Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice

Differentiating supination external rotation (SER) type II and IV ankle injuries is challenging in the absence of a medial malleolar fracture or talar shift on radiographs. The accurate differentiation between a stable SER-II from an unstable SER-IV injury would allow implementation of the appropriate management plan from diagnosis. The aim of this study was to ascertain the practice of orthopaedic surgeons in dealing with these injuries.

A postal survey was undertaken on 216 orthopaedic consultants from three regions.

In the presence of medial-sided clinical signs (tenderness, swelling, ecchymosis), 22% of consultants would perform surgical fixation. 53% would choose non-operative treatment and the majority would monitor these fractures through serial radiographs. The remaining 25% of consultants would perform an examination under anaesthesia (EUA; 15%), request stress radiographs (9%) or an MRI scan (1%). Without medial-sided signs, 85% would advocate non-operative treatment and, of these, 74% would perform weekly radiographs. Interestingly, 6% would perform immediate surgical fixation. Stress radiographs (6%) and EUAs (2%) were advocated in the remaining group of consultants. Foot and ankle surgeons utilised stress radiographs more frequently and were more likely to proceed to surgical fixation should talar shift be demonstrated.

Clinical practice is varied amongst the orthopaedic community. This may lead to unnecessary surgery in SER-II injuries and delay in diagnosis and operative management of SER-IV injuries. We have highlighted the various investigative modalities available that may be used in conjunction with clinical signs to make a more accurate diagnosis.