From the Guidelines
The recommended management for the patient with a distal tibiofibular syndesmosis injury, posterior malleolus avulsion fracture, and likely deltoid ligament injury with medial avulsion fracture is surgical intervention, specifically open reduction and internal fixation (ORIF), to restore the normal anatomical alignment of the syndesmosis and repair the fractures. This approach is supported by the evidence-based clinical guideline for the diagnosis, treatment, and prevention of ankle sprains, which suggests that surgery is only advised for patients that require quick recovery, such as those with severe injuries, or whose complaints are not resolved by conservative treatment 1.
The patient's CT report indicates a significant injury with a distal tibiofibular syndesmosis injury, posterior malleolus avulsion fracture, and likely deltoid ligament injury with medial avulsion fracture, which would likely require surgical intervention to avoid chronic ankle instability, post-traumatic arthritis, and persistent pain. The guideline also recommends that exercise therapy should be started as soon as possible to recover joint functionality, and supervised exercises are advised with the focus on proprioception, strength, coordination, and function 1.
Some key points to consider in the management of this patient include:
- The use of functional support, such as a brace, is preferred over immobilization to allow for early mobilization and rehabilitation 1.
- NSAIDs may be used to reduce pain and swelling, but their use should be limited to the acute phase of treatment 1.
- The patient should be advised to avoid heavy weight-bearing activities for 6-8 weeks post-operatively to allow for proper healing of the fractures and syndesmosis.
- A graduated rehabilitation program should be implemented to focus on range of motion, strength, and proprioception to ensure a full recovery and prevent future ankle injuries.
Overall, the goal of treatment should be to restore the normal anatomical alignment of the ankle joint, promote healing of the fractures and ligamentous injuries, and prevent chronic ankle instability and post-traumatic arthritis.
From the Research
Management of Ankle Injuries
The recommended management for the patient's condition, which includes a distal tibiofibular syndesmosis injury with hematoma, posterior malleolus avulsion fracture, and likely avulsion fracture in the medial aspect with injury to the deltoid ligament, can be guided by the following principles:
- Early mobilization and rehabilitation are crucial for optimal recovery, as evidenced by studies on ankle fractures and other orthopedic injuries 2, 3, 4.
- The use of functional supports, early ambulation, and short-term NSAIDs can be beneficial in managing ankle sprains, according to clinical practice guidelines 5.
- However, the specific management of the patient's condition, including the decision to operate or use external fixation, should be based on the severity of the injury and the patient's overall health status.
Treatment Options
The treatment options for the patient's condition may include:
- Open reduction and internal fixation (ORIF) to stabilize the fractures and repair any damaged ligaments.
- External fixation to stabilize the ankle and allow for healing.
- Early active motion protocol to promote recovery and prevent stiffness.
- The choice of treatment should be based on the severity of the injury and the patient's overall health status, as well as the potential risks and benefits of each option 6, 4.
Rehabilitation
The rehabilitation protocol for the patient's condition should include:
- Early mobilization and weight-bearing exercises to promote recovery and prevent stiffness.
- Range of motion exercises to maintain ankle mobility.
- Strengthening exercises to improve ankle stability.
- The rehabilitation protocol should be tailored to the patient's individual needs and goals, and should be based on the best available evidence 2, 3, 4.