There are many ways to do this. If it doesn’t work for you. That’s fine! Develop a system that does work. Take this one and make it better. Always be on the look out for being more efficient and making things better.
System for Reading Ankle Xrays
Verify correct patient and image date
I’ve seen scenarios where it would have saved hours of time to just look for old images in the medical record to see if a problem was chronic before just jumping in and trying to fix something that is chronic and can’t really be fixed with a reduction.
Say what views your are looking at (AP, Lateral, Oblique)
If you aren’t sure, just say 3 views of a Left vs. Right ankle… for example
Skeletally mature or immature?
Look for obvious injuries and comment on them. Use the most straightforward and correct answer.
Don’t jump into the details right away
Example: AP, lateral and mortise view of a right ankle in a skeletally mature individual with an ankle fracture dislocation…
After you have established the obvious. Go back and systematically go through the images in each view
As always, it is helpful to start looking proximally and work your way distal
AP view
Outline the tibia and fibula looking for fracture lines
Look in medullary canals
Overlap of fibula and tibia is >6mm
Visualize ankle joint space and that there is equal clear space across the ankle joint on all sides, the medial, lateral and plafond.
Look at the length of the fibula, check “Dime sign”
In the image below there is medial clear space widening, the dime sign is off slightly, but is relatively close to where the tip of the lateral malleolus lines up with the talus. If the fibula was short, it would not touch the top of the dime.
Soft tissue review proximal to distal
The picture above shows what a short fibula would look like, the dime sign would be abnormal.
Source: Journal of Foot and Ankle Surgery
Lateral View
Check image quality
Posterior fibula border is overlapping within a ⅓ of the posterior tibial border
In the image below, the posterior fibula border is almost perfectly lined up
Medial and lateral talar dome lines are lined up to create a perfect semicircle at the tibiofibular joint
Source: Wikiradiography.net
Outline tibia, fibula, and medullary canals
Review tibiotalar joint space, talus centered on tibia
Review talus body and outline
Talar-navicular joint
Subtalar-joint
Calcaneus body and outline
Cuboid outline
Soft tissue
Mortise View
Check quality: Medial and lateral malleoli are in profile, which means the anterior edge is perfectly lined up with the posterior edge
Best seen on the medial malleolus
Proximal to distal bone outline and medullary canals
Check syndesmosis
Tibia / fibula overlap >1mm on mortise view
Review Soft Tissue
Source: Radiopedia.org
