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Deltoid Ligament Injuries arising from Ankle Frx


- Discussion:
    - in absence of a medial malleolar fracture deltoid ligament may be stretched or torn in all oblique frx of fibula;
    - this ligament prevents posterior tibial tendon from slipping into ankle joint;
    - ligament ultimately heals in a lengthen position;
    - these patients are often diagnosed as having chronic deltoid sprains;
    - main problem, however, is lateral talar shift resulting from malunited frx of lateral malleolus or a syndesmotic ligament  injury, which
              widens mortise & produces chronic ankle instability;
    - management of deltoid ligament injuries in association w/ fractures of the lateral malleolus is controversial;
    - both operative and non operative treatment is possible;
    - because talus follows fibula when deltoid is ruptured, anatomic restoration of fibula and talus restores medial anatomy & allows medial ligamentous structures
             to heal without the need for operative treatment;
    - repair of deep deltoid ligament is complicated by its short length & position under the medial malleolus;

- Exam Findings:
    - medial ecchymosis appears after 24 hrs when the deltoid  ligament has been disrupted);
    - ref: Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures?

- Operative Indications:
    - exploration of medial side of the ankle should be limited to cases in which the fibula and talus cannot be anatomically reduced:
    - reduction may be blocked by interposed fibers of deltoid ligament or  interposed posterior tibial tendon;
    - evidence for mal-reduction includes medial clear space is widened by > 2 mm following reduction

- References:  
      - Deltoid Ligament Repair vs. Syndesmotic Fixation in Bimalleolar Equivalent Ankle Fractures.
      -  Fractures of the distal part of the fibula with associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament.
      - Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament.
      - Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments.