Syndesmosis injuries

Abstract

Traumatic injuries to the distal tibiofibular syndesmosis commonly result from high-energy ankle injuries. They can occur as isolated ligamentous injuries and can be associated with ankle fractures. Syndesmotic injuries can create a diagnostic and therapeutic challenge for musculoskeletal physicians. Recent literature has added considerably to the body of knowledge pertaining to injury mechanics and treatment outcomes, but there remain a number of controversies regarding diagnostic tests, implants, techniques, and postoperative protocols. Use of the novel suture button device has increased in recent years and shows some promise in clinical and cadaveric studies. This article contains a review of syndesmosis injuries, including anatomy and biomechanics, diagnosis, classification, and treatment options.

Fig. 1

Line drawings depicting anterior (a), posterior (b), and lateral (c) views of the ligaments stabilizing the distal tibiofibular syndesmosis: the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), the transverse ligament (TL), and the interosseous ligament (IOL). The arrows indicate the respective location and point to the cross-sectional view. (Adapted from Hamilton CC: Traumatic Disorders of the Ankle. New York, NY: Springer-Verlag, 1984, with permission)

Fig. 2

Anteroposterior radiographs of a normal ankle (a) and an ankle with syndesmotic injury (b). Note the widened medial clear space, loss of tibiofibular overlap, and widening of the distal tibiofibular syndesmosis

Fig. 3

Fluoroscopic images illustrating unstable supination external rotation fracture pattern with syndesmotic disruption (a), lateral translation stress after fixation of the fibula fracture (b), syndesmosis reduction technique using a large reduction tenaculum (c), and fixation of the syndesmosis with 3.5-mm screws (d)