A twenty-five-year-old man was transferred from a nearby emergency department for evaluation of an injury to the left ankle. The patient stated that he had been playing in a recreational basketball game and landed on another player’s foot after he went up for a shot. Immediate pain caused him to stop playing, and he noticed blood on the sock when he removed the shoe. The patient had no other known medical issues and was a very active individual; he was preparing to try out for a semiprofessional basketball team in the coming weeks.
Physical examination revealed a 2 × 3-cm defect over the lateral aspect of the left ankle, with the lateral malleolus buttonholed through the skin (Fig. 1). The medial aspect of the ankle joint was injected with saline solution, and extravasation exiting the lateral wound was noted. There was diffuse tenderness to palpation and palpable crepitus over the dorsolateral aspect of the ankle. Diffuse edema was noted over the entire ankle. Active dorsiflexion and plantar flexion of the toes were intact, yet ankle motion was limited by pain. Sensation was intact to light touch over the deep and superficial peroneal, tibial, sural, and saphenous nerve distributions in the foot. Dorsalis pedis and posterior tibial pulses were 2+, and there was brisk capillary refill noted in the toes.
Radiographs of the ankle showed no fracture or dislocation (Figs. 2-A, 2-B, and 2-C); however, mild medial talar tilt was noted. The lateral malleolus could not be reduced in the emergency department because of the constrictive effect of the surrounding soft tissues. The patient was taken to the operating room where a Freer elevator was used to remove the skin around the lateral malleolus to allow reduction. A towel clip was used to grasp and pull the fibula that was laterally stressing the syndesmosis, which appeared to be intact under fluoroscopic evaluation. There was no instability noted on the medial aspect of the ankle. The anterior and lateral portions of the capsule along with the ligamentous complex of the lateral aspect of the ankle had been avulsed completely from the fibula during the injury. The destruction and stretching of the capsule and ligamentous complex were so extensive that a surgical repair could not be performed. There was no obvious injury noted to the peroneal tendons.
The wound was irrigated and debrided thoroughly, and the skin was closed with nylon sutures. Because of the gross instability of the ankle, it was decided that the patient would need an extended period of immobilization to allow the soft tissues to heal. In order to continue to monitor the healing of the lateral soft-tissue wound and provide ankle joint stability at the same time, an external fixator was placed in delta-frame fashion across the ankle. Following placement of the external fixator, acceptable reduction of the talus was confirmed under fluoroscopic evaluation. The patient was discharged home the next day.
Three weeks after injury, the external fixator was replaced with a short leg cast, and a removable cast brace was applied at six weeks. The patient remained non-weight-bearing for twelve weeks following the injury, but he began physical therapy for ankle motion and strengthening exercises at six weeks. Once weight-bearing was initiated, he was allowed to progress as tolerated and was told to continue physical therapy.
At four months following the injury, the patient stated that he was doing basketball drills that included running and cutting. He noted that he was not quite at full speed but had minimal pain and noticed no instability in the ankle. On physical examination, he had full strength of ankle dorsiflexion, plantar flexion, inversion, and eversion. There was active ankle dorsiflexion to 5° and plantar flexion to 35°, with full inversion and eversion. There was no instability noted on examination and no tenderness to palpation. The patient was told to resume full activities as tolerated.