Disruption of the DLES is most commonly associated with ankle fractures. Syndesmotic injury without fracture is also well recognized. Attention to detail in radiographic interpretation, a review of the pertinent anatomy and the etiology of these injuries, and an understanding of the basic science investigations that have been done should allow the practitioner to synthesize a reasonable approach to treatment. Despite the conflicting reports in the literature, a rational approach to the treatment of DLES injuries is possible. The treatment of DLES disruption without fracture can be addressed surgically or nonoperatively. The crucial factor is obtaining and maintaining an anatomic reduction of the mortise and DLES. The biomechanical and some recent clinical reports support more stringent application of the syndesmosis screw. Obtaining and maintaining anatomic rigid fixation on both the medial and lateral sides is critical. Intraoperative testing of the syndesmosis after fixation can be a useful adjunct if the stability of the reduction is in question.