Floating position facilitates reduction in Bosworth fracture-dislocation compared to prone approach

IntroductionBosworth fracture-dislocation is a rare and specific variant of ankle injury. Its insidious radiographic features frequently lead to a high clinical misdiagnosis rate. Furthermore, the entrapment of the proximal fibular fracture fragment behind the posterolateral tibial ridge or the posterior malleolar fragment makes closed reduction exceptionally difficult.Case presentationThis report presents the case of a 56-year-old male patient admitted with swelling and deformity of the right ankle following a fall. The diagnosis of a Bosworth fracture-dislocation was confirmed via clinical history, standard radiographs, and computed tomography imaging. The patient required surgical intervention after two failed preoperative manual reduction attempts. Initially, open reduction and internal fixation were performed via a posterolateral approach with the patient in a prone position. However, postoperative imaging revealed a failed reduction characterized by persistent proximal fibular entrapment within the posterior malleolus. Following thorough communication, a revision surgery was performed through the original incision with the patient in a floating position. This approach successfully released the entrapped fibula and reduced the distal tibiofibular syndesmosis, achieving stable fixation and ultimately leading to satisfactory functional recovery.DiscussionThe failure of the initial surgery highlights the hidden entrapment pitfalls associated with this specific injury. The prone position restricts the ability to obtain true intraoperative standard lateral radiographs, increasing the risk of unrecognized persistent subluxation. Adopting a floating position effectively overcomes these limitations by providing ample spatial clearance for real-time fluoroscopic monitoring and utilizing gravity for gentle axial traction, thereby ensuring the definitive visual release of the entrapped fibula.ConclusionBosworth fracture-dislocation is a rare injury that is easily misdiagnosed, making early diagnosis crucial. When closed reduction proves difficult, early open reduction should be performed. Utilizing a floating position intraoperatively helps ensure adequate exposure of the fracture site and facilitates standard lateral x-rays, which is an important strategy to avoid reduction failure.