Syndesmosis injuries in the pediatric and adolescent athlete: an analysis of risk factors related to operative intervention

PURPOSE: To review all paediatric ankle syndesmotic injuries occurring at our institution and identify risk factors associated with operative intervention. METHODS: Among 22 873 evaluations for ankle trauma, we found 220 children suffering from syndesmotic injuries (incidence: 0.96%). We recorded demographic data, details of the injury, features on examination and treatment variables. Univariable and multivariable logistic regression modelling was performed to identify risk factors associated with operative intervention. RESULTS: The mean age at injury was 15.8 years (8.9 to 19.0) with a median follow-up of 13 weeks (IQR 5 to 30 weeks). A sports-related injury was most common (168/220, 76%). A total of 82 of 220 (37%) patients underwent operative fixation, of which 76 (93%) had an associated fibular fracture. Patients undergoing surgery had a higher incidence of swelling and inability to weight bear (p < 0.001). Statistically significant differences were recorded in tibiofibular (TF) clear space, TF overlap and medial clear space (MCS) between the operative and non-operative cohorts (6.0 vs 4.6 mm (p = 0.002), 5.4 vs 6.9 mm (p = 0.004) and 6.4 vs 3.5 mm (p < 0.001)). Multivariable analysis revealed patients with a fracture of the ankle had 44 times the odds of surgical intervention, patients with a closed physis had over five times the odds of surgical intervention and patients with a medial clear space greater than 5 mm had nearly eight times the odds of requiring surgical intervention. CONCLUSIONS: Operative ankle syndesmotic injuries in the paediatric population are often associated with a closed distal tibial physis and concomitant fibular fracture.