Abstract
Introduction: Ankle syndesmosis injuries typically occur when the foot is forced upward and outward. Syndesmosis of the ankle is the joint that connects the tibia and fibula and allows these two bones to work together to provide stability to the lower leg. Case: 24 year old active duty female service member presented to Womack Army Medical Center for left ankle pain approximately 12 weeks after incurring an injury while playing basketball. She reported increased pain with activity and no improvement when using a brace. Imaging studies performed on the weight bearing left leg, ankle, and foot revealed a healed proximal fibular fracture, syndesmosis widening with lateral shift and medial space widening, and decreased longitudinal arch height. A magnetic resonance imaging revealed a deltoid ligament tear and widening of the syndesmosis, but showed no tibialis posterior tendinopathy. The patient was taken to the operating room for open reduction internal fixation of the syndesmosis with a medial displacement calcaneal osteotomy, deltoid ligament repair, gastrocnemius recession, and medial cuneiform opening wedge osteotomy. Discussion: The coexistence of syndesmosis and deltoid ligament injuries modifies ankle joint motion and significantly destabilizes the ankle joint. Radiographs of the affected limb to rule out any fracture are important; however, stress radiographs may be needed to accurately determine stability of the ankle joint as clinical examination cannot assess or diagnose deltoid ligament injury.
Highlights
Ankle syndesmosis injuries typically occur when the foot is forced upward and outward
Radiographs of the affected limb to rule out any fracture are important; stress radiographs may be needed to accurately determine stability of the ankle joint as clinical examination cannot assess or diagnose deltoid ligament injury
The ankle can be analyzed for tenderness or pain by the squeeze test or external rotation test
Summary
The coexistence of syndesmosis and deltoid ligament injuries modifies ankle joint motion and significantly destabilizes the ankle joint. Radiographs of the affected limb to rule out any fracture are important; stress radiographs may be needed to accurately determine stability of the ankle joint as clinical examination cannot assess or diagnose deltoid ligament injury [1]. An examination of the ankle is required to diagnose an ankle syndesmosis injury. To perform the external rotation test the knee is bent, the ankle is 90 degrees with the foot in relation to the leg and the foot is turned outward. Injury is indicated if pain is present at the syndesmosis of the ankle [3]. If the physical examination is indicative of an injury, radiographic evaluations should be performed to assess for fractures and any abnormalities between the distal tibia and fibula. Syndesmosis injuries may require surgery involving screw fixation to reduce separation between the tibia and fibula. Delay of surgical intervention may require more procedures necessary to get the foot/ankle into alignment
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