Diagnostic and Surgical Planning Value of Computed Tomography (CT) in Adult Ankle Fractures: A Narrative Review

Ankle fractures are common adult injuries with complex patterns often inadequately characterised by plain radiographs alone. Computed tomography (CT) has been shown to improve diagnostic accuracy and inform surgical planning, though routine use remains limited due to cautious guidelines. This narrative review synthesises evidence from 20 unique studies (2010-2025) to compare CT with X-rays in adult ankle fractures and evaluate diagnostic precision, fracture classification, and changes in operative strategy. CT consistently enhanced the detection of complex and occult fractures, particularly posterior malleolar and syndesmotic injuries missed on X-rays, with fracture classification altered in up to 44% of cases and surgical management changed in approximately 25%, especially for tri-malleolar and posterior malleolus fractures. Despite these benefits, the evidence base is predominantly level III-IV, with limited data on cost-effectiveness or long-term functional outcomes. In alignment with National Institute for Health and Care Excellence NG38 and the American College of Radiology Appropriateness Criteria (2023), the review concludes that while CT improves diagnostic and surgical decision-making for complex ankle fractures, its routine use lacks proven patient centred benefit; therefore, a selective CT algorithm is proposed to help clinicians identify fracture patterns where CT is most likely to influence management, balancing clinical value, cost, and radiation exposure.