title: Plantar flexion influences radiographic measurements of the ankle mortise.
abstract: BACKGROUND
  The treatment of ankle fractures often depends on the integrity of the deltoid ligament. Diagnosis of a deltoid ligament tear depends on the measurement of the medial clear space. We sought to evaluate the impact of ankle plantar flexion on the medial clear space.
  
  
  METHODS
  Mortise radiographs were made for twenty-five healthy volunteers, with the ankle in four positions of plantar flexion (0 degrees, 15 degrees, 30 degrees, and 45 degrees). Four observers measured the medial clear space and the superior clear space on each radiograph. The mean medial clear space at 0 degrees was defined as the control, and the deviation of the medial clear space from the control value was calculated at 15 degrees, 30 degrees, and 45 degrees of plantar flexion. The ratio of the medial clear space to the superior clear space was determined on all radiographs, and ratios that were false-positive for a deltoid ligament injury were identified.
  
  
  RESULTS
  Fourteen male and eleven female volunteers were evaluated. The average increase in the medial clear space when ankle plantar flexion was increased from 0 degrees to 45 degrees was 0.38 mm (95% confidence interval, 0.18 to 0.58 mm). This increase was significant (p = 0.005). The average increase in the medial clear space was 0.04 mm when ankle plantar flexion was increased from 0 degrees to 15 degrees and 0.22 mm when it was increased from 0 degrees to 30 degrees. Neither of these changes was significant (p = 0.99 and 0.20). The prevalence of false-positive findings of deltoid injury based on the ratio of the medial clear space to the superior clear space increased as ankle plantar flexion increased, but this increase did not reach significance in our study group (p = 0.18).
  
  
  CONCLUSIONS
  Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. The potential for false-positive findings of deltoid disruption increases with increasing ankle plantar flexion.
authors.affiliation: Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Suite 112, San Diego, CA 92134, USA. nelson.saldua@med.navy.mil
authors.forename: Nelson S
authors.initials: NS
authors.lastname: Saldua
authors.forename: James F
authors.initials: JF
authors.lastname: Harris
authors.forename: Lance E
authors.initials: LE
authors.lastname: LeClere
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Girard
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Carney
mesh_terms: D000328:Adult; D016512:Ankle Injuries / Q000000981:diagnostic imaging; D000843:Ankle Joint / Q000000981:diagnostic imaging* / Q000502:physiology; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008023:Ligaments, Articular / Q000000981:diagnostic imaging / Q000293:injuries; D008297:Male; D008875:Middle Aged; D011859:Radiography; D016059:Range of Motion, Articular; D055815:Young Adult