Ankle X-Ray Interpretation: Systematic Approach

Standard 3-view (AP, mortise, lateral) ankle radiographs assess:

1. Bones: tibia, fibula, talus, calcaneus, cuboid, navicular, metatarsal bases. Look for fracture lines, cortical disruption, avulsions.
2. Joint spaces: tibiotalar (ankle), tibiofibular (syndesmosis), subtalar. Symmetric widening = ligamentous injury.
3. Alignment: talar tilt, medial clear space (<4 mm normal), tibiofibular overlap (>1 cm AP, >4 mm mortise).
4. Soft tissue: swelling (capsular distension), fat pad signs.
5. Arthritis: joint space narrowing, osteophytes, subchondral sclerosis/cysts.
6. Foreign bodies – radiopaque fragments.

Key Fracture Patterns

• Lateral malleolus (Weber A/B/C).
• Medial malleolus.
• Posterior malleolus.
• Bimalleolar, trimalleolar.
• Pilon (tibial plafond).
• Talar neck/body.

Always correlate with mechanism, exam, and Ottawa rules.