of The Maisonneuve Fracture the Fibula K

The Maisonneuve Fracture of the Fibula
KEITH DOUGLAS MERRILL, M.D.
Nine patients sustained a Maisonneuve fracture of
the fibula (MFF), which is a proximal fibula fracture associated with an ankle fracture or deltoid
ligament tear. Eight were treated with closed reduction and plaster casts. One was treated by open
reduction and internal fixation. Reexamination
was performed at an average of 25.7 months. This
included subjective, objective, and functional evaluations, along with stress roentgenograms. Six patients had an excellent result, two a good result,
and one a fair result. The MFF is often more stable
than generally assumed. For injuries with only a
partial syndesmotic disruption, nonoperative
treatment is recommended.
The Maisonneuve fracture of the fibula
(MF'F) is often considered one of the most
unstable ankle injuries. This is because of the
presumed disruption of all the syndesmotic
ligaments and the interosseous membrane
from the ankle joint to the level of the fibula
fracture.8,'0On those cases requiring surgery,
exploration of the entire interosseous membrane is not feasible, and creating the injury
in anatomic specimens is difficult. Therefore,
little data exist concerning what structures
are disrupted or how unstable the injury actually is.
This study investigates the stability of Maisonneuve fractures and determines whether
surgical intervention is routinely necessary.
The syndesmotic ligaments (Fig. 1) con-
From the University of Missouri Kansas City, Kansas
City, Missouri.
Reprint requests to Keith Douglas Memll, M.D., Department of Orthopaedic Surgery, Medical University of
South Carolina, I7 1 Ashley Ave., Charleston, SC 29425.
Received: March 5, 1991.
Revised: August 2, 1991.
Accepted: August 15, I99 1.
necting the distal tibia to the distal fibula are
three-dimensional and include the following,
from anterior to posterior: the anterior tibiofibular ligament, the interosseous ligament,
the posterior tibiofibular ligament, and the
transverse tibiofibular ligament. The anterior
tibiofibular ligament is the weakest of the
complex. The interosseous ligament is triangular in shape, with its apex proximal and its
base distal. It can be regarded as the fishtailed terminal portion of the interosseous
membrane that extends from just below the
fibular head to just above the ankle joint. The
posterior tibiofibular ligament originates on
the posterolateral aspect of the distal fibula
and inserts into the posterolateral tubercle of
the tibia. The transverse ligament originates
from the digital fossa of the fibula and inserts
across the entire posterior articular surface of
the tibia. The majority of its insertion is medial to the posterolateral tubercle of the tibia.
It is more elastic and stronger than the posterior tibiofibular ligament.4
On the medial side of the ankle, the deltoid
ligament is divided into the superficial and
deep portions. This superficial portion is fanshaped and can be divided into two parts: the
tibionavicular and tibi~calcaneal.~
The deep
deltoid is attached to the undersurface of the
medial malleolus, is oriented horizontally,
and attaches to the medial surface of the
talus.
With the above anatomic points in mind,
one can imagine a plumb line dropped vertically through the center of rotation of the tibia and talus (Fig. I). The talus can externally
rotate and the posterior ligamentous structures can maintain their integrity since they
218
Number 287
February, 1993
The Maisonneuve Fracture of the Fibula
219
I
FIBULA
CENTER OF
ROTATION
TIBIA
,
CENTER OF
ROTATION
HAL
LEOLUS
INTEROSSEOUS
FIBULAR
MALLEOLUS
TERIOR TlBlOFlBULAR
A
i
POSTERIOR TALOFIBULAR
LIGAMENT
LIGAMENT
B
TRANSVERSE
TlBlOFlBULAR
LIGAMENT
FIGS. I A AND I B. The lateral (A) and end on views (B) ofthe ankle depicting the center of rotation ofthe
talus. With external rotation of the talus the anterior ligaments will be disrupted, but the posterior
ligaments can remain intact (Modified and printed with permission from Kelikian, A. S., and Kelikian,
H.: Disorders of the Ankle. Philadelphia, W. B. Saunders, 1985, pp. 498 and 5 12).
are not under tension with an external rotation force. This concept is extremely important in understanding the partial diastasis
that often occurs with an external rotation
injury. It also shows anatomically why the
presence of tenderness anteromedially or anterolaterally cannot be interpreted as a complete ligamentous disruption, but examination for stability and possibly stress roentgenograms can be used to determine the degree
of instability.
In his discussion of ankle fractures, Wilson” states, “In general, the more proximal
the fibula fracture, the greater the damage to
the tibiofibular ligaments. The most extensive tearing is found with fractures of the
proximal one-third of the fibula (Maisonneuve fracture) in which the interosseous
membrane is usually torn as far proximally as
the fibular fracture.” Pankovich* states,
“This is a severe injury to the ankle, which
includes complete diastasis of the distal tibiofibular syndesmosis and often rupture of the
anteromedial joint capsule and deltoid ligament or fracture of the medial malleolus.
Surgical treatment is necessary in later
stages.”
Bonnin,’ on the other hand, believes that
in an MFF, the interosseous ligament, the interosseous membrane, and the posterior tibiofibular ligament are intact. He classifies it
as a partial diastasis that is relatively stable,
and believes that surgery is not necessary.’
MATERIALS AND METHODS
From 1980 until 1986, 1 1 patients with MFF
were treated at several Kansas City hospitals. Two
of these fractures occurred within four months of
the review and were excluded from the study
group. Examination of nine patients ranged from
eight months to 4.5 years (average, 25.7 months).
In seven of the nine, clinical examination and external rotation stress roentgenograms were completed. A special jig was used to ensure standard
roentgenograms as recommended by Bolin,’ and
the mortise roentgenograms were made with the
foot in 20” of internal rotation. In the other two, a
review of the chart and roentgenograms and a telephone interview were conducted.
Baseball, softball, and slipping on ice or water
accounted for most of the injuries. In all nine
cases, the fracture occurred in the proximal one
third of the fibula, and the patients’ symptom was
ankle pain. Four of the nine patients (44%) were
able to bear weight on the injured extremity with
an antalgic gait and came for evaluation between
one day and three weeks after injury. One patient
220
Clinical Orthopaedics
and Related Research
Merrill
had an associated medial malleolus fracture and
eight (89%) had ligamentous injuries medially,
based on tenderness and swelling found in the region of the anteromedial capsule. In four of nine
(44%),the diagnosis was missed by the initial physicians because they focused their attention toward the sore ankle and did not examine or obtain
roentgenograms of the proximal fibula. Four of
the nine (44%)had nondisplaced or minimally displaced fractures of the posterolateral tubercle of
the tibia, none greater than 10% of the articular
surface. All four of these were treated nonoperatively.
Eight of nine (89%) were treated by closed reduction and casting; six in short leg casts for four
to eight weeks, and two in long leg casts for six to
eight weeks. One was treated by joint exploration,
deltoid ligament repair, and insertion of a syndesmotic screw. The treatment was determined by the
treating physician’s preference.
At the time of the most recent examination,
eight of nine (89%) had resumed their preinjury
activity level, including roller skating, basketball,
softball, and construction work. The one patient
who did not return to his previous occupation had
a peroneal nerve palsy since the injury and could
not return to house painting. The etiology of the
palsy was not identified.
In the seven patients reexamined, the range of
motion (ROM) in the ankle and subtalar joints
was equal to that of the contralateral side. On follow-up roentgenogram, eight of nine (89%)
showed no increase in the medial clear space or in
the syndesmosis. One had a I-mm increase in the
medial clear space. One patient had mild subchondral sclerosis of the distal tibia and was the only
patient with any roentgenographic arthrosis. The
talocrural angle was used to evaluate fibular
length. This angle is formed by the intersection of
two lines, one drawn parallel to the tibial articular
surface and the second drawn between the tips of
the malleoli on the mortise roentgenogram.’ It was
within 2” of the contralateral uninjured ankle in
all cases. This is considered normal.’
Six patients (67%)were judged to have an excellent result (returned to preinjury activities with no
more than mild occasional discomfort and no
roentgenographic abnormalities). Two patients
(22%) had a good result (mild roentgenographic
abnormalities) and one ( 1 1%) had a fair result (peroneal nerve palsy).
DISCUSSION
Maisonneuve6 published the results of his
experiments on the ankle in 1840. The illustration depicting the injury that bears his
name shows the proximal fibula fracture and
also shows the interosseous membrane intact
(Fig. 2). In the same illustration, the analogy
between the fracture and two volumes of a
book with an external rotation force applied
between them is shown. This demonstrates
the posterior hinge around which one volume rotates. The posterior hinge in the fracture is the posterior tibiofibular ligament and
the transverse ligament. Even with a fracture
of the posterolateral tubercle of the tibia,
which rarely involves more than one fourth
of the tibial vault, the transverse ligament will
maintain the integrity of the posterior syndesmosis because of its insertion across the
entire posterior tibial surface. It will provide a
posterior hinge for the syndesmosis.’ LaugeHansen5 describes a proximal fibula fracture
HINGED
- POSTERlOAL”
FIG. 2 . Maisonneuve’s conception of the fracture that bears his name, and conceptualization of
an external rotation force between two books,
hinged posteriorly and opening anteriorly. Inset
below also shows external rotation of the fibula
and disruption of the anterior ligamentous structures (Modified and printed with permission from
Kelikian, A. S., and Kelikian, H.: Disorders of the
Ankle. Philadelphia, W. B. Saunders, 1985, p.
116).
Number 287
February, 1993
caused by external rotation of the foot with
the dorsal ligaments of the syndesmosis intact, which is a description of a partial diastasis. Pankovich' created the Maisonneuve
fracture in anatomic specimens. He found
the interosseous membrane intact in the
cases he was able to create. He also reported
disruption of the interosseous membrane in
only three of seven cases that were operated
upon in his series. Approximately one half of
his patients were treated nonoperatively. Despite these findings, Pankovich' considered
the Maisonneuve fracture a severe injury to
the ankle with complete diastasis of the syndesmosis and recommended surgical treatment.
It is easy to understand how the posterior
ligamentous structures can remain intact
with an external rotation injury resulting in a
partial syndesmotic diastasis. It is slightly
more difficult to understand how the interosseous membrane could remain intact with
a fracture of the proximal fibula. The interosseous membrane is a fascia1 structure connecting the tibia and fibula in one plane, preventing lateral displacement of the fibula but
doing little to prevent anterior and posterior
displacement of the fibula.2 Also, because of
its linear insertion, the interosseous membrane affords little rotational control to the
fibula, and can remain intact while the fibula
rotates. The proximal fibula fracture occurs
when the rotation of the fibula is prevented
by the capsuloligamentous structures of the
proximal tibiofibular joint.
In an anatomic specimen, the entire proximal and distal syndesmotic ligaments and
joint capsules were cut, leaving only the interosseous membrane intact between the
tibia and fibula. The fibula could be easily
rotated externally approximately 150" without disruption of the interosseous membrane. The interosseous membrane was easily disrupted by applying an abduction force
to the distal fibula.
The clinical, roentgenographic, and surgical findings of a patient seen recently with a
Maisonneuve fracture demonstrate the par-
The Maisonneuve Fracture of the Fibula
221
tial diastasis that can occur with this injury.
The patient sustained an external rotation injury to his ankle while moving furniture late
at night. The next day he came to the hospital
with pain, swelling, and tenderness in the anteromedial and anterolateral aspects of his
ankle. Initial ankle roentgenograms showed
slight widening of the medial clear space.
Roentgenogram of the knee showed the
FIG. 3 . Abduction stress roentgenograms of a
patient with a Maisonneuve fracture, showing that
the medial clear space is widened to approximately 5 mm.
222
Clinical Orthopaedics
and Related Research
Merrill
proximal fibula fracture. Stress roentgenograms showed that the medial clear space
opened to 5 mm with straight abduction (Fig.
3), and to 7 mm with external rotation of the
foot (Fig. 4).
T
FIG. 5. Internal rotation, valgus stress roentgenograms of the same ankle demonstrating closing of
the medial clear space. Anatomic reduction with
the above force demonstrates the presence of an
intact posterior hinge that with internal rotation of
the foot closes the book and prevents lateral subluxation.
FIG. 4.External rotation stress roentgenographs
of same patient demonstrating increased widening
of the medial clear space.
A mortise-view roentgenogram with internal rotation of the foot on the tibia and application of a valgus force showed anatomic reduction of the talus. This finding demonstrated the presence of the posterior hinge
between the tibia and fibula (under tension
because of the internal rotation of the foot)
and prevented lateral subluxation of the talus
(Fig. 5).
Because this patient’s transient lifestyle limited his availability for close follow-up care
with the authors, ankle exploration and ligament repair were performed. The findings at
operation included avulsion of the anterior
capsule and the anterior one half of the super-
Number 287
February. 1993
ficial deltoid ligament from the tibia, and
disruption of the anterior one third of the
deep deltoid ligament with the posterior two
thirds intact. On the lateral side the anterior
tibiofibular ligament was disrupted, and the
interosseous ligament was disrupted. A nerve
hook was used to probe the posterior syndesmotic ligaments, which were intact. The interosseous membrane was intact where it was
probed, just proximal to the syndesmosis.
The anterior capsule, the deltoid ligament,
and the anterior tibiofibular ligament were
repaired. An external-rotation stress roentgenogram showed anatomic reduction. Gentle lateral traction applied to a bone hook
around the distal fibula caused no displacement of the fibula. Therefore, no syndesmotic screw was thought necessary based on the
recommendation of De Souza et aL3 Muller
et al.,’ and Pankovich.8
This series of patients with Maisonneuve
fractures, the above-described roentgenographic and surgical findings, along with a
review of the literature, show that the Maisonneuve fracture can, and often does occur
with a partial syndesmotic diastasis. These injuries are relatively stable, and they can be
The Maisonneuve Fracture of the Fibula
223
treated nonoperatively by internally rotating
the foot and thus using the posterior hinge to
“close the book”, yielding an anatomic reduction.
REFERENCES
I . Bolin, H.: The fibula and its relationship to the tibia
and talus in injuries ofthe ankle due to forced external rotation. Acta Radiol. 56:439. I96 1.
2. Bonnin, J. G.: Injuries to the ankle. London, Heineman Medical Books, 1950, pp. 163-164.
3. De Souza, L. J., Gustilo, R. B.. and Meyer, T. J.:
Results of operative treatment of displaced external
rotation-abduction fractures of the ankle. J. Bone
Joint Surg. 67A: 7, 1066, 1985.
4. Kelikian, A. S., and Kelikian, H.: Disorders of the
Ankle.St. Louis, W.B. Saunders, 1985.pp.6. 15-18.
478, 499.
5. Lauge-Hansen, N.: Fractures of the ankle. Arch.
Surg. 56:259, 1948.
6. Maisonneuve, M. J. G.: Recherches sur la fracture
du perone. Arch. Gen. Med. 7:165,433. 1840.
7. Muller, M. E.. Allgower. M.. Schneider. R.. and Willenegger, H.: Manual of Internal Fixation, ed. 2. Berlin, Springer-Verlag, 1979. p. 296.
8. Pankovich, A. M.: Maisonneuve fractures of the fibula. J. Bone Joint Surg. 58:3. 337, 1976.
9. Sarkisian, J. S., and Cody, G. W.: Closed treatment
of ankle fractures: A new criterion for evaluation: A
review of 250 cases. J. Trauma 16:323. 1976.
10. Wilson, F. C.: Fractures and dislocations of the ankle. In Rockwood, C. A,, and Green, D. P. (eds.):
Fractures in Adults. vol. 2, ed. 2. Philadelphia. J. B.
Lippincott, 1984. p. 1674.
`