The document discusses lesion sindismal (syndesmotic ligament injury) of the ankle. It notes that these injuries account for 10% of all ankle luxations and often occur during sports. The diagnosis is controversial due to being commonly underdiagnosed or misdiagnosed. Radiographs and clinical exams like the squeeze test are used to diagnose these injuries when the mechanism of injury involves external rotation. Surgical treatment may involve use of a syndesmotic screw, with considerations for screw size, number of cortices, and position. Postoperative management includes immobilization and progressive weight bearing.

1. LESION SINDESMAL
Roberto Muñoz M.
Tobillo y Pie
Hospital Regional
Antofagasta

2. INTRODUCCION
10% de todas las luxofx tobillo
55% en actividades deportivas
Varones, jóvenes

3. INTRODUCCION
Controversial
Sub diagnosticada
Dificil manejo
Chissell H, Jones J. The influence of a diastasis screw on the outcome of Weber type-C
ankle fractures. J Bone Joint Surg 1995;77B:435 – 7.
Ebraheim N, Mekhail A, Orth M, Gargasz S. Ankle fractures involving the fibula proximal
to the distal tibiofibular syndesmosis. Foot Ankle Int 1997; 18(8):513– 21.

4. MECANISMO
ROTACION EXTERNA
Denis Weber C - Pronación RE
Denis Weber B -Supinación RE
Chissell H, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. J Bone Joint
Surg 1995;77B:435 – 7.
Ebraheim N, Mekhail A, Orth M, Gargasz S. Ankle fractures involving the fibula proximal to the distal tibiofibular
syndesmosis. Foot Ankle Int 1997;18(8):513– 21.
Leeds H, Ehrlich M. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J
Bone Joint Surg 1984;66A:490–503.
Parfenchuck T, Frix J, Bertrand S. Clinical use of a syndesmotic screw in stage IV pronation- external rotation
fractures. Orthop Rev 1994;23:23– 8.
Yamaguchi K, Martin C, Boden S. Operative treatment of syndesmotic disruptions without use of a syndesmotic
screw: a prospective clinical study. Foot Ankle Int 1994;15:407– 14.
Hopkinson WJ, St. Pierre P, Ryan JB, et al. Syndesmosis sprains of the ankle. Foot Ankle 1990;10:325–30.
Rasmussen O. Stability of the ankle joint: analysis of the function and traumatology of the ankle ligaments. Acta
Orthop Scand 1985;211:1– 75.
Kelikian H, Kelikian AS. Disorders of the ankle. Philadelphia: W.B. Saunders; 1985.
Fritschy D. An unusual ankle injury in top skiers. Am J Sports Med 1989;17:282–6.

5. DIAGNOSTICO
Anamnesis
DM, Fumador
Mecanismo
Examen clínico
Cargar peso ?
Tumefacción
Deformidad
Equimosis

6. DIAGNOSTICO
Examen clínico
Puntos dolorosos
Diáfisis fibular
Squeeze Test
Otawa
Hopkinson WJ, St. Pierre P, Ryan JB, et al. Syndesmosis sprains of the ankle. Foot Ankle 1990;
10:325–30.
Teitz CC, Harrington RM. A biomechanical analysis of the squeeze test for sprains of the syndesmotic
ligaments of the ankle. Foot Ankle Int 1998;19:489– 92.

7. ESTUDIO RX
Rx. AP – lateral
Rx. Mortaja

8. ESTUDIO RX
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot
Ankle 1989;10:156– 60.
Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior
radiographic anatomy of the ankle syndesmosis. Foot Ankle 1995;16:128– 31.
Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar
and trimalleolar ankle fractures. J Bone Joint Surg 1984;66A:490–503.

9. ESTUDIO RX
Espacio claro medial
Lesión deltoideo prof
> 4mm es (+)

10. TENGO CLINICA PERO RX NORMAL…
QUE HAGO ?

11. RX STRESS
Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and
Prediction of return to function . J Orthop Sports Phys Ther 1998;27:276– 84.

12. RX STRESS

13. RX STRESS
RX CARGA COMPARATIVA
Sospecha clínica
Mecanismo rotacional
Edema sobre sindesmosis
Dolor a proximal,
Fx tobillo Weber B y C
Fx maleolo medial aislado

14. TORNILLO SINDESMAL
No importa la posición del tobillo
Sin diferencias 3 ó 4 corticales
Sin diferencias 3.5 , 4.5 mm
1 ó 2 tornillos ?
Compresión ? Altura ?
McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P. Syndesmotic screw
placement: a biomechanical analysis. Foot Ankle Int 1997;18:262– 6.
Thompson M, Gesink D. Biomechanical comparison of syndesmosis fixation with 3.5- and
4.5-millimeter stainless steel screws. Foot Ankle Int 2000;21:736–41.
Chissell H, Jones J. The influence of a diastasis screw on the outcome of Weber type-C
ankle fractures. J Bone Joint Surg 1995;77B:435 – 7.
Ebraheim N, Mekhail A, Orth M, Gargasz S. Ankle fractures involving the fibula proximal to
the distal tibiofibular syndesmosis. Foot Ankle Int 1997;18(8):513– 21.
Leeds H, Ehrlich M. Instability of the distal tibiofibular syndesmosis after bimalleolar and
trimalleolar ankle fractures. J Bone Joint Surg 1984;66A:490–503.
Yamaguchi K, Martin C, Boden S. Operative treatment of syndesmotic disruptions without
use of a syndesmotic screw: a prospective clinical study. Foot Ankle Int 1994;15:407– 14.
Wuest T. Injuries to the distal lower extremity syndesmosis. J Acad Orthop Surg
1997;5:172 –81.
Boden S, Labropoulos P, McCowin P, Lestini W, Hurwitz S. Mechanical considerations for
the syndesmosis screw: a cadaver study. J Bone Joint Surg 1989;71A:1548–55.

15. EVALUACION SINDESMAL INTRA OP
Post fijación maleolos
Reducción anatómica
Largo y rotación fibular
Test Cotton o test rotación externa

16. EVALUACION SINDESMAL INTRA OP
Test Cotton

17. EVALUACION SINDESMAL INTRA OP
Test Cotton

18. EVALUACION SINDESMAL INTRA OP
Test rotación externa

19. Tornillo sindesmal

20. Tornillo sindesmal

21. TAC
TAC: 2 mm o 5 grados
Hasta 20% requiere re operación
Kaj Klaue. Detection of fibular torsional deformities after surgery for
ankle fractures with a Novel CT Method. Foot and Ankle Int 2006

22. MANEJO POST OP
Inmovilización por 3 semanas
kine sin carga hasta 6º semana
Carga progresiva desde 6º sem

23. RETIRO TORNILLO SINDESMAL ?
Sin retiro
Si se saca, no antes de 8 a 12 semanas

24. RESUMEN
Tobillo posición indiferente
Tornillo 3.5 cortical
3 corticales
1 tornillo
2 cm del plafond
Siempre Cotton intra op
Sin compresión
Sin reparar deltoideo
Sin retiro

25. CASO LESION SINDESMAL
Colega que se lesiono en vacaciones…

26. CASO LESION SINDESMAL
Fue operado quedando con sindesmosis abierta

27. CASO LESION SINDESMAL
Re operado tres
semanas después
Tornillo sindesmal
percutáneo

28. 2ª CASO LESION SINDESMAL
Mujer, 25 años, consulta por torsión tobillo

29. 2ª CASO LESION SINDESMAL
Se diagnosticó esguince tobillo …

30. 2ª CASO LESION SINDESMAL
2da consulta a TMT,
se solicita Rx stress

31. GRACIAS