title: Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.
abstract: OBJECTIVE
  The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management.
  
  
  METHODS
  A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid.
  
  
  RESULTS
  The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries.
  
  
  CONCLUSIONS
  The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width.
  
  
  METHODS
  IV.
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands.
authors.forename: C Niek
authors.initials: CN
authors.lastname: van Dijk
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy. g.longo@unicampus.it.
authors.forename: Umile Giuseppe
authors.initials: UG
authors.lastname: Longo
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Loppini
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
authors.forename: Pino
authors.initials: P
authors.lastname: Florio
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
authors.forename: Ludovica
authors.initials: L
authors.lastname: Maltese
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Ciuffreda
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Denaro
mesh_terms: D016512:Ankle Injuries / Q000145:classification* / Q000175:diagnosis*; D006801:Humans; D008023:Ligaments, Articular / Q000293:injuries; D017410:Practice Guidelines as Topic
keywords: Acute; Classification systems; Clinical tests; Diagnosis; Imaging; Syndesmotic injury