A syndesmosis(韌帶聯合) is a slightly movable fibrous joint in which bones such as the tibia and

fibula are joined together by connective tissue. Examples include the distal tibia fibular joint as well as the
radioulnar joint. Injuries to the ankle syndesmosis are commonly known as a "high ankle sprain". Although
the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the

syndesmotic ligaments. 通常中間的結締組織形成股間膜或韌帶與骨相連接

Syndesmosis
 Anterior-inferior tibiofibular ligament (AITFL)
 Posterior-inferior tibiofibular ligament (PITFL)
(deep portion of this ligament sometimes reffered to as the inferior transverse ligament)
 Transverse tibiofibular ligament (TTFL)
 Interosseous ligament (IOL)
 interosseous membrane (IO)
A Pilon fracture, also called a Plafond fracture, is a fracture of the distal part of the tibia, involving its articular
surface at the ankle joint. Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a
height or motor vehicle accidents. Pilon fractures are rare, comprising 3 to 10 percent of all fractures of the tibia
and 1 percent of all lower extremity fractures, but they involve a large part of the weight bearing surface of the
Tibia in the ankle joint. Because of this, they may be difficult to fixate and are historically associated with high
rates of complications and poor outcome.
Pilon is the French word for pestle and was introduced into orthopedic literature in 1911 by pioneer French
radiologist Étienne Destot.[1]

 Often, the posterior fragment reduces simultaneously when the lateral malleolus is reduced because of
their respective attachments to the posteroinferior tibiofibular ligament (PITFL). This fragment, also
known as a Volkmann's fragment, can then be fixed with lag screws inserted from anterior to posterior.
This expected reduction is not likely if the ankle is not being fixed acutely because of the interposition
of organized hematoma or callus. Further, it would seem that a supine approach to an ankle fracture
with a posterior malleolus fragment fixed with screws placed anterior to posterior would be analogous
to fixing a lateral tibial plateau fracture with screws from the medial side.
The tarsal sinus (or sinus tarsi) is a cylindrical cavity located between the talus and calcaneus on the lateral aspect
of the foot. MRI is the investigation of choice for evaluating the tarsal sinus structures.

Gross anatomy

The tarsal sinus is situated on the lateral side of the foot; distal and slightly anterior to the lateral malleolus. It is a
space bordered by the neck of the talus and anterosuperior aspect of the calcaneus. The tarsal sinus opens medially,
posterior the sustentaculum tali of the calcaneus, as a funnel-shaped tarsal canal. The sinus tarsi separates the
anterior subtalar joint and posterior subtalar joint 3-4.
Posterolateral approach

 Often, the posterior fragment reduces simultaneously when the lateral malleolus is reduced because
of their respective attachments to the posteroinferior tibiofibular ligament (PITFL). This fragment, also
known as a Volkmann's fragment, can then be fixed with lag screws inserted from anterior to posterior
 This expected reduction is not likely if the ankle is not being fixed acutely because of the interposition
of organized hematoma or callus.
 This allows fixation of the medial and posterior malleoli through the same incision.
 One such approach is to use the same posteromedial incision and access the posterior malleolus by incising the sheaths of
the tibialis posterior and flexor digitorum longus tendons and retracting them anteriorly
 Prone, decubitus position if no medial traulma.
 The lesser saphenous vein and sural nerve are identified and protected.
 Perform meticulous blunt dissection in the subcutaneous tissue to protect sural nerve.
 Retracting the peroneal tendons medially gives access to the posterior aspect of the lateral malleolus.
 The flexor hallucis longus is lifted off the posterior tibia allowing access to the posterior malleolus.
 He found it especially useful for patients with smaller, posterior fragments

 Advantages of posterolateral approach of ankle

1. The main advantage is that it allows a direct inspection and reduction of the posterior fragment.
2. Anatomical reduction of articular surfaces is a basic principle in fracture surgery, and this approach certainly promotes that
goal.
3. the direct visualization allows for the joint to be inspected for osteochondral fragments, talar chondral damage or impaction
injury.
4. With this exposure, the surgeon can choose to supplement fixation of the posterior malleolus with a buttress plate, also a
basic fixation principle in a weight-bearing joint that will experience axial load or shearing forces during weight bearing.
5. In addition, this is the exposure of choice for the use of an antiglide plate for fibular fixation. Such a posterolateral fibular
construct has been shown in biomechanical studies to be superior to the more commonly used lateral plate
6. Soft-tissue coverage for the plate is also enhanced in the posterior fibular position.