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Injuries to the Distal Lower Extremity Syndesmosis.

Disruption of the distal syndesmosis of the lower extremity is most commonly associated with ankle fractures but can also occur without gross bone injury. Definitive management of these injuries remains controversial. The current indications for syndesmosis fixation are based on tibiotalar joint mechanics as determined in cadaveric and biomechanical studies, as well as radiologic evaluation and an understanding of the pertinent anatomy and the etiology of these injuries. Such data support the use of syndesmotic screws in selected fractures that include a disruption of the syndesmosis. However, definitive fixation recommendations for syndesmosis disruption with or without ankle fracture remain under investigation. Distal lower extremity syndesmosis sprains without fracture or subluxation consistently require longer recovery time than typical lateral sprains and can be associated with greater long-term disability.

Treatment of Posterior Malleolus Fractures

Posterior malleolus fractures may occur in isolation or, more commonly, in association with bimalleolar or trimalleolar fracture patterns. These fractures result from posterior tibiofibular ligament avulsion, or bony impaction from the talus. Isolated posterior malleolus fractures have also been reported to occur in conjunction with spiral tibial shaft fractures. Posterior malleolus fractures may be identified on standard AP, mortise, and lateral radiographs of the ankle; however, CT allows for better assessment of displacement and the location of fracture lines. Generally, nondisplaced fractures with less than 25% involvement of the articular surface may be treated nonsurgically with short-term immobilization followed by range-of-motion exercise and gradual return to weight bearing. Surgical options include minimally-invasive, percutaneous fixation, although formal open reduction and internal fixation using a posteromedial, posterolateral, or combined approach is often necessary.