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Optimal management of ankle syndesmosis injuries.

Porter DA, Jaggers RR, Barnes AF, Rund AM - Open Access J Sports Med (2014)

Bottom Line: If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted.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.Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible.

View Article: PubMed Central - PubMed

Affiliation: Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA.

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.

No MeSH data available.


Related in: MedlinePlus

Abduction and external rotation anterior-posterior stress image of left ankle demonstrating unstable syndesmosis and wide medial clear space.
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f1-oajsm-5-173: Abduction and external rotation anterior-posterior stress image of left ankle demonstrating unstable syndesmosis and wide medial clear space.

Mentions: When radiographically examining the ankle joint, weight-bearing anterior–posterior, lateral, and mortise views of the ankle joint should be obtained. If necessary, injections of local anesthetic may be used around the ankle joint to minimize discomfort and allow the stress of full weight bearing.17 When required, 1% lidocaine was used in the deltoid (3–5 mL) and distal syndesmosis (4–6 mL). Xenos et al13 determined stress lateral radiographs to be more accurate at assessing diastasis than stress mortise radiographs. However, Lin et al2 found weight-bearing mortise radiographs to be the best assessment of ankle instability. Since no agreement exists in the literature, all three views should be examined carefully. In all views, the authors prefer physiological stress to help evaluate occult deltoid and syndesmotic ligament injuries. This helps to differentiate between an isolated lateral malleolus fracture and a bimalleolar equivalent injury and between grade I and grade II injuries. Stress external rotation views are obtained if the weight-bearing films are inconclusive regarding stability (Figure 1).


Optimal management of ankle syndesmosis injuries.

Porter DA, Jaggers RR, Barnes AF, Rund AM - Open Access J Sports Med (2014)

Abduction and external rotation anterior-posterior stress image of left ankle demonstrating unstable syndesmosis and wide medial clear space.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4128849&req=5

f1-oajsm-5-173: Abduction and external rotation anterior-posterior stress image of left ankle demonstrating unstable syndesmosis and wide medial clear space.
Mentions: When radiographically examining the ankle joint, weight-bearing anterior–posterior, lateral, and mortise views of the ankle joint should be obtained. If necessary, injections of local anesthetic may be used around the ankle joint to minimize discomfort and allow the stress of full weight bearing.17 When required, 1% lidocaine was used in the deltoid (3–5 mL) and distal syndesmosis (4–6 mL). Xenos et al13 determined stress lateral radiographs to be more accurate at assessing diastasis than stress mortise radiographs. However, Lin et al2 found weight-bearing mortise radiographs to be the best assessment of ankle instability. Since no agreement exists in the literature, all three views should be examined carefully. In all views, the authors prefer physiological stress to help evaluate occult deltoid and syndesmotic ligament injuries. This helps to differentiate between an isolated lateral malleolus fracture and a bimalleolar equivalent injury and between grade I and grade II injuries. Stress external rotation views are obtained if the weight-bearing films are inconclusive regarding stability (Figure 1).

Bottom Line: If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted.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.Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible.

View Article: PubMed Central - PubMed

Affiliation: Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA.

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.

No MeSH data available.


Related in: MedlinePlus