A Novel Technique for a Successful Closed Reduction of a Bosworth Fracture-Dislocation of the Ankle

Abstract

The Bosworth fracture is defined as a bimalleolar fracture-dislocation of the ankle, with entrapment of the fibula behind the posterior tubercle of the distal tibia. In the current orthopedic literature, not only is this fracture pattern rare, but this type of fracture-dislocation has also been reported to be near impossible to close reduce, with the majority requiring early open reduction and internal fixation to prevent complications and poor clinical outcomes. Reported early complications include compartment syndrome and soft tissue complications from repeated closed reduction attempts. Complications associated with delayed operative intervention include post-traumatic adhesive capsulitis of the ankle and ankle stiffness. We present a case study of a 34-year-old male who sustained a Bosworth fracture-dislocation of the right ankle after a skateboarding accident. We describe a successful closed reduction performed in the emergency department, with a novel closed reduction technique. The patient tolerated the procedure well, with no complications. He was then scheduled for open reduction and internal fixation five days afterward, and upon post-operative follow-up, he recovered well with no complications. This technique focuses on reduction forces applied to the proximal fibular fragment, which is entrapped behind the posterolateral portion of the tibia. We believe that the key to successful reduction is applying an anterolateral/internal rotation force to this entrapped fragment. If successful, this fracture pattern may not require admission for compartment checks or early open reduction and internal fixation, thereby preventing complications and poor clinical outcomes. Our technique allows for a successful closed reduction of Bosworth fractures; however, further research exploring this reduction technique is warranted.

Case Report: Bosworth Fracture-Dislocation managed by Closed Reduction and Conservative Treatment

“…In their review study, the preoperative diagnostic rate of Bosworth fracture-dislocation before surgery was only 56.86% (29 of 51); some cases were diagnosed intraoperatively and 12 (23.53%) cases that were not diagnosed during surgery were diagnosed as Bosworth fracture-dislocations. A Bosworth lesion should always be suspected in cases of marked external rotation of the ankle with respect to the knee (5). The axilla sign is a radiographic marker that can be used to identify patients with Bosworth fracture-dislocations.…”

Bosworth fracture complicated by unrecognized compartment syndrome: a case report and review of the literature

“…Overall, including the case presented here, 9 cases of compartment syndrome [ 5 – 11 ] have been described in the literature (Table 1 ). This results in a calculated prevalence of 5.4% out of 167 reported Bosworth fractures (Weber B and C types) [ 3 , 4 , 9 – 11 , 18 , 19 ]. Given the extreme paucity of CS in malleolar fractures, this is a high prevalence.…”

“…The cases of Lieder et al [ 8 ] and Ren et al [ 10 ] described above could be interpreted as a postischemic CS following a circulatory deficit of the lower leg [ 21 ]. Further soft tissue complications associated with BF include skin necrosis and ankle stiffness particularly after delayed reduction [ 2 , 3 , 9 , 19 , 22 ].…”

Bosworth Fracture-dislocation of the Ankle: A Case Report and Literature Review

“…X-ray imaging has many typical features for the diagnosis of Bosworth fracture-dislocation, including the Axilla sign on the mortise view, posterior dislocation of the talus on the lateral view, and the distance between bula and talus on the external oblique view. [8][9][10] The Axilla sign is mainly due to the continuous internal rotation of the tibia, and the axilla of the medial tibial plate can be seen on the X-ray. The mortise view of the ankle is a 15-25-degree internal rotation projection position.…”