Signs and Symptoms of High Ankle Fracture
High ankle fractures (syndesmotic injuries) present with specific signs and symptoms that distinguish them from standard ankle sprains, including pain above the ankle joint, inability to bear weight, and positive crossed-leg test. 1
Mechanism of Injury
- Caused by dorsiflexion and eversion of the ankle with internal rotation of the tibia 1
- Often results from high-energy ankle injuries, particularly in high-collision sports 1
- Can occur as isolated ligamentous injuries or be associated with ankle fractures
- The "Logsplitter" injury is a severe form resulting from high-energy trauma disruption of the ankle 1
Clinical Presentation
Key Signs and Symptoms
- Pain located higher than typical ankle sprains (above the ankle joint)
- Pain in the syndesmosis area (between tibia and fibula)
- Rapid onset of swelling
- Inability to bear weight immediately after injury
- Positive crossed-leg test: pain in syndesmosis area when pressure is applied to the medial side of the knee 1
- Point tenderness over the distal tibiofibular joint
- Pain with external rotation of the foot
Physical Examination Findings
- Swelling around the distal tibiofibular joint
- Hematoma formation
- Pain on palpation of the syndesmotic region
- Limited ankle dorsiflexion
- Instability of the ankle joint
- Pain with compression stress of the midfoot and hindfoot 1
Diagnostic Tests
Clinical Tests
- Crossed-leg test: highly specific for syndesmotic injury 1
- External rotation stress test: positive in syndesmotic disruption 2
- Squeeze test: pain in syndesmosis when squeezing the fibula and tibia together at mid-calf
- Cotton test: excessive lateral movement of the talus when the distal fibula is pushed laterally
Imaging
- Standard ankle radiographs may appear normal in isolated syndesmotic injuries
- Weight-bearing radiographs are preferred to detect dynamic abnormalities 3
- MRI is highly accurate for ligamentous injuries with excellent sensitivity (93%-96%) and specificity (100%) 1
- CT can identify syndesmotic injuries through measurements of the distal tibiofibular relationship 1
Distinguishing Features from Other Ankle Injuries
- Pain location is higher than typical lateral ankle sprains
- Mechanism of injury differs from typical inversion ankle sprains
- More prolonged recovery time than standard ankle sprains
- Positive crossed-leg test (not typically positive in standard ankle sprains)
- Often associated with high-energy trauma or sports injuries
Complications if Missed
- Chronic ankle instability
- Persistent pain
- Early development of post-traumatic arthritis 4
- Delayed healing and prolonged recovery time
- Need for surgical intervention if not properly identified and treated
Ottawa Ankle Rules Application
The Ottawa Ankle Rules should be applied to determine the need for radiographs:
- Inability to bear weight immediately after injury
- Point tenderness over the medial or lateral malleolus
- Pain on palpation of the posterior edge or inferior tip of either malleolus 1
High ankle fractures require careful assessment as they can be easily missed on initial evaluation, leading to significant long-term morbidity and decreased quality of life if not properly diagnosed and treated.