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Ankle Fractures: syndesmosis

Ankle Fractures: syndesmosis. Arash Aminian MD June 7, 2013. DISCLOSURE. I have no conflicts of interest. Syndesmosis : Why?. 20% of all ankle sprains 10% of all ankle fractures. Questions: evidence vs eminence based. A deltoid tear can be seen with medial malleolar fracture? T

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Ankle Fractures: syndesmosis

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  1. Ankle Fractures: syndesmosis Arash Aminian MD June 7, 2013

  2. DISCLOSURE • I have no conflicts of interest

  3. Syndesmosis: Why? 20% of all ankle sprains 10% of all ankle fractures

  4. Questions: evidence vs eminence based A deltoid tear can be seen with medial malleolar fracture? T Medial tenderness is predictive of deep deltoid tear? F Intra-operative post reduction stress views should be performed after lateral malleolus fixation? T

  5. Know your enemy Bone quality Pre-reduction films: energy of injury Patient factors: BMI Commonly mal-reduced: IR or anterior translation Not every fracture is the same Don’t be in a hurry

  6. Anatomy: Tib fib syndesmosis AITF PITF Transverse TF IOS

  7. Anatomy: ligamentous stability Deltoid Ligament: Superficial Deep: prevents lateral shift and resists ER

  8. Vascular Anatomy of the tibiofibularsyndesmosis Contribution from peroneal/AT Peroneal artery perforates IO membrane 3 cm proximal to ankle JBJS 2012

  9. Biomechanics Fibula migrates 2.4 mm and ER with DF Deltoid cut 2 mm shift/15 degrees valgus – Harper 1987

  10. LOCATION OF FRACTURE AND SYNDEMOTIC INJURY • Can have a high fibula fx without complete rupture of the IO, deep deltoid • 39% Weber B – Tornetta JOT 2007 Boden JBJS 1989

  11. Syndesmosis fixation? Why, When, How??? Maintain talus in mortise 1 mm shift-42% loss of contact surface RH 1976, 40% Lloyd FAI 2006 2 mm – 49% pressure Zindrick 1985

  12. Clinical evaluation Medial Tenderness Anterior tenderness – nonspecific ER test Squeeze test Check proximal fibula tenderness

  13. Radiographic evaluation AP WB x-rays Mortise: Medial clear space “Shenton’s line” Talocural angle 83 +/- 4 degrees on mortise Tib fib overlap/clear space

  14. Syndesmosis classification Stable vs Unstable Acute vs Chronic Latent vs Frank

  15. Hook test sensitivity/specificity 0.25/0.98 ER test sensitivity/specificity 0.58/0.96

  16. Stress xrays: ER, cotton, xenos test

  17. Fixation 3 vs 4 cortices? 3.5 vs 4.5 mm? Biomechanically similar (FAI 2000) Location of the screw? Postero-lateral to anteromedial TSS fixation level above plafond? 2-5 cm

  18. FIXATION • Use a clamp? Prevents motion, shifting of the drill hole • Position of the ankle? DF (JBJS 2001) • HWR? • Fix a high fibula fracture vs only screws? • Fixing the posterior malleolus? Displacement/stability

  19. Post-op rehab 2 wks in splint, then CAM NWB 6 wks WBAT with boot for 6 wks Counsel about hardware breakage

  20. Thank you

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