A new assessment for syndesmosis injury – The ‘Chertsey test’ Robert P.R. Boyd *, Syed Zuhair Nawaz, Arshad Khaleel Ashford & St Peter’s Hospitals NHS Foundation Trust, United Kingdom Introduction Injury to the syndesmosis occurs with a variety of ankle trauma and may require operative fixation. It is known that if a syndesmosis injury is not detected or not treated it leads to pain and arthritis [1]. Syndesmotic injury may be detected either by clinical testing or radiologically. Many fixation methods have been described, and currently there is no consensus on the best technique. What has been shown is up to 40% of fixations have a degree of malreduction [2]. We describe a simple technique, which both gives accurate intra-operative assessment of injury to the syndesmosis and also can check how well the fibula has been reduced, if required. The syndesmosis is a fibrous articulation between the distal tibia and fibula. The fibular sits in a shallow groove of the tibia called the incisura and is held firmly by three strong ligamentous complexes: that of the anterior and posterior, as well as the interosseous ligaments. There is a small recess of the ankle joint vertically into the syndesmosis (recessus tibiofibularis) which is almost always present and varies in size but can be up to 25 mm [3–5]. The type of ankle injury which is most associated with disruption of the syndesmosis is the pronation external rotation or pronation abduction type resulting in a high fibula fracture; either a Weber C or Maissonneurve pattern. It can also arise from a supination external rotation injury associated with a lower, Weber B fracture [6,7]. Rarely, there is complete disruption without bony injury [8]. Injury, Int. J. Care Injured xxx (2016) xxx–xxx A R T I C L E I N F O Article history: Accepted 4 March 2016 Keywords: Ankle Syndesmosis Injury Chertsey test A B S T R A C T Introduction: If a syndesmosis injury is not detected, or not treated appropriately, it can lead to pain and arthritis. Various techniques have been described to look for the presence of a syndemosis injury. If concern is raised regarding malreduction, the most recognised way of checking accuracy of the reduction (of the fibula into the incisura) is bilateral postoperative ankle CT scans. This not only exposes the patient to further radiation, but can normally only be done once the surgery is completed and so if adjustment is needed, this requires a further operation, encompassing further surgical risks. We developed a simple assessment, which both gives accurate intra-operative demonstration of an injury to the syndesmosis and also can check how well the fibula has been reduced (if required), without the need for further radiological investigation or surgical intervention. The objectives were to test how easy it was to perform the test and apply it to a number of different ankle fractures. Methods: Peri-operatively, 2–4 ml of contrast medium was injected into the ankle joint in cases where there was concern about injury to the syndesmosis. If there was a ‘positive’ test, and a ‘blush’ of dye leaked into the surrounding soft tissues, then fixation of the syndesmosis was performed (as per the surgeon’s preferred technique). After fixation was completed, a further injection of contrast medium was injected to see if the fibular had been anatomically reduced into its incisura. The test was performed on 15 ankles. Results: There were no difficulties in performing the test and no complications reported. The test clearly demonstrated where there had been an injury to the syndesmosis and also confirmed the accurate reduction of the fibula when there had been stabilisation of the syndesmosis. Conclusions: It has proved to be an easy and reliable adjunct to ankle fixation surgery and may have further indications. ß 2016 Elsevier Ltd. All rights reserved. * Corresponding author at: 16 Fordington Road, Winchester, Hampshire SO22 5AL, United Kingdom. Tel.: +44 1962 869655/7790021992. E-mail address: robertboyd@doctors.org.uk (Robert P.R. Boyd). G Model JINJ-6636; No. of Pages 4 Please cite this article in press as: Boyd RPR, et al. A new assessment for syndesmosis injury – The ‘Chertsey test’. Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.03.005 Contents lists available at ScienceDirect Injury jo ur n al ho m epag e: ww w.els evier .c om /lo cat e/inju r y http://dx.doi.org/10.1016/j.injury.2016.03.005 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.