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Maisonneuve Fracture

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Overview

Exam Detail:

Key Revision Focus: The Lauge-Hansen mechanism (Pronation-External Rotation), the relationship between Medial Clear Space >5mm and Syndesmotic injury, and the management of the syndesmosis (Screw vs TightRope). Always examine the knee in ankle injuries!

1. Clinical Overview

Maisonneuve Fracture is a specific pattern of ankle injury defined by a fracture of the proximal third of the fibula associated with a disruption of the distal tibiofibular syndesmosis and the deltoid ligament (or medial malleolus). It is essentially a high ankle sprain that exits through the proximal fibula.

Clinical Pearl:

The "Knee" Pearl: Every patient with a painful ankle must lead you to examine the proximal calf/knee. A "sprained ankle" with tenderness at the fibular head is a Maisonneuve fracture and implies an unstable syndesmosis requiring surgery. Missing this leads to long-term arthritis.

Key Concepts

  1. Mechanism: Pronation-External Rotation (PER). The foot is planted (pronated) and the body rotates externally.
  2. Anatomy of Injury:
    • Medial Malleolus fracture OR Deltoid Ligament rupture.
    • Anterior Inferior Tibiofibular Ligament (AITFL) rupture.
    • Interosseous Membrane (IOM) tear extending proximally.
    • Posterior Inferior Tibiofibular Ligament (PITFL) rupture.
    • Proximal Fibula fracture (spiral).
  3. Instability: By definition, the syndesmosis is unstable. The fibula can migrate laterally, widening the mortise.
  4. Radiology: Medial Clear Space (MCS) >4-5mm on gravity stress view indicates deltoid rupture and instability.
  5. Peroneal Nerve: Travels around the fibular neck. Risk of injury with the fracture or surgery.

Clinical Pearls

  • The "Unseen" Fracture: The actual fracture (fibula) is often not visible on standard ankle X-rays. You must order a full-length Tib/Fib view.
  • Hook Test: Intra-operative test where you pull the fibula laterally. If it moves >2-3mm, the syndesmosis is unstable.
  • Weight Bearing: If fixed with screws, NWB is traditionally advised. If fixed with Suture Button (TightRope), early WB may be allowed.

2. Epidemiology

  • Incidence: ~5% of all ankle fractures.
  • Demographics: Young athletes (football, skiing) and general trauma.
  • Missed Diagnosis: A notoriously missed injury in Emergency Departments ("It's just a sprain").

3. Pathophysiology

Mechanism (Lauge-Hansen: PER)

Pronation - External Rotation

  1. Stage 1 (Medial): Tensile failure of Deltoid Ligament OR transverse fracture of Medial Malleolus.
  2. Stage 2 (Anterior): Rupture of AITFL.
  3. Stage 3 (Lateral/High): Rupture of Interosseous Membrane (IOM) traveling up the leg -> spiral fracture of proximal Fibula (Maisonneuve).
  4. Stage 4 (Posterior): Rupture of PITFL or Posterior Malleolus fracture.

The force travels in a circle: Medial -> Anterior -> Up the membrane/Fibula -> Posterior.

4. Clinical Presentation

  • Ankle Pain: Medial side (Deltoid) and Anterolateral (Syndesmosis).
  • Calf Pain: Proximal lateral calf pain.
  • Deformity: Often none (unless gross dislocation).
  • Inability to weight bear.

5. Clinical Examination

  1. Look:
    • Swelling at the ankle.
    • Bruising medial ankle.
    • No bruising at the knee usually.
  2. Feel:
    • The Squeeze Test: Pain at the ankle when squeezing the mid-calf.
    • Proximal Fibula: Palpate the fibular head/neck. Tenderness here is diagnostic.
    • Medial Malleolus/Deltoid: Tenderness implies stage 1 injury.
  3. Move:
    • External rotation of the foot causes pain (Stress test).
  4. Neuro:
    • Check Common Peroneal Nerve (Dorsiflexion/EHL/Sensation dorsal foot). Rarely injured but possible.

6. Investigations

X-ray

  • Ankle Series:
    • May look "Normal" initially.
    • Medial Clear Space (MCS): Measure between talus and MM. >4mm is suspicious. >5mm on stress is diagnostic.
    • Tibiofibular Overlap: Should be >6mm on AP, >1mm on Mortise. Reduced overlap = Syndesmosis widening.
  • Tib-Fib Full Length:
    • MANDATORY. Reveals the proximal fibula fracture.
  • Stress Views (Gravity or Manual):
    • Standard of care to assess Deltoid competence. If MCS widens, it's unstable.

CT Scan

  • Sensitive for assessing the rotation of the fibula in the incisura notch.
  • Often used post-reduction to confirm reduction quality.

MRI

  • High sensitivity for AITFL/PITFL tears ("High Ankle Sprain") but usually not needed for frank Maisonneuve if X-ray is positive.

7. Management

Principle: The fibula fracture itself does NOT need fixing. The goal represents stabilizing the Syndesmosis to reduce the ankle mortise.

ASCII Algorithm:

          MAISONNEUVE FRACTURE
                   ↓
┌──────────────────────────────────────┐
│        ASSESS STABILITY              │
│ - Stress X-rays (Gravity)            │
│ - MCS > 5mm?                         │
│ - Tib-Fib Overlap reduced?           │
└──────────────────┬───────────────────┘
                   ↓
           UNSTABLE (Usually)
                   ↓
┌──────────────────────────────────────┐
│           SURGICAL FIXATION          │
│                                      │
│ 1. Reduce Ankle (Clamp/Percutaneous) │
│ 2. Fix Medial Malleolus (if broken)  │
│ 3. Fix Syndesmosis                   │
└──────────────────┬───────────────────┘
                   ↓
┌──────────────────┴───────────────────┐
│         FIXATION OPTIONS             │
├──────────────────┬───────────────────┤
│    METAL SCREW   │   SUTURE BUTTON   │
│ (Positional Screw) │    (TightRope)    │
│ - Rigid          │ - Physiologic     │
│ - Needs Removal? │ - No removal      │
│ - Breakage risk  │ - Knot irritation │
└──────────────────┴───────────────────┘

1. Conservative (Rare)

  • Only if stress X-rays show STABLE mortise (MCS <4mm) and patient is low demand.
  • Long leg cast (to control rotation) for 6 weeks.
  • Most surgeons operate on true Maisonneuve.

2. Surgical Fixation

A. Syndesmosis Screws

  • Technique: Clamp reduction. Drill 3 or 4 cortices. Insert 3.5mm or 4.5mm screws (1 or 2).
  • Position: 2-3cm above joint line. Parallel to joint. Angled 30 deg anteriorly.
  • Post-Op: Non-Weight Bearing (NWB) for 6-10 weeks.
  • Removal:
    • Routine Removal: At 3-4 months (prevents breakage, restores physiological movement).
    • Leave in: Risk of breakage. Broken screws are usually asymptomatic.

B. Suture Button (TightRope)

  • Technique: Heavy suture tensioned between two buttons across Tib/Fib.
  • Pros: Allows physiological micro-motion. No need for removal. Earlier weight bearing allowed? (Surgeon dependent).
  • Cons: Cost. Knot irritation subcutaneous. Malreduction if path of drilling is not perfect.

C. Medial Fixation

  • If Medial Malleolus fractured: Fix with screws.
  • If Deltoid Ruptured: Usually left to heal by scarring once lateral side reduced. Repair indicated in high-demand athletes? (Controversial).

8. Complications

  • Malreduction of Syndesmosis: The #1 cause of poor outcome. Fibula often clamped in internal rotation. Use CT or open reduction.
  • Arthritis: Rapid onset if talus shifts 1mm (40% contact area loss).
  • Stiffness: 30% loss of dorsiflexion common.
  • Hardware Issues: Painful screws/knots.
  • Peroneal Nerve Injury: Iatrogenic or from injury.

9. Prognosis & Outcomes

  • Good outcomes if anatomic reduction achieved.
  • Return to sports: 4-6 months.
  • Missed injuries lead to chronic pain and early ankle fusion/replacement.

10. Evidence & Guidelines

Guidelines

  • BOA Standards (UK): Assess syndesmosis stability in all Weber C fractures.
  • AAOS: Strong evidence for operative fixation of unstable syndesmosis.

Landmark Trials

  • Coetzee Study (2018): Suture Button vs Screws.
    • Result: Suture button patients had better PROMs and earlier return to work/sport. Lower reoperation rate (no removal). [PMID: 29337583]
  • Ramsey & Hamilton (1976): Cadaver study.
    • Result: 1mm lateral shift of talus = 42% decrease in tibiotalar contact area. Rationale for anatomic reduction. [PMID: 963206]
  • Weening (2005): Malreduction rates with screws.
    • Result: 16% malreduction rate with percutaneous clamping. Open reduction is safer.

11. Patient Explanation

What happened?

You twisted your ankle so severely that the force traveled all the way up your leg and snapped the small bone (fibula) near your knee. The real problem, though, is at the ankle—the ligaments holding the two leg bones together have torn apart.

Why surgery?

If we leave it, the ankle bones will drift apart like a mortise and tenon joint becoming loose. This causes the ankle to wobble and wear out (arthritis) very quickly. We need to tie the bones back together.

The "TightRope" vs "Screw"

We can use a metal screw or a heavy-duty suture (TightRope) to hold the bones. The suture is newer and acts like a seatbelt—it allows a little bit of natural movement. The screw is rigid and might need a second operation to remove it later.

12. References

  1. Seymour R, et al. Suture button versus screw fixation of the syndesmosis: a systematic review and meta-analysis. Foot Ankle Int. 2013;34:1040-1048.
  2. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976 Oct;58(3):356-7. [PMID: 963206] (Classic Paper).
  3. Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950.
  4. Coetzee JC, et al. Functional Results of Open Reduction Internal Fixation of Syndesmotic Disruptions With a Suture Button. Foot Ankle Int. 2018.
  5. Pankovich AM. Maisonneuve fracture of the fibula. J Bone Joint Surg Am. 1976.
  6. Klammer G, et al. The posterior malleolus fracture: often missed, often neglected? Unfallchirurg. 2018.
  7. Tornetta P 3rd, et al. The "hook" test for syndesmotic instability. J Orthop Trauma. 2012.
  8. Stufkens SA, et al. Long-term outcome after 1836 ankle fractures. J Foot Ankle Surg. 2010.
  9. Miller AN, et al. Direct visualization for syndesmotic reduction: a cadaveric study. Foot Ankle Int. 2009.
  10. Hunt KJ. Syndesmosis injuries. Curr Rev Musculoskelet Med. 2013.

13. Examination Focus

Common Exam Questions (FRCS/Boards)

  1. What is the Lauge-Hansen mechanism? (Answer: Pronation-External Rotation / PER).
  2. How do you diagnose instability on X-ray? (Answer: MCS >5mm on stress view, or Tib-Fib overlap <1mm).
  3. Describe the Hook Test. (Answer: Intra-op lateral pull on fibula. >3mm diastasis = Positive).
  4. What nerve is at risk proximally? (Answer: Common Peroneal Nerve).
  5. Why do we fix the syndesmosis but not the proximal fibula? (Answer: The prox fibula is non-weight bearing and muscle covered. The ankle stability is key).

Viva "Buzzwords"

  • "Medial Clear Space >5mm"
  • "Tibiofibular Overlap"
  • "Pronation-External Rotation"
  • "TightRope vs Screw"
  • "Hook Test"
  • "Ramsey & Hamilton (42% contact loss)"

Common Pitfalls

  • Missing the proximal fracture: Not examining the knee/calf.
  • Malreduction: Clamping the fibula in internal rotation or too posterior.
  • Removing screws too late: Or breaking them.
  • Allowing weight bearing too early on screws: Leads to breakage.

At a Glance

EvidenceStandard
Last UpdatedRecently

Clinical Pearls

  • spiral fracture of proximal Fibula (Maisonneuve).
  • Up the membrane/Fibula -
  • 5mm? │

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines