Emergency Medicine

Case Presentation
Name: James Powers, D.O., Melissa B. Weimer, OMS III, and Alice Merritt, OMS II
Rotation Site: Carilion NRV Medical Center

Abstract
A Maisonneuve Fracture is defined as a fracture of the proximal third of the fibula
associated with rupture of the deltoid ligament or fracture of the medial malleolus and
disruption of the tibiofibular syndesmosis. A thorough history, especially the mechanism
of injury, and physical exam as well as appropriate radiologic testing are paramount in
diagnosing cases of ankle trauma. Maisonneuve Fractures can be easily misdiagnosed as
the ankle pain often overshadows the pathology present in the fibula. The goal of this
article is to present a case of a typical Maisounneuve fracture presentation to heighten the
clinician's degree of suspicion for these cases when ankle traumas present to their
Emergency Department.

Introduction
A 47 year old female stepped out of her mobile home and fell approximately 5-7 feet.
She presents to the emergency department with severe ankle pain and swelling. The
history and physical exam, as well as the radiologic findings will be reviewed followed
by a discussion of her diagnosis of a Maisounneuve fracture. Maisounneuve fractures are
seen in cases of ankle trauma, which are the result of forceful external rotation of the
ankle mortise joint and a subsequent transmission of force to the proximal fibula.

Narrative
Attending: James Powers, DO
Patient: PN
Sex: Female
Age: 46
History of Present Illness: PN stepped out of her trailer home, forgetting that a stoop was
not present, and fell approximately 5-7 feet to the ground twisting her ankle. PN
experienced immediate pain (10/10) and swelling in her right ankle. She is unable to bare
weight on it. She did not lose consciousness or hit her head during the fall. Pt has never
broken or injured her right ankle before, though she does have pain from time to time due
to fibromyalgia. She denies dizziness, headache, blurry vision, dyspnea, nausea,
vomiting, fever, and pain and/or swelling in her other extremities. The pt has not taken
any medication for the pain or applied ice to the injury.
Past Med Hx: Fibromyalgia, osteoporosis, scoliosis, depression.
Medications: Neurontin 300mg TID, Effexor 75 mg BID
Past Surgical Hx: tubal ligation, surgery for endometriosis
Social Hx: _ -1 ppd smoker, 5-6 beers/day, no drugs, lives with her family.
Review of Systems:
Patient denies fever, chills, weight loss, diaphoresis, trouble swallowing, dyspnea,
wheezing, and chest pain. Pt does complain of decreased range of motion of right ankle
and knee. Pt denies change of sensation, numbness, or tingling in any of her extremities.
Pt does complain of back pain, but that is normal for her. Patient also complains of body
aches, but that is normal for her.
Physical Exam:
Vitals: BP 142/88; P 100; R 16; T (oral) 97.2, pulse ox 98% on RA
General: well-nourished, acute distress from pain, appropriate affect, smell of ethanol on
her breath
HEENT: NC/AT, PEERLA, EOMI, throat pink and moist
Lungs: clear to auscultation bilaterally, no wheezes, no rales, no rhonci
Heart: regular rate and rhythm, no murmur, no rub, no S3 or S4
Abdomen: soft, nontender, bowel sounds present x 4 quadrants
Skin: nondiaphoretic, warm and dry
Extremities: swelling and ecchymosis in right ankle in medial, posterior, and lateral
malleolar regions, diffuse pain throughout the ankle and foot, palpable pain in the right
proximal fibula, no swelling noted in the right or left legs, no swelling in the left ankle or
foot, upper extremity without lesion or swelling
Vascular: pulses equal bilaterally in radial region and dorsalis pedis region
Neuro: CN 2-12 grossly intact, sensation in upper and lower extremities intact, decreased
dorsiflexion, plantarflexion, and inversion in the right ankle, increased eversion in the
right ankle, decreased flexion and extension in right knee, good active and passive ROM
in all other extremities
X-ray:
Right ankle 4 views = Fracture of the posterior and medial malleolus.
Right Tibia/Fibula 2 Views = Fracture of proximal fibula, medial and posterior malleolar
fracture of the distal tibia.
Assessment:
1- Maisonneuve's Fracture
2- Tobacco abuse
Plan:
1- Splint right ankle and distal lower extremity into its functional position.
2- Elevate and do not bare weight on the right lower extremity.
3- Follow-up with Dr. Donnelly, orthopedist, tomorrow for surgical open reduction
and internal fixation of right ankle.
4- Follow-up with your PCP following surgery for possible interventions for your
osteoporosis.

Discussion
A Maisonneuve fracture is a fracture of the proximal third of the fibula associated with
rupture of the deltoid ligament or fracture of the medial malleolus and disruption of the
tibiofibular syndesmosis. It is considered a Weber C (a) , bimalleolar fracture on a
functional basis (1). Maisonneuve fractures result from forceful external rotation of the
ankle with transmission of forces through the tibiofibular syndesmosis and to the
proximal fibula. More descriptively, the forceful external rotation of the ankle pulls on
the deltoid ligament of the ankle and (potentially) tears the medial malleolus. This injury
disrupts the ankle mortoise and the talus moves laterally, or creates a valgus talar shift.
The valgus talar shift can precipitate the following injuries: a posterior malleolus fracture,
a disruption of the tibiofibular syndesmosis, and a fracture of the proximal fibula and
shortening of the fibula. (2-5)
Maisonneuve fractures present with pain and swelling of the medial ankle and tenderness
along the proximal fibula. The patient may deny any direct trauma to the proximal fibular
area. Because the pain from the ankle may overshadow the pain in the proximal fibula, it
is important to palpate the proximal fibula as a standard part of the ankle examination to
ensure that a Maisonneuve fracture is not missed.
The keys to diagnosing a Maisonneuve fracture are careful consideration of the
mechanism of injury and a high index of suspicion. Clinical examination of the area is
followed by anteroposterior and lateral radiologic views of the entire tibia and fibula as
well as an ankle mortise view (Figure 1). (3)
Treatment principles for a Maisonneuve fracture in the Emergency Department are the
same as those for ankle fractures in general. Current Diagnosis and Treatment in
Orthopedics recommends four criteria for the optimal treatment of ankle fractures: 1)
dislocations and fractures should be reduced as soon as possible; 2) all joint surfaces must
be precisely restored; 3) the fracture must be held in a reduced position during the period
of bony healing; 4) joint motion should be initiated as early as possible. If these treatment
goals are met, a good outcome can be expected. Therefore, initial treatment of ankle
fractures should include immediate closed reduction and splinting, with the joint held in
the most normal position possible to prevent neurovascular compromise of the foot. If the
fracture is open, the patient should be given appropriate intravenous antibiotics and taken
to the operating room on an emergent basis for irrigation and debridement of the wound,
fracture site, and ankle joint.

With all of this in mind, because the Maisonneuve fracture involves an unstable ankle
with a disrupted ankle mortoise, it requires an orthopedic surgical consult and probable
surgery to stabilize the joint. Maisonneuve fractures are usually treated by open
reduction, internal fixation. Operative treatment restores fibular length, repairs the lateral
and medial ankle ligamentous structures, and places one or two suprasyndesmotic screws.
Such operative treatment has been shown to provide satisfactory results in 88.4% of
patients (4-5). Failure to obtain surgery may result in permanent painful degenerative
ankle arthrosis (5). It is especially important to be mindful of this complication in ankle
injuries due to the ankle’s thin articular cartilage and high ratio of joint congruence to
articular cartilage thickness. Loss in congruity of the ankle joint following fracture will
be poorly tolerated and lead to posttraumatic arthritic changes. It has been shown that a
lateral talar shift of as little as 1 mm will decrease surface contact at the tibiotalar joint by
40% (1).
________________________________________________________________________
a Weber Type C: Fracture of the fibula proximal to the syndesmotic ligament complex,
with consequent disruption of the syndesmosis. Medial malleolar avulsion fracture or
deltoid ligament rupture is also present. Posterior malleolar avulsion fracture can also
occur. Current Diagnosis and Treatment in Orthopedics, 2003
References
1. Smith, W, Shank, J, Skinner, H, Diao, E, Lowenberg, D. “Musculoskeletal
Trauma Surgery”. Current Diagnosis and Treatment in Orthopedics - 3rd Ed. (2003).
2. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed.
3. Hamilton: Emergency Medicine: An Approach to Clinical Problem-Solving, 2nd
ed.
4. Hensel, KS, Harpstrite JK. Maisonneuve fracture associated with a bimalleolar
ankle fracture-dislocation: a case report. Jornal of Orthopedic Trauma. 2002 August; 16
(7): 525-8.
5. Babis GC, Papagelopoulos PJ, Tsarouchas J, Zoubos AB, Korres DS, Nikiforidis
P. Operative treatment for Maisonneuve fracture of the proximal fibula. Orthopedics.
2000 July; 23 (7): 687-90.
6. Duchesneau S, Fallat LM. The Maisonneuve fracture. Journal of Foot and Ankle
Surgery. 1995 Sept-Oct; 34 (5): 422-8.

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