BACKGROUND: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound.
METHODS: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle.
CONCLUSIONS: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy.

UNASSIGNED: Extensor retinaculum syndrome (ERS) is a relatively rarely diagnosed compartment syndrome-like entity caused by elevated pressures in the tissues deep to the superior extensor retinaculum (SER). ERS is identified as out-of-proportion anterior ankle pain, pain with passive toe plantarflexion, elevated SER pressures (>40 mm Hg), and ultimately toe extension weakness and first web space numbness. Although previously described in a pediatric population, this case series is the first to our knowledge in an adult population.
UNASSIGNED: Seven nonconsecutive cases over 18 years from 2 surgeons are reported who underwent complete SER release for ERS either through the direct lateral approach to the fibula or the anterolateral approach to the distal tibia. All were associated with traumatic injuries including 3 bimalleolar ankle fractures, 3 tibial pilon fractures, and 1 distal tibial/fibular shaft fracture. All patients developed writhing anterior ankle pain worsened with passive toe plantarflexion. SER compartment pressures ranged from 50 to >135 mm Hg. Five cases displayed decreased first web space sensation.
UNASSIGNED: The diminished or absent first web space sensation uniformly improved post-release. Complications included 1 patient with complex regional pain syndrome type 1, 1 patient required hardware removal, and 2 had persistent but improved first web space sensation changes.
UNASSIGNED: Clinical suspicion for possible ERS should arise after distal tibial/fibular fractures when the excruciating pain localizes to the ankle instead of the classic anterior leg muscle bellies. If pain is worsened with passive toe plantarflexion, this diagnosis should be considered. Recommended treatment involves complete release of the SER anywhere on the anterior surface between the tibia and fibula depending on the approach needed for fixation of the associated fracture.
UNASSIGNED: Level IV, case series.

BACKGROUND: Fracture of the lateral tubercle of the posterior process of the talus (Shepherd fracture) is an uncommon injury seen in sport. It is secondary either to indirect trauma on the plantarflexed foot or to high-impact direct trauma. The fracture can be missed with conventional X-rays and therefore advanced imaging methods such as CT scans are usually warranted for management planning. There is a low threshold towards surgical management in the displaced or comminuted case as the delayed functional outcome with conservative treatment is frequently sub-optimal with long-term pain, degenerative changes and non-union. In this regard, recent years saw an increasing interest in the role of minimally invasive approaches for Shepherd´s fracture treatment, such as arthroscopic reduction and internal fixation (ARIF).
METHODS: We present a case of a 27-year-old white male professional football player from Serbia who had Shepard fracture and successfully managed with arthroscopic osteosynthesis. The technical approach is detailed with posterior ankle arthroscopy offering the advantages of a minimally invasive approach with low morbidity and a rapid return to regular sporting activities.
CONCLUSIONS: The utilization of the 2-port arthroscopic approach this method enables the direct observation of the articular surface along with the corresponding fracture lines, thereby affording the surgeon the chance to achieve accurate reduction via a minimally invasive soft tissue aperture. We advocate that Arthroscopic reduction and internal fixation (ARIF) is a reliable method for the fixation of Shepherd\'s fracture in the hands of experienced ankle arthroscopists.

Isolated Tillaux fracture is a rare anterolateral distal tibia fracture frequently misdiagnosed in adults. It typically occurs in adolescents nearing skeletal maturity by avulsion of the anterior-inferior tibiofibular ligament. This case-based literature review study aims to elicit the existing information regarding this fracture in adults, and summarize its injury mechanism, diagnosis, and treatment procedures. According to the literature, this is only the eighth case described: a 46-year-old woman that suffered an isolated Tillaux fracture with 4 mm of displacement, and open reduction and fixation with double cannulated screws were performed. After proper rehabilitation, an excellent functional and radiological outcome was reached. It is important to recognize and appropriately treat these distinct injuries to prevent further instability, degenerative changes, and ankle joint function limitation. Early diagnosis and appropriate osteosynthesis play a significant role in a successful recovery prognosis.

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

BACKGROUND: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture.
METHODS: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility.
METHODS: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS).
METHODS: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits.
RESULTS: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification.
CONCLUSIONS: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

METHODS: A 19-year-old woman sustained an open ankle fracture with complete destruction of the left medial malleolus and significant soft-tissue loss. After temporizing external fixation and coverage with a rotational posterior tibial artery perforator flap, the medial malleolus was reconstructed with an autologous iliac crest bone graft and direct repair of the deltoid ligament. The patient achieved excellent improvement in functional outcomes at 21 months with adequate restoration of ankle motion.
CONCLUSIONS: This case shows reconstruction of the medial malleolus with autologous iliac crest bone graft after traumatic loss can be a viable treatment option for young patients.

BACKGROUND: Results of operative fixation for ankle fractures had been suboptimal, with cases of posttraumatic osteoarthritis occurring following the surgeries. Intra-articular injuries have been suggested as the cause of this problem. This case report aims to present an ankle pilon fracture Ruedi Allgower type II case treated with percutaneous fixation and arthroscopy evaluation.
METHODS: Female, 17 years old, complained of pain and swelling at the right ankle. The physical examination revealed swelling, deformity, tenderness, and limited range of motion at the right ankle. The radiological examination showed a Ruedi Allgower type II pilon fracture with right ankle dislocation. The patient underwent closed reduction, arthroscopy to evaluate her right ankle and percutaneous internal fixation. The post-surgery evaluation showed a stable ankle.
CONCLUSIONS: Patients undergoing ankle fracture surgery may benefit from ankle arthroscopy because it may increase visualization of articular reductions, assess and repair cartilage and ligament damage, remove loose bodies, decrease soft tissue exposure, preservative vascularity, and evaluate syndesmosis. Moreover, rapid arthroscopic evaluation has a low complication rate. The ability of arthroscopy to improve syndesmotic instability diagnosis suggests that arthroscopy may play a significant role in managing ankle fractures.
CONCLUSIONS: Arthroscopy-assisted internal fixation provides more benefits and information as a single case report, and more studies are warranted; regarding patients\' intra-articular injuries, preventing future complications, such as posttraumatic osteoarthritis.

BACKGROUND: Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously.
METHODS: In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident.
METHODS: The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation.
METHODS: As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital.
RESULTS: During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital.
CONCLUSIONS: The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.

A common ankle fracture that can have major consequences and expensive medical bills is the trimalleolar fracture. The trimalleolar fracture is the least frequent type of ankle fracture. The number of afflicted malleoli, the kind of fracture of the lateral and medial malleolus and the congruence of the ankle joint were all examined in detail for the trimalleolar ankle fracture. This type of fracture is brought on by high-energy trauma. In this case report, we describe a 56-year-old female patient who was involved in a road traffic accident. After being taken to the hospital for further examination, her ankle fracture was determined to be a trimalleolar one. She had an internal fixation with canulated cancellous screws and nails for open reduction. For such patients, we designed a physiotherapy course based on early rehabilitation and sensorimotor retraining to help with proprioception training, gait training and lower-limb muscular strength training. The lower limb\'s strength and range of motion were improved with the treatment. The outcomes used were the numerical pain rating scale (NPRS), functional independence measure (FIM), lower-extremity functional scale (LEFS), range of motion (ROM), gait parameters and manual muscle testing (MMT).