Evaluation and Treatment Recommendations for Acute Injuries to the Ankle Syndesmosis Without Associated Fracture
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REVIEW ARTICLE
Evaluation and Treatment Recommendations for Acute Injuries to the Ankle Syndesmosis Without Associated Fracture Timothy L. Miller • Timothy Skalak
Ó Springer International Publishing Switzerland 2013
Abstract Ankle ligamentous injuries are commonly seen in athletes in a variety of sports. Surveys of physicians and trainers of professional sports teams have identified syndesmotic injuries as among the most difficult to treat. In particular, injuries of the ankle syndesmosis have been strongly linked with a prolonged recovery and increased time to return to play. Due to sudden external rotation with the tibiotalar joint in dorsiflexion, these structures are commonly injured in association with fractures of the distal fibula. Surgery is indicated in cases with associated fractures and ligamentous instability, but optimal treatment for syndesmosis injuries without an associated fracture is less clear. A thorough history and physical examination, as well as appropriate imaging, are necessary to effectively diagnose and classify the injury. For stable injuries, short-term immobilization and functional rehabilitation is recommended. Unstable Grade 2 and 3 injuries require surgical fixation. Debate currently exists over rigid screw fixation versus suture button techniques as the ideal fixation method.
T. L. Miller The Ohio State University Sports Medicine Center, 2050 Kenny Road, Suite 3100, Columbus, OH 43221, USA T. L. Miller (&) Care Point Lewis Center, 6515 Pullman Drive, Suite 1100, Lewis Center, OH, USA e-mail: [email protected] URL: http://sportsmedicine.osu.edu T. Skalak The Ohio State University College of Medicine and Public Health, Columbus, USA
1 Introduction Injuries of the ankle syndesmosis are commonly encountered in the treatment of athletes participating in a wide variety of sports. Injury to the ankle syndesmosis has been reported at approximately 15 cases per 100,000 people of the general population [1]. Due to the increased stresses placed upon the ankle in athletic activity, syndesmotic injury is more commonly seen in this population, but exact figures in athletes are not completely reliable because of lack of reporting. This injury can occur in many sports, but has been most commonly reported in sports requiring the ankle to be held in a fixed boot, such as skiing or hockey [2, 3]. Most commonly, an injury to the ankle syndesmosis is accompanied by a fracture of the distal fibula, which often requires surgical stabilization. Instability is often associated with a proximal fibula fracture. However, when the ankle syndesmotic injury occurs in the absence of a fracture, both the diagnosis and the optimal treatment can be more elusive [4]. If all ligamentous components of the syndesmosis are completely disrupted, the diagnosis of ligamentous instability is clear and surgical stabilization is indicated [5]. Disruption of only the anterior ligaments does not constitute instability of the distal tibiofibular ligament and therefore does not commonly require surgical fixation. Ankle
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