You are working on a typical busy night in the ED. The waiting room (as usual) is full and the ED full of boarding patients. Knowing that you're always happy to help, you get a call from one of the nurses in triage. There is a middle aged lady who fell down 3 steps and twisted her left ankle. She did not syncopize, denies any other injuries and had ankle films performed which have been read as normal:
What would you do next? Scroll down for the Case Conclusion.
Final Diagnosis: Maisonneuve Fracture
Case Conclusion: You examine the radiograph more closely and note that the medial clear space appears widened (> 4 mm) and that the overlap between the tibia and fibula is less than expected (10 mm):
These findings suggest a significant twisting force and injury to the deltoid ligament, distal tibiofibular ligament and interosseous membrane. The patient is examined more closely. She is found to have pain to palpation along the proximal fibula as well. A tib/fib radiograph is performed demonstrating a proximal fibula fracture, confirming the diagnosis of a Maisonneuve fracture.
Orthopedic Surgery sees the patient and she undergoes operative fixation (ORIF) 3 days later:
Learning Points: Twisting injuries of the ankle are a common emergency department complaint. A Maisonneuve fracture is a spiral fracture of the proximal fibula associated with a tear of the distal tibiofibular ligament and interosseous membrane as well as rupture of the deltoid ligament and/or fracture of the medial malleolus. A Maisonneuve fracture is the result of forceful internal rotation of the leg on a planted foot with external rotation of the ankle. With this violent twist, there is sequential injury leading to the final pattern :
This injury pattern was first described in the 1840’s by the French surgeon Jules Francois Maisonneuve, who became known for his work in describing external rotation as a cause of ankle fractures.
The Maisonneuve fracture is an important clinical diagnosis as it leads to significant ankle instability and requires early surgical fixation to ensure a good functional outcome. This is particularly important because the Maisonneuve fracture is often missed as patients complain predominantly of ankle symptoms and the proximal fibula is not imaged. Therefore, it is very important to palpate the proximal fibula in any patient with an ankle complaint, get three views of the ankle (including mortise) when evaluating for traumatic injury, and pay close attention to the spatial relationship of the tibia, fibula and talus once such radiographs are obtained.
For a nice little video about the Maisonneuve fracture, check this out.
Case Conclusion by Maia Dorsett (@maiadorsett)
1. Taweel, N. R., Raikin, S. M., Karanjia, H. N., & Ahmad, J. (2013). The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures. The Journal of emergency medicine, 44(2), e251-e255.
2. Pankovich, A. M. (1976). Maisonneuve fracture of the fibula. J Bone Joint Surg Am, 58(3), 337-342.
3. O'Keeffe, D., Nicholson, D. A., Driscoll, P. A., & Marsh, D. (1994). ABC of emergency radiology: the ankle. BMJ, 308(6924), 331-335.