Bosworth Fracture Research Articles

Superficial Peroneal Nerve Laceration and Repair in the Setting of a Bosworth Fracture: A Case Report

The superficial peroneal nerve (SPN) is at increased risk of injury in the setting of ankle fractures. We report a case of SPN laceration in the setting of a Bosworth fracture that likely occurred as the fibula became entrapped behind the tibia upon initial injury, pulling the SPN posterior and resulting in a traction tear. Radiographic evaluation performed when the patient presented to the emergency department demonstrated a Bosworth fracture, widening of the medial clear space, and posterior ankle dislocation. Closed reduction was attempted. Although the fibula remained entrapped behind the tibia, the talus was successfully reduced, and a short leg splint was applied. Fracture fixation and acute, direct repair of the nerve were completed during operative fixation 15 days from the initial injury, following the resolution of soft tissue swelling. The patient reported a complete return of sensation in SPN distribution 2 weeks postoperatively. Radiography showed an anatomically reduced ankle with hardware intact and in place. At 1-year follow-up, SPN sensation remained intact, radiography ultimately indicated a healed fracture site, and the patient reported that she was able to ambulate without pain. Our case provides support for acute, direct repair of SPN lacerations in concomitant Bosworth fractures. Level of Evidence: Level V, case report.

Bosworth ankle fracture-dislocation: current concept review.

Bosworth fracture (BF) is a special type of locked ankle fracture-dislocation, characterized by displacement of a fragment of the fractured fibula from the fibular notch behind the posterior surface of the distal tibia. BF is a complex injury affecting multiple structures of the ankle joint, which is still frequently misjudged even today, potentially leading to severe complications. CT examination, including 3D reconstructions, should be the diagnostic standard in BF, as it provides a complete picture of the fracture pathoanatomy, most prominently the morphology of the frequently associated posterior malleolar fracture. BF requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction. Non-operative treatment of BF almost always fails. The standard treatment procedure is early open reduction internal fixation. Due to the relative severity and paucity of the injury, BF seems to be particularly prone to soft tissue complications, including compartment syndrome. The results of operative treatment are mixed. Many studies report persistent pain even after a short time interval, with limitations of the range of motion or even stiffness of the ankle joint, and development of degenerative changes. Larger studies with long-term results are still missing.

Bosworth ankle dislocation fracture - current concept review.

Bosworth fracture (BF) is a rare, but a severe injury to the ankle, characterized by displacement of a fragment of the fractured fibula (mostly of Weber B type) from the tibiofibular incisure to the posterior surface of the distal tibia. In 70% of cases, it is associated with a fracture of the posterior malleolus. This injury is not quite well known, with only 175 cases described in the literature to date. BF requires CT examination, including 3D reconstructions. Closed reduction almost always fails as there is an increased risk of compartment syndrome, mainly after repeated attempts at closed reduction. Therefore, operative treatment is indicated as a standard. The outcome of the operation should be always checked by postoperative CT examination.

A Case Series of Bosworth Fracture-Dislocations and Review of 129 Reported Cases.

Bosworth fracture dislocations of the ankle are rare injuries of the ankle caused by extreme external rotation of the supinated foot where the proximal fibula fracture fragment is posteriorly dislocated and entrapped behind the posterior-lateral ridge of the tibia. This case series aims to document three such cases treated in our institution over a nine year period. We also provide a review of 129 cases in the existing literature. Medical records and relevant radiographs for each patient were analysed and collected from the time of presentation till the point of latest follow-up. During each clinic visit, all physical exam findings as well as all complications were recorded. The American Foot and Ankle Society (AOFAS) Hindfoot score was also tabulated for each patient at the point of latest review. Closed reduction was unsuccessful in all three patients, and all required open reduction. One patient had an uncomplicated recovery whilst the remaining two suffered significant soft tissue complications. One patient suffered severe soft tissue swelling preventing primary closure at the time of surgery, whilst another suffered post-operative wound dehiscence and infection. Eventually all fractures healed, and all three patients obtained satisfactory AOFAS scores. The diagnosis of Bosworth fracture dislocations of the ankle is often delayed or missed, due to its rare occurrence. Closed reduction is often unsuccessful, and early open reduction is required to avoid poor clinical outcomes due to severe soft tissue damage or even compartment syndrome.

Management of Bosworth Fracture: Case Report

Introduction: Bosworth fracture is an uncommon fracture that involves the distal fibula associated with a dislocation of the proximal fibula fragment being posterior to the tubercle of the tibia distally. As the proximal fibula fragment becomes entrapped behind the Tibia it subsequently makes it irreducible which then necessitates the correction of this fracture surgically. Making an initial diagnosis of this fracture is quite difficult as it is rare and few data in our setting have been recorded with only a handful of documented cases worldwide. Although attempts have been made to reduce this fracture with closed reduction, the outcomes are generally unfavourable and counterproductive. Bosworth fracture is well documented in medical literature but often not easily picked at presentation.
 Case Presentation: This case report evaluates a 19 year old female student who presented with a 2 hours history of pain and deformity to her right ankle after she had accidentally externally rotated her ankle with the foot in a prone position while running down the stairs. Examination revealed a deformed and swollen right ankle joint, overlying skin was intact, tender limitation of joint movement. She had a failed closed reduction and was subsequently counselled for open reduction and internal fixation with plates and screws.

Percutaneous threaded pin reduction of Bosworth fracture: a novel surgical technique.

Percutaneous threaded pin reduction of Bosworth fracture: a novel surgical technique.

Bosworth fracture complicated by unrecognized compartment syndrome: a case report and review of the literature

IntroductionCompartment syndrome (CS) is exceedingly rare in ankle fractures. However, the risk of CS development seems to be increased in the presence of a Bosworth fracture-dislocation (BF), a rare variant of locked dislocation of the fibula behind the tibia.Materials and methodsHere, we report the case of a 39-year old man with delayed diagnosis of CS after having sustained a BF and failed attempts on closed reduction. The patient developed a flexion contracture of the hallux necessitating secondary fusion.ResultsAt 3 years after the injury, the patient was capable of running, but had 10 degrees limitation of ankle dorsiflexion, persisting decreased sensation on the plantar surface and clawing of the lesser toes. A thorough review of the literature revealed nine cases of CS after 167 reported BF resulting in a calculated prevalence of 5.4%.ConclusionsGiven the extreme paucity of CS in malleolar fractures, CS in BF has a relatively high prevalence. Risk factors include severe dislocations, repeated attempts on closed reduction, and a long interval to definite surgery. A high index of suspicion is required because delayed diagnosis leads to lasting functional restrictions.

Bosworth fracture treated with immediate open reduction and internal fixation 6 hours after injury: A case report

Ankle fractures are among the most common fractures from orthopedic injuries. Bosworth fracture-a rare ankle fracture-occurs when the proximal fibular fragment gets impacted behind the posterior tubercle of the distal tibia. Given the rarity of the Bosworth fracture, delayed management of or neglect in reducing the entrapped proximal fibula behind the posterior tibia may lead to catastrophic complications, including compartment syndrome, early arthritic changes, and residual ankle pain. Here, we present a case of this rare type of ankle injury that was treated with immediate open reduction and internal fixation (ORIF) 6 hours after injury and review the previous literature on ankle injuries. The proximal fibula was levered out from behind the tibia with posterior traction, and the proximal fibular fragment was internally rotated gently to minimize the damage to the surrounding soft tissues. Immediate ORIF performed within 6 hours resulted in good surgical outcomes in our case.

Maisonneuve fracture.

Maisonneuve fracture (MF) is agenerally known entity in ankle trauma. However, details about this type of injury can be found only rarely in the literature. For these reasons we have decided to perform astudy on MF epidemiology and pathoanatomy. The group comprised 70 patients (47 men, 23 women), with the mean age of 48 years, who sustained an ankle fracture-dislocation involving the proximal quarter of the fibula. Ankle radiographs in three views and lower leg radiographs in two views were performed in all patients. Atotal of 59 patients underwent CT examination in three views, including 3D CT reconstruction in 49 of these patients. MRI was performed in 4 patients. Operative treatment was used in 67 patients; open reduction of the distal fibula into the fibular notch was opted for in 54 of them. The highest MF incidence rate was recorded in the 5th decade in the whole group and in men, while in women the peak incidence was in the 6th decade. After the age of 50, the share of women significantly increased. In 64 cases, the fibular fracture was subcapital, and in 6 cases it involved the fibular head. In 24% of the patients, the fibular fracture was seen only in the lateral radiograph of the lower leg. Widening of the tibiofibular clear space was shown by radiographs in 40 cases. Posterior dislocation of the fibula (Bosworth fracture) and tibiofibular diastasis were recorded in 2 cases each. An injury to the anterior and posterior tibiofibular ligaments was found in all 54 patients with open reduction of the distal fibula. Afracture of the medial malleolus was identified in 27 cases (39%) and acomplete lesion of the deltoid ligament in 36 cases (51%); in 7 cases (10%) the medial structures were intact. Afracture of the posterior malleolus occurred in 54 (77%) patients. Osteochondral fracture of the talar dome was diagnosed in 2 patients and compression of the articular surface of the distal tibia in the region of the fibular notch in 1 patient. Maisonneuve fracture includes awide range of injuries both to bone and ligamentous structures of the ankle. Therefore, CT examination is an indispensable part of assessment of this type of fracture.

Ankle arthroscopy–assisted closed reduction in Bosworth fracture dislocation

The Bosworth fracture dislocation is a rare type of ankle fracture and is usually unrecognized on initial radiographs, therefore early open reduction is recommended. This study reports a 51-year-old female with uncommon imaging and clinical features. Preoperative X-ray, computed tomography, and magnetic resonance imaging of the ankle showed posterior detached dislocation of the intact distal fibula, the loose osteochondral fragments located in the tibiotalar joint, and the rupture of the deltoid ligament. Due to the initial infected wound on the severely swollen ankle, delayed arthroscopy-assisted closed reduction and internal fixation, removal of loose bodies, and repair of the deltoid ligament were performed, 19 days after injury. Postoperative imaging, including the X-ray, computed tomography, and magnetic resonance imaging, demonstrated the anatomic reduction of the ankle joint. After 6 months of follow-up, the patient gained a pain-free motion of the ankle with a range of passive 10° dorsiflexion and 40° plantar flexion, and resumed her normal gait and activity. This report indicates that the detached posterior dislocation of the intact distal fibula is a rare variant of the Bosworth fracture dislocation, and suggests that arthroscopy-assisted closed reduction and removal of loose osteochondral fragments in joint space are useful technique for this special type of the Bosworth lesions.

The irreducible ankle dislocation: beware of the Bosworth injury

A luxation fracture of the ankle characterized by a dislocation of the fibula posterior to the tibial tubercle is defined as a Bosworth injury. The Bosworth fracture is a frequently overlooked complex injury of the ankle joint. Associated injuries such as apilon fracture and posterior malleolus fracture have rarely been reported. In the case of a closed irreducible ankle fracture dislocation, Bosworth injuries should be considered as apotential cause. This article reports the course, treatment and clinical outcome 12months after trauma of aBosworth fracture with associated impaction of the posteromedial pilon and fracture of the posterior malleolus. To date, there are only few reports of comparable injuries in the German language literature.

Analysis of Clinical Outcomes and Prognostic Factors in Bosworth Fractures

Category: Trauma Introduction/Purpose: Unlike routine ankle fractures, Bosworth fracture-dislocation lead to devastating complication such as compartment syndrome, neurovascular injury, and subsequent ankle OA more frequently. However, due to the low incidence of this injury, no study have reported clinical outcomes of Bosworth fracture in comparison to which of routine ankle fractures or these prognostic factors. Therefore this study was performed to assess and compare the outcomes of Bosworth fracture- dislocation to that of routine ankle fractures and understand the prognostic factors in order to prevent the irreversible and severe status. Methods: Twelve patients were followed for more than 1 years after surgical management for Bosworth fracture-dislocation. The mean age was 39.2 years, and the mean follow-up period was 38.4 months. All patients were treated with ORIF including syndesmosis fixation. The clinical evaluation consisted of the AOFAS ankle-hindfoot score, Olerud & Molander scale. Reduction of tibiofibular syndesmosis and restoration of the ankle mortise were evaluated with plain radiographs and 3-D CT. The clinical and radiological outcomes were compared to those of routine ankle fractures (50 patients). To detect prognostic factors affecting the clinical results, age, fixation methods, interval to operation, existence of post. malleolar fractue, shape of fibular fracture, number of syndesmotic screw, frequency of closed reduction trial were studied. Results: Clinical results of Bosworth fracture-dislocation showed improvement including AOFAS score (87.6 on average) and Olerud and Molaner scale (89.7 on average), and corresponded to those results of routine ankle fracture (p = 0.234). All the patients achieved union in 12.6 weeks on average. However, postoperative CT revealed syndesmotic diastasis in 5 of 12 cases As complication, there were two cases of compartment syndrome, 2 cases of posttraumatic OA, 2 cases of ankle stiffness. Interval to operation and frequency of closed reduction trial were foud to be predictive factors of poor outcomes (p = 0.003, 0.011 respectively). Conclusion: The results of our study showed that although the clinical results were comparable statistically, Bosworth fracture are more frequently associated with the development of complications than routine ankle fractures. More specifically, prolonged interval between occurrence of fracture and surgical fixation and repeated attempts of closed reduction are at risk for poor outcomes. A prospective study with sufficient power would be needed to further identify risk factors associated with complications.

Acutely Irreducible Ankle Fracture Dislocation: A Report of a Bosworth Fracture and its Management

BackgroundAcutely irreducible ankle fractures are uncommon. Irreducibility caused by interposition of soft tissue and entrapment of fracture fragments has been well described. An irreducible ankle fracture due to a locked fibular shaft fragment behind the tibia, a Bosworth fracture, is a rare injury. Case ReportWe describe a Bosworth fracture in a 19-year-old man subsequent to a fall. ConclusionThe Bosworth fracture dislocation is a rare injury to the ankle, the correct diagnosis of which depends on awareness of the variant and careful evaluation of the initial clinical and radiographic features. As with our patient, a good outcome is achievable despite the severe nature of these injuries.

An Irreducible Ankle Fracture Dislocation: The Bosworth Injury

Irreducible fracture dislocations of the ankle are rare and represent true orthopedic emergencies. We present a case of a fracture dislocation that was irreducible owing to a fixed dislocation of the proximal fibular fragment posterior to the lateral ridge of the tibia. This particular type of injury, known as a Bosworth fracture dislocation, was not appreciated on the initial radiographs taken in the emergency room but was identified at urgent surgical management. The trauma mechanism, radiographs, treatment, and relevant published data are discussed in the present report.

Ankle stiffness and osteoarthritis in fracture-dislocation: an avoidable complication or natural history

Dear Editor, We read the article “Ankle stiVness after Bosworth fracture dislocation of the ankle” by Lui et al. [1] with great interest. They presented four cases who had ankle stiVness after Bosworth fracture dislocation. In their study, three of the four cases were transferred to hospital late, and the authors suggest that delayed treatment in these patients was the cause of stiVness or ankle osteoarthritis or both. One early case that was treated immediately did not have such problems. Hockenbury and Friermood [2] reported a patient with dislocation of the intact Wbula, small avulsion fracture of the medial malleolus, rupture of the deltoid ligament and tarsal injury. Although the patient was treated by open reduction and internal Wxation without delay, he subsequently developed talar avascular necrosis and degenerative arthritis. In fracture-dislocation cases, there may also be some additional intra-articular pathology like osteochondral injuries. Hoblitzell et al. [3] described a large osteochondral fragment from posterior malleolus after such injury. The authors also found osteochondral lesions in three out of their four patients. Therefore, they commented that “this may have some bearing on the prognosis, as ankle degeneration developed in all three patients.” Bosworth fracture dislocation is characterized with the Wxed displacement of the Wbula behind the tibia; however, anatomic conWguration may change. For instance, in our series of ankle osteoarthritis patients that were treated with total ankle arthroplasty, a patient had a fracture dislocation without Wbular entrapment who was operated immediately after the injury (Fig. 1). The ankle anatomy was restored (Fig. 2). However, in the follow-up, degenerative arthritis was seen (Fig. 3). We have been performing ankle replacement for advanced osteoarthritis, and during our observations regarding the natural history and etiology of our series, we observed that despite the early motion that can be obtained after early reduction and stable internal Wxation some

A Constant Radiological Sign in Bosworth's Fractures: “The Axilla Sign”

We describe a rare ankle fracture pattern called "the Bosworth fracture," originally described in 1947. A Bosworth fracture has been defined as a fixed posterior fracture-dislocation of the distal part of the fibula in which the proximal fibular shaft fragment locks behind posterior tibial tubercle. This fracture is frequently irreducible by closed means. Severe early and late morbidity, resulting from failure to identify and promptly treat this fracture pattern, have been reported. We describe a new radiographic sign seen on anterior-posterior mortise radiographic view showing cortical density in the axilla of the medial tibial plafond: "the Axilla sign." This feature was also noted on the radiographs of other case reports with this unique injury. The presence of this sign should alert the treating surgeon to a possible Bosworth fracture.

Ankle stiffness after Bosworth fracture dislocation of the ankle

The purpose of this study is to review the result of patients with Bosworth fracture dislocation of ankle. Retrospective case series. Four patients with Bosworth fracture-dislocation of ankle are evaluated clinically and radiologically. All four cases have failed initial closed reduction of the ankle and open reduction is required. Three patients with delayed presentation suffered from post-traumatic ankle stiffness and subsequently developed ankle degeneration. Early recognition and prompt reduction of the dislocated ankle is important in case of Bosworth fracture dislocation in order to prevent late complication. Closed reduction of dislocated ankle is usually not helpful and repeated attempts may be harmful. Emergency operation of open reduction and internal fixation is usually required to reduce the ankle joint without delay.

Fracture–dislocation of the ankle with fixed displacement of the fibula behind the tibia—a rare variant

We describe a case of fracture–dislocation of the ankle with fixed displacement of the fibula behind the tibia (Bosworth's fracture). The fracture was irreducible until the anterior tibio-fibular ligament was divided at operation. We believe this to be the first reported case of this fracture in which the ligament was intact. Bosworth first described this fracture in 1947 in a series of five patients and alerted readers to the poor outcome if the injury was missed [ [1] Bosworth D.M. Fracture dislocation of the ankle with fixed displacement of the fibula behind the tibia. J. Bone Jt. Surg. 1947; 29: 130-135 PubMed Google Scholar ].

Bosworth Fracture Treated by the Anti: Glide Plate Technique: A Case Report

Bosworth Fracture Treated by the Anti: Glide Plate Technique: A Case Report

Posterior fracture-dislocation of the distal part of the fibula. Mechanism and staging of injury.

The Bosworth fracture, a fixed posterior fracture-dislocation of the distal part of the fibula due to external rotation of the supinated foot, is a rare injury. In this report we review the literature, present two new cases, and describe our cadaver studies, showing that the initial stages of the injury are identical to those of a Maisonneuve fracture. The final stages that are unique to this fracture-dislocation are the posterior dislocation and fracture of the fibula and the fracture of the medial malleolus or rupture of the deltoid ligament. The objectives of treatment are reduction of the dislocation, repair and stabilization of the tibiofibular syndesmosis, and restoration of the ankle mortise to its anatomical position.