Restoring the function of the ankle joint in chronic ruptures of the distal tibiofibular syndesmosis ligaments. Damage to the ankle joint: diagnosis, treatment Rupture of the deltoid ligament and syndesmosis

The interfibular syndesmosis is an element of the musculoskeletal system, consisting of three types of interosseous membrane: transverse, posterior and anterior, as well as articulating bones. This is a sedentary joint; such joints are quite rare in the musculoskeletal system. A rupture of the tibiofibular syndesmosis is a mechanical damage to the connecting membrane caused by a strong transverse force on the limb. ICD 10 trauma code – marking S83.6.

A rupture of the tibiofibular syndesmosis of the ankle joint is diagnosed in only 0.5% of cases of visits to traumatologists.

Most often, connective tissue rupture is observed in athletes.

Often this same injury occurs in factories or during car accidents. The ligament can also be torn when falling from a small height.

What is a rupture of the tibiofibular syndesmosis?

Rupture of the distal tibiofibular syndesmosis is damage to the integrity of the membrane connecting the bone tissue. Often this injury is combined with fractures or displacements. The ligament rupture itself leads to a violation of the integrity of the ankle joint, and often the bones involved in its formation.

The symptoms of the injury can be confused with a dislocation or sprain.

It is accompanied by unbearable pain, the victim cannot fully move.

It varies in severity, depending on the nature of the impact on the area of the small ankle joints. The victim needs urgent qualified medical care.

Without proper treatment, the limb may permanently lose functionality.

Symptoms

Rupture of the tibiofibular joint of the ankle

A rupture of the tibiofibular joint in the ankle joint is accompanied by immediate and extremely painful symptoms:

sharp and nagging pain that covers the entire affected area is the first sign of injury;
when feeling the lower leg, the pain syndrome intensifies many times;
the appearance of strong, constantly increasing swelling with a burgundy or blue tint;
unnatural position of the foot: as a rule, it turns outward. The photo shows the typical position of the affected areas. As a result of severe damage to the distal membrane, the lower leg is so deformed that the person cannot stand on his leg as a result;
the presence of foci of internal hemorrhage is usually localized at the site of the bruise.

Without treatment, clinical symptoms do not disappear, but only intensify.

Using only an external examination of the damaged area, it is impossible to correctly diagnose damage to the ankle membrane, as well as the degree of rupture. The most informative method for diagnosing damaged syndesmosis is radiography.

You can get an x-ray done in either a paid or free public clinic. It should be done immediately after injury. The image allows you to accurately identify the tear and the degree of damage to the membrane. It may rupture partially or completely.

The deeper the gap, the longer it will take to recover.

Treatment of a rupture of the distal tibiofibular syndesmosis at home is contraindicated: conventional methods of pain relief and inflammation relief in this case will not give any effect. This applies to both complete and partial divergence of the tibiofibular ligament.

Degree of damage to the syndesmosis (classifier)

Ultrasound examination to detect pathology

Tibiofibular ligament ruptures are classified depending on the extent of the damage. The anatomy of this area and its deformation are easily monitored on an x-ray, resulting in one of three degrees of injury severity being determined:

mild degree, as a result of injury the posterior or transverse ligament may rupture, often the damage is combined with a rupture of the deltoid ligament and an avulsion fracture of the medial malleolus;
moderate severity of injury: partial rupture of the distal tibiofibular syndesmosis with an avulsion fracture of the inner malleolus and an oblique fracture of the outer malleolus;
severe injuries are characterized by rupture of the distal tibiofibular ligaments with an avulsion fracture of the ankle, as well as an oblique fracture of the tibia.

The degree of injury is characterized by the state of the membrane after its damage.

Syndesmosis requires long-term recovery in a clinical setting using special devices and medications.

The ICD (international classification of diseases) allows not only to determine the degree of damage to the syndesmosis, but also to prescribe the correct treatment and rehabilitation after injury.

Therapy for rupture of the DMBS

In international practice, there are several methods for treating rupture of the distal tibiofibular syndesmosis. This joint has a complex anatomy due to the location and type of membrane tissue, so it takes quite a long time to restore it.

Depending on the severity of the injury, conservative treatment methods or surgical intervention are used.

Conservative methods

Plaster on the leg for rapid fusion of bones

Conservative treatment is used for varying degrees of damage to the DMBS. Treatment regimen:

novocaine blockade;
the affected limb is completely immobilized, a plaster cast is applied to the ankle joint, the duration of wear is 4-6 weeks;
the area of injury is compressed as much as possible, this will facilitate the regeneration of the ligaments.

After the cast is removed, a removable splint is placed on the ankle joint to further restore the ligaments. You will have to walk with her for another two weeks; at the same time, therapeutic exercises, massages and other restorative procedures are prescribed to speed up the connection of joints and bones. The entire cycle of procedures will take from one to six months. In the case of old injuries, such methods are often ineffective.

Operative method

Tendoplasty to restore the fibula

Surgery is required if the injury is advanced or conservative treatment has failed. In this case, based on the X-ray image, the type of surgical intervention is determined. It could be:

Tendoplasty. The syndesmosis, or part of the fibula, is replaced with a piece of healthy fascia, usually from the patient's thigh. Subsequently, the ligament is completely restored, the success rate of such treatment is 92%.
Using a tie bolt or compression screw. Additional elements make it possible to strengthen the ankle fork, while the bones are fixed at the correct distance relative to each other, which eliminates joint contracture.

The technology is chosen by the doctor based on the severity of the injury and the patient’s condition.

Recovery after injury

The duration of treatment and recovery after a syndesmosis rupture will depend on the freshness and severity of the injury. If it was received less than 20 days before the start of therapy, it is considered recent.

To treat such injuries, conservative methods are usually used.

In other cases, it is better to start therapy immediately with surgery. How long it will take for complete recovery depends on the effectiveness of the treatment and how carefully the patient follows the doctor’s recommendations.

The invention relates to the field of medicine, namely to orthopedics and traumatology, and can be used in the restoration of the distal tibiofibular syndesmosis of the tibia. The method includes making a canal in the fibula. In this case, through an external incision along the lateral surface of the tibia 3.0 cm above the joint space of the ankle joint, a through hole is made in the lower third of the fibula in the transverse direction in the frontal plane. A 3.0 cm long cortical screw is screwed through this hole. The screw is inserted all the way into the tibia and then passes along its posterior surface paraossally. The use of this invention makes it possible to prevent possible complications - contracture of the ankle joint, fusion of both tibia bones, reduce trauma to bone tissue during surgery, and reduce treatment time. 1 ill., 2 ave.

Drawings for RF patent 2493794

The invention relates to the field of medicine, in particular orthopedics, and concerns the treatment of damaged distal tibiofibular syndesmosis of the tibia.

It is known that damage to the distal tibiofibular syndesmosis is accompanied by fracture-dislocations in the ankle joint, leading to expansion of the intermalleolar fork. In these cases, treatment can be carried out by connecting the tibia bones to each other using external fixators and submersible fixators (tie bolt, compression screw, etc.), creating compression in the tibiofibular joint at the level and above the distal tibiofibular syndesmosis.

This solution may be the method of choice for transsyndesmotic fractures of the fibula, which are bone damage to the distal tibiofibular syndesmosis. Quite often this leads to the formation of synostosis between the tibia and the development of deforming arthrosis in the ankle joint [Guryev V.N. Conservative and surgical treatment of ankle joint injuries. Moscow, 1971. P. 134).

There are known methods of treating distal tibiofibular syndesmosis, aimed at restoring the structural integrity of the tibiofibular syndesmosis, normalizing the structure of the dense fibrous connective tissue of the tibiofibular joint.

The method, including the formation of channels in the distal metaphysis of the tibia and the outer malleolus, passing through the channels of a bone-tendon graft with wedging of a bone fragment of the graft in one of the channels, is characterized in that a posterior canal is formed in the tibia from the inside out with an exit behind the external malleolus, forming the second canal in the outer malleolus from back to front in the sagittal plane, form the anterior canal in the tibia from the outside inward with a hole in front of the outer malleolus, pass the graft in the posterior canal until the larger bone fragment is jammed, pass the graft through the second canal and insert it into the anterior one, at the exit from of the anterior canal, the graft is stretched as much as possible and sutured to the tibia [pat. 2187269 Russian Federation. Method for treating rupture of the distal tibiofibular syndesmosis]. Immobilization up to 12 weeks. Dosed load on the operated limb after 12 weeks.

The trauma to bone tissue is significant and the recovery period is long.

There is a known method for the treatment of chronic ruptures of the distal tibiofibular syndesmosis, which includes the formation of a channel with a diameter of 4-10 mm through the metaphyses of the tibia, additionally 1-2 cm above the first channel, a second one is made, with a smaller diameter - 3.5 mm, in which a tie bolt is installed and with using a nut, the ankle joint is tightened when the doctor dorsiflexes the patient’s foot at an angle of 20°, then the patellar ligament is exposed through the median approach, its longitudinal extreme part is isolated, corresponding in thickness to the diameter of the first channel, then isolated from the associated tuberosity of the tibia and patella bone fragments, one of which is equal in thickness to the diameter of the first canal, and the other is 1-2 mm smaller than it, the edges of both fragments are stitched with lavsan thread, leaving their ends free, after which the formed autograft, corresponding in length to the first canal, is carried out with a thinner end forward and installed in the canal as a newly created ligament, which is tensioned and fixed with threads to the ends of the tie bolt [pat. 2263482 Russian Federation. Method of surgical treatment of chronic ruptures of the distal tibiofibular syndesmosis].

The method is multi-stage, involves additional trauma and the possibility of infection when taking an autograft, and provokes complications associated with the long course of the operation. Full weight bearing is allowed 4 months after the intervention. Screw removal no earlier than 9 months after the main operation.

There are known methods for restoring the distal tibiofibular syndesmosis by connecting the tibia bones to each other using grafts and external fixators (staples, transosseous devices, etc.) (see, for example, RF Pat. 235867. METHOD FOR RESTORING THE LIGAMENTS OF THE DISTAL INTIFIBULAR SYNDESMOSIS BY A TENDON GRAFT through the channels in the distal parts of the leg bones, characterized in that the external displacement of the foot is first eliminated using two knitting needles with stops inserted through both tibia bones in the syndesmosis zone, the knitting needles are fixed in the ring of the Ilizarov apparatus, then).

The methods are complex in technique, require the use of expensive equipment, fixation in the apparatus and treatment last for several months.

There is a known method for treating damage to the tibiofibular syndesmosis using a tie bolt [Traumatology and Orthopedics / G.S. Yumashev, S.Z. Gorshkov, L.L. Silin et al.; Ed. G.S. Yumasheva. 3rd ed., revised. and additional M.: Medicine, 1990. P.322].

The method is associated with the appearance of instability of the tibiofibular joint and can lead to the development of residual subluxations of the talus outward.

The closest is the method of surgical treatment of chronic ruptures of the distal tibiofibular syndesmosis, which includes making a channel through both tibia bones with a diameter of 3.5 mm, for example, with an electric drill, from the side of the outer ankle from back to front and from bottom to top at an angle of 45 degrees to the long axis of the tibia, installation in tightening the tie bolt with the subsequent tightening of the ankle joint with a nut until matching, with the dorsiflexion of the foot [Guryev V.N. Conservative and surgical treatment of ankle joint injuries. Moscow: Medicine, 1971. P.109-110].

This technique is based on rigid fixation of both tibia bones in their lower part until complete fusion of the ligaments or bones. When synostosis occurs in the area of the distal tibiofibular syndesmosis, the biomechanics of the ankle joint is disrupted, the range of movements is sharply limited and arthrosis quickly develops.

Thus, all the above solutions have common disadvantages. Trauma to bone tissue during the operation is significant; there is always damage to the cortical layers of both tibias with the formation of small fragments that provoke bone fusion. The tibia bones come together in one plane, which often leads to compression of the ankle joint, the formation of synostosis between the tibia and fibula, and the development of deforming arthrosis in the ankle joint.

The purpose of the proposed invention is to prevent a common complication - contracture of the ankle joint, preventing the possibility of fusion of both tibia bones. Reducing trauma to bone tissue during surgery, reducing treatment time.

The method is carried out as follows.

Through an external incision of 2 cm along the lateral surface of the tibia 3.0 cm above the joint space of the ankle joint, the fibula in the lower third is exposed. The drill is made in the frontal plane of the fibula. A 3.0 cm long cortical screw is screwed through the hole made, which passes along the posterior surface of the tibia and stops paraosseously. In this case, the distal end of the fibula, thanks to the screw, is simultaneously shifted 0.5 cm anteriorly and rotated along the axis by 4-6°. Rare stitches on the wound. Immobilization with a U-shaped plaster splint.

The method is illustrated in Fig. 1:

A - damaged syndesmosis;

B and C - restoration (view in the frontal plane and transverse section in n/3 of the leg),

where 1 - talus, 2 - damaged anterior tibiofibular ligament, 3 - diastasis of the tibiofibular joint, 4 - tibia, 5 - tibia, 6 - cortical screw.

Patient S., 78 years old, diagnosis: damage to the distal tibiofibular syndesmosis of the right tibia.

24.11.10. Operation: through a lateral incision of 2.0 cm in n/3, the fibula is exposed 3.0 cm above the joint space of the ankle joint. In the transverse direction in the frontal plane, a through hole was made through the fibula using a 2.5 mm drill. A cortical screw with a diameter of 3.0 mm and a length of 30 mm was screwed into the stroke made, which, resting on the tibia, slipped and passed along its posterior edge. Stability control. The wound is sutured with rare stitches. Immobilization with plaster splints.

After 2 weeks, the plaster was removed and the stitches were removed. Operation: screw removal. Exercise therapy, FTL.

3 weeks after the operation he was walking without additional support.

Patient F., 24 years old, diagnosis: damage to the distal tibiofibular syndesmosis on the left.

Under general anesthesia, the fibula was exposed through a 2.0 cm lateral incision in the lower third of the left tibia. Hole drilled.

The cortical screw slid forcefully along the posterior surface of the tibia. Intraoperatively - checking for stability. Stitches on the wound. Iodine. Aseptic alcohol dressing. Immobilization with plaster splints.

After 2 weeks, the splints were removed and the sutures were removed. Operation: screw removal. Exercise therapy, FTL.

After 3 weeks from the date of surgery, return to work.

The method is technologically advanced, low-traumatic, and therefore provides a reduction in treatment time. Prevents a common complication - contracture of the ankle joint, the possibility of fusion of both tibia bones.

CLAIM

A method for restoring distal tibiofibular syndesmosis of the tibia, including making a canal in the fibula, characterized in that through an external incision along the lateral surface of the tibia 3.0 cm above the joint space of the ankle joint, a through hole is made in the lower third of the fibula in the transverse direction in the frontal plane, a 3.0 cm long cortical screw is screwed through the hole until it stops into the tibia and then passed paraosseously along its posterior surface.

When looking for information about various ligament and joint injuries, you may come across the term “syndesmosis.” This word denotes a sedentary or immobile joint of the bones of the human body. ligaments are common, especially when it comes to athletes or people whose work involves intense physical activity. So what is syndesmosis and what are the results of its injury? Is rupture of this joint dangerous and what treatment methods can modern medicine offer?

Syndesmosis - what is it?

As is known, in the human musculoskeletal system, bones articulate with each other both movably and immobile. For example, joints connect the elements of the skeleton, allowing movement. If we are talking about fixed joints, then it is necessary to call syndesmosis. This is a path of connection through strands of dense connective tissue. Such structures do not allow for movement. For example, this is how the bones of the skull, vertebrae, forearm and lower leg bones are articulated with each other.

Of course, there are several varieties of this connection. Membranous syndesmosis is something that can be seen by examining the articulation of the fibula and tibia. But the bones of the skull are connected to each other by different types of “sutures”.

Features of syndesmosis injuries

Alas, syndesmosis injuries can hardly be considered a rarity. Quite often, rupture of the membranes between the shin bones occurs. Ankle injuries are often reported in athletes while jumping or running. Ballerinas, gymnasts and circus acrobats are prone to the same injuries.

With traumatic brain injuries, as well as injuries to the spine, the articulations between the bones may be disrupted. In newborns, rupture of the syndesmosis between the structures of the skull sometimes occurs during passage through the birth canal. But when the patient also shows partial damage or stretching of the fibers - the ligaments between the vertebrae.

Distal tibiofibular syndesmosis and its rupture

According to statistics, 10% of sprain injuries are associated specifically with injury to a structure called “interfibular syndesmosis.” It is worth saying that no one is insured against this damage, since the membrane can stretch or be damaged if the foot is turned strongly outward while simultaneously turning the toe inward.

On the other hand, there are people who are more prone to this type of injury due to their profession - these are athletes, dancers, acrobats, etc. By the way, constantly wearing high-heeled shoes, especially with an unstable instep, also increases the likelihood of stretching the tibiofibular membrane.

Symptoms of tibiofibular membrane injury

Damaged distal syndesmosis is a common problem, and it is accompanied by a fairly pronounced clinical picture. As a rule, the first symptom is sharp pain. Unpleasant sensations intensify significantly during movement or when trying to change the position of the foot. The pain also increases with palpation.

Another symptom is swelling of the soft tissue around the injury - the swelling increases quickly, increasing in size in a matter of minutes. The patient's foot, as a rule, acquires a forced, unnatural position - in most cases it is turned outward. In addition, the skin in the area of injury turns red, and small subcutaneous hemorrhages can often be seen on it.

Of course, in order to diagnose a tibiofibular syndesmosis tear, some testing is necessary. During a physical examination, the doctor may already suspect the presence of stretching or damage to the membrane, but to make an accurate diagnosis and determine a treatment regimen, you need to undergo an X-ray examination. In the photographs, the specialist can clearly see the widening of the gap between the bones, as well as determine the line of rupture and notice the presence of fractures.

Conservative treatment and its features

To begin with, conservative treatment is carried out. In order to alleviate the patient's condition, the pain is relieved by performing a novocaine blockade. The main goal of therapy during this period is to immobilize the limbs, compress the tibiofibular gap and give time to the tissues to recover on their own. That is why a mandatory element of treatment is a plaster cast, which is applied in the shape of a boot. You will have to wear the cast for about 5-6 weeks.

After this, the bandage is removed and replaced with a removable splint - during this period, active movements are contraindicated, but the patient needs rehabilitation. For this purpose, people are usually prescribed various physiotherapy procedures and regular massage sessions. Special therapeutic exercises are also necessary, which are carried out under the supervision of a specialist; it is he who selects a set of exercises, determines the time and appropriate loads.

Often, rupture of the syndesmosis is associated with other injuries, including disruption of normal blood circulation. An example of complications is thrombosis of venous vessels, so the patient’s condition must be monitored very carefully and, if necessary, anticoagulants should be introduced into the treatment regimen.

It should be said right away that conservative therapy is a long process. Often, in order to fully restore mobility and physical capabilities, the patient needs more than 6 months.

In what cases is surgery necessary?

Unfortunately, conservative treatment is not effective in every case. In case of severe injuries, improper fusion of bones and in the absence of effect from physiotherapeutic treatment, the doctor may decide on surgical intervention.

Today, there are many techniques for restoring ligaments. Quite often, a new ligament is implanted during the procedure. It is formed from preserved tendon, fascia lata and Dacron tape. Special channels are made in the tibia, to which the ligament is attached. By the way, in 92% of cases the operation is successful, and the patient regains mobility.

There is another way, namely the use of a compression screw made of a metal alloy. Such a screw is a reliable tightening mechanism - it fixes at a certain distance, preventing them from moving or merging.

In any case, it is worth understanding that damaged syndesmosis is a serious problem, and self-medication is inappropriate here. Immediately after receiving an injury, you should consult a doctor.

An injury like a torn ankle ligament can happen to anyone. It is enough to make one sudden movement or awkwardly turn your leg at the joint. Women who wear high heels and athletes are most at risk.

Symptoms

Ankle ligaments are formations consisting of connective tissue. They are located between the bones of the foot and lower leg. Damage to a ligament or tendon most often occurs when the leg is twisted or as a result of sudden support on it.

Ankle ligament rupture can be complete or partial.

In the first case, the ligament breaks into two parts or is completely torn from the attachment point. In the second, some fibers break. Treatment must be carried out in both cases.

Partial ligament rupture

Symptoms of partial ligament rupture are as follows:

it is painful for the victim to step on his foot;
hematomas appear;
swelling occurs in the area of the front surface of the foot and on the sides.

Complete ligament rupture

Signs of a complete ligament rupture are more severe:

, resulting from a violation of the integrity of the vessels supplying blood to the joint;
severe pain when walking and palpating the injured area;
spread of edema and hematoma to the entire surface of the foot, as well as to its sole.

To confirm symptoms, the ankle joint is tested for a syndrome called “drawer syndrome.” Verification steps:

The patient is taken by the lower part of the lower leg.
Push the back of the foot forward.
When it is displaced, the diagnosis is confirmed.

Tomography of the ankle joint is an important diagnostic method

Symptoms are not the only indicator for making a diagnosis. Visual inspection and external signs are very important. A complete picture for understanding the situation (complete or partial ligament rupture, whether there is a bone fracture or tendon injury) is provided by more accurate examination methods:

radiography.

Treatment for ruptured ankle ligaments is prescribed only after all symptoms have been clarified and the degree of tissue damage has been determined.

Treatment

In case of partial rupture, conservative therapy is used. In case of complete (for example, injury to the tibiofibular syndesmosis or disruption of the integrity of the deltoid ligament), medical care is provided in a hospital setting in the form of surgical intervention followed by rehabilitation.

The main treatment methods for partial ligament rupture are:

Cold treatment - first aid for ankle injury

providing the leg with a state of complete rest;
fixation of the joint with a bandage (bones, tendons, muscles must be completely immobile);
application of compresses;
use of medicinal painkillers and anti-inflammatory drugs (including in the form of ointments);
physiotherapy.

If the ligaments are completely torn, surgical intervention becomes necessary. If it is not performed within a month after the injury, the consequences will occur immediately, and the symptoms will bother the victim for a long time.

Special cases: syndesmosis injury

One of the severe cases of tissue damage in the ankle joint is a rupture of the syndesmosis, which combines the connections originating from the top of the inner side of the ankle and the tibiofibular ligaments (posterior and anterior).

In most cases, syndesmosis injury occurs when the foot turns outward. In this case, the ligaments are torn from the bone. Almost always, a syndesmosis injury is accompanied by an ankle fracture.

In order to diagnose such a gap, an x-ray examination is performed. In this case, the anterior surface of the syndesmosis and the ankle from the inside are preliminarily anesthetized.

Treatment for such ligament injuries can be prescribed either surgical or conservative.

If the patient refuses surgical intervention to remove the consequences of an injury to the tibiofibular syndesmosis or if the operation is inappropriate, therapeutic medical care is provided step by step.

An alcohol-novocaine blockade is carried out.
A plaster cast is applied for a period of 5 weeks.
A removable splint is placed for 14 days.
Massage of the area of injury to the tibiofibular syndesmosis is prescribed.
Exercise therapy is recommended.

Unfortunately, it is not always possible to restore tissue integrity using only conservative treatment methods.

If, after therapy, pain and discomfort during movement remain for a period of 3 months to six months, then surgical intervention for trauma to the syndesmosis is necessary.

During surgery, ligaments can be repaired through channels in the bones (Dacron tape, strips of fascia, and tendons are threaded through and the gap is secured with a bolt).

Special cases: violation of the integrity of the deltoid ligament

Such an injury usually occurs during fractures, so its detection occurs during an X-ray examination of the joint.

If a deltoid ligament rupture is confirmed, treatment takes place in several stages.

Local anesthesia is performed.
The foot is adducted at the ankle joint.
The fibers of the deltoid ligament are sutured (surgery is performed).
A plaster cast is applied.
Rehabilitation measures are carried out (help in developing muscles and tendons).

Very severe cases of deltoid ligament rupture occur. For such damage, plaster can be applied for up to 2 months. After its removal, the recovery process takes 60 days or more.

Rehabilitation

In order to completely eliminate all the consequences of the injury, the patient is entitled to rehabilitation, including sanatorium-resort rehabilitation. It includes:

exercise therapy classes;
massage;
mud therapy;
water procedures;
physiotherapy.

Rehabilitation is aimed not only at eliminating all residual symptoms of the rupture, but also at consolidating the treatment.

Application of orthoses

During the entire recovery period, the patient must wear a rigid bandage or orthosis - a special device with which ligaments, tendons, and muscles are fixed and unloaded. This significantly reduces the risk of pathological deformation processes in the joint or bone displacement.

To choose an orthosis, it is not necessary to take the patient to the pharmacy. You just need to know a few details:

foot size;
ankle volume at the narrowest point;
ankle circumference (under the bone);
calf circumference (between the ankle and knee).

Orthoses can be of two types:

hard;
semi-rigid.

The first are used for very serious injuries, the second - if the rupture was partial.

The use of orthoses is not permitted if treatment of mixed injuries (burns and skin wounds) or rehabilitation after these injuries is carried out.

Treatment is important at any stage - from diagnosis to the end of rehabilitation. Only if you take the whole process seriously and work diligently is a successful recovery without complications possible.

When the groan is turned outward, pronation damage occurs. In this case, the deltoid ligament is first stretched. Depending on the individual ratio of strength characteristics, it either ruptures itself or tears off the inner ankle. The talus bone gains freedom to move outward and, with continued impact, puts pressure on the lateral malleolus and “breaks out” it with the fracture line moving obliquely upward. Nothing holds the foot in place, and subluxation or dislocation occurs outward.

If the lateral malleolus is strong, then the outward pressure of the talus block leads to rupture of the ligaments of the distal tibiofibular syndesmosis. Under the influence of ongoing pronation, as well as additional load along the axis of the tibia under the weight of the body, the talus block continues to push the lower part of the fibula outward and begins to wedge between it and the tibia. The fibula bends and breaks at its weakest point - in the lower third, 5-8 cm above the ankle joint. A fracture of the inner malleolus not above the level of the joint space, of the fibula in the lower third with a rupture of the distal tibiofibular syndesmosis is called Dupuytren.

Another order of occurrence of damage is also possible. If, in turn, the syndesmosis turns out to be strong enough, then first a fracture of the fibula may occur in the lower third of the bend with a fixation point in the area of the syndesmosis, and then a rupture of the latter. However, in practice, a fracture of the fibula in the lower third with an indirect mechanism of injury is synonymous with damage to the syndesmosis.

With both the supination and pronation mechanisms, the effect can stop at any stage. Thus, completed and incomplete injuries can occur from the indirect influence of force.

It is necessary to note an important feature of the biomechanics of the ankle joint, which is important for assessing the severity of its injuries and choosing treatment tactics. Loads of a supination nature occur when walking mainly on uneven surfaces, running, etc., so to speak, “in dynamics.” Other effects are also observed “in dynamics”: flexion-extension, rotation. Pronation loads are different from others. The fact is that when the body is in a vertical position, the axis of gravity does not coincide with the geometric centers of the horizontal parts of the articular surfaces of the distal metaepiphysis of the tibia and talus and passes outward from them. In this regard, the talus experiences a penetrating effect, and the distal parts of the tibia, held by the syndesmosis, tend to separate.

Thus, the only displacing effect on the talus and the entire ankle joint, which manifests itself both in static conditions and with each step, even when walking slowly on a flat plane, is a pronation effect. Related to this is the importance attached to the timing and nature of the axial load in cases of damage to the ankle joint with loss of pronation stability.

The vast majority of ankle injuries are rotational or contain an element of rotation in their mechanism. For example, with external rotation, tension occurs in the anterior portion of the deltoid ligament, its rupture, or an avulsion fracture of the inner malleolus. The talus is free to rotate outward and presses on the front of the lateral malleolus. Further, depending on the individual ratio of strength characteristics, a fracture of the lateral malleolus with a rupture of the distal tibiofibular syndesmosis, a rupture of the anterior portion or the entire syndesmosis with a helical fracture of the fibula in the upper third may occur. With continued exposure, external and rotational subluxation and dislocation of the foot occurs. A rotational fracture of the medial malleolus, a helical fracture of the fibula in the upper third with a rupture of the distal tibiofibular syndesmosis are called Maisonneuve's fracture.

Fractures of the posterior and anterior parts of the distal metaepiphysis of the tibia are associated with:

with excessive flexion or extension, causing the tension capsule to tear off the marginal fragment of the metaepiphysis on the side opposite to the direction of movement of the foot;

with a load along the axis of the tibia in a flexion position, in this case large fragments are formed;

with a fragment of the posterior part being torn off by the posterior portion of the syndesmosis during pronation and rotational injuries.

With excessive plantar flexion, a divergence of the articular surfaces in the anterior part occurs, which leads to rupture of the anterior part of the articular capsule and the lateral ligamentous apparatus. Receiving additional freedom of movement backwards, the talus, depending on the degree of plantar flexion, either breaks out a section of the posterior part of the distal metaepiphysis of the tibia, and then, tearing off both or one ankle, or first breaks out the ankles, wedging in with its wide anterior section of the trochlea, and then the posterior part tibia.

Currently available classifications of ankle injuries are based on three principles:

on the mechanism of injury;

fracture location;

severity of damage.

The classification of fractures by the number of broken bone elements is clearly outdated, since it does not take into account ligament damage, which is no less important for the function of the joint.

In our opinion, in the classification of fresh injuries of the ankle joint it is necessary to use a functional approach based on its anatomical and physiological characteristics, namely, the significance of the damaged elements for the pronation stability of the joint. Therefore, it seems to us that the classifications of foreign authors that use the concept of ligamentous equivalents of fractures are the most justified. In accordance with them, damage to the medial and lateral parts of the joint is distinguished.

The N. Lauge-Hansen classification is the most widely recognized abroad, according to which all injuries of the ankle joint are divided into supination-eversion, supination-adduction, pronation-abduction, pronation-eversion.

In addition, damage caused by direct violence is highlighted. This classification describes in detail the features of the mechanism of individual injuries of the ankle joint, including injuries of the syndesmosis, and is very interesting from a scientific point of view. Unfortunately, it is not applicable in practice, since it allows for ambiguous interpretation in 43% of cases.

The AO classification, often used in Western countries and the USA, is focused primarily on determining the indications and methods of surgical treatment of fractures. It is based on the division of fractures within each anatomical region into three types, then into groups and subgroups in accordance with the principle of increasing the severity of damage to bones and soft tissues and makes it possible to universally formalize the designation of fractures.

Classification of fibula fractures

at the level;

above the level of syndesmosis, since this determines the condition of the tibiofibular joint and affects treatment tactics.

The syndesmosis is damaged in the last two cases, and in the second option one of its portions may remain intact, and in the third all portions are torn.

Classification of talus fractures

Here, fractures of the body, neck and posterior process are distinguished; they may be accompanied by subluxation and dislocation of the subtalar joint, total dislocation of the body and the entire talus.

The anatomical and functional significance is determined to a greater extent not by the presence of certain bone injuries, but by the magnitude of the primary displacement, the presence of subluxation and dislocation in the subtalar joint, total dislocation of the talus, reflecting the degree of violation of its vascularization, and in case of marginal fractures - the formation of free cartilaginous or bone inside the articular bodies, which subsequently provoke the development of arthrosis.

Assessment of the severity and characteristics of damage to the ankle joint should be based on the following algorithm:

support of the articular platform of the tibia - preserved, impaired, features of the violation;

pronation stability of the joint – preserved, absent, features of the disorder;

stability in relation to other influences – preserved, absent, features of the violation;

the presence of damage to less significant elements that do not cause the above violations.

The support of the articular platform of the tibia is lost in case of fractures of its distal metaepiphysis with the size of the posterior fragment equal to 1/3, a fragment of the anterior section - 1/4 of the articular platform or more, valging of the articular platform, to a lesser extent - with its other angular displacements and decreases with compression of the outer parts of the distal metaepiphysis of the tibia.

The stability of the ankle joint with respect to pronation is disrupted by fractures of the lateral malleolus not lower than the horizontal portion of the joint space, ruptures of the distal tibiofibular syndesmosis, deltoid ligament and their bone equivalents.

The stability of the ankle joint in relation to supination is lost with fractures of the outer

ankle or rupture of the external collateral ligaments of the ankle joint, fractures of the internal malleolus and decreases with fractures of the inner part of the distal metaepiphysis of the tibia.

Additionally, it should be noted that fractures of the neck of the talus with subtalar subluxation or dislocation of the foot, fractures of its body with displacement or subluxation or dislocation in the subtalar joint, and especially complete dislocation of the body or the entire talus are the most severe injuries and, therefore, dominate in relation to tactics and forecast, but are rare.

Diagnosis of ankle injuries

Based on medical history, clinical and x-ray examination of the victim. Clinical diagnosis is based on general traumatological principles and does not need a detailed description. The final judgment on the presence and degree of displacement and imbalance in the ankle joint is possible on the basis of X-ray data.

X-ray examination.

A strictly anteroposterior x-ray projection is not very informative. For a complete diagnosis of the condition of the ankle joint and distal tibiofibular syndesmosis, radiography in the intermalleolar plane is required, i.e. with inward rotation of the tibia. A slight rotation allows the posterior part of the tibiofibular space and the internal vertical section of the joint space to be brought into projection, and an inward rotation of approximately 25° allows the outer vertical section of the joint space to be projected. Inward rotation of 95 0 -35° makes it possible to projectively align the edges of the fibular notch of the tibia so that in some patients none of the sections of the tibia and fibula overlap the other bone, and also to obtain an image of the anterior part of the tibiofibular space. In order to evaluate the relationships in all parts of the ankle joint, inward rotation of 18-20° is optimal.

The most accurate method for assessing the relationships in the joint is comparative radiography. A relative sign of expansion of the tibiofibular space or other disturbances in the relationships in the joint is a difference between a healthy and damaged joint of up to 1 mm, an absolute sign is a difference of 1 mm or more.

It should be mentioned once again that the most important, often decisive, importance belongs to the correct understanding of the mechanism of damage, the clarification of which is carried out at all stages of the examination of the patient.

Therefore, for the treatment of most injuries of the ankle joint with a violation of its “fork”, the best way to install the talus with a narrow transverse size of its block in the “fork” seems to be the formation at the time of reposition of an artificial minimal subluxation of the foot anteriorly in a position at an angle of 90° to the axis of the tibia. The fact is that, due to the concave shape of the distal epiphysis of the tibia in the sagittal plane, such anterior subluxation of the talus does not pose a danger to the patient and spontaneously disappears due to the tone of the lower leg muscles and especially the axial load on the limb in the plaster cast and after its removal.