, so
this will need reduction and post-mold
w/ stirrup and strict NWB status.

13. Which ligament is likely NOT ruptured
in this patient?
A. Anterior talofibular ligament
(ATFL)
B. Deltoid ligament
C. Posterior talofibular ligament
(PTFL)
D. Poster tibiofibular ligament
E. Calcaneofibular ligament

14. Answer: B
The fracture pattern is a Weber C
(either 3 or 4, depending on if the
posterior malleolus is intact or not).
First we see the spiral fibular fracture
above the mortise (red
arrow), pathognomonic for a
pronation-exorotation (or Weber C)
injury. The first ligament injured is the
ATFL and commonly the PTFL is
involved as well.
Secondly, note the syndesmotic
widening (blue arrow) and therefore
disruption.
The medial malleolus is sheared off
(circle), so the deltoid ligament is likely
intact.
Lastly, note the high fibular fracture
(that could have been missed.

15. What is this patient’s disposition?
A. Home w/ an Ace wrap?
B. Home w/ an air cast and WBAT?
C. Home w/ an air cast and NWB until f/u?
D. Post-mold w/ stirrup, crutches, o/p f/u?
E. Straight to OR?

16. Reference:
Conservative treatment of isolated fractures of the medial malleolus
D. Herscovici, Jr, DO; J. M. Scaduto, ARNP; A. Infante, DO, Florida Orthopaedic
Institute, 13020 Telecom Parkway, Temple Terrace, Florida 33637, USA.
Answer: C
Isolated medial malleolar
fractures often have good
outcomes with conservative
measures. You should have the
patient maintain non-weight
bearing status (NWBS) until
their ortho f/u and inform them
that they will likely be casted for
4-6 weeks.

17. How many fractures did this patient sustain?
A. One
B. Two
C. Three
D. Four
E. Five

18. Answer: A
The spiral fibular avulsion fracture (outlined) at the
level of the mortise (Weber B) is the only apparent
fracture, the tibial abnormality is likely physeal
scarring (arrow).

19. This 13yo F was climbing a tree when she
jumped down approximately 8 feet and
landed on her feet. She is complaining of
severe pain to her plantar foot and heel.
What is your plan of management for this
patient?
A. Ortho referral for possible surgery
B. Splint, NWBS and f/u w/ PMD
C. Aircast and WBAT
D. Reassurance and discharge to home
E. Amputation

20. Answer: D
This is a calcaneal physis, not an
avulsion fracture. The pt likely
has some plantar fascial
irritation and strain from the
fall, but there is no evidence of
fracture. Note the lack of
cortication of the fragment.
Another indirect way of teasing
out if this is a fracture or physis
is to draw lines to approximate
the edges. If the extra bone
looks like it couldn’t fit on the
underlying area perfectly, it’s
likely not a fracture. In this
case, the fragment looks well
aligned with the outer margins
of the calcaneus.

21. By what mechanism did this patient likely injury himself?
A. Suppination, exorotation injury
B. Shin strike onto a hard surface
C. There is no fracture
D. Pronation, exorotation injury
E. Fall from height

22. Answer: E
Pilon fractures most commonly occur as a
result of axial loading and special mortise
views such as this should be obtained to
thoroughly evaluate the plafond.
This patient should be splinted, given
crutches, instructed on NWBS and
referred to orthopedics for definitive
management. This patient will not likely
require surgery given that they are young
in age (note the many ossification
centers).

23. Which Weber class does this injury represent?
A. Weber A2
B. Weber B2
C. Weber C1
D. Weber C2
E. Weber C3

24. Answer: E
First, the spiral fibular fracture above
the mortise (red arrow) identifies this
as a Weber C.
Second, the tibiofibular overlap is
widened (green arrow), indicating ATFL
disruption.
Third, the medial malleolus is
avulsed, making this more severe than
a Weber B.
If the posterior malleolus is fractured
on the lateral film, this would become a
C4

25. This patient slipped on the curb and
currently only has lateral malleolar
tenderness, therefore you DO NOT
need to obtain knee films to assess
the proximal fibula?
A. True
B. False

26. Answer: False
The spiral fracture above the
mortise makes this a Weber C
which are the only fracture patterns
that commonly cause the
Maissoneuvre fracture.
The lack of medial malleolar
swelling and pain is less
worrisome, but isolated severe
spiral fractures often are not found
in isolation.

27. You are a community EP working in
Montana when a 24yo M comes in after
“just missing” a “killer jump” on his
skateboard. You immediately recognize the
fracture type, and you plan on…
A. Apply a fiberglass splint, strict NWBS w/
crutches and Ortho f/u in 3-5 days
B. Call Ortho to discuss the case for
possible OR pinning during this
admission
C. Aircast and toe-touch weight bearing
with follow up in 1-2 weeks
D. Doing nothing, these commonly heal
without any intervention
E. Asking the patient for a copy of the
video he shot of him eating it

28. Answer: B
This is as severe as they come, Weber C4.
The spiral fibular fracture above the mortise
(blue arrow) makes this a class C, the anterior
supratalar widening of the joint space (green
arrow) indicates ligamentous disruption and
the posterior malleolar fracture (circle)
makes this a C4.
Ortho might have you splint and have the
patient follow up in the office tomorrow for
surgery, but most likely they will want to
stabilize this sooner rather than later, but
either way, the patient should not leave
without Ortho knowing about this patient.