Maisonneuve Fracture: A Rare
But Significant Injury
Marjorie J. Albohm, MS, ATC
Joellyn M. Seward, ATC
Kendrick Memorial Hospital, Mooresville, IN
N ANKLE injury is by far the most
common joint injury in sports and
one of the oldest documented in
history. Ankle injuries can vary
from a simple inversion sprain to a total
dislocation, but rarely seen in athletics
is the Maisonneuve
fracture. This fracture
involves disruption
of the syndesmosis
ligaments.
The mechanism
normally associated
with this injury is extreme external rotation (abduction) and
pronation of the foot.
This causes rupture
of the anterior tibiofibular ligament and
a fracture of the proximal fibula.
Following is a
rare case study illustrating the key symptoms associated with
this injury and emphasizing the subsequent instability
ki FIGURE 1
created by this morNondisplaeed
tise dislocation.
wroximal fracture
of the fibula.
Column Editor
leg from the medial side causing a violent
external rotation of the foot and lower leg.
About a year earlier, he had suffered a Grade
2 inversion ankle sprain with no significant
complications.
Injury evaluation on the field revealed
no obvious deformity of the ankle or lower
leg. The athlete exhibited tenderness in the
area of the anterior talofibular and tibiofibular ligaments and the calcaneal fibular
ligament. Immediate effusion was observed around the ankle joint. Pain was also
indicated at the proximal fibula and the area
was extremely sensitive to palpation. Fracture of the lower leg and/or ankle was suspected. The foot and leg were immobilized
and the athlete was taken to the emergency
room for Xrays.
Xrays revealed a nondisplaced fracture in the
proximal fibula (Figure 1).Stress Xrays also
showed a lateral widening displacement of
the ankle mortise to approximately 9 mm
(Figure 2). This injury is classified as a
Maisonneuve fracture. The athlete denied
any numbness or paralysis in his lower leg
and foot. His lower leg was placed in a half
cast for the night and the athlete was told to
return the next day for orthopedic evaluation.
The evaluation confirmed the initial
diagnosis. Surgery was scheduled for
oven reduction and internal fixation of the
Maisonneuve fracture.
Surgery consisted of placing a 4.5 x 32 x
34-mm fully threaded cortical screw through
the tibia and fibula, reducing the mortise. The
I
An 18-year-old high school football player
sustained an ankle injury during a game. His
foot was abducted while planted in a rut. Simultaneously he received a blow to the lower
O 1998 Human Kinetics
March 1998
Mhleglc mewmToday
15
At 10 weeks the athlete was
able to bear full weight and the
3D boot was no longer needed.
Range-of-motion exercises were
initiated, including use of the
BAPs board while seated, and
marble pick-up and towel crunch
exercises. Assisted toe raises,
Achilles tendon stretches, and
progressive strengthening exercises of the quadriceps and hamstrings were prescribed. These
exercises were increased according to the athlete's performance
and strength.
FIGURE 2 The two arrows show
the lateral widening of the ankle
mortise.
screw was started at the posterolateral aspect of the right fibula
about 3 cm proximal to the ankle
joint (Figure 3). Surgery was successful and the athlete was placed
in a 3D boot splint with the ankle
in slight plantar flexion and slight
inversion.
The athlete was instructed to be
non-weight-bearing for at least 6
weeks. He was instructed on the
use of crutches and rehabilitative
exercises including knee flexion/
extension, quadriceps contraction/hold sets, and hip range of
motion. Isometric strength exercises for both the quadriceps and
hamstrings were prescribed.
After 7 weeks the athlete was
allowed to begin partial weightbearing, gradually increasing to
full weight-bearing. Support with
a 3D boot continued and the athlete was advised to continue his
exercise program.
16
FIGURE 3 Shows the cortical screw
approximately 3 cm proximal to the
ankle joint and the correct space of the
ankle mortise between the two arrows.
Early recognition and stabilization of the disrupted syndesmosis are key elements to a successful
recovery from a Maisonneuve
fracture injury. Prompt stabilization allows time for the syndesmosis ligaments to begin healing.
The fibula fracture is usually
nondisplaced and heals without
complication.
There is some controversy
regarding removal of the syndesmotic screw prior to weightbearing. Studies have shown that
sometimes the screw can prevent
normal range of motion of the
fibula, especially during external
rotation. Other studies have
shown that the presence of the
screw presents no adverse effects.
In this case the screw was left in
place during the management of
the fracture and presented no adverse effects.
Prognosis of a Maisonneuve
fracture is generally good as long
as the ankle mortise is stabilized
with less than a 2-mm widening
and the syndesmosis remains
stable. The athlete in this case
study has continued sports participation at the college level without further complications.
m
JoelIyn M. Seward,an ATC at Kendrick Memorial Hospital, has senred as head trainer for
several4nd&na High Schoolsport events and
the 1997 National Outdoor Track and Field
Championships. She also participated in medical coverage at the 1996 Olympics in Atlanta.
Sport-specific movements
such as side-to-side slides, acceleration, kareokee, backpedaling, m d Figure 8 movements
were gradually added to the rehabilitation program. At 5 months
post-op the athlete exhibited comparable bilateral lower extremity
strength and was able to complete
sport-specific functional tests.
WgkleSie memmTadagg
March 1998
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