Fracture dislocation of the ankle with the fibula trapped behind the tibia. A case report

Complicated Bosworth fracture-dislocation: A case report and review of the literature

Bosworth fracture and dislocation is relatively rare, accounting for about 1% of ankle fractures. It is characterized by the proximal fibula fracture embedded in the posterolateral distal tibia. Due to an insufficient understanding of this fracture, it is easy to cause missed diagnosis and misdiagnosis in clinical practice. Due to the insertion of the fracture, it is challenging to perform closed reduction, and improper treatment is easy to cause complications. Surgical treatment is recommended for this type of fracture. In order to improve the understanding of orthopedic surgeons about Bosworth fracture and dislocation, this paper reports the diagnosis and treatment of 2 cases of Bosworth fracture and dislocation, and reviews the literature on Bosworth fracture's mechanism, diagnosis, classification, complications, and treatment options in recent years.

A Case Series of Bosworth Fracture-Dislocations and Review of 129 Reported Cases

Introduction

Bosworth fracture dislocations of the ankle are rare injuries of the ankle caused by extreme external rotation of the supinated foot where the proximal fibula fracture fragment is posteriorly dislocated and entrapped behind the posterior-lateral ridge of the tibia. This case series aims to document three such cases treated in our institution over a nine year period. We also provide a review of 129 cases in the existing literature.

Materials and methods

Medical records and relevant radiographs for each patient were analysed and collected from the time of presentation till the point of latest follow-up. During each clinic visit, all physical exam findings as well as all complications were recorded. The American Foot and Ankle Society (AOFAS) Hindfoot score was also tabulated for each patient at the point of latest review.

Results

Closed reduction was unsuccessful in all three patients, and all required open reduction. One patient had an uncomplicated recovery whilst the remaining two suffered significant soft tissue complications. One patient suffered severe soft tissue swelling preventing primary closure at the time of surgery, whilst another suffered post-operative wound dehiscence and infection. Eventually all fractures healed, and all three patients obtained satisfactory AOFAS scores.

Conclusion

The diagnosis of Bosworth fracture dislocations of the ankle is often delayed or missed, due to its rare occurrence. Closed reduction is often unsuccessful, and early open reduction is required to avoid poor clinical outcomes due to severe soft tissue damage or even compartment syndrome.

Bosworth-type fibular entrapment fracture of the ankle without dislocation: a rare case report and a review of the literature

Bosworth fracture-dislocation of ankle is a rare and irreducible type of ankle injury, with a high incidence of complication. This type of fracture was defined originally as entrapment of the proximal fragment of the fibula behind the posterior tubercle of the distal tibia. Recently, many variants of this type of fracture dislocation have been reported, but all of those reports included the syndesmosis ligament injury of ankle. Here, we report a case of a particularly rare variant of Bosworth fracture-dislocation without syndesmosis ligament injury of ankle. A 48-year-old male presented with a Bosworth fracture dislocation with entrapment of proximal fragment behind the tibia. After temporary treatment in emergency department was applied, emergency open reduction and internal fixation with a plate and screws was performed due to irreducibility of the fracture fragment. The fractured lateral malleolus was entrapped behind the tibia and rupture of the interosseous ligament was found intraoperatively. The anterior inferior tibiofibular ligament, a part of syndesmosis ligament of ankle, was grossly intact and no abnormal findings was seen by fluoroscopy with external rotational stress. Moreover, the deltoid ligament was found to be normal in ultrasonography. There were no complications after surgery and the patient showed full functional recovery at 2 years follow up. These fractures will frequently be irreducible and should be considered for open reduction and internal fixation with the careful evaluation of injury mechanisms with syndesmotic stability.

Posterior malleolus fractures in Bosworth fracture-dislocations. A combination not to be missed

OBJECTIVES

Posterior malleolar fractures (PM) have been linked to inferior outcome in malleolar fractures. This study aims to analyze the prevalence and pathoanatomy of PM fractures in Bosworth fracture-dislocations (BF).

MATERIALS & METHODS

Radiographs and computed tomography (CT) scans of 13 patients treated at our institution and 97 cases published between 1947 and 2018, identified in a systematic literature search, were evaluated with respect to the pathoanatomy of BF. In all 13 cases from the present study and in 10 cases from the literature, axial CT scans were performed.

RESULTS

All 13 patients (100%) with BF from the present series and 61 of 97 documented cases (63%) of BF from the literature were associated with a PM fracture. In patients with a complete CT analysis, dislocation of the fibula behind the posterior tibial rim was associated with extraincisural (Bartoníček / Rammelt type 1) PM fractures. Displacement of the fibula between the displaced PM fragment and the tibia was associated with Bartoníček / Rammelt types 2 and 3 PM fractures.

CONCLUSIONS

Seventy prevent of all reported BF are associated with a PM fracture. The true prevalence may be even higher because of the historically infrequent use of CT imaging. The pathoanatomy of the PM fragment is highly variable as is the kind of fibular displacement in BF. Therefore, CT scanning should be performed routinely in BF. Displaced PM fractures in BF involving the incisura should be treated operatively via a direct posterolateral approach.

Rare variants of Bosworth fracture-dislocation: Bosworth fracture-dislocation with medial malleolus adduction type fracture

Bosworth ankle fracture-dislocation is rare, known to be an irreducible type of ankle injury, with a high incidence of complication. We present two cases of even rarer variants of Bosworth ankle fracture-dislocation. The first case is a type of supination external rotation adduction, and the second case is a type of supination external rotation adduction. These types have not been described before. In both of the cases we failed to achieve close reduction, and therefore proceeded with emergency surgeries, with open reduction and internal fixation. Both of the cases were performed with a postero-lateral approach to reduce the dislocations, and fix the fractures successfully. Unfortunately in one of the cases, acute compartment syndrome developed post-surgically. However, both cases showed good functional outcomes.

Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition

A patient with severe irreducible open fracture dislocation of the ankle was admitted to our emergency department. After wound irrigation and debridement, skeletal traction was applied to the calcaneus to minimize soft tissue injury and swelling. The patient was followed in traction for 1 week, after which reduction and fixation of the fibula was attempted but not achieved. We extended the incision distally, visualized the ankle, and located the tibialis posterior tendon between the distal tibia and fibula, thereby inhibiting the reduction. The tendon coursed into the tibiotalar joint anteriorly and pushed the talus anterolaterally. After manipulation of the tendon to its anatomically correct location, the ankle was easily reduced. The wound at the medial side was closed with a fasciocutaneous rotational flap. The ankle was then immobilized for 6 weeks postoperatively. The patient regained her full range of motion, and there were no problems with the tibialis posterior tendon, such as rupture or insufficiency. Isolated tibialis posterior tendon interposition between the distal tibiofibular and tibiotalar joints has rarely been reported, and can inhibit anatomical reduction of the fractured ankle.

Bosworth-type fibular entrapment injuries of the ankle: the Bosworth lesion. A report of 6 cases and literature review

OBJECTIVES

To evaluate patients with Bosworth-type fibular entrapment injuries of the ankle.

DESIGN

Retrospective clinical study and analysis of the literature.

SETTING

University hospital.

PATIENTS

Six cases treated for Bosworth-type fibular entrapment injuries (the Bosworth lesion) in the period 2001 to 2004.

INTERVENTION

Five patients were treated with open reduction and internal fixation (ORIF), and 1 patient was treated with closed reduction and cast.

RESULTS

All patients treated by ORIF healed without complications with a good subjective outcome. In 1 case treated nonoperatively, an ankle fusion had to be performed 2 years after injury for severe osteoarthritis. Additionally, we have recorded 3 cases, 2 not previously described in the literature, in which the fracture of the fibula was located at the middle or proximal third of its shaft.In the literature we found another 54 cases with dislocation of the fibula behind the posterior tubercle of the distal tibia. The analysis showed that morphology of the Bosworth lesion, as we prefer to refer to this complex fracture-dislocation, changes with age and may be divided into 3 basic types. In children and adolescents the dislocation of the distal fibula is associated with epiphyseolysis of the distal tibia; in young adults the fibula dislocates without fracture; in middle-aged and older adults, the dislocated fibula fractures, probably because of the decreased elasticity.

CONCLUSIONS

The Bosworth lesion is a severe injury of the ankle, and its successful treatment requires a correct diagnosis based on careful initial clinical and radiographic evaluation and early surgical treatment.