Maisonneuve Fracture in Athletes

What is a Maisonneuve Fracture?

A Maisonneuve fracture is caused due to two injuries that happened simultaneously. The first injury is generally a fracture in the fibula (a long bone in the lower extremity that is positioned on the lateral side of the tibia). The second injury is an ankle sprain (an injury that stretches or tears the rugged bands of tissue, called ligaments, that help hold the ankle bones together). Maisonneuve fractures occur when the foot and leg get twisted at an awkward angle while falling or hitting the ground.

What is the Anatomy of the Ankle Joint?

The ankle joint is the soft tissue attachment of the distal tibia, fibula, and talus. The ankle provides stability to walk on the surface and allows the ability to invert, evert, plantarflex, and dorsiflex the foot. However, when disturbed, the patient will experience unstable gait and pain. There may be the development of osteoarthritis. The articular surface of the ankle is formed by joining-

• The anterior surface of the talus.

• The medial malleolus of the tibia.

• The lateral malleolus of the fibula.

How Do the Maisonneuve Fractures Occur?

Maisonneuve fractures result from external rotation of a planted foot, most often with foot pronation. This extreme force significantly strains the bones and ligaments that make up the ankle joint and leads to an unstable ankle. The talus externally moves and applies force on the medial aspect of the ankle and causes deltoid ligament breakdown or fracture of the medial malleolus. In addition, the talus creates pressure on the lateral malleolus and causes syndesmotic disruption between the tibia and fibula. This pressure passes through the deltoid ligament and leaves the proximal fibula as a fracture.

What is the Mechanism of Maisonneuve Fracture?

• The external rotation of the foot leads to lateral motion of the talus (a bone that makes up the lower part of the ankle joint). It ultimately leads to disruption of the ankle mortise(a hinge joint that connects the ends of the tibia and fibula to the talus). This structural spill starts from the medial ankle and drifts proximally and laterally. Next, it passes over the interosseous membrane and runs across the proximal fibula.

• Medial ankle pathology includes fractures of the medial malleolus and rupture of the deep deltoid ligament. In addition, there can be posterior malleolar injuries.

• It is classified as a pronation-external rotation (PER) injury in the Lauge-Hansen ankle injury classification or Danis-Weber.

• Maisonneuve describes the rotation of a ruler placed between two books: "As the ruler rotates, it separates the two books."

• Isolated fibula fractures from direct force to the lateral fibula should be differentiated from external rotation injuries, whereby there is no concern for associated ankle joint instability.

What Are the Features of Maisonneuve Fracture?

Maisonneuve fracture can be seen as:

• It is a combination of proximal fibula fracture allied with an unstable joint injury of the ankle.

• In addition, there is an injury in the ligament known as distal tibiofibular syndesmosis, a fibrous interosseous membrane that connects the tibia or fibula with the deep deltoid ligament.

• There is a medial or posterior malleolus fracture in the proximal third.

• It occurs in around 5 percent of all ankle injuries.

What Are the Symptoms of Maisonneuve Fracture?

Maisonneuve fracture has the following signs and symptoms:

• Ankle sprain.

• Swelling, bruising and restricted range of motion.

• Ankle instability.

• Pain.

How Is a Maisonneuve Fracture Diagnosed?

Physical Examination:

Ankle injuries need to be ruled out as Maisonneuve fractures. Many patients recall a twisting motion to their ankle sometimes. There may be ankle pain with significant swelling. The "Squeeze Test" is done by palpating the tibia and fibula at the mid-calf level, and if it returns positive for tenderness, it suggests a syndesmotic injury. An external rotation stress test can also be performed in which the foot is in a neutral position, followed by an external rotation of the tibia. The tenderness of the external course confirms syndesmotic injury. The fracture is established if the proximal fibula tenders. Maisonneuve fracture is suspected if both the findings are there.

Imaging Tests:

Imaging plays an essential role in diagnosing Maisonneuve fracture in the initial stages. Plain radiographs are vital as they can confirm-

• Fibular fractures.

• Fibular shortening.

• Any spacing between the tibia and fibula in case of syndesmotic disruption.

Generally, ankle radiographs are taken in the anterior-posterior (AP) view, stress view (abduction and external rotation), mortise view, and lateral view. Therefore, it is necessary to acquire AP(anteroposterior view) and lateral radiographs of the knee with tibial and fibular opinions to determine the extent of the fibular fracture.

The following points to be focused on while reviewing the radiographs-

• The tibiofibular clear space.

• Clear medial length.

• Tibiofibular overlap.

The tibiofibular clear area is estimated at one cm above the talus and measures the distance between the fibula's medial border and the tibia's lateral wall. Usually, the tibiofibular clear space is less than five to six millimeters on the AP and mortise views. Therefore, anything more excellent than 10 mm is diagnostic of a syndesmotic injury.

How To Treat Maisonneuve Fracture?

Non-Operative Method

Non-operative treatment is rarely used to treat Maisonneuve fractures. Patients who undergo non-operative intervention either have a poor surgical prognosis or have no fracture or ankle joint displacement.

Operative Method

The surgical method is a definitive treatment for ankle instability and the associated fibular fracture. The proximal fibular fracture is indirectly stabilized by fixating the distal fibula to the tibia with trans-syndesmotic screws. The fibular length is restored when the distal end of the fibula is elongated into its anatomical position for trans-syndesmotic fixation. Other stabilization techniques include-

• Bio absorbable screws.

• Syndesmotic staples.

• Circular wire external fixators.

• Kirschner wires.

• Flexible implants.

• Syndesmotic hooks.

• Syndesmotic bolts.

• Cerclage wires.

Metal screw fixation, a suture loop between two buttons, or some combination of the two remains the most popular choice among orthopedic surgeons. The use of screws carries the downside of requiring additional surgery to remove the screws but may be more effective at maintaining length. In addition, the fibular size is adequately restored, and the ankle mortise is appropriately reestablished using these screws.

Conclusion

Maisonneuve fracture is the joint fracture of the fibula and the ankle commonly. It most commonly occurs in the athletes and sports persons belonging to the sports like skiing, gymnastics, or dancing. The fracture causes ankle sprain, instability of the ankle, or swelling/bruising of the ankle. Non-operative and operative methods can be done to manage Maisonneuve fracture.