Is an orthopedic (ortho) referral needed for interpretation with no discrete fracture, nonspecific increased density inferior to the medial malleolus, and widening of the medial tibial-talar joint?

From the Guidelines

An orthopedic referral is recommended for this ankle imaging finding. While there is no discrete fracture, the combination of nonspecific increased density inferior to the medial malleolus and widening of the medial tibial-talar joint suggests a possible ligamentous injury or subtle fracture that may require specialized evaluation. These findings could indicate deltoid ligament injury or an occult fracture that isn't clearly visible on initial imaging. According to the American College of Radiology Appropriateness Criteria for acute trauma to the ankle 1, MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important for determining the grade of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries. The presence of bone bruise and adjacent soft-tissue edema has shown a higher association with acute ligamentous injuries and tendon abnormalities in patients with negative radiographs 1.

The orthopedic specialist can perform a more detailed clinical assessment, potentially order additional imaging like MRI to evaluate soft tissue structures, and determine if the joint widening represents instability requiring treatment. Key points to consider in the evaluation include:

• The possibility of ligamentous injury without fracture on radiography, as noted in studies comparing MRI and radiography 1
• The importance of high-resolution evaluation of tendons and ligaments to distinguish between tendinopathy, sprain, and partial or complete tears
• The potential for MRI to help exclude Salter 1 fractures in the pediatric population, if applicable 1

In the meantime, the patient should follow RICE protocol (rest, ice, compression, elevation), use appropriate pain control with acetaminophen or NSAIDs if not contraindicated, and avoid weight-bearing or use an assistive device like crutches until evaluated. Early orthopedic assessment can prevent complications like chronic instability or post-traumatic arthritis that might develop if these findings represent a significant injury requiring intervention.

From the Research

Orthopedic Referral for Interpretation

• The presence of no discrete fracture, nonspecific increased density inferior to the medial malleolus, and widening of the medial tibial-talar joint may indicate a potential syndesmotic injury or other ankle pathology 2.
• Syndesmotic injuries can occur in up to 11% of all ankle sprains and may lead to ankle instability and early osteoarthritis of the tibiotalar joint 2.
• The widening of the ankle mortise can decrease the contact area of the tibiotalar joint, leading to instability and potential osteoarthritis 2.
• Stress fractures of the medial malleolus are rare, but can be difficult to diagnose and treat, and may require surgical or conservative management 3.
• Posterior malleolar fractures can also affect the tibiotalar joint and may require operative or nonoperative treatment, with the goal of restoring medial and lateral constraints of the ankle 4.
• Alternative fixation techniques, such as headless compression screws, may be effective in managing medial malleolus fractures and reducing the risk of non-union and hardware removal 5.
• In some cases, extra-articular displacement of osteochondral fractures may occur, and prompt diagnosis and treatment are necessary to achieve full recovery 6.

Potential Indications for Referral

• Unclear or complex ankle pathology
• Suspected syndesmotic injury or medial malleolus fracture
• Widening of the medial tibial-talar joint or ankle mortise
• Persistent pain or instability despite conservative management
• Need for advanced imaging or surgical intervention