A Maisonneuve fracture is a spiral fracture of the proximal third of the fibula combined with disruption of the interosseous membrane, anterior and posterior inferior tibiofibular ligaments (syndesmosis), and a medial ankle injury (deltoid ligament tear or medial malleolus fracture). It accounts for up to 7% of all ankle fractures and is one of the most commonly missed fractures in the emergency department because patients present with ankle pain but minimal proximal leg complaints. [1-3]
1. History
- Mechanism: Extreme external rotation and pronation of a planted/fixed foot — classically a violent twisting injury [4]
- Common scenarios: sports injuries, misjudging a step, falls with rotational force [4-5]
- Chief complaint is typically ankle pain, not knee or proximal leg pain — this is the key reason the injury is missed [1][6]
- Ask about: ability to bear weight, sensation of a "pop" or "snap," prior ankle injuries, swelling onset and location
- Patients may report pain along the medial ankle, lateral leg, or diffuse lower leg discomfort
- Important negative: patients often deny significant proximal fibula pain despite having a fracture there [1][7]
2. Alarm Features
- Medial ankle pain or widened medial clear space on ankle radiograph with no visible distal fibula fracture — must suspect Maisonneuve [6]
- Inability to bear weight
- Gross ankle deformity or dislocation
- Neurovascular compromise (peroneal nerve runs near the proximal fibula — assess for foot drop)
- Open fracture at the proximal fibula
- Talar shift or ankle mortise widening on radiographs
- Posterior malleolus fracture (present in ~80% of cases) [8-9]
3. Medications
- Acute pain management: NSAIDs (ibuprofen 400–600 mg PO q6h, ketorolac 15–30 mg IV), acetaminophen, opioids for severe pain
- Avoid anticoagulants acutely if surgical intervention is anticipated
- DVT prophylaxis should be considered during immobilization (especially if non-weight-bearing for extended periods)
- No specific medication contraindications unique to this fracture pattern
4. Diet
- Generally not a primary concern
- Adequate calcium and vitamin D intake for bone healing
- Ensure adequate protein intake during recovery
- Smoking cessation counseling — smoking impairs fracture healing
5. Review of Systems
- MSK: Pain location (ankle vs. proximal leg vs. knee), swelling, ability to bear weight, range of motion
- Neuro: Numbness/tingling in the foot (peroneal nerve injury), weakness of dorsiflexion or eversion
- Vascular: Skin color, temperature, capillary refill distally
- Constitutional: Mechanism details, prior similar injuries, baseline activity level
6. Collateral History and Family History
- Witnesses to the mechanism (rotational vs. direct blow) — helps distinguish from isolated ankle sprain
- Prior ankle injuries, chronic instability, or previous surgeries
- Family history is generally not contributory
- Social context: occupation, athletic demands, ability to comply with non-weight-bearing restrictions
7. Risk Factors
- Sports participation (most common setting) — football, basketball, soccer, skiing [4-5]
- Activities involving sudden pivoting or rotational forces on a planted foot
- Prior ankle sprains or chronic ankle instability
- Hyperpronation foot mechanics
- Peak incidence in the 5th decade overall; in women, peak in the 6th decade [9]
8. Differential Diagnosis
- Isolated high ankle sprain (syndesmotic injury without proximal fibula fracture) — most important mimic
- Isolated lateral ankle sprain — the most common misdiagnosis when the proximal fibula is not examined [1]
- Isolated medial malleolus fracture — may be the only finding on ankle films
- Weber type C fibula fracture (suprasyndesmotic but not proximal)
- Bosworth fracture-dislocation (fibula trapped behind posterior tibial tubercle) [9]
- Pilon fracture — higher-energy axial loading mechanism
- Tibial shaft fracture with associated fibula fracture
- Proximal fibula fracture from direct trauma (without syndesmotic disruption)
- "Double Maisonneuve fracture" — distal fibula fracture combined with proximal fibula fracture [10]
9. Past Medical History
- Prior ankle fractures, sprains, or surgeries
- Chronic ankle instability
- Osteoporosis or metabolic bone disease
- Diabetes, peripheral vascular disease (affect surgical candidacy and healing) [11]
- Connective tissue disorders (ligamentous laxity)
10. Physical Exam
- Ankle: Swelling, ecchymosis, tenderness over the medial malleolus and deltoid ligament; assess ankle mortise alignment
- Proximal fibula: Palpate the entire length of the fibula — tenderness at the proximal fibula is the key finding that clinches the diagnosis [1][7][12]
- Squeeze test (compression of the mid-calf): Pain at the distal tibiofibular syndesmosis suggests syndesmotic injury [12-13]
- External rotation stress test: Passive external rotation of the foot with the ankle in dorsiflexion reproduces syndesmotic pain [12]
- Anterior drawer and talar tilt: Assess lateral ligament integrity
- Neurovascular exam: Dorsalis pedis and posterior tibial pulses; peroneal nerve function (dorsiflexion, eversion, sensation in the first web space)
- Vital signs: Generally normal unless polytrauma
11. Lab Studies
- Labs are generally not required for isolated Maisonneuve fractures
- Preoperative labs if surgery planned: CBC, BMP, coagulation studies, type and screen per institutional protocol
- Consider HbA1c in diabetics (wound healing risk stratification)
12. Imaging
- First-line: AP, lateral, and mortise views of the ankle — may show widened medial clear space (>4 mm), widened tibiofibular clear space, or medial malleolus fracture [4][6]
- Critical step: Full-length tibia/fibula radiographs (AP and lateral) if syndesmotic injury is suspected or proximal fibula tenderness is present — this reveals the proximal fibula fracture [4][7]
- CT of the ankle: Recommended preoperatively to assess posterior malleolus fractures (present in ~80%), fibula position in the fibular notch, and associated injuries [2][8][14]
- MRI: Useful adjunct to evaluate deltoid ligament integrity, interosseous membrane disruption, and osteochondral lesions when CT is insufficient [3][15]
- When imaging is unnecessary: Standard ankle radiographs alone are insufficient — if there is any suspicion of syndesmotic injury, full-length leg films are mandatory [7]
Pearl: In 24% of cases, the proximal fibula fracture is visible only on the lateral view of the lower leg. [9]
13. Special Tests
- Ottawa Ankle Rules: Useful for determining need for ankle radiographs, but do not assess for proximal fibula pathology — a negative Ottawa rule does not exclude Maisonneuve fracture
- Squeeze test: Compress the fibula against the tibia at mid-calf level; pain at the syndesmosis is positive
- External rotation stress test: Most sensitive clinical test for syndesmotic injury
- Cotton test / Hook test: Intraoperative assessment of syndesmotic stability (though reliability has been questioned) [16]
- Gravity stress test: Assess medial clear space widening under stress
- Olerud-Molander Ankle Score and AOFAS Ankle-Hindfoot Scale: Used for functional outcome assessment post-treatment [15]
14. ECG
- Not routinely indicated
- Consider if the patient is elderly, has cardiac comorbidities, or is being evaluated for surgical clearance
15. Assessment
The Maisonneuve fracture is an unstable ankle injury that is frequently missed in the ED because the primary complaint is ankle pain, and the proximal fibula fracture is clinically silent. [1][6] The injury pattern is classified as a Lauge-Hansen pronation-external rotation (PER) type and always involves disruption of the anterior tibiofibular ligament and interosseous membrane. [2][8] The injury ranges from stable to highly unstable depending on the extent of associated injuries. [2]
Key associated injuries include:
- Posterior malleolus fracture: ~80% of cases [8-9]
- Deltoid ligament rupture: ~50% [8]
- Medial malleolus fracture: ~37% [8]
- Medial structures intact: ~13% [8]
Complications of missed diagnosis include lateral talar shift, progressive ankle instability, and post-traumatic osteoarthritis — even 1 mm of lateral talar displacement reduces tibiotalar contact area by ~42%. [11]
16. Treatment Plan
Initial stabilization (ED)
- Posterior splint with stirrup (sugar-tong or posterior mold) in neutral position
- Strict non-weight-bearing
- Ice, elevation, analgesia
- Urgent orthopedic consultation
Definitive treatment — surgical (standard of care)
- ORIF is recommended for most Maisonneuve fractures due to inherent instability [1][5][17-18]
- Medial malleolus fixation if fractured [17]
- Syndesmotic fixation: 1–2 transsyndesmotic screws (3- or 4-cortical) placed percutaneously, or suture-button device [2][17]
- Posterior malleolus fixation if fragment is large or displaced — must be reduced first to restore the fibular notch [2][14]
- Open reduction of the distal fibula into the fibular notch is preferred over closed reduction (closed reduction has up to 50% malposition rate) [2][14]
- The proximal fibula fracture does not require fixation [17]
- Deltoid ligament repair is generally not necessary [17]
- Postoperative CT to confirm reduction accuracy [2]
Conservative treatment: Rarely appropriate; may be considered in select cases with minimal syndesmotic displacement, though evidence is limited to case reports. [15]
17. Disposition
Admission criteria
- Open fracture or fracture-dislocation requiring emergent reduction
- Significant soft tissue swelling requiring monitoring for compartment syndrome
- Polytrauma
- Planned urgent/emergent surgical fixation
Discharge criteria
- Closed injury, adequately splinted, with confirmed non-weight-bearing status
- Reliable patient with orthopedic follow-up arranged within 5–7 days
- Adequate pain control and clear return precautions
Specialist consultation
- Orthopedic surgery consultation[1][17-18]
18. Follow Up / Return Precautions
- Follow-up: Orthopedic surgery within 5–7 days of ED visit for surgical planning and CT
- Post-surgical follow-up per orthopedic protocol (typically 2 weeks for wound check, 6 weeks for radiographic assessment, screw removal at 8–12 weeks if applicable)
- Return precautions — return immediately for:
- Increasing pain despite immobilization (compartment syndrome)
- Numbness, tingling, or weakness in the foot
- Color change, coolness, or swelling of the toes
- Fever, wound drainage, or erythema (if post-surgical)
- Expected recovery: 3–6 months for return to full activity; operative outcomes are good/excellent in ~86–89% of cases [5][17-18]
- Counsel on the importance of strict non-weight-bearing compliance and follow-up attendance
Clinical Pearl: The single most important teaching point — always palpate the proximal fibula in every patient presenting with an ankle injury. This 5-second exam maneuver prevents the most commonly missed fracture pattern in emergency medicine. [1][7][12-13]
Images
References
1. The Proximal Fibula Should Be Examined in All Patients With Ankle Injury: A Case Series of Missed Maisonneuve Fractures. — Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The Journal of Emergency Medicine. 2013.
2. Maisonneuve Fractures of the Ankle: A Critical Analysis Review. — Bartoníček J, Rammelt S, Tuček M. JBJS Reviews. 2022.
3. Maisonneuve-Hyperplantarflexion Variant Ankle Fracture. — Hinds RM, Tran WH, Lorich DG. Orthopedics. 2014.
4. A Maisonneuve Fracture in an Active Duty Sailor: A Case Report. — Richmond RR, Henebry AD. Military Medicine. 2018.
5. Outcome After Surgery for Maisonneuve Fracture of the Fibula. — Sproule JA, Khalid M, O'Sullivan M, McCabe JP. Injury. 2004.
6. Maisonneuve Fracture: Case Report of a Missed Diagnosis. — Lock TR, Schaffer JJ, Manoli A. Annals of Emergency Medicine. 1987.
7. ACR Appropriateness Criteria® Acute Trauma to the Ankle. — Smith SE, Chang EY, Ha AS, et al. Journal of the American College of Radiology : JACR. 2020.
8. Pathoanatomy of Maisonneuve Fracture Based on Radiologic and CT Examination. — Bartoníček J, Rammelt S, Kašper Š, Malík J, Tuček M. Archives of Orthopaedic and Trauma Surgery. 2019.
9. Maisonneuve Fracture. — Kašper Š, Bartoníček J, Kostlivý K, Malík J, Tuček M. Rozhledy v Chirurgii : Mesicnik Ceskoslovenske Chirurgicke Spolecnosti. 2020.
10. "Double Maisonneuve Fracture": An Unknown Fracture Pattern. — Kašper Š, Bartoníček J, Rammelt S, Kamin K, Tuček M. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2022.
11. Surgical Versus Conservative Interventions for Treating Ankle Fractures in Adults. — Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. The Cochrane Database of Systematic Reviews. 2012.
12. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. — Herring SA, Kibler WB, Putukian M, et al. Medicine and Science in Sports and Exercise. 2024.
13. Telemedicine Management of Musculoskeletal Issues. — Yedlinsky NT, Peebles RL. American Family Physician. 2021.
14. Maisonneuve Ankle Fracture. — Bartoníček J, Fojtík P, Bunganičová E, Tuček M. Rozhledy v Chirurgii : Mesicnik Ceskoslovenske Chirurgicke Spolecnosti. 2023.
15. Maisonneuve Fracture Treated With Short Leg Cast: A Case Report With 41-Month Follow-Up. — Wang C, Dong S, Li X, et al. Medicine. 2024.
16. Ankle Fracture With a Complex Injury Mechanism and Misleading Hook Test Result: A Case Report. — Guo H, Huang W, Zeng C. The Journal of Foot and Ankle Surgery : Official Publication of the American College of Foot and Ankle Surgeons. 2020.
17. Evidence-Based Treatment of Maisonneuve Fractures. — Stufkens SA, van den Bekerom MP, Doornberg JN, van Dijk CN, Kloen P. The Journal of Foot and Ankle Surgery : Official Publication of the American College of Foot and Ankle Surgeons. 2010.
18. Operative Treatment for Maisonneuve Fracture of the Proximal Fibula. — Babis GC, Papagelopoulos PJ, Tsarouchas J, et al. Orthopedics. 2000.