Maisonneuve injury with no fibula fracture: A case report

Investigation of the Characteristics and Mechanism of Interosseous Membrane Injuries in Typical Maisonneuve Fracture

OBJECTIVES

Previous studies on the mechanism and scope of interosseous membrane injury in Maisonneuve fractures have been inconsistent. In order to better guide clinical treatment, the characteristics and mechanism of interosseous membrane injuries and proximal 1/3 fibular fracture in typical Maisonneuve fracture were investigated.

METHODS

The study comprised 15 patients between January 2019 and June 2021 with Maisonneuve fracture. All patients received X-ray and MRI examination of the calf and ankle joint, and CT scanning of the ankle joint. The injuries of medial structure, inferior tibiofibular syndesmosis, fibula, posterior malleolus, and interosseous membrane were evaluated.

RESULTS

MR images of the calf showed that the injury of interosseous membrane (IOM) was from the syndesmosis to the proximal fibular fracture site in two patients, with a range of 32.3 and 29.8 cm, respectively. In the other 13 patients, the IOM rupture was not only confined to the distal third of the calf, but also close to the fibula fracture, and the IOM was intact between the two fracture sites. The range of distal IOM rupture was 3.7-12.2 cm, with an average of 8.06 ± 2.35 cm. The proximal IOM was completely ruptured from the fibular side at the site of the fibular fracture and the range was 4.1-9.1 (average: 6.75 ± 1.64) cm. The average length of the integrate middle segment of the IOM was 14.55 ± 4.11 (5.6-20.3) cm. MR images of the calf also showed partial rupture of the posterior tibial muscle at the ending point on the fibula in 15 cases, partial rupture of soleus muscle and flexor hallucis longus in seven cases.

CONCLUSIONS

The rupture of the IOM was caused by a combination of abduction and external rotation violence. It was manifested in two forms, most of which was not only distal end but also near fibular fracture site ruptures with the middle part intact, and a few were ruptures of the IOM from the ankle to the near fibular fracture site. The tibialis posterior muscle may be related to the location of the fibular fracture.

Nonoperative treatment of avulsion fracture of the anterior tibia with proximal fibular fracture: A case report

Background

Avulsion fracture of the anterior tibia with proximal fibular fracture commonly occurs in Maisonneuve fracture, which generally involves ankle instability and requires surgical correction. Nonoperative treatment of this type of fracture has been rarely reported in the literature.

Case presentation

A 48-year-old male reported pain in the lateral part of his left lower leg and ankle during a badminton play. Physical examination revealed tenderness and swelling of the lateral aspects of the left ankle, as well as the proximal aspect of the fibula. Preoperative plain x-ray image, computed tomography, and magnetic resonance imaging revealed an avulsion fracture of the anterior tibia by the anterior inferior tibiofibular ligament without medial and posterior fracture, rupture of the deltoid ligament, or interosseous membrane. Nonoperative management was performed and successful recovery was observed at a 6-month follow-up.

Conclusions

Nonoperative management can be a better option for some variations of Maisonneuve fracture with a stable ankle joint. The selection of treatment options should be based on careful examination and radiological evaluation of the ankle.

Rare pattern of Maisonneuve fracture: A case report

BACKGROUND

Maisonneuve fracture is a special type of ankle fracture that consists of proximal fibular fracture, a lesion of the inferior tibiofibular syndesmotic complex (interosseous ligament, anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament), and injury of the medial structure of the ankle (deltoid ligament tear or medial malleolar fracture). The accepted mechanism of Maisonneuve fracture is pronation external rotation according to the Lauge-Hansen classification. In this paper, we report a rare pattern of Maisonneuve fracture, which has the characteristics of both pronation external rotation ankle fracture and supination adduction ankle fracture.

CASE SUMMARY

A 31-year-old female patient accidentally sprained her right ankle while walking 5 d before hospitalization in our hospital. The patient was initially missed in other hospitals and later rediagnosed in our outpatient department. Full-length radiographs of the lower leg revealed proximal fibula fracture, inferior tibiofibular joint separation, and medial malleolar fracture involving the posterior malleolus, which was also revealed on computed tomography scans. Magnetic resonance imaging revealed rupture of the anterior inferior tibiofibular ligament and anterior talofibular ligament. We diagnosed a rare pattern of Maisonneuve fracture with proximal fibular fracture, inferior tibiofibular joint separation, medial malleolar fracture and ruptures of the anterior inferior tibiofibular ligament and anterior talofibular ligament. The patient underwent open reduction and internal fixation in our hospital. A 6-mo postoperative follow-up confirmed a good clinical outcome.

CONCLUSION

To our knowledge, this rare pattern of Maisonneuve fracture has not been previously described. The possible mechanism of injury is supination adduction combined with pronation external rotation. Careful analysis of the injury mechanism of Maisonneuve fracture is of great clinical significance and can better guide clinical treatment.

Maisonneuve Fractures of the Ankle: A Critical Analysis Review

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Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.

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The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).

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The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.

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Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.

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Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.