|Dear EM Cases listener,|
Q: A 20-year-old soccer player comes to the ED following a right ankle injury. He describes a mechanism involving external rotation of the ankle and dorsiflexion. On physical exam, his ankle is swollen and he is unable to weight bear, but there is no bony tenderness to the malleoli, navicular bone or fifth metatarsal. What physical exam findings might suggest the presence of a syndesmosis injury (high ankle sprain)?
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A: In patients with ankle injuries, the following signs suggest the presence of a syndesmosis injury:
- Toe walking (to prevent painful dorsiflexion)
- Positive squeeze test (Hopkins test): squeeze the tibia and fibula at the level of the mid-calf, eliciting pain at the anterior/inferior ankle joint
- Positive external rotation test: stabilize the patient’s leg with the hip and knee flexed to 90 degrees, then hold the foot and externally rotate at the ankle while applying dorsiflexion, eliciting pain at the syndesmosis
If X-rays of the ankle are negative for a fracture or joint widening, but a syndesmosis injury is suspected, patients should be made non-weight bearing and placed in an aircast or posterior slab with orthopedic follow up.
For more on this topic click here to go to Episode 105