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World J Orthop. 2011 Jul 18;2(7):51-6. doi: 10.5312/wjo.v2.i7.51.

Diagnosing syndesmotic instability in ankle fractures.

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Michel PJ van den Bekerom, Academic Medical Center, Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, 1105 AZ Amsterdam, The Netherlands.


The precise diagnosis of distal tibiofibular syndesmotic ligament injury is challenging and a distinction should be made between syndesmotic ligament disruption and real syndesmotic instability. This article summarizes the available evidence in the light of the author's opinion. Pre-operative radiographic assessment, standard radiographs, computed tomography scanning and magnetic resonance imaging are of limited value in detecting syndesmotic instability in acute ankle fractures but can be helpful in planning. Intra-operative stress testing, in the sagittal, coronal or exorotation direction, is more reliable in the diagnosis of syndesmotic instability of rotational ankle fractures. The Hook or Cotton test is more reliable than the exorotation stress test. The lateral view is more reliable than the AP mortise view because of the larger displacement in this direction. When the Hook test is used the force should be applied in the sagittal direction. A force of 100 N applied to the fibula seems to be appropriate. In the case of an unstable joint requiring syndesmotic stabilisation, the tibiofibular clear space would exceed 5 mm on the lateral stress test. When the surgeon is able to perform an ankle arthroscopy this technique is useful to detect syndesmotic injury and can guide anatomic reduction of the syndesmosis. Many guidelines formulated in this article are based on biomechanical and cadaveric studies and clinical correlation has to be established.


Ankle fracture; Instability; Ligament; Operative treatment; Stabilisation; Syndesmosis

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