Syndesmotic injuries....AKA High Ankle Sprains:

HPI: Middle-aged male s/p MCC.

PE:  Ecchymoses, swelling, and tenderness about ankle. Tender over proximal fibula and pain with squeezing of calf.

Figure 1: Mortise view of ankle showing widened mortise medially

Figure 2:  Leg film showing proximal fibular fracture

Ankle Sprains:
-        Divided into grades
o   I: Minor, no significant ligamentous damage. Able to bear weight.
o   II: Associated with partial ligamentous tear. Significant ecchymoses/swelling. Difficulty bearing weight.
o   III:  Associated with complete ligamentous tear. Significant functional loss and universal inability to bear weight.

-        When should we obtain radiographs?:
o   If pretest clinical suspicion is high based on mechanism of injury or patient cannot be ruled out for fracture based on Ottawa ankle rules:

Syndesmotic injuries (AKA “high” ankle sprains):
o   PE and mechanism:

• Physical exam may have tenderness with calf squeeze, pain in syndesmosis with external rotation and dorsiflexion of foot, and translation of fibula with anterior/posterior force.
  
• If mechanism of injury involves hyper-dorsiflexion or significant eversion of the ankle, and patient has tenderness of the medial malleolus, a maisonneuve fracture (proximal fibular fracture associated with syndesmotic tear and deep deltoid ligament rupture) should be suspected. Order both ankle films as well as tib/fib films.  As in patient above, Ankle film may show widened mortise, indicating joint instability.
  

o   Treatment:

• Non-operative: Patient may be made NWB and placed in a boot, short-leg cast, or posterior short-leg splint + sugar tong splint. 
  
• Indications for non-op management:

                  -   Syndesmotic sprain without diastasis or ankle instability
                  -   Otherwise patient needs syndesmotic screw fixation. Patient can be immobilized and follow-up as an outpatient for surgical fixation