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Introduction:A Pott's fracture, is an archaic term loosely applied to a variety of bimalleolar anklefractures. The injury is caused by a combined abduction external rotation from aneversion force. This action pulls on the extremely strong medial (deltoid) ligament, oftentearing off the medial malleolus. The talus then moves laterally, shearing off the lateralmalleolus or, more commonly, breaking the fibula superior to the tibiofibularsyndesmosis. A bIntroBimallelolar fracture with syndesmosis disruption is not a common injury that you seeevery day. Out of all the ankle injuries evaluated only 15% end up being anklefractures. In the past 20 yrs the frequency of ankle fractures has increased to about 187in 100,000 person/ year. The ratio for ankle fractures from male to female is 2:1, butpeople who get ankle fractures that are older than 50 usually are female and youngerthan 50 are usually male. Bimalleolar fractures are called Pott’s fractures, which meansthat at least 2 elements of the ankle ring are involved. Pott’s fractures require urgent

orthopedic attention because the ankle is unstable. 

AnatomyThe articulation between the distal ends of the fibula and tibia form the distal tibiofibular joint. This is a

syndesmotic type joint allowing only a limited amount of motion. This joint is supported by the anterior-

inferior tibiofibular ligament, interosseous ligament, and posterior- inferior fibular ligaments (Figure 1)

The pertinentThe bony anatomy of the ankle for (talocrural) joint, also known as the ankle

consistincludes s of the fibula, tibiula, calcaneous and talus bones. The rounded malleolar prominences

on each side of the joint form a mortise for the upper surface of the talus. (Figure 2)  The joint and bones

are stabilized via ligaments some of which include the anterior talofibular ligament, calcaneofibular

ligament, tibionavicular ligament, and the anterior tibiotalar ligament. A few of the musculature of the

ankle and lower leg are anterior and posterior tibialis, peroneus tertius, longus and brevis and externsor

hallucis longus and brevis.

The anterior-inferior tibiofibular ligament, interosseous ligament, and posterior- inferior fibular

ligaments. make up the syndesmosis. 

Common MOI

Common mechanism of injury for a bimalleolar fracture include blunt force trauma or in

the case of this athlete, a team tackle. The syndesmosis injury usually occurs when the

foot is forced upward and outward. 

Signs and Symptoms

The chief complaint following a The signs and symptoms of a bimalleolar fracture are is

severe pain throughout the whole ankle. Other signs and symptoms include a

significant amountThere will also be lots of swelling present in the foot, ankle and lower

leg. There will be a majorand deformity seen from the dislocation and you will possibly

be able to see the fx’s. One of the main things is that the athleteFunctionally the patient 

Comment [MSOffice1]: Citation?

Comment [MSOffice2]: Citation?

Formatted: Font: (Default) Arial, 12 pt

Formatted: Font: (Default) Arial, 12 pt

Comment [MSOffice3]: Citation

Comment [MSOffice4]: Pott’s fractures are

named after the individual that described them

originally… see

http://www.whonamedit.com/synd.cfm/1126.html

Formatted: Strikethrough

Comment [MSOffice5]: Probably don’t need to

mention the muscles involved.

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will be unable to bear weight on their ankle. Mild to moderate syndesmosis sprains may

at first feel like a routine sprained ankle. The signs and symptoms of syndesmosis

disruption include pain and swelling on the outside lateral side of the ankle. The patient

may also reportMay get pain in the ankle joint if they try to turn or twist their ankle . The

pain can also radiating paine upward along the lower part of the leg. 

Sugrical Intervention? 

Rehabilitation

Post-op: bulky jones dressing, NWB, elevation

7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated.

Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without

the brace.

6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right

leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking

(sigvaris, Jobst) 20-30mmHg

3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed

only after a full range of motion of the ankle has been achieved

6 Months: Return to sport / full activities.

1Yr: Assess outcomes, F/U xrays.

Manual Therapy

Therapeutic exercises

Modalities

Neuromuscular Re-education

Patient Education

Return to playAthletes who fracture both malleoli can return to play once their fractures are completely healed. They

also need to have full and pain free range of motion. When testing their muscle strength they need to

have at least 90% back when compared to their uninvolved extremity. To completely clear and athlete

to return to play they need to be ran through a functional tests and pass them.

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Case Study

On April 11, 2009, a 20 yr old intercollegiate football athlete at a Division I-AA institution was

involved in a team tackle where his ankle was “caught under the pile at practice.” He was evaluated on

the field by Brian Norton, MS, ATC. The athletes’ ankle was noticeably dislocateddeformed, so thus he

was splinted and sent to the ER. There Dr. James Dunlaphe patient was diagnosed the athletes injury

aswith a closed bimalleolar fracture with a / syndesmosticis disruption after x-rays. On April 12, 2009 the

athlete was scheduled for surgery, which was performed by Dr. James Dunlap at Providence Orthopedic

Specialists. The surgery wasthe patient underwent an open reduction internal fixation. The athlete was

able to start physical therapy on May 21st

at U District PT “Institute of Sports Performance”one month

later. He went twice a week for 8- 10 weeks. After returning to play and starting out the fall season, the

athlete was injured again while playing in a game. On September 28, 2009 during the football game

against Sacramento State the athlete tore his ACL. He was evaluated on the field side lines by Brian

Norton, MS, ATC and Dr. Dan Dami. Dr. Dan Dami stated that the ACL had been injured in the spring

when his other injury had occurred. After returning to Eastern Washington University the athlete wasseen by team physician, Dr. Halverson, who also confirmed that the ACL had been injured in the spring

season prior to that game, but during the Sacramento State game he ended up completely tearing it.

For the athlete ACL he had an MRI on September 30, 2009. The results of that MRI were that the athlete

had a grade 3 ACL and a partially torn meniscus. The athlete and head athletic trainer Brian Norton, MS,

ATC decided that it would be better to have surgery after season but would continue playing with a

brace. The athlete had a scheduled surgery for January 4, 2010. After his surgery the athlete is now

currently doing rehab with EWU Athletic Training and is making good progress. 

I would only mention the ACL tear in passing (see status section below) 

Rehabilitation (Can you put this into the narrative format? …and be specific to

your patient)

Post-op: bulky jones dressing, NWB, elevation

7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated.

Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without

the brace.

6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right

leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking

(sigvaris, Jobst) 20-30mmHg

3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed

only after a full range of motion of the ankle has been achieved

6 Months: Return to sport / full activities.

1Yr: Assess outcomes, F/U xrays.

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Manual Therapy

Therapeutic exercises

Modalities

Neuromuscular Re-education

Patient Education

Return to playAthletes who fracture both malleoli can return to play once their fractures are completely healed. They

also need to have full and pain free range of motion. When testing their muscle strength they need to

have at least 90% back when compared to their uninvolved extremity. To completely clear and athlete

to return to play they need to be ran through a functional tests and pass them.

Status: I would mention that the patient’s return to play has been complicated by another injury… 

References (personal communications are not listed in the reference listing) 

Anderson M., Hall S., & Martin M. (2004). Foundations of athletic training. Philadelphia: Lippincott

Williams and Wilkins.

Pudda, G., Giombini, A., & Selvanetti, A. (2001). Rehabilitation of sS ports iInjuries: Current cC oncepts .

Berlin/Heidelberg: Springer.

Norton, Brian MS ATC, initial evaluation

http://emedicine.medscape.com/article/824224-overview 

Author: Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General

Hospital

Coauthor(s): Andrew A Aronson, MD, FACEP, Vice President, Physician Practices, Bravo Health Advanced Care Center;

Consulting Staff, Department of Emergency Medicine, Taylor Hospital, Ridley Park, Pennsylvania

http://eorif.com/AnkleFoot/Ankle%20Fx%20ORIF.html 

Figure 1

Comment [MSOffice6]: Fix this citation.

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I didn’t see an abstract attached… Here is my suggestion… 

A Pott's fracture, is an archaic term loosely applied to a variety of bimalleolar anklefractures - which means that at least 2 elements of the ankle ring are involved. Abimallelolar fracture with syndesmosis disruption is not a common injury that you seeevery day. Out of all the ankle injuries evaluated only 15% end up being anklefractures. This case study describes the history and rehab of a 20 yr old intercollegiate

football athlete at a Division I-AA institution that was diagnosed with a closed bimalleolar

fracture with a syndesmostic disruption.

Comment [MSOffice7]: Citation?