Date: Wed, 19 Mar 2003 22:54:36 EST

Subject: Syndesmotic injury - ? Conservative care

Dear friends:

Looking for advice. ORIF of severe trimalleolar ankle fracture dislocation. Plate fixation on fibula, medial malleolar screw fixation.

At time of surgery I thought stable syndesmosis, no syndesmotice screw.

Today, 17 days after surgery xrays out of cast shows wide mortise, 2-3 mm, which improved with new cast molded to reduce mortise (essentially perfect mortise in cast).

How does the group feel about the ability to heal a syndesmotic injury with casting in a reduced position?

Sincerely and respectively,

M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
Arlington Heights, Illinois 60005

Reply at: Orthopaedic Trauma Association forum

Date: Wed, 19 Mar 2003 22:51:36 -0600

From: Sciadini, Marcus

Not seeing xrays, but based upon your description, I would reoperate and place syndesmotic screw or screws. These injuries can fail to heal adequately even with syndesmosis screw placement. I would not feel comfortable relying on the ability of my cast to hold this reduction.

Marcus F. Sciadini, M.D.

Date: Thu, 20 Mar 2003 07:39:24 -0500

From: James Carr


I do believe it can heal in a cast, but I am always worried about late displacement. I never get to see the cases that do well in a cast- just the ones where it was tried and failed. I would recommend fixation. Its always tough to take patients back, but sounds like they have a tough problem to begin with, and don't need any more variables in the equation.

Jim Carr

Date: Thu, 20 Mar 2003 08:04:49 -0500

From: Fred Barrick

How does the group feel about the ability to heal a syndesmotic injury with casting in a reduced position?

Not good.

Date: Thu, 20 Mar 2003 08:06:00 -0500

From: Clifford Jones, M.D.

Unless you want to treat the patient in a long leg cast for 3 months after ORIF, creating a very stiff ankle, I would reduce and apply syndesmosis screw.

Date: Thu, 20 Mar 2003 08:15:41 -0600

From: Frederic B. Wilson, M.D.

I agree. It's not worth taking the chance. A delayed reconstruction of the syndesmosis is not a pleasant prospect (as attested to by the recent thread on the malreduced fibula fracture).

Frederic B. Wilson, M.D.
Assistant Professor
Trauma and Adult Reconstruction
Department of Orthopaedic Surgery
Tulane University School of Medicine
New Orleans, LA, 70112

Date: Thu, 20 Mar 2003 08:34:12 -0800

From: Bruce Sangeorzan

a cast will not do the trick. do not wait for further widening. repair and fix with screws now

Bruce J Sangeorzan, MD
Professor and Vice Chair Dept. Orthopedics and Sports Medicine
University of Washington
Chief of Orthopedics, Harborview Medical Center

Date: Thu, 20 Mar 2003 19:11:49 -0600

From: Obremskey, William T

Even though it is inconvenient for you and patient, I would recommend bite the bullet and place syndesmosis screw. The unanswered questions are : resorbable screw or not 3.5, 4.5 or 6.5 mm screw 3 or 4 cortices remove or leave? (my opinions underlined) Not much data on the above, but not much question on the need of a syndesmosis screw.