An unusual ankle injury

A 47-year-old woman was brought into the Emergency Department having twisted her left ankle while walking on flat ground earlier that day. There was no evidence of direct impact injury to either the left ankle or leg. Prior to this event, the patient had no medical problems, was not on any regular medication, and had no previous history of ligamentous laxity or ankle sprains. On examination, the left ankle was grossly swollen and the whole foot was displaced medially. This provided somewhat of a distraction and comprehensive examination of the remainder of the leg was not performed. The ankle injury was closed and there was no neurovascular deficit. Beighton’s score was zero. A preliminary diagnosis of a medial ankle dislocation was made and immediate closed reduction was performed in the Emergency Department. Closed reduction took precedence over radiological investigation of the injury since any delays in the restoration of normal anatomy could potentially compromise the integrity of the overlying skin and also increase the risk of neurovascular damage. Accordingly, it is institutional policy that ankle dislocations are reduced immediately without the need for X-rays. Having reduced the dislocation confirmatory X-rays were then taken. While the patient was being positioned on the X-ray table it was noted by the radiographer that she had some tenderness around the upper leg. Radiographs were therefore taken of this anatomical region too. These illustrated a fracture of the proximal fibula in conjunction with a widened syndesmosis (Figures 1 and 2). Interestingly there was no malleolar fracture seen. The injury was therefore considered to be in keeping with a Maisonneuve fracture and thus operative intervention was planned. The patient was taken to theatre the following day for further examination of the injury with a view to stabilize the syndesmosis. Under general anaesthesia and tourniquet control the ankle was screened under image intensification. This illustrated a grossly unstable syndesmosis and therefore two trans-syndesmosis screws were inserted (Figures 3 and 4). A below-knee non-weightbearing cast was then applied and following an uneventful postoperative recovery the patient was discharged two days later. The patient was kept strictly non-weight-bearing for eight weeks following which the syndesmosis screws were removed under general anaesthesia. Following this, progressive weight-bearing was commenced in conjunction with physiotherapy. At the latest clinic review the patient had returned to normal activities with few restrictions and has been discharged with no further follow-up.