title: Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI.
abstract: OBJECTIVE
  Acute ankle sprains are frequently accompanied by syndesmotic injuries. These injuries are often overlooked in clinical examinations. The aim of this study was (1) to evaluate the incidence of syndesmotic injuries in acute ankle sprains using MRI, (2) to determine the accuracy of common clinical diagnostic tests, (3) to analyse their inter-rater reliability, and (4) to evaluate the role of clinical symptoms in the diagnosis of syndesmotic injuries.
  
  
  METHODS
  A total of 100 patients with acute ankle sprain injury without associated fractures in plane radiographs were enrolled. The clinical assessment was performed by two independent examiners. Local findings, ankle ligament palpation, squeeze test, external rotation test, Drawer test, Cotton test, and the crossed-leg test (two examiners) were compared with MRI results (read by two blinded radiologists) as a reference standard.
  
  
  RESULTS
  Ninety-six participants (57% male) met the inclusion criteria. MRI detected a ruptured anterior inferior tibiofibular ligament (AITFL) in 14 patients (15%); 9 partial tears and 5 complete tears were evident. Evidence of pain at rest was found to predict syndesmotic injuries most accurately (p = 0.039). The palpation test over the proximal fibula produced the highest inter-rater correlation (κ = 0.65), but the lowest sensitivity for syndesmotic injuries of 8%. All other clinical tests demonstrated moderate to fair inter-rater reliabilities (κ = 0.37-0.52). Low sensitivity values were found with all clinical tests (13.9-55.6%).
  
  
  CONCLUSIONS
  In this study, clinical examination was insufficient to detect syndesmotic injuries in acute ankle sprains. MRI scanning revealed a syndesmotic lesion in 15% of patients. MRI scanning should be recommended in patients with ongoing pain at rest following ankle sprains.
  
  
  METHODS
  I.
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. lgrosste@uke.de.
authors.forename: Lars Gerhard
authors.initials: LG
authors.lastname: Großterlinden
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Hartel
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Jin
authors.initials: J
authors.lastname: Yamamura
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Bjoern
authors.initials: B
authors.lastname: Schoennagel
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Nils
authors.initials: N
authors.lastname: Bürger
authors.affiliation: Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Mathias
authors.initials: M
authors.lastname: Krause
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Spiro
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Hoffmann
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Lehmann
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Johannes Maria
authors.initials: JM
authors.lastname: Rueger
authors.affiliation: Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Rupprecht
mesh_terms: D000293:Adolescent; D000328:Adult; D016512:Ankle Injuries / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008023:Ligaments, Articular / Q000000981:diagnostic imaging / Q000293:injuries*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010173:Palpation; D010808:Physical Examination; D015203:Reproducibility of Results; D013180:Sprains and Strains / Q000175:diagnosis*; D055815:Young Adult
keywords: Ankle; Ankle ligaments; General sports trauma; Magnetic resonance imaging