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Pronation-External Rotation Injuries of the Ankle

- Sequence of Injury:
    - medial side is injuried first;
          - transverse frx of medial malleolus or disruption of deltoid ligament;
    - anterior tibiofibular ligament disruption;
          - external rotation then results in rupture of the anterior tibiofibular ligament or its bony insertion;
    - short oblique or spiral frx of fibula above the level of the joint;
          - spiral fibular frx, w/ distal end usually 4 to 7 cm above tibial plafond (and hence, the frx is above the syndesmotic ligaments);
          - fibular frx is spiral, but runs anterosuperior to posteroinferior, & interosseous membrane is ruptured up to the level of fibula frx;
    - posterior injury:
          - tibiofibular ligament rupture or avulsion of posterior malleolus;

- Treatment: (same as Weber C)

Mechanical considerations for the syndesmosis screw. A cadaver study.

Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures.

The effect of fibular malreduction on contact pressures in an ankle fracture malunion model.