PURPOSE: Bosworth fracture-dislocations (BF) with entrapment of a fibular fragment behind the posterior rim of the distal tibia are rare but potentially serious injuries to the ankle. MATERIALS AND METHODS: We analyzed the radiographs of 23 consecutive patients with a mean age of 44 years who were treated for BF. All patients underwent routine radiological examination of the ankle and presence of a BF was confirmed intraoperatively in 22 cases and / or with CT in 15 cases. RESULTS: Tibiofibular overlap intersecting the joint line in the anteroposterior view of the ankle was found in 20 of 23 cases (87%) and persisted in 17 of 18 cases (94%) after unsuccessful closed reduction. Posterior subluxation of the talus in the lateral view was revealed in 21 of 23 cases (91%). Tibio-fibular dissociation, i.e., posterior displacement of the distal fibula relative to the distal tibia in the lateral view was found in 22 of 23 cases (96%). This sign remained positive in all 18 cases with unsuccessful closed reduction. Closed reduction of the talus beneath the distal tibia was associated with an average increase of anterior fibular angulation of 24.5 degrees in case of inadequate closed reduction. CONCLUSIONS: Bosworth fracture represents a rare but still highly variable ankle injury that may lead to misinterpretation of the initial radiographs. Reliable radiological signs are triangular tibiofibular overlap, posterior talar subluxation and tibiofibular dissociation that should prompt CT imaging which is essential for revealing the complex pathoanatomy and planning the surgical approach.

Clinic of Surgery 1st Faculty of Medicine Charles University and Thomayer University Hospital Vídeňská 800 Prague 4 140 59 Czech Republic

Department of Orthopaedics 1st Faculty of Medicine Charles University and Military University Hospital Prague U Vojenské Nemocnice 1200 Prague 6 169 02 Czech Republic

Department of Radiodiagnostic Military University Hospital Prague U Vojenské Nemocnice 1200 Prague 6 169 02 Czech Republic

University Center for Orthopaedics Trauma and Plastic Surgery University Hospital Carl Gustav Carus at TU Dresden Fetscherstrasse 74 Dresden 01307 Germany

See more in PubMed

Bosworth DM. Fracture-dislocation of the ankle with fixed displacement of the fibula behind the tibia. J Bone Joint Surg. 1947;29:130–35. PubMed

Bartoníček J, Rammelt S, Tuček M. Bosworth ankle fracture-dislocation: current concept review. EFORT Open Rev. 2024;9:448–57. https://doi.org/10.1530/EOR-23-0050 . PubMed DOI PMC

Bartoníček J, Rammelt S. History of Bosworth fracture-dislocations. Fuss Sprungg. 2022;20:284–90.

Schatzker J, Mc Broom R, Dzioba R. Irreducible fracture dislocation of the ankle due to posterior dislocation of the fibula. J Trauma. 1977;17:397–401. https://doi.org/10.1097/00005373-197705000-00013 . PubMed DOI

Hamilton WC. Traumatic disorders of the ankle. New York: Springer; 1984. pp. 41–2.

Khan F, Borton D. A constant radiological sign in bosworth´s fracture: the axilla sign. Foot Ankle Int. 2008;29:55–7. https://doi.org/10.3113/FAI.2008.0055 . PubMed DOI

Bartoníček J, Rammelt S, Tuček M, Kostlivý K, Stöckigt C. Bosworth fracture: pathoanatomy, complications, and medium-term results of treatment. Foot Ankle Int. 2025;46:332–42. https://doi.org/10.1177/10711007241311925 . DOI

Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10:156–60. https://doi.org/10.1177/107110078901000308 . PubMed DOI

Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int. 1995;16:128–31. https://doi.org/10.1177/107110079501600304 . PubMed DOI

Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int. 2012;33:870–6. https://doi.org/10.3113/FAI.2012.0870 . PubMed DOI

Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 2002;23:107–11. https://doi.org/10.1177/107110070202300205 . PubMed DOI

Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135:505–16. https://doi.org/10.1007/s00402-015-2171-4 . PubMed DOI

Kostlivý K, Bartoníček J, Rammelt S. Posterior malleolus fractures in Bosworth fracture-dislocations. A combination not to be missed. Injury. 2020;51:537–41. https://doi.org/10.1016/j.injury.2019.10.088 . PubMed DOI

Cecil ML, Fenton PJ, Ebraheim NA. Fracture-dislocation of the ankle with fixed displacement of the fibula behind the tibia. Orthop Rev. 1993;22:1255–8. PubMed

Mori K, Nishitsuji K, Araki H, Imai T. Bosworth fracture-dislocation of ankle joint: A case report. Orthop Traumatol (Japan). 2004;53:332–7.

Bartoníček J, Rammelt S, Tuček M. Maisonneuve fractures of the ankle: A critical analysis review. JBJS Rev. 2022. https://doi.org/10.2106/JBJS.RVW.21.00160 . 21;10(2). PubMed DOI

Rammelt S, Boszczyk A. Computed tomography in the diagnosis and treatment of ankle fractures: A critical analysis review. JBJS Rev. 2018;6:e7. https://doi.org/10.2106/JBJS.RVW.17.00209 . PubMed DOI

Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8:328–31. https://doi.org/10.1097/00005131-199408000-00009 . PubMed DOI

Kumar A, Mishra P, Tandon A, Arora R, Chadha M. Effect of CT on management plan in malleolar ankle fractures. Foot Ankle Int. 2018;39:59–66. https://doi.org/10.1177/1071100717732746 . PubMed DOI

Rammelt S, Bartoníček J, Kroker L. Pathoanatomy of the anterolateral tibial fragment in ankle fractures. J Bone Joint Surg Am. 2022;104:353–63. https://doi.org/10.2106/JBJS.21.00167 . PubMed DOI

Hoblitzell RM, Ebraheim NA, Merritt T, Jackson WT. Bosworth fracture-dislocation of the ankle. Clin Orthop Rel Res. 1990;255:257–62.

He S, Zhu J. Ankle arthroscopy-assisted closed reduction in Bosworth fracture dislocation. SAGE Open Med Case Rep. 2020;8:2050313X20974525. https://doi.org/10.1177/2050313X20974525 . PubMed DOI PMC