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Syndesmotic Injury

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Other Names

  • High ankle sprain
  • Syndesmotic Tear
  • Tibioperoneal diastasis

Background

History

  • The first case of syndesmotic injury was described by Quenu in 1907[1]

Epidemiology

  • Far less common than lateral ankle sprains
    • Historically thought to be rare, representing 1% to 18% of ligamentous lesions of the ankle[2]
    • More recently, thought to be much more common, seen in 17% to 74% of all sports injuries of the ankle[3]
  • Time lost: ranges from 0 to 137 days; averages ranging from 10 to 14 days up to 52 days[4]

Pathophysiology

The syndesmosis ligaments: anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior inferior tibiofibular ligament (PITFL).[5]
  • Incomplete/ partial sprain
    • Torn: partial or complete tear of anterior portion of the AITFL
    • Intact: PITFL, IOM
    • XR: Mortise intact
  • Complete sprain/ disruption
    • Torn: AITFL, PITFL, IOM
    • XR: Widened mortise

Mechanism

  • External rotation, hyperdorsiflexion and talar eversion (most common)
  • Hyperdorsiflexion with external rotation
  • Axial loading
  • Inversion

Associated Conditions

Pathoanatomy


Risk Factors

  • Sports
    • Football[2]
    • Ice Hockey
    • Soccer
    • Alpine Skiing[6]

Differential Diagnosis

Differential Diagnosis Leg Pain

Differential Diagnosis Ankle Pain


Clinical Features

Illustration of the cross leg test [7]
  • History
    • Patients should be able to describe mechanism of injury
    • Swelling is often absent in isolated syndesmotic injuries (may be present if lateral or medial ankle sprain)
    • Trouble bearing weight
  • Physical Exam: Physical Exam Ankle
    • Pushoff during gait may be abnormal[8]
    • Tenderness along syndesmosis, AITFL, PITFL
    • Antalgic heel raise or calf raise
  • Special Tests

Evaluation

Radiology

Illustration of radiographic measurements. Depicted are the tibiofibular clear space (TFCS), tibiofibular overlap (TFO) and the medial clear space (MCS) on AP and mortise views as described by Harper and Keller[16]
  • Weight bearing mortise view
    • Can be helpful to evaluate displacement, patients may not tolerate
    • Consider bilateral weight bearing
  • Tibiofibular clear space
    • Definition: space between the medial border of the fibula, lateral border of the posterior tibial prominence
    • Measure: 1 cm above tibial plafond
    • Normal: Intact syndesmosis should be < 6 mm
  • Tibiofibular overlap
    • Definition: maximal overlap between the medial border of the fibula, the lateral border of the distal tibia
    • Measure: 1 cm above tibial plafond
    • Normal: tibiofibular overlap for the AP view is > 6 mm, mortise view > 1 mm
  • Standard Radiographs Leg

CT

  • Can precisely assess the position of the fibula in the incisura
    • More sensitive at 2-3 mm diastasis than radiographs[17]
  • May identify avulsion fractures which occur in up to 50% of syndesmotic injuries[18]

MRI

  • Benefits
    • Good visualization of the AITFL and the PITFL
    • Clearly define the lesion, associated injuries
    • Useful in determining prognosis following a syndesmosis sprain

Ultrasound

  • Not currently recommended for syndesmotic injuries

Classification

ESSKA AFAS classification[19]

ESSKA AFAS Classification

  • General
    • Graded by acuity: acute (6 weeks or less), subacute (6 weeks to 6 months), chronic (greater than 6 months)[20]
  • Acute
    • Stable: lesion of AITFL, with or without IOL, intact deltoid
    • Unstable: also includes deltoid ligament lesion
      • Latent: diastasis compromises AITFL, with or without IOL, deltoid ligament lesion
      • Frank: diastasis of all syndesmotic ligaments, deltoid ligament
  • Subacute
    • Reparable: adequate remnants of AITFL
    • Non-repairable: inadequate remnants of AITFL
  • Chronic
    • Arthritic changes
    • No arthritic changes

Grading of Syndesmotic Injury by MRI Findings

  • Grade I
    • MRI: Edema adjacent to an intact ligament
    • Lesion: Stretching of the ligament without fiber disruption
  • Grade II
    • MRI: Thickening of the ligament with partial fiber disruption and associated edema
    • Lesion: Partial tearing of the ligament
  • Grade III
    • MRI: Discontinuity of the ligament and extensive edema
    • Lesion: Complete tear of the ligament

Management

Nonoperative

  • Indications
    • Simple syndesmotic sprains without diastasis or associated fracture
  • Immobilization
    • Short Leg Cast for 2 - 6 weeks with non weight bearing status
    • There is no consensus on duration of immobilization[21]
  • Proposed nonoperative strategy by Mulligan et al[22]
    • Grade I sprains without diastasis
      • Immobilization: 0-3 days
      • Weight bearing as tolerated
    • Grade II sprains with latent diastasis
      • Immobilization: 3-7 days
      • Weight bearing can begin after 1-2 weeks
    • Grade III sprains with frank diastasis,
      • Immobilization: Greater than 7 days
      • Non weight bearing minimum of 2-3 weeks
  • Corticosteroid Injection
    • Sped up return to play in NFL players by approximately 10 days[23]

Operative

  • Indications
    • Non-fracture syndesmotic injury with displaced and widened mortise
    • Syndesmotic injury with associated ankle fracture
  • Goal[24]
    • Restore ankle stability
    • Maintain correct alignment of tibia and fibula to allow sufficient healing of the syndesmotic ligaments
  • Technique
    • Screw fixation
    • Suturing of the syndesmosis
    • Syndesmosis hooks
    • Bioabsorbable screws
    • Endo Buttons
    • TightRope device

Rehab and Return to Play

Rehabilitation

  • 3 phase program for syndesmotic sprain[25]
    • Phase 1: joint protection, reduction of inflammation, and pain-free walking.
    • Phase 2: Minimal pain, edema, and antalgic gait are present
      • Goals: return of strength, mobility, and a normal gait
    • Phase 3: jog, and hop repetitively without difficulty

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • General
    • Greater recovery time is needed for syndesmotic injuries compared to lateral ankle sprain[26]
  • Nonoperative treatment of stable, isolated syndesmotic injury
    • Taylor et al found a good to excellent score in 86% of 44 collegiate football players[27]
    • Nussbaum found at 6 months after injury, 53 of 60 athletes rated their outcomes as good or excellent[28]
  • Surgical fixation of isolated syndesmotic injury
    • Taylor et al in a series of 6 patients found average RTP was 40.7 days, all patients reported good to excellent outcomes[29]
  • Predictors of poor outcomes
    • Increased number of fractured malleoli leads to poorer outcomes[30]
    • Age, BMI and duration of immobilization[31]
    • Increasing BMI[32]
  • Predictors of good outcomes
    • Egol et al found that greater age, male sex, absence of diabetes, lower American Society of Anesthesiologists (ASA) class all predicted better functional outcomes at a one-year follow-up[33]

Complications

  • Overall complications
    • Rate up to 68% in non-surgical management of isolated syndesmotic injuries[34]
  • Heterotropic Ossification (HO)
    • May not be radiographically evident until 6 months after the injury
    • Taylor found 11 of 22 patients had radiographic HO at follow up without any difference in symptoms[27]
  • Implant failure and screw removal
    • Between 7% and 91% of screws loosen or break[5]
  • Stiffness
  • Pain with activity
  • Residual painful instability

See Also


References

  1. Quenu E. Du diastasis de l’articulation tibio-peronie’re inferieure. Rev Chir (Paris) 1907;36:62-90. (In French)
  2. 2.0 2.1 Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.
  3. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med 2004;32:1941-1945.
  4. Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. 2007;455:173–5
  5. 5.0 5.1 Jones, Clifford B., Alex Gilde, and Debra L. Sietsema. "Treatment of syndesmotic injuries of the ankle: a critical analysis review." JBJS reviews 3.10 (2015).
  6. Fritschy D. An unusual ankle injury in top skiers. Am J Sports Med. 1989;17:282–5. 5–6. discussion.
  7. Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006;74(10):1717
  8. Spaulding S. Monitoring recovery following syndesmosis spraa case report. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1995 Oct;:655–60.
  9. https://www.orthobullets.com
  10. Kellett, John J., et al. "Diagnostic imaging of ankle syndesmosis injuries: A general review." Journal of medical imaging and radiation oncology 62.2 (2018): 159-168.
  11. https://radiopaedia.org/cases/68182
  12. https://radiopaedia.org/cases/78719
  13. Takao M, Ochi M, Naito K, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 2001;17:836-843.
  14. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32:1941–5.
  15. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29:3l–5
  16. Kellett, John J., et al. "Diagnostic imaging of ankle syndesmosis injuries: A general review." Journal of medical imaging and radiation oncology 62.2 (2018): 159-168.
  17. Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1997;18:693–8.
  18. Sclafani SJ. Ligamentous injury of the lower tibiofibular syndesmosis: radiographic evidence. Radiology. 1985;156:21–7.
  19. de-las-Heras Romero, Jorge, et al. "Management of syndesmotic injuries of the ankle." EFORT open reviews 2.9 (2017): 403-409.
  20. van Dijk CN, Longo UG, Loppini M, et al. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 2016;24:1200-1216
  21. van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24:1217–1227.
  22. Mulligan EP. Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport. 2011 May;12(2):57-69. Epub 2011 Apr 2.
  23. Mansour AA, Porter DA, Young JP, Hammer D, Boublik M, Schlegel TF. Corticosteroid injections hasten return to play of National Football League players following stable ankle syndesmosis sprains. Orthop J Sports Med. 2013 Sep;14.
  24. Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. J Am Acad Orthop Surg. 2015;23:661–673.
  25. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001 Jan-Feb;29(1): 31-5.
  26. Sman AD, Hiller CE, Rae K, Linklater J, Black DA, Refshauge KM. Prognosis of ankle syndesmosis injury. Med Sci Sports Exerc. 2014 Apr;46 (4):671-7.
  27. 27.0 27.1 Taylor DC, Englehardt DL, Bassett FH 3rd. Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med. 1992 Mar Apr;20(2):146-50.
  28. Nussbaum, Eric D., et al. "Prospective evaluation of syndesmotic ankle sprains without diastasis." The American journal of sports medicine 29.1 (2001): 31-35.
  29. Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35:1833–1838.
  30. Schepers, Tim, et al. "Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury." Injury 45.4 (2014): 775-779.
  31. Van Schie-Van der Weert, E. M., et al. "Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures." Archives of orthopaedic and trauma surgery 132.2 (2012): 257-263.
  32. Mendelsohn, Elliot S., et al. "The effect of obesity on early failure after operative syndesmosis injuries." Journal of orthopaedic trauma 27.4 (2013): 201-206.
  33. Egol, Kenneth A., et al. "Predictors of short-term functional outcome following ankle fracture surgery." JBJS 88.5 (2006): 974-979.
  34. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29:31–35
Created by:
John Kiel on 26 June 2019 19:53:55
Last edited:
19 July 2021 23:20:42
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