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Ankle Syndesmotic Injury

Dr. Zalavras is Associate Professor, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA. Dr. Thordarson is Professor and Vice Chair, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California.

None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Zalavras and Dr. Thordarson.

Reprint requests: Dr. Zalavras, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 2025 Zonal Avenue, Los Angeles, CA 90089-9312.

Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.