Review Question - QID 3914

The AITFL inserts on the site marked with an arrow. The fracture should be fixed and then an assessment of the syndesmosis should be performed.

The AITFL is part of the distal tibiofibular syndesmosis. It originates from the anterolateral tubercle of the tibia (Chaput tubercle) and inserts on the anterior tubercle of the fibula (Wagstaffe's tubercle). In some cases, direct repair of the fracture will stabilize the syndesmosis, however, in most cases syndesmotic fixation is required. There is no optimal surgical treatment for syndesmotic injuries at this time as there are conflicting reports on how they should be treated.

Zalavras and Thordarson performed a review of ankle syndesmotic injuries. They report that the mechanism of syndesmotic injury involves an external rotation force applied to the foot relative to the tibia. The injury may be ligamentous or there may be an associated boney injury as well. They conclude that restoration of the proper tibio-fibular relationship involves regaining fibular length and reestablishing correct rotation and position of the fibula relative to the tibia.

Nelson performed a review on the examination and repair of the AITFL in transmalleolar fractures and he describes a technique on AITFL repair. He reports that anatomic repair of the AITFL injury restores the stability of the ankle mortise and improves the stability of the bone repair, allowing for an early return to functional exercises and activities. He concludes that syndesmotic fixation was not necessary when the AITFL was repaired.

Figure A demonstrates an axial CT slice with an arrow indicating Wagstaffe's tubercle. The AITFL inserts at this site. Illustration A & B (Zalavras and Thordarson) are illustrations demonstrating syndesmotic structures, (IOL: Interosseous ligament, PITFL: Posterior inferior tibiofibular ligament, ITL: Inferior transverse ligament).

Incorrect Answers:
Answer 2: The anterior talofibular ligament originates at the anteroinferior border of the fibula and attaches at the neck of the talus. It is not part of the syndesmosis.
Answers 3, 4, 5: These structures do not insert on Wagstaffe's tubercle. A syndesmotic screw may not be necessary and the status of the syndesmosis should be assessed prior to fixation.