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.
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.
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.
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.
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
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
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