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Physical Examination, Diagnosis, and Arthroscopic-Assisted Reduction of Syndesmotic Injury

March 01, 2020

Contributors: Kevin D Martin, DO, FAAOS; J Preston Van Buren, DO; Jeffrey L. Wake, ATC, BS

Keywords: Instability; Physical Exam

Clear standards are lacking with regard to the diagnosis of, radiographic findings of, and treatment options for ankle syndesmotic injuries. The syndesmotic complex is a relatively simple construct of ligaments; however, the dynamic kinematics and the effects of disruption of the syndesmotic complex are points of contention with regard to diagnosis and management. Various physical examination maneuvers have been described to aid in the diagnosis of syndesmotic injuries, all of which are difficult to interpret and apply clinically. Similarly, various surgical evaluation and reconstruction techniques have been described to restore function and anatomic dynamics. This video discusses the physical examination, diagnosis, and arthroscopic reduction and internal fixation of syndesmotic injuries. Ankle syndesmotic injuries, which also are known as high ankle sprains, may be difficult to diagnose and differentiate from common ankle sprains. The syndesmosis consists of a combination of static and dynamic anatomic structures that work symbiotically to create a stable and highly dynamic relationship between the tibia and the fibula. The key static stabilizer is the incisura, which is a concave groove in the distal tibia in which the fibula rotates. The syndesmotic ligamentous structures consist of the anteroinferior tibiofibular ligament, interosseous membrane, posteroinferior tibiofibular ligament, and inferior transverse ligament. Injury to the syndesmosis typically results from high-speed collisions or rotational injuries that cause the foot to externally rotate while in a dorsiflexed position. Because of the mechanism of injury, minimal trauma to the lateral ankle ligaments is present in patients with a high-grade syndesmotic injury. Lateral ankle sprains are associated with a 17% rate of concurrent low- to high-grade syndesmotic injury. Diagnosis requires a combination of several physical examination findings, radiographic findings, and a strong clinical suspicion. After accurate diagnosis, surgeons must be able to restore anatomy and function; however, this is difficult because a paucity of vaguely defined techniques have been described. This video discusses diagnostic examination maneuvers and demonstrates arthroscopic-assisted reduction for patients with a syndesmotic injury based on current evidence-based medicine.

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