The distal tibiofibular syndesmosis maintains the ankle mortise integrity through four ligaments: the anterior inferior tibiofibular, posterior inferior tibiofibular (the strongest), interosseous tibiofibular, and inferior transverse tibiofibular ligaments. High ankle sprains from external rotation-dorsiflexion mechanisms disrupt the syndesmosis, producing the widened mortise visible on radiograph with fibular squeeze test pain.
Syndesmotic injury is confirmed by the squeeze test (fibular compression at the midleg produces distal pain), cotton test (lateral fibular translation test under fluoroscopy), and external rotation stress test. Stable syndesmotic injuries are managed with progressive rehabilitation; unstable injuries require suture button fixation or syndesmotic screw fixation to restore mortise width.
Syndesmotic ligament disruption from external rotation mechanism producing mortise widening managed with suture button fixation for unstable injuries.
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