Instability of the Tibio-Fibular Syndesmosis: Have We Been Pulling in the Wrong Direction?

"Ankle syndesmosis injuries are notoriously difficult to manage if initially undiagnosed, and it has been emphasized recently that subtle syndesmosis injuries can accompany Weber B distal fibular fractures in which the syndesmosis has traditionally been considered to be stable. All ankle fractures and other injuries with suspected disruption of the syndesmosis should be examined under anesthesia as well as fluoroscopically in order to determine whether there is syndesmotic widening with load. The so-called Cotton or Hook test refers to the demonstration of coronal plane (lateral) instability manifest as distal tibia-fibular widening on an anteroposterior x-ray of the ankle. Others have recommended an external rotation test, with similar demonstration of coronal plane instability."