Outer Ligament Tear at the Upper Ankle and Syndesmotic Tear at the Upper Ankle: “Lateral Collateral Ligament and Lateral Chain”

Abstract

1.1 Rationale of application: X-ray-free diagnosis and therapy of fractures and capsular ligament injuries/instabilities in the area of the outer ankle and the lateral foot.

Differentiation from the most common accompanying injuries: peroneal tendons, inner ankle, delta ligament, and tibia. Anterior and posterior tendon.

1.2 Evidence level: Ib for violations of the lig. fibulotalare anterius (FTA), tibiofibulare anterius (VS), and deltoideum (LD); IIa for the lig. fibulocalcaneare (FC) and calcaneocuboideum (CC). For violations of the lig. fibulotalare posterius (FTP), of the lig. tibiofibulare posterius (DS) and the osseous accompanying injuries in the area of the “lateral chain” can be assumed from an evidence level IIb to IV. So far, meta-analyzes of several randomized, controlled studies are missing, not least because of the still inconsistent examination techniques.

1.3 Indication: X-ray-free diagnosis and therapy control after sprains of the ankle and lateral foot if suspected capsular ligament injuries/instabilities or fractures of the ankle or hind and metatarsus.

1.4 Contraindications: open fractures with large or infection-prone skin and soft tissue damage.

1.5 Age of the patient: no age limit.

1.6 Examination:

Structure / section plane / examination technique / question:

 1. Fibula / longitudinal, semicircular / dorsal, lateral, and ventral / fracture.

 2. MT5 / longitudinal, semicircular / dorsal, lateral, and ventral / fracture.

 3. FTA / transverse, fibula to neck of talus / neutral, stress anterior talus drawer / lesion signs, instability >2 mm.

 4. AS / transverse, tibia to fibula / neutral, stress extension + external rotation / injury signs, instability >1 mm.

 5. FC / longitudinal along the ligament, fibula tip to tub. innom. calcan / neutral, stress varus / lesion signs, instability >4 mm.

 6. CC / longitudinal semicircular, calcaneus to cuboid / lateral + dorsal, stress add/supp / lesion signs, joint gapping.

 7. FTP / transversal along the ligament / neutral / lesion signs.

 8. PS / transverse tibia to fibula / neutral / lesion signs.

 9. MM/LD / longitudinal MM + along the lig. deltoideum / neutral, semicircular, 3 parts of the ligament / fracture, signs of lesions.

1.7 Indications for additional X-ray diagnostics:

 – Dislocated fracture of the fibula or tibia with suspected surgical indication.

 – Planned surgery.

 – To exclude intraosseous or intra-articular changes, osteochondrosis dissecans (OD), structural disorder, arthrosis, TU, dysostosis, and so on, for example in case of joint effusion of unclear genesis.

 – Held X-ray stress recordings before secondary ligament reconstruction.

 – Lack of adequate trauma.

 – When an intra-articular cartilage/bone lesion or OD is suspected and, if necessary, CT/MRI.

1.8 Pitfalls:

 – Calcaneus, talus, and tarsal fractures in areas not accessible in sonography.

 – Additional shaft fractures or proximal lower leg fractures.

 – Undisplaced epiphyseal plate injuries.

 – Systemic diseases (e.g., osteogenesis imperfecta, M. Ollier, etc.) are not easy to get by sonography alone.

 – Stability check recommended after completion of treatment.

 – Strict attention must be paid to maintain the original cutting plane during the stress test.

 – Counter tension of the patient can conceal band instability during the initial examination. Then repeat after a week.

1.9 Red flags:

 – Severe pain, swelling, and/or restricted movement without evidence of a fracture, capsular ligament lesion, or soft tissue lesion (cave DD: infection, TU, nerve root lesion, somatoform reaction, etc.).

 – Fracture without adequate trauma.

 – Pre-traumatic complaints at this location.

 – Refracture.

 – Increasing complaints under therapy.

 – Family history of relevant systemic diseases.

 – Ankle or hindfoot pain with stress pain after 7 days.

1.10 Algorithm:

Ankle/hind and metatarsal injury: lateral chain.