Distal Tibiofibular Joint Injection

Other Names

• Distal Tibiofibular Joint Injection
• Distal TibFib Injection
• High Ankle Injection

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Background

Illustration of the normal tibiofibular syndesmosis

Key Points

• Needle: 25 gauge, 1.5 inch
• Transducer: high frequency, linear
• Optimal approach: short axis, out of plane

Anatomy of the Distal Tibiofibular Joint

• Syndesmotic articulation of the concave tibia with the convex distal fibula
• Stabilized by the anterior inferior tibiofibular and posterior inferior tibiofibular ligaments and the interosseous membrane

Palpation Guidance vs Ultrasound Guidance

• This procedure can not be safely or reliably performed by landmark guidance
• There are no papers comparing landmark to ultrasound guidance

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Indications

• No clear guidance
• High Ankle Sprain
• Injury to the Distal Tibiofibular Joint

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Probe position for the short axis, out of plane approach

Ultrasound view with needle trajectory (white arrow) for short axis, out of plane approach

Probe and needle position for long axis, in plane technique

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Best visualized in long axis
• Acute findings
  • Ligament disruption
  • Hematoma formation
  • Dynamic instability with stress views
• Chronic findings
  • Thickening of the ligaments
  • Calcification of the ligament/syndesmosis

Technique: Short Axis, Out of Plane

• Patient Position
  • Supine, leg extended
• Transducer Position
  • Short axis to the anterior aspect of the joint
• Needle Approach/ Orientation
  • Out of plane, superior to inferior
  • Use step-down technique if possible
• Target
  • Anterior tibiofibular ligament/ Distal tibiofibular joint space
• Pearls and Pitfalls
  • The ligament is very superficial
  • Bending the needle may give a better angle of approach

Technique: Long Axis, In Plane

• Patient Position
  • Supine, Leg Extended
• Transducer Position
  • Long axis to the limb
• Needle Approach/ Orientation
  • In plane, superior to inferior
• Target
  • Anterior tibiofibular ligament/ Distal tibiofibular joint space
• Pearls and Pitfalls
  • Requires a large amount of sterile gel and a step off

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Aftercare

• Motor exam should be intact
• No major restrictions in most cases
• Can augment with ice, NSAIDS
• Consider Ankle Compression Sleeve

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Complications

• Infection
• Damage to surrounding tissue

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See Also

• Procedures Main

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