Addressing diagnostic challenges in neglected Bosworth dislocation with open reduction and soft tissue reconstruction: a case report

Introduction and importance: Bosworth fracture-dislocation is a rare and complex ankle injury characterized by the distal fibular fragment becoming entrapped behind the tibia, often following an oblique fibular fracture. Due to its unique anatomical presentation, the injury is frequently misdiagnosed or overlooked, particularly in chronic or neglected cases, leading to long-term complications. This case report explores a novel surgical technique for managing chronic Bosworth fracture-dislocation. Case presentation: An 18-year-old woman presented with persistent pain and difficulty bearing weight on her left ankle 6 months after a motor vehicle accident. Initial evaluations missed the diagnosis, but X-rays revealed a posterior dislocation of the distal fibula behind the tibia, confirming Bosworth fracture-dislocation. Given the chronicity of the injury, surgical intervention was required. The patient underwent a direct lateral approach to reduce the dislocated fibula, followed by fixation with two 4.0-mm syndesmotic screws and augmentation using a split peroneus brevis tendon graft for enhanced lateral ankle stability. Clinical discussion: Bosworth fracture-dislocations are challenging to manage due to the difficulty of reducing the fibula and the lack of consensus on the optimal surgical approach. The failure of closed reduction techniques necessitates open reduction and internal fixation. This case utilized a combined approach of syndesmotic screw fixation and soft tissue reconstruction. This technique effectively restored both bony alignment and soft tissue integrity. Conclusion: This case report highlights the diagnostic difficulties and rarity of Bosworth fracture-dislocation, especially in chronic cases. This surgical technique offers a successful approach for managing chronic Bosworth fracture-dislocation.