Download OF THE TIBIO-FIBULAR LIGAMENTS

OF
INJURIES
THE
TIBIO-FIBULAR
C. J. E. MONK,
Senior
The
ligaments
by forces
of the
the
that
transmitted
hold
or of the
tibio-fibular
ligaments
bony
injury.
The
objects
ligament
have been
University
the
ends
of the tibia
These
and
not
of this
injuries,
damaged.
lower
ankle.
shaft
may
ENGLAND
Surgery,
the
fibular
LIVERPOOL,
in Orthopaedic
together
through
malleoli
tibio-fibular
which
they
Lecturer
LIGAMENTS
may,
subluxation
be recognised
paper
and
forces
are
and
fibula
at the
same
or dislocation
because
firstly
secondly
of Liverpool
of the
attention
to draw
to suggest
are
time,
damaged
fractures
ankle.
Lesions
is directed
attention
a method
often
cause
to
of
towards
the
the
significance
of establishing
the
of
degree
to
HISTORY
Maisonneuve
ankle
found
associated
Maisonneuve
with
observations
was
the
first
to draw
attention
to lateral
the
effects
workers,
syndromes
as the treatment
and Sallis
1958).
Watson-Jones
tibio-fibular
ligaments.
This
is especially
interesting
when
before
the discovery
of x-rays.
years
and
by several
clinical
to the
His work
fifty
anatomy
reported
the
damage
fracture.
about
The
on
(1840)
of isolated
especially
of tibio-fibular
of choice
(Alldredge
(1955)
sections
Close
and
ligament
1940,
stressed
of the
(1956)
the
Lee
severity
separation
radiologically.
of the lower
relationship
These
ligaments
coronal
plane
necessary
element
pass
and
in the
from
interosseous
from
the
from
the
tibia
tibio-fibular
lateral
aspect
the
constitute
the
stability
Standard
textbooks
describe
anterior
tibio-fibular
ligament.
laterally
OF
lower
1943,
and
TIBIO-FIBULAR
end
of the
of the
tibio-fibular
of the
combined
the
The
lower
This consists
tibia to the
been
writers
screws
Mullins
with
with
tibio-
a plaster-
in assessing
to assess
the
their
degree
of
LIGAMENTS
tibia
to the
fibula.
tibio-fibular
mortise
fibres
and
fibula
difficulty
(Fig.
are
more
of short
adjacent
thick
medial
Their
syndesmosis.
ligament
obliquely
robust
They
run
in
are
than
complex.
downwards
1) The
and
the
2) The
upper.
fibres passing
directly
surface
of the lower
ligament.
The fibres of this ligament
pass from
the postero-medial
border
of the lower
fibula.
stronger
and thicker
than
the upper
and their
the posterior
edge of the articular
surface.
These
tibio-fibular
ligament.
THE
fibres
1).
three
main
components
of this
The fibres
of this ligament
pass
ligament.
of the lower
with
1953,
fixation
to
have
of the
fixation
Costigan
anaesthesia
in the
known
as the
he made
these
Most
fracture
screw
talus
of the ankle.
He
third of the fibula
ligaments
(1960).
recommend
Horan
under
ligaments
of the
to the fibula.
3) The posterior
tibio-fibular
border
of the lower tibia to
fibres
of this ligament
are
tibia extends
medially
along
to
as
the inferior
transverse
THE
tibio-fibular
of high
He suggested
examination
tibia and fibula.
ANATOMY
330
of the
injury
is still
we realise
that
Grath
damage
and
fibular
and medial
ligament
injuries
and recommended
of-Paris
cast as the method
of immobilisation.
Bonnin
(1957)
drew
attention
to these
injuries
the
rotation
mortise
as a mechanism
of the production
of fractures
in the region
that lateral
rotation
may also cause a fracture
in the middle
or upper
JOURNAL
OF
BONE
across
fibula.
the postero-lateral
The most inferior
attachment
to the
fibres are referred
AND
JOINT
SURGERY
a
INJURIES
Two
facts
syndesmosis
have
emerged
extends
varies
2 centimetres
to
in others
from
our
greatly
virtually
TIBIO-FIBULAR
dissections.
331
LIGAMENTS
Firstly,
in different
6 centimetres
varies
greatly
ligament
interosseous
and
about
OF THE
the height
individuals.
to which
It varies
above
the ankle
joint.
in different
individuals.
the tibio-fibular
in height
from
about
Secondly,
the strength
In some
it is tough
and
of the
fibrous
non-existent.
P
A
4-i-
,
,
I
-
‘
1
FIG.
Figure
1-The
three
ligament.
P=postenor
The “ anterior
type
tibio-fibular
ligaments
malleolus
2
FtC.
components
of the tibio-fibular
ligament
complex.
A=anterior
tibio-fibular
ligament.
I =interosseous
tibio-fibular
ligament.
“
of tibio-fibular
ligament
tear showing
the torn anterior
and
(1), and the torn medial ligament
of the ankle (2). Alternatively
may be fractured.
The posterior
tibio-fibular
ligament
(not shown)
tibio-fibular
Figure 2-
interosseous
the medial
is
intact.
/
,
,
\
3
FIG.
/
4
FIG.
Figure 3-The
total type
tear of tibio-fibular
ligament showing the torn anterior,
interosseous
and posterior
tibio-fibular
ligaments(1),
and the torn medial ligament
ofthe ankle(2).
Alternatively
the medial malleolus
may be fractured.
Figure 4-Showing
the posterior
or
third
malleolar
“
“
“
fragment.
This
may
be either
from
the
postero-medial
INJURIES
From
strain-view
types
(“
study
of
radiographs
of
injury
the
type
posterior
anterior
being
a
occur:
and
posteror
VOL.
51 B, NO. 2,
“)
findings
1) tearing
tibio-fibular
MAY
produced
and
which
allows
tibio-fibular
1969
of
the
the joint
ligament
ligaments
(“
postero-lateral
“
part
of the
tibia.
SUSTAINED
experimentally
operation
or the
injuries
in patients
anterior
and
in
amputation
we have
interosseous
to be opened
like the
(Fig. 2) ; and 2) tearing
total
type
“),
which
allows
specimens
concluded
that
tibio-fibular
covers
of the
the
and
two
of
main
ligaments
of a book,
the hinge
anterior,
interosseous
fibula
to
be
abducted
332
C. J. E. MONK
away
the
from
ligaments
limit
we
lower
have
of the
end
found
inferior
the
of
tibia
a fracture
(Fig.
of the
tibio-fibular
joint
3).
fibula.
to the
In all significant
This may occur
head
to the medial
side of the ankle joint-either
ligament,
or a fracture
of the medial
malleolus.
The
mechanisms
by which
these
injuries
experiment
and strain-view
radiographs.
Tear
of the
damage
I
most
I
and
I
I
:
I
‘
I
some
medial
are caused
have
also
been
ascertained
by
of the anterior
fibular
ligament
is produced,
is
I
treatment.
I
the
insignificant
The
of
attachments
ligaments
/
and
they
CLINICAL
by
the
mention
of the
ligament
that may accompany
the common
ofthe
lateral
malleolus.
This particular
ligament
and is usually,
quite
rightly,
disregarded
in
fracture
line in the fibula
usually
passes
between
fracture
injury
#,
the
anterior
therefore
PICTURE
and
escape
OF
THE
/
posterior
serious
tibio-fibular
injury
TIBIO-FIBULAR
(Fig.
5).
LIGAMENT
INJURIES
/
-
1
-
There
may
the foot caused
/
Often,
taneously
_
5
FIG.
Showing
the
amount
of
tibio-fibular
fracture
insignificant
damage
ligaments
tke oblique
lateral
of
the
the
to the
found
rotation
lateral
be abduction
by subluxation
however,
or has
the
displacement
has become
reduced
sponreduced
by the first-aid
attendants
during
of splintage
at the site of the accident.
In these
physical
signs
will be swelling
and
tenderness
only
over the tibio-fibular
medial
side of the
mal-
ligaments,
ankle.
RADIOLOGICAL
Conventional
may
antero-posterior
be at any
level
from
medial
joint
Strain-view
injuries
space
on the
of
radiographs-We
the tibio-fibular
Method-With
plantigrade
of the
finding
the
position,
antero-posterior
radiograph
the
ankle
have
ligaments
other
indicative
angle
of the
he subjects
ankle.
the
fracture
site
and
the
the
“
type).
malleolus
“
be
foot
leg.
The
With
ankle
fracture
upwards.
ligament
damage.
essential
for
of the fibula,
The fracture
Damage
to the
or widening
of
No
reliance
should
joint.
found
these
to
in most cases.
to the
the
(the
anterior
of the medial
of medial
ankle
anaesthetised,
at a right
fibular
FINDINGS
type of injury
as a fracture
of an undisplaced
patient
the
and lateral
radiographs
show
the top ofthe
inferior
tibio-fibularjoint
line is usually
oblique
in the rotational
medial
side of the ankle
may be evident
be placed
or lateral
rotation
deformity
of
or dislocation
at the ankle joint.
the
been
application
cases
leolus.
the
also
of the
tear
tibio-fibular
oblique
“
which
is usually
or complete,
probably
a total
anterior
‘
I
in
There
partial
by the posterior
tibio-fibular
ligament
or knocked
off
talus at the time of injury
(Fig. 4).
Lateral
rotation
fractures
of lateral
nialleolus-So
far no
has been made
of the minor
damage
to the inferior
fibres
I
I
.‘..
fibula.
a tear,
the tibio-fibular
from
the upper
by a lateral
rotation
strain
applied
to the ankle,
of all three
ligaments
by an abduction
strain.
Often
there
is a fracture
of the posterior
surface
of the
tibia-the
so-called
posterior
malleolar
fracture.
The mechanism
of this fracture
is uncertain
; the fragment
is either
pulled
off
I
4
injuries
of
at any point
and
x-ray
one
fix it and
with
and
abduction,
plantarfiex
had been
adduction
and lateral
rotation
strains.
the ankle.
Antero-posterior
radiographs
produced
in each direction.
ankle
tube
hand
inferior
are
assessment
placed
in
is set up as for
the
operator
tibio-fibular
Care
must
be
are taken
when
THE
a correct
JOURNAL
taken
not
the greatest
OF
BONE
normal
a conventional
grasps
joints
the
of
the
tibia
to
successively
to
to
or
AND
dorsiflex
displacement
JOINT
SURGERY
INJURIES
Interpretation-If
the tibia,
If the
rotated
the
all three
lower
anterior
and
end
ligaments
lower
end of the
around
its own
have
fibula
long
interosseous
OF THE TIBIO-FIBULAR
of the
been
fibula
can
torn-”
tibio-fibular
ligaments
but
malleolus
Adduction
and
and
ofthe
abduction
tearing
(“
anterior
type
deformity
two
fragments
VOL.
51 B,
of
the
lower
the
2, MAY
of
tend
fragment
level
1969
strain-view
of the
The
projection
may also
at
NO.
lesion).
“
antero-posterior
fibular
fragment
of the
above
tibio-fibular
lateral
the tibia
to swing
may
fibular
not
lower
film,
the
inferior
showing
radiographs
film
(“
in
be recognised
fracture
lower
(Figs.
end
of
6 and
7).
of the tibia but can be
has been a tear of the
tibio-fibular
(Fig.
fractures
tibio-fibularjoint.
this
case
by the
9).
of
Figure
demonstrating
total type “).
but a lateral
projection
behind
the tibia (Fig. 8).
also
end
there
the
tear
of the posterior
radiographs
ligaments
rotation
from
ligament
ligament
7
lateral
fibula
away
6
FIG.
and
333
tibio-fibular
“
cannot
be abducted
from the
axis, as shown
on the rotation
6-Antero-posterior
medial
be abducted
total
FiG.
Figure
LIGAMENTS
the
7-
complete
is classical:
it shows
of the fibula.
The presence
discrepancy
an
The lower
of a rotatory
in width
of the
334
C. J. E. MONK
TREATMENT
if
it is established
that
there
has
been
either
an
anterior
tear
or
a total
tear
of
the
tibio-fibular
ligaments,
one’s
natural
inclination
is to fix the lower
end of the fibula
to the
tibia
by means
of screws
as suggested
by Alldredge
(1940).
However,
this is by no means
always
necessary
; if the ankle
can be held in its normal
position
by external
splintage,
the
inferior
tibio-fibular
to be satisfactory
joint will also be held immobilised.
it is necessary
that the ankle
is stable
and lateral
fibula around
rotation
its long
strain-view
axis indicating
I
Conventional
antero-posterior
showing
rotation
of the lower
splintage
of these joints
straining-that
is, that
8
FIG.
Abduction
For external
to adduction
radiographs
showing
an “ anterior
type
rotation
of the
lesion.”
1G. 9
view and lateral
rotation
strain-view
fragment
of the fibula
indicating
an
radiographs
anterior
“
type
lesion.”
the
medial
malleolus
immobilisation
subtalar
joints
and
ligaments
the
It is
displacement
toes
to
rotational
is intact.
in plaster
are
once
and
force
again
to undergo
particularly
by lateral
groin
(Figs.
which
applied
If this
is so,
10 to 12).
stable.
these
The
It may
injuries
plaster
take
eight
may
be
satisfactorily
should
be retained
or ten
weeks
for
until
the
treated
the
ankle
fractures
by
and
to unite
repair.
important
rotation
that
strains.
holds
to the
the knee
limb will
the
For
plaster
should
protect
the ligaments
against
this reason
we use a plaster
which
extends
from
flexed
at least by 20 degrees.
This ensures
that
act at the hip joint
and not at the site of injury.
THE
JOURNAL
OF
BONE
AND
JOINT
any
SURGERY
INJURIES
OF THE
TIBIO-FIBULAR
FIG.
335
LIGAMENTS
11
!.
FIG.
Figure
10-Conventional
a fracture
antero-posterior
12
and
lateral
radiographs
showing
of the fibula above the inferior
tibio-fibular
joint and a “posterior
malleolar
“
fracture
of the tibia.
Figure
1 1-Abduction
and lateral rotation
strain-view
radiographs
showing
rotation
of the inferior
fragment
of the
fibula indicating
“
anterior
type “ of tibio-fibular
ligament
injury.
Figure
12-The
same ankle a year later.
Treatment
was by manipulative
reduction
and immobilisation
in an above-knee
plaster.
VOL.
51 B,
NO.
2, MAY
1969
336
C. J. E. MONK
If
the
operation
by means
medial
is necessary.
of a single
two
horizontal
and
then
malleolus
Our
oblique
screws.
to rely
is fractured
and the ankle
is unstable
to adduction
straining,
practice
is to reduce
the medial
malleolus
and to immobilise
it
screw and then to fix the inferior
tibio-fibular
joint
by means
of
it would
also
on a plaster-of-Paris
be justifiable
cast
to fix the
to hold
the
ankle
medial
and
malleolus
inferior
with
a screw
tibio-fibular
joints
in
position.
FIG.
13
FIG.
14
_
f
Figure
13-Antero-posterior
fragment
which included
method
of screw fixation
has also been immobilised
and lateral
radiographs
showing
a large posterior
part of the medial
malleolus.
Figure
14-Showing
the
of the posterior
fragment.
The inferior
tibio-fibular
joint
by screws for an ‘anterior
type” tear of the ligaments.
POST-OPERATIVE
When
screws,
are
the
both
a pressure
immobilised
end of which
allowed
to walk
the
medial
dressing
malleolus
is applied
on a right-angled
the sutures
are
with
crutches.
and
the
inferior
at the conclusion
foot splint.
removed
and
The
plaster
CARE
tibio-fibular
joint
of the operation
have
and
been
the foot
fixed
and
by
ankle
The patient
is kept
in bed for two weeks,
at
a full leg plaster
applied.
The patient
is then
is retained
for
THE
eight
to ten
JOURNAL
OF
weeks.
BONE
AND
JOINT
SURGERY
Soft-tissue
and
may
INJURIES
OF THE TIBIO-FIBULAR
OTHER
INDICATIONS
interposition
necessitate
may
operation.
prevent
For
adequate
come to lie lateral
to the medial
malleolus
fragment
(the “ posterior
malleolus
“)
surface
of the
these
with
behind
tibia
patients
forwards
Some
and
may
in the
(Figs.
surgeons
favour
reduction
the
open
position
I 3 and
OPERATION
of the
tendon
of the
displacement
tibialis
reduction
and
fixing
and
the
We
with
ankle
muscle
the posterior
of the inferior
fixation.
fragment
of the
posterior
in the anklejoint.
Sometimes
may
include
a significant
part
necessitate
prone
FOR
example,
337
LIGAMENTS
favour
a screw
may
marginal
articular
operating
passed
from
14).
operative
repair
of
do not feel that these
tears,
of themselves,
prefer
to immobilise
the ankle
in a reduced
tears
the
of
constitute
position
an
and
medial
ligament
of the
indication
for
allow
spontaneous
ankle.
We
open
reduction
but
repair
to occur.
SUMMARY
1.
Attention
described
2. The
3.
4.
is drawn
: the
clinical
to lesions
anterior
type and
and radiological
of the
inferior
The value of strain-view
radiography
A plan of treatment
is suggested.
I would like to thank Professor
reproduction
of the diagrams
tibio-fibular
the total type.
characteristics
Robert
Roaf
and radiographs.
are
ligaments.
Two
main
types
are
described.
is stressed.
for his encouragement
and
advice,
and
Mr A. F. Taunton
for the
REFERENCES
R. H. (1940):
ALLDREDGE,
American
BONNIN,
Books
Medical
Diastasis
J. G. (1957) :
Ltd.
A
of the Distal
Tibiofibular
Joint
and
Associated
Textbook
of Fractures
and
Related
Injuries.
London
Some Applications
of the Functional
Anatomy
of the Ankle
38-A, 761.
P. G. (1953) : Treatment
of True Widening
of Ankle
Mortise.
Canadia,,
Joint
Journal
Heinemann
: William
J. R. (1956):
CLOSE,
Lesions.
the
of
I 15, 2136.
Association,
Joint.
Journal
Medical
ofBone
and
Surgery,
COSTIGAN,
Medical
Association
Journal,
69, 310.
GRATH,
LEE,
H.
G.-B. (1960): Widening
of the
G., and HORAN,
T. B. (1943):
Obstetrics,
MAISONNEUVE,
76,
Ankle
Mortise.
Internal
Fixation
J.-G. (1840): Recherches
sur Ia fracture
J. F. P., and SALLIS, J. G. (1958):
Recurrent
andJoint
Surgery,
40-B,
270.
Sir
London:
VOL.
51B,
R.
(1955):
E. & S. Livingstone
NO.
C/zirurgica
Scandinavica,
Injuries
of the Ankle.
Supplementum
Surgery,
263.
Gynecology
and
593.
MULLINS,
WATSON-JONES,
Acta
in
2, MAY
1969
Fractures
Ltd.
and
Joint
du p#{233}ron#{233}.
Archives
Sprain ofthe Ankle
Injuries.
Fourth
G#{233}n#{233}rales
du M#{233}decine, I, 165, 433.
Joint
edition,
with
Vol.
Diastasis.
II, p. 823.
Journal
Edinburgh
of Bone
and