What is the management for an anterior talofibular ligament (ATFL) tear with a fractured distal fibula?

Management of Anterior Talofibular Ligament Tear with Fractured Distal Fibula

Surgical fixation of the distal fibular fracture with concurrent ATFL repair is the recommended treatment for this injury to optimize functional outcomes and reduce the risk of chronic ankle instability.

Diagnostic Approach

Initial evaluation should include:

1. Radiographic assessment:

   • Standard ankle radiographs to evaluate the distal fibular fracture
   • Apply Ottawa Ankle Rules to determine need for imaging 1
   • Weight-bearing views if possible to assess stability (medial clear space <4mm indicates stability) 1

2. Advanced imaging:

   • MRI has excellent sensitivity (93-96%) and specificity (100%) for visualizing ligament injuries, osteochondral defects, and occult fractures 1
   • MRI is particularly valuable when suspecting high-grade ligament injuries or syndesmotic injuries accompanying the fracture 1

3. Physical examination:

   • Anterior drawer test for ATFL integrity (optimally performed 4-5 days post-injury when sensitivity is 84% and specificity is 96%) 1
   • Assessment for hematoma, pain on palpation around distal fibula 1

Treatment Algorithm

Phase 1: Acute Management

• PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for initial symptom management 1
• Cryotherapy combined with exercise therapy may help reduce swelling 1
• Non-weight bearing with appropriate immobilization until surgical intervention

Phase 2: Definitive Management

For this combined injury (ATFL tear with distal fibular fracture):

1. Surgical approach:

   • Surgical fixation of the distal fibular fracture 2
   • Concurrent ATFL repair during the same procedure

2. ATFL repair options:

   • Open repair using a single knotless suture anchor at the distal fibula location for efficient and anatomic restoration of the ATFL 3
   • Arthroscopic all-inside ATFL repair allows exploration of the ankle joint, treatment of concomitant pathology, and anatomical reattachment of the ATFL to its fibular location 4

3. Special considerations:

   • If the ATFL tissue is severely attenuated, anatomic reconstruction using autograft (such as tibial tuberosity-patellar tendon) may be considered 5
   • Be aware that ATFL avulsion fractures can occur from either the fibular or talar attachment (though talar avulsions are rare) 6

Phase 3: Rehabilitation

Two rehabilitation protocols can be considered:

1. Traditional rehabilitation:

   • Cast immobilization for 4 weeks
   • Progressive weight bearing after immobilization
   • Return to full athletic activity around 18-19 weeks post-surgery 7

2. Accelerated rehabilitation (when appropriate fixation techniques are used):

   • Early mobilization without cast immobilization
   • Earlier return to full athletic activity (approximately 13-14 weeks post-surgery) 7
   • Shown to achieve equivalent stability and functional outcomes while reducing recovery time 7

Expected Outcomes

With appropriate surgical management and rehabilitation:

• Significant improvement in ankle stability
• Reduction in pain
• Return to pre-injury activity levels
• Prevention of chronic lateral ankle instability

Potential Complications

• Recurrent ankle instability if ATFL repair is inadequate
• Malunion or nonunion of the fibular fracture
• Post-traumatic arthritis
• Stiffness and reduced range of motion

Follow-up

• Regular radiographic follow-up at 3 weeks and at cessation of immobilization 2
• Clinical assessment of ligament stability and fracture healing
• Progressive rehabilitation based on healing progress

This combined approach addressing both the fracture and ligament injury provides the best opportunity for full functional recovery and prevention of chronic ankle instability.