The tibiofibular clear space is the radiographic measurement of the distance between the medial wall of the fibula and the incisural surface of the tibia on an anteroposterior ankle X-ray, normally less than 6 mm at 1 cm above the plafond. It is the primary radiographic indicator of syndesmotic integrity and mortise width.
A tibiofibular clear space greater than 6 mm on mortise view X-ray indicates syndesmotic diastasis requiring surgical stabilisation. The tibiofibular overlap (normally greater than 6 mm on AP view) complements the clear space measurement. CT provides three-dimensional assessment of subtle syndesmotic widening not apparent on X-ray. Dynamic fluoroscopy with external rotation stress reveals occult diastasis in equivocal cases. Syndesmotic screw or tightrope fixation restores normal clear space.
Widening of the tibiofibular clear space beyond 6 mm from complete syndesmotic ligament disruption, requiring surgical stabilisation with a syndesmotic screw or suture-button device to restore mortise congruence.
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