Optimal management of ankle syndesmosis injuries

Abstract

Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

Keywords: athletes; deltoid ligament; operative fixation; rehabilitation; syndesmosis.

Figures

Figure 1

Abduction and external rotation anterior-posterior stress image of left ankle demonstrating unstable syndesmosis and wide medial clear space.

Figure 2

Postoperative left anterior-posterior ankle radiograph after open reduction and internal fixation of Weber C fibular shaft fracture with lag screws, one third tubular plate and two suture button fixation of the syndesmosis demonstrating anatomic alignment of the syndesmosis, medial clear space and fibular shaft. The deltoid ligament was also repaired in this athlete.

Figure 3

Postoperative anterior-posterior ankle radiograph after open reduction and internal fixation of unstable syndesmosis injury with five hole one third tubular plate, two suture buttons and one 4.5 mm cannulated screw demonstrating anatomic alignment of the syndesmosis and the medial clear space. The deltoid was also repaired.