Gravity Reduction View: A Radiographic Technique for the Evaluation and Management of Weber B Fibula Fractures

Background: While various radiographic parameters and application of manual/gravity stress have been proposed to elucidate instability for Weber B fibula fractures, the prognostic capability of these modalities remains unclear. Determination of anatomic positioning of the mortise is paramount. We propose a novel view, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise.Methods: The patient is positioned lateral decubitus with the injured leg elevated on a holder with the fibula directed superiorly. The x-ray cassette is placed posterior to the heel, with the beam angled at 15˚ of internal rotation to obtain a mortise view. Our proposed treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view (and in comparison to the superior clear space (SCS)) and is based on reducibility of the MCS. A retrospective review of patients evaluated utilizing the GRV was performed.Results: 26 patients with Weber B fibula fractures were managed according to this treatment algorithm. Mean age was 50.57 years old (range: range:18-81, SD=19). 17 patients underwent operative treatment and 9 patients were initially treated nonoperatively. 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, at a mean follow-up of 26 weeks, all patients had a final MCS that was less than the SCS (final mean MCS 2.86 mm vs. mean SCS of 3.32) indicating effectiveness of the treatment algorithm.Conclusion: The GRV is a novel radiographic view in which deltoid competency, reducibility and initial positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the GRV. We have developed a treatment algorithm based on the GRV and have found it to be useful in guiding treatment and successful at achieving anatomic mortise alignment.