Distal tibiofibular syndesmosis rupture

Interfibular syndesmosis is the connection of the tibia and fibula bones in the distal part of the ankle and ankle joint. It can be a consequence of excessive external rotation or dorsiflexion of the foot with simultaneous traumatic exposure. Excessive rotation of the foot almost always leads to a primary rupture of the connections between the bones. If this injury is ignored, then in the future there may be complete separation of the distal condyles of the tibia and fibula. This leads to rapid deformation of the ankle joint and the development of osteoarthritis with loss of the ability to move freely in space.

People who lead an active lifestyle and engage in sports such as volleyball, football, high and long jumps, running, tennis, etc. are susceptible to this type of traumatic injury. In young people, a rupture of the syndesmosis may be associated with a fracture of the ankle bones.

The distal tibiofibular syndesmosis includes the following anatomical structures:

1. anterior ligament between the tibia and fibula;
2. posterior inferior ligament between the condyles of the tibia and fibula;
3. transverse ligament between the tibia and fibula;
4. interosseous membrane;
5. inferior transverse and interosseous ligaments.

In its normal state, the syndesmosis resists excessive axial shock-absorbing load and does not allow displacement of the talus. When walking, due to the elasticity of all tissues of the syndesmosis, the tibiofibular gap can increase by up to 10 mm in width. The deltoid ligament stabilizes and reduces the amplitude of expansion.

With minor damage to the tibiofibular syndesmosis, a poor clinical picture is observed. The person does not lose the ability to move independently. All symptoms (pain, weakness of the lower leg muscles, limited mobility of the foot) quickly disappear even in the absence of adequate treatment. But over time, this leads to the formation of scar deformation. If numerous minor injuries of the same type occur to the tibiofibular syndesmosis, then gradually this entails its complete rupture.

Even after a minor injury, comprehensive rehabilitation is recommended. To do this, you should contact a manual therapy clinic. In Moscow, you can make an appointment for a free appointment with a doctor at our center. Experienced doctors work here who have every opportunity to assist patients with any problems of the musculoskeletal system.

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Syndesmoses as types of bone connections

Syndesmosis bone connections are continuous and can be divided into synchondrosis (with the inclusion of cartilage fiber), synostosis (using bone tissue). True syndesmoses include only connective tissue ligament fibers. They have a high degree of elasticity and strength.

Common types of syndesmoses are interosseous membranes, fontanelles in a newborn, ligaments and sutures between bones.

Interosseous varieties of syndesmoses are found in the forearm and lower leg. In the first case, it connects the condyles of the radius and ulna, in the second - the fibula and tibia. These types serve to strengthen the connections between individual bones. In their projection, tendon and muscle tissue are attached. The interosseous membranes made of connective tissue have special openings through which large nerves and blood vessels pass. Therefore, if the integrity of the syndesmosis is violated and the subsequent process of cicatricial deformation, there is a high probability of developing ischemic and trophic damage to tissues located distal to the site of damage.

Ligaments, in turn, consist of connective tissue fibers filled with fibrin and collagen. They are characterized by a high degree of strength and elasticity. If necessary, they can stretch and restore their original shape. When deformed, the ligaments partially lose their physiological properties and become more susceptible to fission and rupture.

It makes no sense to talk a lot about fontanelles, since these types of syndesmosis are present only in infants under the age of 12 months.

A person may have interosseous sutures for the rest of his life. They are divided into:

• serrated, which are located at the base of the human skull;
• scaly, for example, connecting the temporal and parietal bones to each other;
• flat or smooth - they are mainly found on the front of the skull.

Types of syndesmosis - temporary and permanent. The former gradually disappear, the latter persist throughout life.

Functions of the distal tibiofibular syndesmosis

The distal syndesmosis of the lower extremities is primarily intended to connect the condyles of the tibia and fibula. Since the fibula does not enter the cavity of the knee joint, it has a certain degree of mobility. Meanwhile, it participates in the formation of the ankle joint and is responsible for the uniform distribution of shock-absorbing load during various human movements. Therefore, it is very important to ensure reliable fixation of the fibular condyle with the tibia.

The distal tibiofibular syndesmosis provides stability to the ankle joint and does not allow rotation of the talus even with severe twisting of the foot. The following negative factors can contribute to its destruction:

• incorrect placement of the foot in the form of flat feet or club feet;
• choosing low-quality shoes for everyday walking and sports;
• excessive physical stress on the ankle joint;
• valgus or varus curvature of the bones of the lower limb;
• violation of tissue trophism (varicose veins of the lower extremities, atherosclerosis, obliterating endarteritis, diabetic angiopathy, etc.).

The risk of damage to the tibiofibular syndesmosis increases significantly in people who are overweight, lead a sedentary lifestyle, smoke and drink alcoholic beverages.

Damage to the tibiofibular syndesmosis

The tibia and fibula are connected distally by the tibiofibular syndesmosis, which is located above the ankle joint. Syndesmosis ensures the congruence of two joints - the distal tibiofibular and ankle, the correct relationship and mobility of the tibia in several planes. The tibiofibular syndesmosis consists of 4 ligaments. The distal anterior ligament measures 20 mm and runs at an angle to the horizontal and sagittal plane. The ligament has the least strength of all structures of the syndesmosis. It supports both tibias, maintains the strength of the femora and prevents rotation of the talus. The distal posterior ligament is located horizontally, runs at an angle to the horizontal plane and has 2 layers. It is the strongest ligament and interacts with the anterior ligament to hold the ankle joint in place and prevent the talus from translating backwards. The inferior transverse ligament covers the edge of the tibia and forms the posterior cartilaginous lip. The ligament protects the tibia from pressure from the talus and prevents its translation. The interosseous tibiofibular ligament is located between the protrusions of the tibia above the ankle joint. This is a short and powerful ligament 20 mm wide with fascicles diverging back and forth. The ligament stabilizes the distal articulation of the tibia and fibula. The ligament dampens the sprain of the ankle joint.

Rice. 1. Anatomy of the tibiofibular syndesmosis

Both tibias, together with the upper and lower tibiofibular joints, form a frame-like structure. In the tibiofibular joints, the tibia rotates along the longitudinal axis of the tibia and translates in the horizontal plane. The amplitude of external rotation of the tibia during flexion is 5-6°, and when walking, the total amplitude of rotation is 3 times greater. The fibula moves relative to the tibia in three directions: back and forth, up and down, and rotates around its own axis. When the foot is extended, the talus block enters the fork of the ankle joint with its anterior wide part, as a result of which the ankle fork expands up to 1.5 mm, the fibula moves back and rotates outward. When the foot flexes, the block of the talus moves out of the ankle joint, which causes the fork to narrow and the fibula to move in the opposite direction. The position of the foot in the ankle joint affects the load experienced by the ligaments. In a neutral foot position, most of the load is placed on the anterior and interosseous ligaments and a smaller part of the load is placed on the posterior ligament. When the foot extends, the load on the posterior ligament increases and the load on the anterior ligament decreases; when the foot flexes, the sprain of the ligaments decreases. The share of the load on the anterior inferior ligament is 35%, on the deep part of the posterior inferior ligament - 33%, on the interosseous - 22%, on the superficial part of the posterior inferior ligament - 9%. The tibiofibular syndesmosis interacts with the membrane stretched between the tibia bones. When loaded along the axis of the tibia, the syndesmosis stretches simultaneously with the membrane, which allows the load to be distributed over the bones of the tibia. The tibia, which is located along the axis of the segment, absorbs 5/6 of the load falling on the lower leg, and the fibula absorbs the remaining 1/6 of the load. The tibiofibular syndesmosis is a stabilizer of the ankle joint when the foot moves in the sagittal and horizontal plane. In the tibiofibular syndesmosis, the main stabilizers are the posterior, inferior transverse and interosseous ligaments. The posterior ligament is the strongest ligament that prevents the translation of the talus backwards, the interosseous ligament absorbs the expansion of the fork of the tibia. The syndesmosis interacts with the ligaments along the medial and lateral surfaces of the joint. Movement of the fibula is limited by ligaments on the anterior surface of the tibiofibular joint capsule. As the foot extends, the lateral malleolus at the distal tibiofibular joint moves posteriorly and outward. If the foot assumes a neutral position, the load on the posterior ligament becomes less than on the anterior ligament. When the foot is flexed, the fibula in the tibiofibular joint moves forward and inward, the block of the talus is installed in the ankle fork with its narrow part, the tension of the ligaments decreases in the tibiofibular syndesmosis, the load on the syndesmotic ligaments is distributed evenly. Stabilization of the hindfoot and limitation of the load on the tibiofibular syndesmosis occurs due to the tension of the triceps surae muscle. When walking, the tibial and peroneal muscles, through their tension, provide stability to the tibia bones. The muscles simultaneously bring the tibia and tarsal bones closer together, which restrains the expansion of the syndesmosis in the frontal plane and counteracts the vibrations of the torso.

Rice. 2. Mechanism of syndesmosis rupture

Damage to the syndesmosis is associated, firstly, with a combination of external rotation in the ankle with pronation of the foot in 2/3 of cases and with supination in 1/3 of cases, and, secondly, with a combination of external rotation with hyperextension in the ankle. More often the injury occurs when the foot is twisted. Less commonly, injury occurs during a jump while landing. When the foot is placed on the support, the lower leg continues to extend on the fixed foot, the wide part of the talus block enters the ankle joint, pushes it apart and injures the ligaments. With a rupture of the anterior ligament, the diastasis between the bones is 2 mm; with a combination of rupture of the anterior fibular and interosseous ligament, the diastasis doubles; with a defect of all ligaments, it reaches 7 mm. Following ankle injury, instability of the distal tibiofibular joint and syndesmotic insufficiency develop. The incidence of syndesmosis sprain among all ankle ligament injuries is 10-17%. Damage to the syndesmosis simultaneously destabilizes the distal tibiofibular joint and the ankle joint, resulting in subluxation or dislocation of the talus at the ankle joint. Failure of the syndesmotic ligaments is accompanied by rupture of the interosseous membrane. If rotational force is applied, then damage to the tibiofibular syndesmosis is combined with bone fracture. Violation of the integrity of the syndesmosis and interosseous membrane is observed with a spiral fracture of the fibula. During a syndesmosis injury, the patient experiences sharp pain, which is localized above the ankle joint. In the early stages after injury, acute damage to the tibiofibular syndesmosis has striking manifestations. The pain is accompanied by impaired movement in the joint. Upon examination, the patient is diagnosed with widening of the ankle joint, displacement of the fibula, external rotation of the foot, and limited extension in the ankle joint. With chronic instability of the tibiofibular syndesmosis, complaints are inconsistent and do not always correspond to the pathological mobility of the tibia.

Rice. 3. Damage to the tibiofibular syndesmosis, external rotation of the talus, anterior and posterior views

To diagnose damage to the syndesmosis, special tests are used. The doctor rotates the foot outward as far as possible, and then increases the degree of rotation of the foot, which causes pain along the front of the shin. The physician presses his finger on the talus bone under the medial malleolus in a lateral direction, which causes outward displacement of the talus bone with crepitus and pain. The doctor presses with both hands on both bones of the lower leg in the middle third in the transverse direction, which causes pain distal to the place of compression in the area of ​​the syndesmosis. The doctor grabs the outer ankle from the front and back with his fingers and moves it back and forth. In this case, pain appears above the ankle in the area of ​​syndesmosis. On a radiograph in the anteroposterior projection, the main manifestations of syndesmotic insufficiency are widening of the ankle joint, widening of the medial joint space and tilt of the talus in the frontal plane, traumatic erosion of the tibial plafond. A posterior dislocation of the fibula in the distal part of the leg is seen as a posterior displacement of the fibula relative to the tibia. Radiographs are taken with internal and external rotation of the tibia, which show asymmetry of the joint space, widening of the ankle joint, posterior displacement of the lateral malleolus and tilt of the talus. The syndesmosis may be damaged in the absence of radiographic changes. The most informative method that allows you to examine the condition of individual ligaments, identify a defect in the syndesmosis and determine the relationship of the bones of the lower leg is MRI.

In the acute period after injury, cold applications are used to relieve swelling. A splint is placed on the foot and lower leg, or a splint is a foot holder that limits flexion-extension in the ankle joint so that the talus does not push the ankle bone apart and does not injure the syndesmosis. After the swelling subsides, a circular plaster cast is applied for up to 8 weeks. After the cast is removed, an elastic brace is worn.

Surgery is performed for rupture of the anterior and posterior ligaments of the tibiofibular syndesmosis, rupture of ligaments with a divergence of the tibia of more than 2 mm, rupture of ligaments with dysfunction of the ankle joint. In case of acute damage to the syndesmosis, which causes instability, an operation is performed during which the fibula is reduced into the tibial notch and the bones are fixed with a screw. In case of rupture of the syndesmosis in combination with a fracture of the tibia and fracture-dislocation of the ankle joint, osteosynthesis of both tibia bones and fixation of the syndesmosis by tying the ankle joint are performed. For chronic instability caused by rupture of the syndesmosis, operations such as reconstruction of the anterior, posterior and interosseous ligaments of the syndesmosis, tenodesis of the peroneus brevis muscle, autoplasty with a graft from the peroneus longus tendon, and alloplasty using synthetic ligaments are performed. After the intervention, plaster immobilization is applied. To restore the integrity of the syndesmosis, an operation is performed to fix the tibiofibular syndesmosis with screws or tighten the tibia with a ligament. The bones are temporarily screwed together using a compression screw for 6 weeks. The leg is in a plaster cast for 3 weeks. After the cast is removed, an orthosis or splint is placed on the leg. The splint limits foot movement in the sagittal plane and exerts a compressive effect on the ankles. Thanks to the pressure on the tibia bones on both sides, the required distance between them is maintained, which promotes the fusion of the syndesmotic ligaments. In the long term after surgery, for leg stability and confidence in walking, boots with high tops or boots that limit the movement of the tibia and create moderate compression of the ankles are recommended. The rigid heel prevents excessive movement of the calcaneus and talus in the frontal plane. The shoe has an instep support to place the foot in the correct position.

Rice. 8. Elimination of rupture of the tibiofibular syndesmosis after screw fixation surgery

Rice. 11. Perseus boots with high tops B 101, B 102, B 105, B 108

Rice. 12. Perseus boots S 18, S 19, S 23

Literature:

Bartonicek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat, 2003 (25), pp. 379-386 Elgafy H., Semaan HB, Blessinger B., Wassef A., Ebraheim NA Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol, 2010 (39), pp. 559-564 Harper MC Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int, 2001 (22), pp. 15-18. Tourné Y., Molinier F., Andrieu M., Porta J., Barbier G. Diagnosis and treatment of tibiofibular syndesmosis lesions. Orthopedics & Traumatology: Surgery & Research. 2021, V. 105, I. 8, Supplement, P. S275-S286

Mitskevich V.A. traumatologist-orthopedist, doctor. honey. sciences

Distal tibiofibular syndesmosis rupture

Syndesmosis rupture can be partial or complete. With a partial rupture of the tibiofibular syndesmosis, the possibility of independent movement remains. But it causes a lot of pain. There is no significant discrepancy between the tibia and fibula on the x-ray.

A complete rupture of the distal syndesmosis is characterized by a divergence of the condyles of the tibia and fibula by 4 cm or more. A person cannot walk independently. There is significant deformation of the ankle joint.

A rupture of the distal tibiofibular syndesmosis is an injury that requires immediate medical attention from a traumatologist. You will not be able to cure such a disease on your own. In severe cases, surgery may be required.

Anatomy

The tibiofibular syndesmosis plays an important role in the stability of the ankle joint. To better treat this region, we need to know the anatomy.

Anterior inferior tibiofibular ligament

The anterior inferior tibiofibular ligament (AITFL) arises from the anterior tubercle of the distal epiphysis of the tibia (9.3 mm above its lower edge), runs obliquely downward at an angle of 35° and attaches to the anterior surface of the lateral malleolus (30.5 mm above its lower edge) . The ligament consists of 3-5 strands, which depends on the individual anatomy of the person. Together, they form a trapezoid with short accessory fibers located proximally and long main fibers located distally.

Posterior inferior tibiofibular ligament

The posterior inferior tibiofibular ligament (PITFL) is also trapezoidal. It is a continuation of the interosseous membrane located above. The posterior inferior tibiofibular ligament consists of 2 parts, superficial and deep. The deep one is also often called the inferior transverse tibiofibular ligament. The superficial fibers originate from the posterolateral tubercle of the distal epiphysis of the tibia (8 mm above its lower edge) and attach to the posterior surface of the fibula (26.3 mm above its lower edge). Deep fibers are denser, the places of their attachment to the tibia bones are oval.

Interosseous tibiofibular ligament

The interosseous tibiofibular ligament (ITFL) stretches between the tibial notch and the medial surface of the fibula. It consists of short dense connective tissue fibers and adipose tissue. Its upper edge is located 49.4 mm above the distal epiphysis of the tibia and 70.4 mm above the lower edge of the fibula. From the tibia, the fibers of the ligament run obliquely downwards and are inserted 34.5 mm above the lower edge of the lateral malleolus. The interosseous tibiofibular ligament is a continuation of the interosseous membrane. There are diametrically opposed opinions regarding its function: some consider the ligament to be unimportant, while others argue that it is the main connecting structure that is critical to the stability of the ankle joint.

Consequences of rupture of the ankle joint syndesmosis

The ankle joint syndesmosis is the most important anatomical structure that ensures a strong connection of the bones and their stable position in the joint capsule. Large blood vessels and nerves pass through here. They provide blood supply and nutrition to the tissues of the foot and its toes.

Therefore, the following types of negative consequences are often observed when the syndesmosis of the ankle joint ruptures:

• violation of the trophism of soft tissues, which in severe cases can lead to necrosis and the development of dry gangrene, trophic ulcers; in milder cases, peeling and disruption of the integrity of the skin begins, pallor of color appears and a decrease in the intensity of pulsation;
• disruption of the innervation of foot tissues, including its muscles, which can provoke their paresis, paralysis and even atrophy (muscle strength decreases and there is a lack of mobility of the toes);
• instability of the position of the bone heads in the ankle joint, which leads to the development of deforming osteoarthritis;
• increasing the shock-absorbing load on other tendons and ligaments in the ankle area;
• lameness, impaired mobility, contractures.

Complete rupture of the ankle syndesmosis, if not treated in a timely manner, can lead to complete divergence of the tibial and femoral condyles. This will cause gross deformation of the lower limb and loss of mobility in the joint. The person may remain disabled for the rest of his life.

Diagnosis and treatment

Now that we understand the anatomy of this region, our treatment must be more specific. In particular, we must be able to palpate the anterior inferior tibiofibular ligament (AITFL), just as we palpate the talofibular ligaments: anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), and calcaneofibular ligament (CFL) ). Most physical therapists palpate only the distal fibular epiphysis to rule out a potential fracture and determine which talofibular ligaments are injured. However, we also need to check the anteromedial aspect of the fibula and the anterior inferior tibiofibular ligament for swelling and tenderness. If there is pain in this area, then most likely it is a sprain of the syndesmosis and lateral malleolus. In this case, you need to press the fibula against the tibia and stabilize the talocalcaneal region. The patient should avoid dorsiflexing the foot (eg, during deep squats or calf stretches).

The video demonstrates taping of the ankle joint. This technique was developed by Brian Mulligan. This type of taping is used in people after an inversion ankle sprain. The idea is to reposition the distal tibiofibular syndesmosis, resulting in a significant increase in range of motion and decreased pain levels.

Signs of damage to the ankle syndesmosis

Damage to the syndesmosis can be extremely traumatic. Accordingly, clinical symptoms of ankle syndesmosis rupture appear after a fall, twisted leg, blow, or other traumatic impact.

The first signs of damage to the tibia syndesmosis are:

1. acute pain that intensifies when trying to step on the heel;
2. inability to perform rotational movements of the feet without assistance;
3. in this case, the forced movement of the foot occurs in a greater amplitude than before the injury;
4. there is a rapid increase in soft tissue swelling;
5. the leg in the ankle area becomes deformed and swells;
6. tingling and pain appear in the foot area, which is associated with impaired nerve conduction and blood flow.

If such clinical symptoms appear, ice should be applied to the injury site and a tight bandage should be applied that will secure the tibia and fibula. After this, you need to visit a traumatologist. If this is difficult, call an ambulance.

Treatment of damage to the interfibular syndesmosis

Damage to the tibiofibular syndesmosis must be treated at a stage when a complete rupture of the ligaments has not yet occurred. Unfortunately, with a complete rupture of the fibular syndesmosis, only surgical treatment is possible. Using endoscopic intervention through an arthroscope, doctors restore the integrity of the ligaments.

For a small area of ​​damage to the syndesmosis, treatment can be carried out using manual therapy methods. In our clinic, doctors use the following methods to restore the integrity of ligaments and tendons:

• osteopathy to restore all processes of microcirculation of lymphatic fluid and blood at the site of traumatic injury;
• massage to enhance elasticity and cellular nutrition of ligament and tendon tissues;
• therapeutic exercises to strengthen the muscular system, accelerate the processes of diffuse nutrition;
• reflexology to launch tissue regeneration processes by using the hidden reserves of the human body;
• laser and physiotherapeutic effects and much more.

The course of treatment is always developed individually. Therefore, to obtain detailed information regarding your clinical case, it is recommended to make an initial free appointment with an orthopedist at our manual therapy clinic. To do this, you can use the form located further on the page. Fill it out and a specialist from our clinic will contact you shortly and clarify all the details of your future visit.