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Failure to adequately reduce and stabilize syndesmotic injuries has been repeatedly linked to poor outcomes in unstable ankle fractures. There remains controversy with regard to the ideal management of these injuries. This article reviews the background of syndesmotic injuries, as well as recent aspects of management that have generated controversy. Particular emphasis is placed on assessment of reduction, syndesmotic stability, and of various methods of fixation.Level of Evidence: Level V—review article, expert opinion. See instructions for authors for a complete description of levels of evidence.