Revista del Pie y Tobillo Palabras clave. Osteocondroma. Tobillo. Sindesmosis. Resección en bloque. Key words. Osteochondroma. Ankle. Syndesmosis. PDF | Syndesmosis injuries occur when there is a disruption of the distal 6, 9 El diagnóstico de las fracturas de tobillo y lesiones de la sindesmosis se realiza. The ZipTight Fixation System for Ankle Syndesmosis is a low profile, knotless suture fixation system featuring ZipLoop Technology. It provides a fixation Missing: tobillo | Must include: tobillo.
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Based on a cadaver study, Boden et al[ 20 ] proposed that syndesmotic fixation is unnecessary if rigid medial malleolar fixation can be achieved or, in the case of deltoid disruption, the fibular fracture is 3 to 4.
Recently we observed that the Boden criteria may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal pronation-external rotation syndesmosis del tobillo fractures[ 19 ]. Even the Lauge-Hansen classification is not able to predict syndesmotic instability.
This system can be used only as a guide in the diagnosis and management of ankle fractures and not solely relied upon for decisions on treatments such as syndesmotic stabilisation[ 21 ]. Computed tomography scanning[ 22 ], ultrasound[ 23 ] and magnetic resonance imaging MRI [ 2425 ] could syndesmosis del tobillo valuable in detecting syndesmotic disruption in patients with chronic or isolated syndesmotic injuries but their usefulness in predicting instability in acute ankle fractures is not proven.
Vogl et al[ 26 ] and Oae et al[ 27 ] concluded that magnetic resonance imaging of the syndesmotic complex is a highly sensitive and specific tool for the evaluation of syndesmotic injury[ 26 ] and even syndesmotic disruption[ 27 ].
MRI does not provide a dynamic assessment of the distal tibiofibular syndesmosis, so although a rupture of one or more of the ligaments can be identified, instability cannot be diagnosed but only suspected with a MRI scan.
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Another disadvantage is that he MRI is expensive and often not readily and rapidly available[ 28 ]. Pre-operative assessment is less valuable in detecting syndesmosis del tobillo instability in acute ankle fractures but can be helpful in planning.
The external rotation test used as a manual stress or a gravity stress test is widely recognized as a clinical tool for the diagnosis of deltoid ligament incompetence in SER ankle fractures[ 30 syndesmosis del tobillo.
The absence of distal tibiofibular diastasis on static radiographs is not sufficient to exclude syndesmotic instability in patients with ankle injuries. Intra-operative stress testing, in sagittal, coronal or exorotation direction, is essential in the diagnosis and treatment of rotational ankle fractures.
On the syndesmosis del tobillo of a biomechanical cadaveric study, Stoffel et al[ 28 ] concluded that use of the lateral bone hook stress test or Cotton test[ 32 ] and examination of the tibiofibular clear space on stress radiographs intra-operatively is more reliable, because of the greater displacement when performing this test, than the exorotation stress test.
Several authors[ 283334 ] have concluded that assessment of sagittal plane movement appears to be a more sensitive test of inferior tibiofibular instability than assessment of movement in coronal plane[ 33 ].
Diagnosing syndesmotic instability in ankle fractures
Coronal plane instability as observed on syndesmosis del tobillo AP mortise view only occurs where the deltoid ligament or the whole interosseous membrane is also divided[ 33 ]. Candal-Couto et al[ 33 ] used the Hook test in both directions and Xenos et al[ 34 ] used the exorotation test. The lateral view is more reliable that the AP mortise view because of the greater displacement in this direction.
Most studies do not syndesmosis del tobillo the level or type of force used in tests to detect syndesmotic instability[ 28 ].
Boden et al[ 20 ] used a combined pronation-external rotation force of N, whereas Stoffel et al[ 28 ] used an external rotation load of N resulting in an external moment of 7. The tibiofibular clear space is relatively independent of external rotation force and there may be no benefit in using an external rotation moment of more than 7.
Based on these data, application of a force of N seems appropriate. Currently available literature does not provide clear guidelines for the amount of displacement syndesmosis del tobillo degree of diastasis required for performing syndesmotic stabilisation.
Jenkinson et al[ 29 ] used a 1-mm increase in tibiofibular clear space on an external rotation stress radiograph as an indication for syndesmotic stabilisation. With the external rotation test, the knee is bent and the ankle is placed in neutral or 90 degrees with the foot in syndesmosis del tobillo to the leg, and the foot is turned to the outside.
If there is pain at the syndesmosis or the high ankle ligament area, then this indicates injury.
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X-rays are very important. A broken bone must be assessed and ruled out.
- Diagnosing syndesmotic instability in ankle fractures
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- High Ankle Sprain
Three views of the ankle including the whole leg syndesmosis del tobillo needed. A fracture on the back portion of the tibia may indicate an injury to the high ankle ligaments given that this is where the PITFL attaches. It is also important to look for increased space between the tibia and the fibula because this may also indicate an injury to the high ankle ligaments.
MRI is becoming very helpful in diagnosing these injuries. A CT scan can also help to assess the relationship of the tibia with the fibula.