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Fig. 1
External oblique views of normal (A) and Bosworth-type fracture (B). A vertical line is drawn along the center of the proximal fibula, until it divides the horizontal line of the talar dome. Posteromedial fibula displacement increases the α/(α + β) ratio.
Fig. 2
Box plots showing α/(α + β) ratio of each group. The ratios of groups 1 and 2 were significantly higher than those of other groups. Ratios significantly decreased and normalized after open reduction of Bosworth-type fracture (P < .0001). 
Radiographs taken after first reduction was attempted; †Postoperative radiographs of Bosworth-type fracture; ‡Bimalleolar fracture.
Fig. 3
Anteroposterior and external oblique views of a Bosworth-type fracture (A and B) and bimalleolar fracture that were not reduced after closed reduction (C and D). The α/(α + β) ratios in the external oblique view were 0.4837 (B) and 0.2292 (D), respectively. Posteromedial fibular displacement was evident in the Bosworth-type fracture as indicated by the increased α/(α + β) ratio.
Fig. 4
We overlapped 2 transparent axial CT images taken at the level of the syndesmosis and talar dome, respectively, to depict the position of the displaced and locked distal part of the fibular shaft and talus.
Abstract
Introduction
Bosworth described an unusual fracture dislocation of the ankle with fixed posterior fracture dislocation of the fibula. This ankle fracture variant is often not recognized in initial radiographs and requires a computed tomographic scan for verification. It is usually not reducible by the closed method, and repeated trials induce more damage. The purpose of this study was to verify the usefulness of simple external oblique radiographs for diagnosis of Bosworth-type fracture.
Methods
We reviewed the 327 patients who were diagnosed as unilateral malleolus ankle fracture in 2002 to 2012. Four cases of Bosworth-type fracture were identified. External oblique radiograph was taken initially, immediately after first closed reduction, and after open reduction (3 phases) was undertaken to check the position of fibula in relation with the talus. Fifty cases of bimalleolar fractures and unaffected ankle were compared. Longitudinal bisecting line along the proximal fibula was drawn, and the talus was divided in 2 parts. Anterior and posterior part of the talus was defined as part α and β. The ratio resulted from dividing α with (α + β) implies the fibula position relative to the talus.
Results
Mean α/(α + β) ratio of each phase were 0.4994, 0.4891, 0.2875, 0.2698, and 0.2709. There was significant difference in initial and first reduction phase of Bosworth-type fracture than other groups (P = < .0001). There was no significant difference in open reduced Bosworth-type fracture with bimalleolar fractures and unaffected ankles (P = .528, .602).
Conclusions
An external oblique radiograph provides useful information that can differentiate Bosworth-type fracture from other reducible bimalleolar fractures.
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☆Conflicts of interest and source of funding: None of all.
☆☆The study was approved by the institutional review board of the hospital.
