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So this case is a 29-year-old man.

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The provided history was that he, um,

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was a professional football player and had proximal fibular

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and ankle fractures.

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Um, with that history, even without looking at the imaging,

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I think we're thinking is the proximal fibular fracture a

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mazen nerve type fracture

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and maybe there's an unstable ankle injury resulting from a

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pronation external rotation type mechanism.

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So we wanna confirm that our clinicians did not lie to us

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and that there truly are fractures.

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So looking at the bones, we can see there is this fracture

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of the posterior malleolus.

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Um, right here, there's some edema related to the fracture.

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So we can, um, guess that this fracture is recent.

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As we scroll further distally, um,

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you can see some bony irregularity, little osci at the tip

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of the medial malleolus and distal fibula.

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At these, um, sites of bon irregular tn ossicles,

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I don't see a lot of edema,

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so it's not clear if these are related to the recent injury

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or from a preexisting injury.

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Um, so now that we've looked at the bones,

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let's turn our attention to the ligamentous structures.

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So going to our posterior malleolar fracture, we can see

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that this involves that volkman fragment or tubercle,

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and so it's at the attachment

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of the posterior inferior tibial fibular ligament.

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If we look anteriorly,

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the anterior inferior tibial fibular ligament also looks

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disrupted irregular fluid signal in the structure,

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um, clearly abnormal.

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As we come a little further inferiorly, we can see that

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that additional structure, um, that's a little more inferior

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and deep to the posterior inferior tibial fli lament.

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That inferior transverse ligament also looks, um, injured.

1:57

Going to our coronal plane, you can see

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that more triangular structure,

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our posterior inferior tibular tibial fibular ligament,

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that more horizontal structure,

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our inferior transverse ligament looks like

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that inferior transverse ligament is also attaching to, um,

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a non-displaced bone fragment.

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There on our coronal images, um,

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we can see that interosseous ligament,

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but if we look back, cross-referenced to our axial images,

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it's not clear to me that

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that interosseous ligament ever truly attaches to the tibia.

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So I think that's probably injured as well.

2:36

Um, quite a bit of edema within that syndesmotic space

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and more proximally that, um,

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syndesmotic membrane also looks a little irregular,

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though we're getting kind of to the periphery,

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so we're losing signal a bit, um,

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at this more proximal portion.

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So all of these findings together compatible with

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as syndesmotic injury, that high ankle sprain, uh,

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much less common than your typical low lateral ankle

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ligament injuries.

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Only about 1% of all of your ankle injuries.

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Um, and interestingly, that injury

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to the posterior inferior tibial fibular ligament has

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specifically been reported to be associated

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with a longer period of disability

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in professional football players.

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So this person probably gonna take a little while to heal.

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Uh, syndesmotic injuries are often gonna be associated

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with other ankle injuries.

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So if we turn our attention

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to the low lateral ankle ligaments, you'll see

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that your anterior talo fibular ligament also torn,

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um, posterior talo fibular ligament.

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Um, again, emus, irregular, partially torn.

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And then looking at our calcan fibular ligament, um,

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a little bit thickened, so possibly from old injury,

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but there is some increased signal in the ligament near

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the calcaneal attachment.

3:58

If we turn medially, we can see

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that our superficial deltoid ligaments are, um,

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stripped from the medial malleolus.

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Actually, it looks like on our coronal images,

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that the torn fibers are kind of redundant

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and now interposed in the expected location

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of our deep deltoid ligaments, which are also torn.

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Um, so putting it all together,

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thinking about those concepts of the greater

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and lesser rings, um, that Dr.

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Resnick introduced in his talk on the ligaments.

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So we're thinking about the greater ring.

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It looks like there are at least three breaks.

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Our deltoid ligaments medially,

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our lateral ankle ligaments laterally,

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and then our syndesmotic ligaments.

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So that's an unstable ankle injury right there.

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And then thinking about our lesser ring,

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we have a quadruple break.

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So the anterior

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and posterior inferior tibial fibrillary ligaments,

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our interosseous ligament,

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and then also our inferior transverse ligament.

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So there's total tibial fibular instability here.

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Um, so thinking about the bones one more time, we did see

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that posterior malleolar fracture,

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but when you see a syndesmotic injury, what you wanna do is

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also carefully inspect your tail art dome

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and your tibial, hon.

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Because these high ankle sprains are also associated

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with osteochondral injuries,

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you'll get bone contusions elsewhere, um, in

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the ankle as well.

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And then you wanna inspect that tibial fibular joint

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for incongruity.

5:36

In this case, I think he's actually fairly well aligned.

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Not much displacement or distraction here.

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Um, but those are associated findings in the setting

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of syn asmatic injury that you wanna be careful to look for.