The Maisonneuve fracture with medial and posterior malleolar fractures: A case report

The Maisonneuve fracture, first described by Dr. Jacques Maisonneuve in 1840, ers to a combination of a fracture of the ipsilateral fibula and a medial ankle structures injury [1]. Maisonneuve fracture appeared in the literature during the 1960s, mainly thanks to B.G. Weber, a Swiss surgeon [2]. In the medical setting, Maisonneuve fractures are a unique and uncommon type of injury that is often overlooked initially [3]. It is caused by a pronation-external rotation mechanism [4]. In addition to the proximal fibular fracture, there is also a rupture of tibiofibular syndesmosis and deltoid ligament, followed by rupture of the anteroinferior tibiofibular ligament and rupture of the interosseous ligament and interosseous membrane. Some reports do not include all the injuries mentioned above about the Maisonneuve fracture, as currently there is still no defined consensus, and different variants are reported with slight differences, such as non-rupturing of the deltoid ligament or fracture of the medial malleolus [3]. The Gold standard treatment is the surgical treatment that includes a reduction of the distal tibiofibular joint and fixation with a syndesmotic screw. The outcome of patients who underwent surgical treatment for Maisonneuve fractures is not well documented in the literature [5]. To our knowledge, a Maisonneuve fracture, a lateral malleolus fracture, and ankle deltoid ligament injury were described only once by Hensel and Harpstrite in 2002 [6].

A 70-year-old female patient was admitted to the clinic with pain in her right lower limb after falling down the stairs. She had severe pain in her ankle and right knee after the trauma, with the inability to walk. Clinical examination, after excluding possible fractures associated with age group, revealed hematoma on the ankle, edema on the topography of the right lateral malleolus and on the lateral aspect of the right knee. The patient had no neurological or vascular changes.

Leg radiographs were taken in anteroposterior (AP) and PROFILE position which revealed lateral subluxation of the right ankle, increased medial clear space associated with fracture of the medial malleolus, fracture of the posterior malleolus, and proximal fracture of the ipsilateral fibula (Figure 1A and Figure 1B).

The patient was hospitalized for urgent orthopedic surgery, requesting tests and surgical risk. The patient underwent spinal anesthesia associated with sedation. Distal lateral access to the fibula at the distal fibulotibial joint was used, anatomical reduction of the ankle with reduction forceps and placement of a 3.5 mm third barrel plate and two 3.5 mm cortical screws with sizes of 50 and 45 mm under fluoroscopy. Subsequently, closed reduction of the fracture of the medial malleolus was performed with the percutaneous placement of two 3.5 mm cancellous fixation screws, measuring 50 and 45 mm. The maintenance of divergence between the screws was performed with fluoroscopy.

Control radiographs were performed after the surgery (Figure 1C, Figure 1D, Figure 1E). As a result, anatomical reduction and perfect stability were observed, preserving the functional range of motion of the ankle and knee, as well as alignment and rotation (Figure 1F, Figure 1G, Figure 1H, Figure 1I, Figure 1J).

Postoperative care

The patient progressed in the immediate postoperative period without significant pain complaints, which allowed the immediate start of active and passive knee and ankle mobilization under medical and physiotherapeutic guidance.

Postoperative control radiographs were performed after 15 and 30 days, when partial load was released with the aid of two crutches. The total load was released 60 days after surgery.

The patient returned to work 90 days after the operation with preserved range of motion and no pain complaints.

The Maisonneuve fracture was first described in 1840 by Jacques Maisonneuve [1]. It is a rare injury, occurring around 7% of all ankle fractures [7]. It is a fracture of the proximal third of the fibula with a rupture of the distal tibiofibular syndesmosis, interosseous membrane, and associated injuries (e.g., medial malleolus fracture, posterior malleolus fracture, and deltoid ligament tear) [1].

Maisonneuve fracture occurs through a pronating force and external rotation of the ankle with transmission of force through the interosseous membrane causing a proximal fibular fracture. This fooot pronation causes an avulsion fracture of the medial malleolus or rupture of the deltoid ligaments. This is followed by an external rotation force that causes disruption of the syndesmotic ligaments and the interosseous membrane, and the energy pattern continues along the path of the interosseous membrane and exits at the proximal region of the fibula [4].

Pankovich [8] reported a series of 17 Maisonneuve fractures with detailed clinical and operative findings. He found that the fibular fracture showed two patterns. In ten cases out of the 17 described (or 58%), the fracture was similar to that described for an external pronation–rotation fracture. In other two cases, the fracture resembled an external supination–rotation fracture. Although the mechanism producing Maisonneuve's fracture must be external rotation of the foot relative to the tibia, it is unclear whether the foot is in pronation or supination during the injury. A third possibility is that the foot changes its position while the injury is occurring.

Our case report showed the existence of an ankle fracture considered “bimalleolar,” which the main trauma mechanism is external supination–rotation, together with a Maisonneuve fracture, as above-mentioned. This demonstrates that the possibility of the foot to change its position while the injury is occurring should be considered.

Hensel and Harpstrite [6] reported a Maisonneuve fracture associated with a bimalleolar ankle fracture–dislocation. The patient in this study had a distal fibular fracture, a lateral ankle dislocation, a Maisonneuve fracture of the proximal part of the fibula, and a medial malleolar fracture.

Del Castillo and Geiderman described the importance of taking proximal tibiofibular radiographs when patients present with ankle pain [9]. The suspicion of Maisonneuve fracture should occur when there is isolated fracture of the posterior tibial tubercle with evidence of rupture of the deltoid ligament or medial malleolus fracture in the absence of a lateral malleolus fracture or in case of tenderness over the anteromedial capsule of the syndesmosis or tenderness over the syndesmosis.

We can propose, according to our case report, that even if the ankle radiograph shows a well-established fracture, radiography including the whole leg in two different views is necessary to avoid non-detection of a Maisonneuve fracture.

Described more than 180 years ago, the surgical treatment still remains controversial regarding the number of syndesmotic screws, their necessary size and the exact insertion in the distal fibula (Table 1).

The case we describe here is an atypical pattern of Maisonneuve fracture, which is even rarer to occur and requires caution and extreme attention to its diagnosis.

Maisonneuve fracture is an orthopedic emergency that must be diagnosed early, because in most cases a surgical procedure is required. Surgery must be well planned to anatomically restore the ankle joint without causing neurovascular damage. In addition, it needs an adequate postoperative period to rehabilitate the patient. This set of actions will contribute to not bring sequelae to the patient such as early osteoarthrosis and chronic pain. Finally, this is a fracture that requires early diagnosis for definitive treatment to optimize the patient's recovery and reduce joint sequelae.