HIGH ANKLE SPRAIN

DEFINITION

• A traumatic injuries that affect the distal tibiofibular

ligaments and most commonly occur due to sudden
external rotation of the ankle.
 PATHOPHYSIOLOGY

• Most commonly associated with external rotation injuries

• External rotation forces the talus to rotate laterally and push the fibula away
from tibia
• increased compressive stresses seen by the tibia
• increased likelihood of lateral subluxation of the distal fibula
• incongruence of the ankle joint articulation
 ANATOMY
• Distal tibiofibular syndesmosis
includes
• anterior-inferior tibiofibular ligaments
(AITFL)
• posterior-inferior tibiofibular ligament
(PITFL)
• interosseous membrane
• interosseous ligament (IOL)
• inferior transverse ligament (ITL)
• Syndesmosis Biomechanics
• Functions
• Maintains integrity between tibia and fibula
• Resists axial, rotational, and translational forces
• Motions
• During dorsiflexion  wider anterior talus
engages the ankle mortise
• During plantarflexion  the narrow posterior
talus engages the ankle mortise
 PRESENTATION

• Symptoms • Physical exam

• anterolateral ankle pain proximal to AITFL
• may have medial sided ankle
tenderness/swelling
• difficulty bearing weight
• lateral ankle sprains are often able to bear
weight
• Palpation  syndesmosis tenderness
• provocative tests
• Squeeze test (Hopkin's)
• External rotation stress test
• Cotton test
• Anterior and posterior drawer
 RADIOGRAPHS

• Ro findings • CT scan
1. Decreased tibiofibular overlap • When clinical suspicion of syndesmotic
injury with normal radiographs
• normal >6 mm on AP view
• To assess reduction of syndesmosis after
• normal >1 mm on mortise view
fixation
2. Increased medial clear space
• MRI
• normal less than or equal to 4 mm
• Lambda sign  highly sensitive and
3. Increased tibiofibular clear space specific for detecting syndesmotic injury
• normal <6 mm on both AP and
mortise views
1 2 3
 TREATMENT - NONOPERATIVE

• Non-weight-bearing CAM boot or cast for 2 to 3 weeks

• Indication: Syndesmotic sprain without diastasis or ankle instability
• Technique
• delayed weight-bearing until pain free
• physical therapy program using a brace that limits external rotation
 TREATMENT - OPERATIVE

• Syndesmosis screw fixation

• Indications
• syndesmotic sprain (without fracture) with instability on stress radiographs
• syndesmotic sprain refractory to conservative treatment
• syndesmotic injury with associated fracture that remains unstable after fixation of fracture
• Syndesmosis fixation with suture button
• Technique
• fiberwire suture with two buttons tensioned around the syndesmosis
• may be performed in addition to a screw
THANK YOU