Maisonneuve Fractures

Original Editor - Umamah Ejaz
Top Contributors - Umamah Ejaz and Ewa Jaraczewska

Definition and Description

Maisonneuve Fracture of Malleolus

Maisonneuve fractures are characterized by a specific pattern of injuries: a fracture of the medial malleolus or a rupture of the deltoid ligament, a disruption of the ankle syndesmosis ligaments, and a fracture of the proximal fibula.

The injury was first described by French surgeon Jules Germain François Maisonneuve in 1840. Diagnosis is often missed, and these fractures may be more common than initially thought, accounting for 0.7% to 10% of ankle fractures in some studies. They are typically seen in young athletes and are often sports-related.

Epidemiology

Maisonneuve fractures are uncommon injuries, making up about 5–7% of all ankle fractures and around 5% of those that require surgery. They typically occur in men around the average age of 38, and they affect the left and right ankles almost equally. The most common cause is a pronation–external rotation (PER) force, which accounts for nearly all cases. Rarely, a supination–external rotation (SER) mechanism may be involved. These injuries often result from ankle sprains, falls from a height, or traffic accidents.

A Maisonneuve fracture always includes a break in the upper part of the fibula, and is usually accompanied by other injuries such as rupture of the anterior inferior tibiofibular ligament (AITFL), fractures of the medial and posterior malleolus, and sometimes injury to the deltoid ligament or posterior inferior tibiofibular ligament (PITFL). Diagnosing these fractures can be challenging; up to 20% of syndesmosis-related injuries are missed initially, and subtle fibular or posterior malleolar fractures often go unnoticed on standard X-rays, requiring CT or MRI for detection. On imaging, the fracture line in the fibula typically runs from anterosuperior to posteroinferior, consistent with the PER injury pattern.

Clinical Presentation

Maisonneuve fracture Fibula

The clinical presentation of Maisonneuve fracture are given below;

• Ankle pain is often severe and worsened with weight-bearing.
• Swelling and bruising around the ankle and possibly extending up the leg.
• Restricted range of motion in the ankle due to pain and soft tissue damage
• Ankle instability, making it feel like the joint may "give out."
• Pain in the upper leg, especially near the top of the fibula (just below the knee), indicating the proximal fibular fracture.
• Tenderness along the fibula, especially when palpating the upper third.
• Difficulty walking or inability to bear weight on the affected leg.

Diagnostic Procedures

Physical Examination:

When evaluating any ankle injury, it’s essential to check for a possible Maisonneuve fracture, even if the patient only complains of ankle pain and swelling. A history of a twisting injury may or may not be present. Always examine the entire lower leg, not just the ankle.

Key tests include:

• Squeeze Test: Gently press the tibia and fibula together at mid-calf. Pain here suggests a syndesmotic (high ankle) injury.
• External Rotation Stress Test: With the foot in a neutral position, rotate it outward. Pain during this movement indicates a likely syndesmotic injury.
• Proximal Fibular Tenderness: Pain when pressing the upper fibula (just below the knee) suggests a fibular fracture.
• If both syndesmotic signs and fibular tenderness are present, a Maisonneuve fracture should be strongly suspected.

Imaging:

X-rays are essential for confirming the diagnosis.

• Ankle X-rays (AP, mortise, lateral, and stress views) can show signs like fibular fractures, widening of the joint, or syndesmotic separation.
• Knee X-rays (AP and lateral) must also be taken to detect any high fibular fractures.
• Important measurements on radiographs include:
• Tibiofibular clear space: Normally <6 mm; if >10 mm, it suggests syndesmotic injury.
• Tibiofibular overlap and medial clear space should also be assessed for joint alignment and ligament integrity.

Management/Interventions

Surgical Treatment

These fractures are unstable, so surgery is usually required.

Medial Malleolus Fixation

• If the medial malleolus is fractured, it is fixed with open reduction and internal fixation (ORIF), using screws or tension band wiring.

Deltoid ligament rupture

• Typically doesn't need direct repair unless it blocks reduction.

Syndesmotic Stabilization

• To stabilize the syndesmosis, use one or two 3.5-mm or 4.5-mm trans-syndesmotic screws.
• These screws can be placed percutaneously.
• If the posterior malleolus fracture is large (more than 25% of the joint surface), fixation may eliminate the need for syndesmotic screws.

Proximal Fibula Fracture

• No direct fixation is necessary. The syndesmotic screw will help reduce the fracture.
• Open reduction is avoided to prevent peroneal nerve injury.

Postoperative Care

• A non-weight-bearing cast is used for 6–8 weeks.
• Syndesmotic screws can be removed after 6–8 weeks or may be left in place.

Physiotherapy Treatment

Rest and rehabilitation play a key role in recovering from a Maisonneuve fracture. Initially, the patient should rest and avoid putting weight on the injured leg for about 6 weeks. During this time, the leg (from ankle to knee) is immobilized using a splint or cast.

After 6 weeks, the patient can start wearing a walking boot and begin physiotherapy. Treatment focuses on restoring ankle movement and strength through guided exercises. By 8 to 12 weeks, the patient may gradually start weight-bearing activities. Full weight bearing is usually possible by 16 weeks. With consistent rehabilitation, most patients return to sports within 20 to 24 weeks.

Specific Physiotherapy Treatments Include:

• Personalized exercises to stretch and strengthen the ankle, improving mobility and stability
• Cold laser therapy to promote healing of ligaments
• Cold/ice therapy to reduce swelling and stiffness
• Heat modalities (like therapeutic ultrasound) to ease pain and promote tissue healing
• Activity guidance for walking, running, using a walking boot, and safe return to sport