Journal of Musculoskeletal Trauma

Avulsion Fractures in the Ankle and Foot: Gyeong Hoon Lim, Jae Won Kim, Sung Hyun Lee; J Korean Fract Soc 2024;37(2):102-116. Published online April 30, 2024; DOI: https://doi.org/10.12671/jkfs.2024.37.2.102

Abstract PDF: An avulsion fracture occurs when a muscle-tendon unit attached to a bone produces sufficient force to tear a fragment of the bone. If not treated properly, this injury can lead to deformity, nonunion, malunion, pain, and disability. Although avulsion fractures around the foot and ankle can occur anywhere there are tendon and ligament attachments, they are common in the anterior talofibular ligament, anterior-inferior tibiotalar ligament, calcaneal tuberosity, the base of the fifth metatarsal, and navicular bone. The optimal treatment for each fracture depends on the location and severity of the fracture. Conservative treatment involves limiting weight bearing for a period, splint immobilization, and using various orthoses. Surgical treatment is usually reserved for cases of severe displacement or when nonsurgical treatment has failed. The goals of surgery include reduction of the fracture fragment, prevention of nonunion or malunion and soft tissue injury, and early return to function. The decision for each treatment modality may depend on the patient demographics or preferences and the surgeon experience. This review summarizes previous and current views on the pathogenesis, diagnosis, and treatment of common avulsion fractures to guide the treatment and diagnosis.

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Prediction of Syndesmotic Instability according to the Lateral Malleolus Fracture Pattern in Supination-External Rotation Type Ankle Fractures: Short Oblique versus Long Oblique Fracture: Chan-Jin Park, Min-Su Lee, Keun-Bae Lee; J Korean Fract Soc 2024;37(1):39-45. Published online January 31, 2024; DOI: https://doi.org/10.12671/jkfs.2024.37.1.39

Abstract PDF: Purpose
This study examined whether preoperative radiological evaluations can predict syndesmotic instability according to the lateral malleolus fracture pattern in supination-external rotation-type ankle fractures.
Materials and Methods
This study enrolled 132 patients (132 ankles) with supination-external rotation stage 3 and 4 ankle fractures. Three-dimensional computed tomography was used for the morphological classification of the lateral malleolus fractures. A long oblique fracture was defined when the posterior cortical bone height of the fracture was 4.5 cm or more from the plafond of the distal tibial articular surface. A short oblique fracture was defined when the height was less than 4.5 cm. The demographic characteristics and syndesmotic instability of the two groups were evaluated.
Results
Short oblique fractures were confirmed in 102 cases, and long oblique fractures were confirmed in 30 cases. Long oblique fractures occurred at a statistically significantly higher incidence in younger ages and among males compared to short oblique fractures. Syndesmotic instability was more common in long oblique fractures.
Conclusion
In supination-external rotation-type ankle fractures, syndesmotic instability was observed in approximately 13%. Specifically, when the fracture pattern of the lateral malleolus is long oblique, the incidence of syndesmotic instability is approximately three times higher than in short oblique fractures. Therefore, meticulous evaluations of the lateral malleolus fracture pattern and establishing an appropriate treatment plan before surgery are crucial.

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Treatement of Diastasis of the Distal Tibiofibular Syndesmosis: Woo Chun Lee, Han Suk Ko, Cheol Lee, Ki Heon Nam, Kang Hoon Ko, Jong Deuk Rha; J Korean Soc Fract 2001;14(4):677-684. Published online October 31, 2001; DOI: https://doi.org/10.12671/jksf.2001.14.4.677

Abstract PDF: PURPOSE
To investigate the indication of transfixation of distal tibiofibular syndesmosis.
MATERIALS AND METHODS
Twenty-two patients were surgically treated for diastasis of the distal tibiofibular syndesmosis and followed for more than one year. The decision to transfix the syndesmosis was made according to the result of intraoperative stress test.
RESULTS
In patients with bimalleolar fracture, good or excellent clinical results were obtained in all patients, and no widening of the medial clear space and I mm or no widening of the tibiofibular clear space was observed. In patients with deltoid ligament tear, good or excellent results were obtained in five patients, and the medial clear space was widened more than 1mm in three patients and tibiofibular clear space was widened 2mm or more in four patients.
CONCLUSION
We believe that transyndesmotic fixation is not required if anatomical bimalleolar fracture fixation is achieved, and in patients who have deltoid ligament rupture, it may be better to transfix the syndesmosis regardless of the level of fibular fracture.

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Ankle Fracture with Syndesmosis Separation : Radiographic Landmark and Results of Trans-Syndesmotic Screw Fixation: Chong Kwan Kim, Byung Woo Ahn, Sang Guk Lee, Young Hwan Kim, Chae Ik Chung, Sik Hwang; J Korean Soc Fract 1999;12(4):948-955. Published online October 31, 1999; DOI: https://doi.org/10.12671/jksf.1999.12.4.948

Abstract PDF: In the treatment of ankle f1racture, anatomical reduction and restoration of ankle mortise is very important. But tranf-syndesmotic screw fixation for syndesmosis seperation is dependent on the condition in operation field. The purpose of this study is to analyse the radiographic and clinical relults. to evaluate the need for trans-syndesmotic screw fixaition, and to know the effectiveness of radiogrphic landmarks for diagnofis of the syndesmosis separation, retrospectively. The patients were divided into two groups. The Croup I(25cases) were treated with trant-syndetmotic screw and group II(42 cases) were treated without trans-syndesmotic screw fixation . The clinical results were excellent in 13, good 9 in group I and excellent in 19, good in 17 in group II. The radiographic results were excellent in 6, good in 8 in group I and excellent in 23, good 14 in group II. In the radiographic findings, the false negative result of tibiofibular overlap was 15.6%(M: 20.8%, F: 10.4%), tibiofibular clear space was 16.8%(M: 21.6%, F: 11.9%) and ratio of tibiofibular overlap to fibular width was 14.2%(M: 14.9%, F: 13.6%). There was no siginificant statsitical difference in the ratio of tibiofibular overlap to fibular width between male and female. We consider that the ratio of tibiofibular overlap to tibiofibular width are more reliable diagnostic criteria for syndemosis separation than the tibiofibular overlap and tibiofibular clear space. Trans-syndesmotic tcrew fixation is not alswaya required to maintain the integrity of the tibiofibular syndesmosis if the diastasis was satisfactorily reduced with rigid fixation.

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Measurement of Radiologic Criteria for Evaluation of the Syndesmosis in Korean Men: Jong Oh Kim, Hyeong Yeon Choi, Yong Whan Yoo; J Korean Soc Fract 1995;8(3):600-605. Published online July 31, 1995; DOI: https://doi.org/10.12671/jksf.1995.8.3.600

Abstract PDF

The ankle joint is the hinge joint composed of distal tibiofibula, talus and ligaments. Fractures of ankle joint are frequenty associated with ligaments ruptures and especially, as diastasis of ankle joint was easy to be overlooked, patients suffered form the pain and disability of ankle joint. Therefore, diastasis of ankle joint should be accurately diagnosed and properly treated. To obtain this goal, thorough understanding of diastasis and clear-cut diagnostic guide are important. For evaluation of differences between foreigners and Korean, authors measured the radiologic criteria for evaluation of the 100 Korean men from February 1995 to July 1995. The results obtained for this study were as follows. 1. Syndesmosis A : This is a measurement of the tibiofibular clear space form the lateral border of the posterior tibial malleous on anteroposterior(A.P.) radiograph. In Korean men, average measure ment was 3.74mm Â±0.66mm. 2. Syndesmosis B : This is a measurement of the overlap form the medial border of the fibula to the lateral border of the anterior tibial prominence on A.P. radiograph. In Korean men, average measurement was 8.82mmÂ± 1.93mm. 3. Talocrural angle : This angle is formed by a line perpendicular to the distal tibial articular surface and a line joining the tips of both malleoli on the mortise view. In Korean men, average measurement was 77.51 Â± 4.94. 4. Medial clear space This is the distance from the lateral border of the medial malleoulus to the medial border of the talus at the level of the talar dome on the mortise view In Korean men, average measurement was 3.37mm Â±0.66mm. 5. Talar tiIt : This angle is formed by a line drawn parallel to articular surface of the distal tibia and second line drawn parallel to the tatar surface. In Korean men, average measurement was 0.37 Â± 0.68. To analyze the these results, syndesmosis A, medial clear space, and talar tiIt were similar to foreigners and Korean men, but syndesmosis B and talocrural angle were lower value in Korean men than in froeigners.

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Radiographic Evaluation of the Normal Distal Tibiofibular Syndesmosis in Neutral to Dorsiflexion on Weight-Bearing
Seong Kee Shin, Ki Chun Kim, Se Yong Song, Ki Won Young, Kyung Tai Lee
The Korean Journal of Sports Medicine.2021; 39(1): 1. CrossRef

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Injury of Distal Tibio-Fibular Syndesmosis Treated with Trans-Syndesmotic Screw Fixation: Jong Min Sohn, Ju Hai Chang, Dong Heon An, Jong Wook Shin; J Korean Soc Fract 1995;8(3):586-593. Published online July 31, 1995; DOI: https://doi.org/10.12671/jksf.1995.8.3.586

Abstract PDF: Injury of distal tibiofibular syndesmosis Is usually associated with pronation-external rotation, supination-extemal rotation or pronation-abduction injuries at the ankle. In general, there are two methods of treatment for injured distal tibioflbular syndesmosis. The first is direct repair of injured syndesmosis and the second is internal fixation with trans-syndesmotic screw for stability of distal tibiofibular joint. The latter method is generally used because the procedure is simple and the outcome is relatively good. Our patients who had been injured of distal tibiofibular syndesmosis that associated with ankle fractures had treated with open reduction, internal fixation and transfixing screw, and early range of motion exercise was started for decreasing joint stiffness and degenerative change. Between March 1990 and August 1994, twelve patients were treated by open reduction and internal fixation and trans-syndesmotic screw fixation. Early range of motion exercise was started ater 3 weeks, and trans-syndesmotic screw was removed and partial weighting bearing was started at 8-12 weeks after sugery. After full weight bearing, follow up clinical examination and full weight bearing ankle roentgenography was evaluated. The results was as followed 1. Among the 12 cases, male was 7, Female was 5, and the mean age was 30.7 years and the average follow-up period was 27.3 months 2. Range of motion exercise was started at postoperative day 3 weeks. 3. Trans-syndesmotic screw was removed at postoperative day 8-12 weeks and partial weight bearing walking ambulation was started. 4.The full weight bearing ankle anterior-posterior roentgenography was evaluated. 5. There was 3 complicated cases, traumatic arthritis 1 case, infection with diastasis 1 case and distal tibiofibular fusion 1 case. 6. The excellant and good result were achieved in 9 cases(75%)

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