Syndesmotic injuries are common in ankle fractures. Traditional syndesmosis fixation may be associated with a secondary procedure. When the posterior malleolus is fractured, the posterior syndesmotic ligaments may remain intact and attached to the fragment. Our goals were to establish the incidence of syndesmotic ligament ruptures in pronation-external rotation type ankle injuries associated with posterior malleolar fractures, and to assess syndesmotic stability after fixation of the posterior malleolus compared with using a syndesmotic screw. Fifteen patients who sustained pronation-external rotation Stage 4 ankle fractures that involved the posterior malleolus were evaluated using radiographs and magnetic resonance imaging. No complete tears of the posterior-inferior tibiofibular ligament occurred. A pronation-external rotation fracture pattern with a posterior malleolar fragment was created in 10 lower extremity cadaver specimens with random fixation of the posterior malleolus or the syndesmosis. Compared with the intact specimens, stiffness was restored to 70% after fixation of the posterior malleolus, and to 40% after syndesmosis stabilization. Syndesmotic stability may be obtained more effectively by fixation of the posterior malleolus rather than by using a syndesmotic screw. Although additional clinical investigation is warranted, these concepts may be useful in eliminating syndesmotic screw fixation in select patients.

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