MANAGEMENT OF ANKLE SYNDESMOTIC INJURIES

Abstract

Thirteen tendons, two major arteries and veins, and five nerves cross the ankle joint. The tendons are divided into four groups. The Achilles and plantaris tendons lie posteriorly in the midline and are not intimately associated with the ankle joint. The tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles are innervated by the tibial nerve. Their tendons pass posterior to the medial malleolus, held in position by the flexor retinaculum.The tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius muscles are innervated by the deep peroneal nerve. Their tendons pass anterior to the ankle joint and are held in position by the thick, broad extensor retinaculum.The peroneus longus and brevis muscles are innervated by the superficial peroneal nerve and their tendons are held in position behind the fibula by the peroneal retinaculum and peroneal tendon sheath (15).

The anterior neurovascular bundle (anterior tibial artery and deep peroneal nerve) crosses the ankle beneath the extensor retinaculum between the tibialis anterior and the extensor hallucis longus tendons. The posterior neurovascular bundle (posterior tibial artery and tibial nerve) passes behind the medial malleolus within the flexor retinaculum, between the flexor digitorum longus and flexor hallucis longus tendons. Three superficial sensory nerves cross the ankle. The saphenous nerve passes anterior to the medial malleolus, along with the long saphenous vein, and innervates the medial part of the foot. The superficial peroneal nerve is located just lateral to the anterior midline and supplies the skin of the dorsum of the foot. The sural nerve passes posterior to the fibula, along with the short saphenous vein,and supplies the non weight bearing lateral skin (15).