Diagnosis

44-C2 Suprasyndesmotic fracture of the fibula, multifragmentary

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Type C fractures occur with the foot in pronation when an external rotation force is applied. The first injury is a failure of the medial side, either with a deltoid ligament rupture, or a medial malleolar fracture. This frees the talus to move anteriorly as it rotates externally. The talus causes the fibula to rotate externally around its longitudinal axis, sequentially tearing the anterior and interosseous ligaments. Finally the fibula fractures proximal to the syndesmosis.


44-C fractures correspond to pronation-eversion fractures, stages I-IV, in the Lauge-Hansen classification. This is an especially unstable joint lesion that may demand - depending on its stage – a syndesmotic positioning screw.

Options
1. 44-C2.1 With rupture of the medial collateral ligament
2. 44-C2.2 With fracture of the medial malleolus
3. 44-C2.3 With fracture (medial malleolus) and a Volkmann

1. 44-C2.1 With rupture of the medial collateral ligament

44-C2.1

44-C2.1

Fibula
A multifragmentary, diaphyseal fracture occurs above the syndesmotic ligaments; displaced.

Medial lesion
A rupture of the medial collateral ligament.

Syndesmotic complex
Disrupted.

44-C2.1

44-C2.1

2. 44-C2.2 With fracture of the medial malleolus

44-C2.2

44-C2.2

Fibula
A multifragmentary, diaphyseal fracture occurs above the syndesmotic ligaments; displaced.

Medial lesion
A transverse, or oblique, fracture of the medial malleolus.

Syndesmotic complex
Disrupted.

44-C2.2 AP and lateral view

44C2.2 AP and lateral view

3. 44-C2.3 With fracture (medial malleolus) and a Volkmann

44-C2.3

44-C2.3

Fibula
A multifragmentary, diaphyseal fracture above the syndesmotic ligaments, displaced.

Medial lesion
A transverse, or oblique, fracture of the medial malleolus.

Posterior tuberosity of the tibia
The fracture of the posterior tibial lip may be a small cortical avulsion. Rarely in 44-C fractures, a larger fragment, bearing a variable area of the posterior articular surface, fractures off.

Syndesmotic complex
While the foot rotates externally, the syndesmotic ligaments rupture. The talus, rarely, is forced backwards and compresses the posterior lip of the distal tibial joint surface until finally a Volkmann lesion results.

It is possible, that some of these injuries represent vertical compression (posterior pilon) fractures, such as the x-ray below. 

44-C2.3 AP and lateral view

44-C2.3 AP and lateral view