The distal tibiofibular syndesmosis is a fibrous joint between the fibular notch of the tibia and the distal fibula, bound by the anterior and posterior inferior tibiofibular ligaments, the interosseous tibiofibular ligament and the inferior transverse ligament. It holds the fibula against the tibia so the ankle mortise keeps its width, while allowing a few millimetres of fibular movement as the wider front of the talus enters the mortise in dorsiflexion. Disruption allows the fibula to separate (diastasis), widening the mortise and increasing tibiotalar contact stress.
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Syndesmotic injury (high ankle sprain) usually follows external rotation of the foot and causes pain above the ankle joint line. It is assessed with the squeeze test, the external rotation stress test and, under anaesthesia, the Cotton test, and needs longer rehabilitation (often 8 to 12 weeks) than lateral ankle sprains. On radiographs a tibiofibular clear space wider than about 6 mm suggests diastasis, and weight-bearing or stress views help detect subtle instability. Unstable injuries need anatomic reduction and fixation with a syndesmotic screw or suture button device. Malreduction or a missed injury leads to chronic pain and early tibiotalar arthritis.
High ankle sprain from external rotation, producing pain above the ankle and positive squeeze and external rotation tests; unstable injuries widen the mortise and need fixation.
Complete syndesmotic disruption with widening of the mortise, requiring surgical stabilisation with a syndesmotic screw or suture button.
The fibula left malrotated or displaced in the fibular notch after ankle fracture fixation, causing persistent pain and early ankle arthritis; may need revision reduction.
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