Maisonneuve Fracture Research Articles

Report of the Case of a Rare Pattern of Maisonneuve Fracture

The classic Maisonneuve fracture is localized to the proximal portion of the fibula, in association with disruption of the ankle that involves tibiofibular diastasis. This report, however, describes a case involving a Maisonneuve fracture in the presence of intact deltoid and tibiofibular syndesmotic ligaments. When this injury is suspected, further diagnostic imaging and intraoperative assessment may be useful, and operative repair does not require the use of trans-syndesmotic fixation. 4.

Tibial Shaft Fracture and Ankle Joint Injury

Detection of tibial fractures in which a concomitant ankle injury may exist. Prospective study. Department of Trauma Surgery, University Hospital. 43 (20.1%) of 214 patients with a tibial fracture were found to have an associated injury of the ankle joint. Analysis of all patients with tibial fractures regarding typical mechanisms of injuries and typical radiographic criteria for concomitant injuries of the ankle joint. Primary x-rays were analyzed looking for spiral fractures of the tibia or proximal fibular fractures or an intact fibula, typically associated with syndesmotic injury. The assessment of patients was based on radiological findings and functional recovery. 45 ankle injuries in 43 patients were found. There were distal fibular fractures in 14, Maisonneuve fractures in 13, isolated ruptures of the syndesmosis in 3, fractures of the posterior malleolus in 8, and fractures of the medial malleolus in 7 of the cases. In 38 of the 43 patients, the distal tibiofibular syndesmosis was ruptured, and 88.4% of the tibia injuries were spiral fractures located in the distal third. Of the 38 patients who could be followed, 31 were categorized according to the Phillip's Score as very good, 3 as good, 2 as satisfactory, and 2 as unsatisfactory after an average of 19.8 months (12-26). Due to the obvious injury of the tibia, the potential instability of the ankle joint is often overlooked, and the risk of development of secondary osteoarthritis is often consequently underestimated. Added attention should be paid to the ankle in the following tibial fracture cases: pronation-eversion trauma, spiral fracture of the tibia, proximal fibular fracture, or intact fibula. Using these markers, we were able to diagnose 20.1% of combined injuries compared to our retrospective study in 1999, in which only 13.6% of these injuries could be detected (Pearson r=0.1305, not significant).

Arthroscopic findings in Maisonneuve fractures

BackgroundA Maisonneuve fracture consists of a proximal fibular fracture with associated syndesmotic ligament disruption and injury to the medial ankle structures. The treatment outcome is good in most cases, although poor results have also been reported. The purpose of this study was to investigate intra-articular lesions in Maisonneuve fractures. MethodsThe subjects consisted of four patients (four ankle joints) who had suffered a Maisonneuve fracture and had undergone surgical treatment between June 2005 and November 2005. The mean age was 24.2 years. At the time of surgery, we performed ankle arthroscopy and determined the presence of tibiofibular syndesmosis disruption, cartilaginous damage, and ligament damage. Lesions of the articular cartilage were graded by depth as determined by inspection and probing. ResultsAll four of the cases had cartilaginous damage to the medial section of the talar dome. Lateral lesions were not observed. Chondral debris and hemarthrosis were noted in virtually all cases, and each ankle had a tear on the anterior inferior tibiofibular ligament and interosseous tibiofibular ligament. No patients had a tear of the posterior inferior tibiofibular ligament. ConclusionsArthroscopy was useful in identifying associated intra-articular lesions in Maisonneuve fractures.

Leg Anterior Compartment Syndrome Following Ankle Arthroscopy After Maisonneuve Fracture

We report a case of leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. A 21-year-old football player sprained his left ankle. Plain radiography of his left ankle showed a lateral dislocation of the talus without obvious fractures. Plain radiography of his left lower extremity showed a spiral fracture of the proximal fibula approximately one third distal to the fibular head. According to these findings, we diagnosed this fracture as a Maisonneuve fracture and treated it by ankle arthroscopy and drilling of the talar osteochondral injury followed by arthroscopic ankle visualization during syndesmosis screw fixation. Six hours after surgery, the patient complained of pain in the lower extremity. We diagnosed acute compartment syndrome and performed emergent fasciotomy. One year after surgery, he was able to fully participate in athletic activities. We consider ankle arthroscopy to be available for the treatment of ankle fracture with the suspected complication of an intra-articular disorder such as a Maisonneuve fracture. However, with this type of ankle fracture, there is a higher potential risk of acute compartment syndrome developing than with other types of ankle fractures. Therefore we suggest that surgeons guard against this complication.

Maisonneuve Fracture Equivalent with Proximal Tibiofibular Dislocation

The Maisonneuve fracture was initially described in 1840 by Dr. Jacques Maisonneuve1. The initial description involved a proximal fibular fracture associated with an injury to the medial ankle structures. Lauge-Hansen then classified this fracture as a pronation-external rotation variant, with disruption of the syndesmosis2. Danis3 and Weber4 classified these injuries as type-C fractures, and the AO/ASIF Group described them as type-C3 injuries5. This pronation-external rotation mechanism involves either an avulsion fracture of the medial malleolus or disruption of the deltoid ligaments. This is followed by an external rotation force that causes disruption of the syndesmotic ligaments and the interosseous membrane. The energy pattern continues along the path of the interosseous membrane and exits in the proximal fibular region. Proximal tibiofibular dislocation initially was described by Dubreuil6 in 1844 and then by Malgaigne in 18557. Fig. 1 Stress radiograph of the left (injured) ankle, showing the medial clear space of 5.4 mm and the talocrural angle of 6.2°. We present the case of a patient who sustained a pronation-external rotation injury involving an avulsion of the medial malleolus, with disruption of the deltoid ligaments and the proximal tibiofibular joint. There was no fibular fracture, but the patient did sustain an ipsilateral tibiofibular dislocation. On the basis of our review of the literature, we do not believe that this association has been described previously. The patient was informed that data concerning this case would be submitted for publication. Aseventeen-year-old boy presented to the emergency room after a twisting injury of the left ankle. Initially, he was thought to have an ankle sprain with no evidence of fracture. The patient was managed with a splint because of severe soft-tissue swelling and was referred to the orthopaedic surgery department. Fig. 2 Stress radiograph of the right (uninjured) …

Surgical Treatment of Maisonneuve Fractures

Closed or open reduction and internal fixation of Maisonneuve fracture with the goal to restore form and function of ankle joint. Prevention of posttraumatic osteoarthritis. Proximal fibular fractures associated with rupture of the distal tibiofibular syndesmosis, the interosseous membrane, and the deltoid ligament; sometimes associated with fracture of the medial malleolus and the posterior rim of the tibia. Poor skin and soft-tissue conditions. Poor general health. Open or closed reduction and repositioning of lateral malleolus into fibular incisure of the tibia. Internal fixation with one or two temporarily inserted syndesmosis screws. Suture of syndesmosis. Treatment of associated injuries. Split below-knee cast. After wound healing closed below-knee cast for 6 weeks and walking with crutches and partial weight bearing. Removal of syndesmosis screw(s) 6–8 weeks postoperatively. Once ligamentous stability has been ascertained, increasing mobilization and weight bearing. An exact diagnosis, meticulous reduction and internal fixation as well as intensive postoperative physiotherapy will guarantee a satisfactory functional result.

Persistent Diastasis in a Maisonneuve Fracture—Interposition of a Tibial Osteochondral Fragment: A Case Report

We report a case of failed reduction of the distal tibiofibular syndesmosis following a Maisonneuve fracture due to interposition of an osteochondral fragment in the syndesmosis from the tibial plafond. The displaced fragment was not initially appreciated. It is suggested that surgeons consider this as a possible cause of an incompletely reduced diastasis after deltoid ligament interposition has been excluded.

Outcome after surgery for Maisonneuve fracture of the fibula

The aim of this study was to assess outcome in patients treated surgically for Maisonneuve fractures and to highlight factors associated with a suboptimal result. The authors present a review of 14 patients with Maisonneuve fractures. The mean age was 35.5 years. The most common injury mechanism was a twist incurred whilst participating in sport. The goal of treatment was the anatomic restoration of the ankle mortice with accurate renewal of fibular length. All patients had one or two suprasyndesmotic screws inserted percutaneously under fluoroscopic guidance. These were successfully removed under local anaesthesia in 13 cases (93%). Patients were reassessed clinically and evaluated both functionally and radiographically. Average follow-up was 25.3 months. Twelve patients (86%) had a satisfactory result. They returned to previous activity levels and had favourable Global Foot and Ankle (mean: 95.57) and Shoe Comfort (mean: 81.66) Raw Scores. Ankle range of motion and radiographs were normal. Two patients had an unsatisfactory result. Surgical intervention is recommended to maintain reduction of the fibula into the notch on the tibia, as shortening results in mandatory lateral talar displacement, predisposing to painful ankle arthrosis. The severity of the initial injury and co-morbid disease may adversely affect outcome.

Maisonneuve fracture in an adolescent

We present an atypical case with a rare combination of Maisonneuve and triplane fracture A Maisonneuve injury can present with external rotation of foot in the absence of signs and symptoms of a proximal injury. Pre-operative CT scans of the growth plate injury facilitates planning open reduction and internal fixation; it is vital to check the syndesmotic stability by intra-operative imaging. This rare combination of fracture pattern illustrates the need for awareness of the dual pathology and to provide adequate stability to prevent chronic ankle pain.

Dynamics of Distal Tibiofibular Joint in Correlation with the Position of the Syndesmotic Screw in Maisonneuve Fractures of the Ankle - A Cadaver Study

Introduction: Maisonneuve-fractures of the ankle joint are best treated by fixation of the ruptured tibiofibular syndesmosis with one or two syndesmotic screws. A rigid fixation of the syndesmosis however, would lead to pain, limitation of range of motion and to early arthrosis of the ankle joint. The purpose of this study was to investigate the optimal position of the syndesmotic screw, which allows physiological movements in the syndesmosis. The influence of application of the screw through 3 or 4 cortical shells on the distal tibiofibular joints stability was also studied. Material and Methods: 14 pairs of fresh frozen cadaver lower legs with intact knee joints were divided into two groups. In all specimens the soft tissue was removed and the distal tibiofibular ligaments exposed. The specimens were then potted in Araldit-G-bone cement. The syndesmosis and the interosseus membrane were then sharply dissected, to simulate a Maisonneuve-fracture situation. In group I (n = 7) the syndesmotic screw was applied in each pair directly above the upper end of the syndesmosis through 3 cortical shells (lateral and medial fibular shell, lateral tibia shell) on the one side and through 4 cortical shells on the other side. In the group II (n = 7) the syndesmotic screw was applied in each pair through four cortical shells, directly above the syndesmosis and 50 mm above the upper end of the syndesmosis on the either side. In both groups one pair served as control. The specimens were tested with an Instron 2000®-material-testing machine. A medio-lateral translation force was applied to each specimen. All testing was conducted in the plastic range of specimens and were destructive. Single factor analysis of variance and Student's t-Test were used for statistical evaluation. Results: In the control specimen of both groups the mean maximal translation force (mTmax) was 1 500 N. In the first group mTmax for the screw with 3 cortical shells was 300 N, and for the four cortical screw 312 N. In the second group the mTmax with the screw directly above the syndesmosis was 380 N and with the screw inserted 50 mm above the syndesmosis 160 N. The higher the screw-level, the lower was the power needed to break the fibula in the screw level. Discussion and Conclusion: There is no significant difference between syndesmotic screws with 3 or 4 fixed cortical shells at a medio-lateral load-axis: The more proximal the position of the screw, the fewer is the force needed to widen the distal tibiofibular joint. In both groups the stiffness achieved with the screws was significantly less than the control ones. The ankle joint was however, most stable with the syndesmotic screw inserted directly above the syndesmosis.

Ilizarov ring fixator for a difficult case of ankle syndesmosis disruption

Syndesmotic stabilization is recommended for tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia-fibula fractures. In the case presented, a syndesmotic stabilization was performed with a screw inserted 2 cm above the tibiotalar joint Subsequent failure occurred due to the weight of the patient and a lack of compliance with the necessary nonweight bearing protocol. The Ilizarov frame was used to reduce and maintain a stable syndesmosis with a simple two-ring construct which allowed the patient to bear weight on the injured limb while his syndesmosis healed. This is not recommend as a routine method of treatment, but is presented as an extended indication of the Ilizarov frame for difficult cases.

Dynamics of Tibiofibular Syndesmosis in Correlation with the Level of the Syndesmotic Scress in Maisonneuvre Fractures of the Ankle – a Cadaver Study

The objective of this study was to determine the level of the syndesmotic screw, the number of screws needed, and whether one or both cortices of tibia should be engaged to closely reproduce the physiological stability and elastic of the ankle mortise in syndesmotic rupture after Maisonneuve fractures. Material and Methods: Twelve fresh frozen cadaveric pairs of lower extremities were used for this study. The knee was exarticulated and soft tisue removed leaving the lateral and medial ankle ligaments intact. The tibiofibular syndesmosis was then sharply sectioned. All specimens were mounted in an Instron 2000 material testing machine. An axial loading of 500 N was applied. Syndesmotic diastasis was measured by a linear transducer system. The specimens were divided into three groups. In group I, the specimens were instrumented with one syndesmotic screw 2.5 cm above tibia plafond. In group II, the same procedure was performed as in group I with the syndesmotic screw positioned 4 cm above tibia plafond. In group III, the syndesmosis was fixed in each pair with two screws 2.5 and 4 cm above tibia plafond. In all groups, the screws were positioned randomly through three cortices on the one side and through four cortices on the contralateral side. Results: Significant difference was observed between the application of one or two screws through three or four cortical shells on one side and the level of the screw on the other. Conclusions: According to the results of this study, we recommend to use one screw through four cortices 2.5 cm above the tibia plafond.

A sample of Chinese literature MRI diagnosis of interosseous membrane injury in Maisonneuve fractures of the fibula

Objective: In Maisonneuve fractures of the fibula (MFF) it remains controversial whether there is an injury of the interosseous membrane (IOM) and how severely it ruptures. The author studied injuries to the IOM in MFF by MRI to elucidate this question. Method: Twelve patients were examined with MRI before operation. MRI examination to the leg was performed with knee coil in 2 steps to obtain a complete image of the IOM. Using axial scan, we took T1 (TR500/TE40 msec), T1STIR and T2 sequence. The asymptote side was also examined in three patients as a comparison. Result: IOM was ruptured in a range of 32–112 mm, on average 79 mm proximal to the talar dome in all 12 patients. No IOM rupture was found at the level of high fibular fractures. IOM usually orients at the site 30 mm proximal to the talar dome. Anatomy and rupture of IOM are clearly visualized with T1 (TR500/TE40 msec) STIR sequence; haemorrhage and oedema would be seen better on a T2 image. Conclusion: The injury level of IOM in MFF is only at the distal 1 3 part of the leg; it is not consistent with high fibular fractures. MFF is a special type of pronation-external rotation type, there are four stages in the classification of MFF: 1. injury of medial structures, including medial malleolar fracture or rupture of the deltoid ligament 2. rupture of the anterior tibiofibular ligament or avulsion fracture of one of its bone insertions, or one associated with interosseous ligament rupture and partial rupture of IOM in the distal 1 3 of the leg 3. fracture of the proximal part of the fibula 4. avulsion fracture of the posterior tibial tubercle

Operative treatment for Maisonneuve fracture of the proximal fibula.

This study reviewed operative treatment of Maisonneuve fracture of the fibula in 26 patients. Operative treatment consisted of restoration of the fibular length, repair of the lateral and medial ankle ligamentous structures, and placement of one or two suprasyndesmotic screws. After average follow-up of 6.4 years, the clinical results were satisfactory in 23 (88.4%) patients. Operative treatment is the treatment of choice for Maisonneuve fractures, and a satisfactory outcome may be anticipated after appropriate management of any associated bony and syndesmotic injuries.

Percutaneous fixation of Maisonneuve and Maisonneuve-type fractures: a minimally invasive approach

We report five cases of Maisonneuve and Maisonneuve-type fractures which were treated with a single suprasyndesmotic percutaneous diastasis screw with good radiological and functional results. This is an effective and a minimally invasive procedure which we recommend.

DETECTING AND TREATING COMMON FOOT AND ANKLE FRACTURES. PART 1: THE ANKLE AND HINDFOOT

In briefSome of the most common and potentially serious ankle and hindfoot fractures seen in a primary care sports medicine practice are fractures of the tibial plafond, malleolus, calcaneus, and talus (including osteochondral lesions). Making a careful physical exam to detect for sites of tenderness and ordering the appropriate diagnostic images—usually plain films—are important in pinpointing the diagnosis, but some injuries, like Maisonneuve fractures, can be difficult to detect. Certain injuries, like many fractures of the lateral process of the talus, can be managed conservatively with casting, but severe or displaced fractures usually require surgery. Rehabilitation typically focuses on rest and proper strengthening and stretching exercises.

Detecting and Treating Common Foot and Ankle Fractures

Some of the most common and potentially serious ankle and hindfoot fractures seen in a primary care sports medicine practice are fractures of the tibial plafond, malleolus, calcaneus, and talus (including osteochondral lesions). Making a careful physical exam to detect for sites of tenderness and ordering the appropriate diagnostic images - usually plain films - are important in pinpointing the diagnosis, but some injuries, like Maisonneuve fractures, can be difficult to detect. Certain injuries, like many fractures of the lateral process of the talus, can be managed conservatively with casting, but severe or displaced fractures usually require surgery. Rehabilitation typically focuses on rest and proper strengthening and stretching exercises.

Detecting and Treating Common Foot and Ankle Fractures.

In brief Some of the most common and potentially serious ankle and hindfoot fractures seen in a primary care sports medicine practice are fractures of the tibial plafond, malleolus, calcaneus, and talus (including osteochondral lesions). Making a careful physical exam to detect for sites of tenderness and ordering the appropriate diagnostic images-usually plain films-are important in pinpointing the diagnosis, but some injuries, like Maisonneuve fractures, can be difficult to detect. Certain injuries, like many fractures of the lateral process of the talus, can be managed conservatively with casting, but severe or displaced fractures usually require surgery. Rehabilitation typically focuses on rest and proper strengthening and stretching exercises.

Magnetic resonance imaging of acute Maisonneuve fractures.

Magnetic resonance imaging (MRI) studies were performed on five patients with acute Maisonneuve fractures. All patients had sustained a twisting injury to their ankles and complained of ankle pain and pain over their proximal fibula. High quality images with excellent visualization of all the ankle ligamentous structures were obtained. MRI showed that the anterior inferior tibiofibular ligament was disrupted in all patients and the posterior inferior tibiofibular ligament was intact in three of five patients. Also, the anterior talofibular ligament was disrupted in all patients and the calcaneofibular ligament was ruptured in two of five patients. This raises the question of whether patients with Maisonneuve fractures have lateral ankle instability at long-term follow-up. Although the superficial deltoid ligament was disrupted in all patients, the deep deltoid ligament was intact in one patient, partially disrupted in one patient, and completely disrupted in three patients. The interosseous ligament was disrupted at the ankle in all patients, while the interosseous membrane was disrupted in the leg in all patients except one. This patient had an intact interosseous membrane despite rupture of the interosseous ligament at the ankle and the presence of a proximal one third fibula fracture.

The maisonneuve fracture

The authors present a review of the mechanism of injury, classification, and surgical fixation techniques of the Maisonneuve fracture. Previous literature is inconsistent regarding operative criteria and appropriate fixation techniques. The authors recommend surgery of the Maisonneuve fracture to maintain reduction and to stabilize the fibula, preventing the shortening with resultant valgus talar shift that can result in painful degenerative ankle arthrosis. Recommendations are also made regarding fixation, based on the severity of the diastasis.