Ankle ligament injuries

Clinical presentation and diagnostics

Diagnosis requires ruling out concomitant fractures.

• Palpation: if tenderness along the posterior border of the fibula above its tip is mild, this helps rule out a lateral malleolus fracture.
• Passive movements: maximal pain occurs during foot supination.
• Foot subluxation sign: during passive supination, the talus (os talus) shifts anteriorly and medially. This sign indicates a complete rupture of the lateral collateral ligaments (in rare cases, only the anterior talofibular ligament).
• Radiological examination: radiography in two projections is mandatory to rule out bone trauma.

Conservative treatment of ruptures

At the pre-hospital stage, management is limited to applying an figure-of-eight bandage, dry cold, and analgesics. Further tactics depend on the severity of the injury.

In case of a partial rupture:

1. 10 ml of a 1% procaine solution is injected into the hematoma area.
2. A wet figure-of-eight bandage is applied for 5–14 days. As it dries, the bandage shrinks, securely fixing the joint (the lateral edge of the foot is elevated in the process). The use of a brace or elastic bandage is permitted.
3. From days 3–4, thermal procedures and physical therapy are prescribed.

In case of a complete rupture of the collateral ligaments: A plaster cast is applied to the extremity from the toes to the upper third of the lower leg for 4–8 weeks. During the rehabilitation period (within a year), it is necessary to wear high-lace shoes with arch supports.

Complications: recurrent foot dislocation

If a complete rupture of the collateral ligaments goes unrecognized or is treated improperly, chronic instability develops.

• Clinical presentation: patients complain of joint instability and frequent rolling of the ankle, especially when walking on uneven surfaces.
• Diagnostics: stress radiographs demonstrate insufficiency of the anterior talofibular ligament.
• Treatment: conservative treatment of exacerbations is carried out in the same way as for a fresh rupture, but the duration of plaster immobilization is increased to 11–12 weeks. In severe cases, surgical repair of the ligament or permanent wear of orthopedic footwear is indicated.

Ligament injury in pronation and supination fractures

Malleolar fractures are almost always accompanied by disruption of the ligamentous apparatus. The main mechanism of injury is indirect.

Pronation fractures (Dupuytren's): Occur when the foot is turned outward. They follow a strict staging:

1. Tension tears the deltoid ligament (or avulses the medial malleolus).
2. The shifting talus fractures the fibula.
3. The tibiofibular ligaments tear (partially or completely), leading to widening of the ankle mortise with rupture of the interosseous membrane.

The classic "complete" fracture includes all 4 components: medial malleolus fracture/deltoid ligament + fibula fracture + syndesmosis rupture + lateral subluxation/dislocation.

Supination fractures: Forced turning of the foot inward. First, the calcaneofibular ligament (lateral complex) tears, then the medial malleolus fractures. An internal subluxation of the foot occurs. Due to the pull of the peroneal muscles (m. peroneus longus et brevis) left without antagonists, secondary displacement — lateral subluxation — may develop.

Flexion injuries (Pott–Destot fractures)

Occur when pronation/supination is combined with forced plantarflexion or dorsiflexion.

• Fracture of the posterior margin of the tibia (tibia) is accompanied by posterior dislocation of the foot.
• Fracture of the anterior margin leads to anterior dislocation of the foot.

Atypical forms are occasionally encountered, where a large bone fragment is fractured without associated foot dislocation.

Class and exam questions

What else to study on this topic

• Surgical treatment and plastic repair techniques for recurrent foot dislocation
• Technique of hematoma blockade with 1% procaine solution in ligament injuries
• Radiological signs of ankle mortise widening
• Stages of conservative rehabilitation following prolonged plaster immobilization
• The role of the evertor muscle group in the development of secondary instability

Other topics in the "Specialized Adult Traumatology" section

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