01Approach to the Critical Patient/attcp32

Immediate threats requiring urgent action

›Limb-threatening emergencies

›Open proximal fibula fracture

›Wound care, sterile dressing, emergent orthopedic consult

›IV antibiotics within 1 hour of diagnosis

›Vascular compromise of the foot

›Absent dorsalis pedis or posterior tibial pulse

›Immediate vascular surgery or orthopedic consultation

›Compartment syndrome of the lower leg

›Severe pain with passive stretch

›Compartment pressure > 30 mmHg or within 30 mmHg of diastolic

›Emergent fasciotomy if confirmed

Alarm features

›High-risk presentation triggers

›Medial ankle pain with widened medial clear space and no visible distal fibula fracture

›Mandate full-length tibia/fibula radiographs

›Missed Maisonneuve until proven otherwise

›Ankle mortise widening or talar shift on plain film

›Indicates significant syndesmotic disruption

›Urgent orthopedic consultation

›Ankle fracture-dislocation with talar displacement

›Closed reduction attempt prior to imaging if vascular compromise

›Post-reduction neurovascular reassessment

›Peroneal nerve deficit (foot drop, absent first web space sensation)

›Proximal fibula fracture compressing the common peroneal nerve

›Document deficit, urgent orthopedic consultation

Key decision points

›Disposition decision algorithm

02History/hx45

Mechanism and presentation

›Mechanism of injury

›Extreme external rotation and pronation of a planted fixed foot

›Violent twisting injury

›Classifies as Lauge-Hansen pronation-external rotation (PER) type

›Common sporting scenarios

›Football, basketball, soccer, skiing

›Sudden pivoting or rotational force on a planted foot

›Key clinical trap

›Chief complaint is ankle pain, not proximal leg pain

›Proximal fibula fracture is clinically silent in many patients

›Accounts for up to 7% of all ankle fractures

›One of the most commonly missed fractures in the ED

›Primary symptoms

›Ankle pain predominant

›Medial ankle pain or deltoid region tenderness

›Lateral ankle pain may be absent

›Audible or felt "pop" or "snap" at time of injury

›Swelling onset location and rate

›Ability to bear weight after injury

Risk factors

›Patient risk profile

›Athletic activity and sport participation

›Most common setting for this injury

›Peak incidence in the 5th decade overall

›In women, peak incidence in the 6th decade

›Prior ankle injuries or chronic instability

›Prior ankle sprains

03Physical Exam/exam59

Ankle and foot examination

›Ankle inspection and palpation

›Medial ankle swelling and ecchymosis

›Deltoid ligament region tenderness

›Medial malleolus palpation for fracture

›Lateral ankle assessment

›Anterior talofibular ligament tenderness

›Lateral malleolus region

›Ankle mortise alignment

›Gross deformity or asymmetry

›Talar position clinically

›Stress testing

›External rotation stress test

›Passive external rotation of foot with ankle in dorsiflexion

›Most sensitive clinical test for syndesmotic injury

›Reproduction of syndesmotic pain is positive

›Anterior drawer test

›Lateral ligament integrity

›Talar tilt test

›Coronal plane instability

Proximal fibula and leg examination

›Fibula palpation along entire length

›Proximal fibula tenderness

›Key finding that clinches the diagnosis

›Must be performed in every ankle injury patient

›Proximal tenderness with ankle pain mandates full-length leg radiograph

›Mid-fibula and distal fibula assessment

›Syndesmosis-specific tests

04Differential Diagnosis/ddx36

Ankle fracture patterns

›Fibula fracture classification

›Maisonneuve fracture (ICD-10 S82.411A initial encounter)

›Proximal fibula fracture with syndesmotic disruption

›Medial ankle injury (deltoid tear or medial malleolus fracture)

›Weber type C fibula fracture

›Suprasyndesmotic but distal to Maisonneuve level

›Does not involve the proximal fibula

›Isolated medial malleolus fracture (ICD-10 S82.51)

›May be the only finding on ankle films if proximal fibula not imaged

›Double Maisonneuve fracture

›Distal fibula fracture combined with proximal fibula fracture

›Rare but reported pattern

›High-energy ankle injuries

›Pilon fracture (ICD-10 S82.87)

›Axial loading mechanism

›Articular surface comminution

›Tibial shaft fracture with associated fibula fracture

›Higher-energy mechanism

›Bosworth fracture-dislocation

›Fibula trapped posterior to tibial tubercle

›Irreducible by closed means

Syndesmotic and ligamentous injuries

›Syndesmotic spectrum

›Isolated high ankle sprain (ICD-10 S93.4)

›Syndesmotic injury without proximal fibula fracture

›Most important mimic of Maisonneuve pattern

›Squeeze test and external rotation test may be positive

05Laboratory Tests/lt28

Pre-operative assessment labs

›Surgical candidacy evaluation

›Complete blood count

›Baseline hemoglobin and platelet assessment

›Infection screen if open injury

›Basic metabolic panel

›Renal function for contrast and medication dosing

›Electrolyte status

›Coagulation studies (PT, INR, aPTT)

›Anticoagulant use assessment

›Surgical bleeding risk

›Type and screen

›Per institutional pre-operative protocol

›HbA1c in diabetic patients

›Wound healing risk stratification

›Surgical infection risk assessment

DVT risk assessment

›Thrombotic risk evaluation

›D-dimer if DVT suspected during immobilization period

›Clinical context required for interpretation

›Lower extremity Doppler ultrasound if DVT suspected

›Non-weight-bearing status increases thrombotic risk

›DVT prophylaxis consideration during immobilization

›Particularly if non-weight-bearing for extended period

Point of care and ancillary testing

›Adjunct testing

›Urinalysis if urinary tract infection suspected in elderly

›Avoid anchoring to coincidental findings

06Diagnostic Tests/dt108

Scoring Systems

›Ottawa Ankle Rules

›Indication for ankle radiographs

›Bone tenderness at posterior 6 cm of fibula or tip of lateral malleolus

›Bone tenderness at posterior 6 cm of tibia or tip of medial malleolus

›Inability to bear weight immediately and in ED (4 steps)

›Critical limitation for Maisonneuve

›Ottawa rules do not assess for proximal fibula pathology

›A negative Ottawa Ankle Rule does NOT exclude Maisonneuve fracture

›Proximal fibula tenderness mandates leg films regardless of Ottawa result

›Lauge-Hansen Classification

›Mechanism-based ankle fracture classification

›Pronation-External Rotation (PER) type describes Maisonneuve pattern

›Sequence: anterior tibiofibular ligament, then interosseous membrane, then posterior tibiofibular ligament, then medial structures

›Clinical utility

›PER pattern associated with highest rate of syndesmotic disruption

›Guides understanding of associated injury spectrum

›Functional outcome scores

›Olerud-Molander Ankle Score

›Used for post-treatment outcome assessment

›Pain, stiffness, swelling, stair-climbing, running, jumping, squatting domains

›AOFAS Ankle-Hindfoot Scale

›Functional outcome post-operative assessment

›Good to excellent outcomes in approximately 86-89% of cases

Scoring Systems Additional

›Syndesmotic reduction assessment

›Medial clear space measurement

›Normal < 4 mm

›Widening > 4 mm indicates medial structural injury

›Tibiofibular clear space

›Normal < 6 mm on AP view

›Widening indicates syndesmotic disruption

›Tibiofibular overlap

›Normal > 6 mm on AP view

›Normal > 1 mm on mortise view

MRI

›MRI indications for Maisonneuve fracture

›Deltoid ligament integrity assessment

›When medial clear space widening present without visible medial malleolus fracture

›Differentiates deltoid ligament tear from bony avulsion

›Interosseous membrane disruption extent

›Correlates with injury severity and instability

›Extent of interosseous membrane tear affects prognosis

›Osteochondral lesion assessment

›Talar dome injury associated with ankle trauma

›Important for long-term outcome planning

›MRI protocol considerations

›Sequences

›Short tau inversion recovery (STIR) for ligament edema

›Proton density fat-suppressed for cartilage

›T1 weighted for bony anatomy

›Limitations

›Not routine for acute ED evaluation

›Used as adjunct when CT findings are insufficient

›Useful in subacute and pre-operative planning context

CT

›CT indications

›Preoperative assessment of posterior malleolus fracture

›Posterior malleolus fracture present in approximately 80% of Maisonneuve cases

›CT defines fragment size, displacement, and articular involvement

›Fragment size guides fixation decision

›Fibula position in fibular notch assessment

›Determines if fibula is reduced or displaced in fibular notch

›Critical for surgical planning

›Medial malleolus fracture characterization

›Present in approximately 37% of cases

›Fragment anatomy and displacement

›Associated injury identification

›Additional osteochondral or bony injuries not seen on plain film

›CT protocol

›CT of ankle without contrast

›Thin slice reconstruction (1 mm) for ankle joint detail

›Multiplanar reconstruction in coronal and sagittal planes

›Postoperative CT role

›Confirms reduction accuracy after syndesmotic fixation

›Recommended to verify fibula position in notch

›Closed reduction has up to 50% malposition rate (open reduction preferred)

›CT findings in Maisonneuve fracture

›Proximal fibula spiral fracture above the level of the syndesmosis

›Widening of the tibiofibular clear space

›Posterior malleolus involvement

Ultrasound

›Ultrasound role in Maisonneuve fracture

›Soft tissue and ligament assessment

›Deltoid ligament integrity in medial ankle

›Anterior tibiofibular ligament visualization

›Real-time dynamic stress assessment possible

›DVT assessment during immobilization period

›Compressibility of popliteal, femoral veins

›Non-weight-bearing status increases DVT risk

›Point-of-care ultrasound

›Limited role in primary diagnosis

›Plain radiograph and CT are primary imaging modalities

›Ultrasound not recommended as first-line for fracture diagnosis

›Soft tissue swelling characterization

›Hematoma versus fluid collection

›Can guide aspiration if needed

Plain Radiography (Primary Imaging)

›Ankle radiograph series (first-line)

›AP, lateral, and mortise views of the ankle

›May show widened medial clear space > 4 mm

›May show widened tibiofibular clear space

›May show medial malleolus fracture

›Distal fibula may appear normal

›Medial clear space widening without distal fibula fracture

›Must suspect Maisonneuve until proven otherwise

›Mandates full-length tibia/fibula radiographs

›Full-length tibia/fibula radiographs

›AP and lateral views of entire tibia and fibula

›Critical step when syndesmotic injury suspected

›Mandatory when proximal fibula tenderness is present

›Reveals the proximal fibula spiral fracture

›Imaging pearl

›In 24% of cases, proximal fibula fracture is visible only on the lateral view of the lower leg

07Disposition/dispo40

Admission indications

›Criteria requiring hospital admission

›Open fracture at any level

›Requires IV antibiotics and operative wound management

›Emergent orthopedic surgery involvement

›Vascular compromise of the limb

›Absent or diminished distal pulses

›Emergent vascular and orthopedic evaluation

›Compartment syndrome confirmed or suspected

›Emergent fasciotomy planning

›Compartment pressure monitoring

›Planned urgent or emergent surgical fixation

›Fracture-dislocation requiring immediate reduction

›Significant soft tissue swelling requiring monitoring

›Particularly when compartment syndrome risk is elevated

›Polytrauma context

Discharge criteria

›Safe discharge requirements

›Closed injury

›No open wounds or skin compromise

›Adequate immobilization

›Posterior splint with stirrup (sugar-tong or posterior mold) applied

›Neutral ankle position

›Confirmed non-weight-bearing status

›Patient physically capable and cognitively able to comply

›Crutches provided and training confirmed

›Adequate pain control on oral analgesics

›Reliable orthopedic follow-up arranged within 5-7 days

08Treatment/t69

Immediate ED management

›Initial stabilization

›Immobilization

›Posterior splint with stirrup (sugar-tong or posterior mold)

›Ankle in neutral position

›Non-weight-bearing strict instruction

›RICE principles

›Ice application to reduce swelling

›Elevation of the affected limb

›Open fracture management

›Sterile saline irrigation and dressing

›Cefazolin 2 g IV for Gustilo type I and II

›Add metronidazole for farm or heavily contaminated wounds

›Tetanus prophylaxis as indicated

Analgesia

›Pain management protocol

›Oral analgesics for mild-moderate pain

›Ibuprofen 400-600 mg PO every 6 hours with food

›Acetaminophen 1000 mg PO every 6 hours

›Maximum acetaminophen 4 g per 24 hours

›Parenteral analgesics for severe pain

›Ketorolac 15-30 mg IV once

›Limit use if surgery is planned within 24-48 hours

›Avoid in renal impairment

›Morphine 0.1 mg/kg IV titrated for severe pain

›Hydromorphone 0.5-1 mg IV for severe pain in adult

›Nerve block consideration

›Popliteal sciatic nerve block for operative patients

›Significant opioid-sparing effect

›Performed by regional anesthesia or emergency medicine

Definitive surgical treatment

›Open reduction and internal fixation (ORIF)

›Standard of care for most Maisonneuve fractures

›Recommended due to inherent instability of this fracture pattern

›Proximal fibula fracture does NOT require fixation

›Syndesmotic fixation

›1-2 transsyndesmotic screws (3-cortical or 4-cortical) placed percutaneously

›Suture-button device (TightRope) as alternative

›Allows physiologic motion at syndesmosis

›Does not require routine screw removal

›Open reduction preferred over closed reduction

›Closed reduction has up to 50% malposition rate

›Medial malleolus fixation

›Required if medial malleolus fracture present

›Tension band wiring or lag screw technique

›Posterior malleolus fixation

›Required if fragment is large or significantly displaced

›Reduce first to restore fibular notch anatomy

›Fragment size threshold for fixation: typically > 25% of articular surface

›Deltoid ligament repair

›Generally not required

›Medial stability typically restored after bony fixation

›Postoperative CT

›Recommended to confirm fibula reduction accuracy in fibular notch

Conservative treatment

›Non-operative approach

›Rarely appropriate

›May be considered in exceptional cases with minimal syndesmotic displacement

›Evidence limited to case reports

›When considered, immobilization protocol

›Below-knee cast or boot

›Non-weight-bearing for 6-8 weeks

›Close radiographic monitoring required

›Repeat imaging at 1-2 weeks to confirm maintained reduction

DVT prophylaxis

›Thromboprophylaxis consideration

›Non-weight-bearing status increases DVT risk

›Low molecular weight heparin during immobilization period

›Enoxaparin 40 mg SC daily for prophylaxis

›Adjust dose for renal impairment (GFR < 30 ml/min)

›Mechanical prophylaxis

›Pneumatic compression device if pharmacologic prophylaxis contraindicated

›Duration

›Continue until weight-bearing resumed or per orthopedic protocol

09Special Populations/sp89

Pregnancy

›Radiation considerations

›Plain radiographs

›Ankle and leg films may be obtained with abdominal shielding

›Fetal radiation dose from extremity films is minimal

›Benefit of diagnosis outweighs radiation risk

›CT of ankle

›Low dose to fetus from distal extremity imaging

›Use if clinically required for surgical planning

›Discuss risk-benefit with patient

›MRI preferred when additional soft tissue assessment needed

›No ionizing radiation

›Gadolinium contrast should be avoided unless essential

›Analgesia in pregnancy

›Acetaminophen preferred analgesic

›Safe across all trimesters for short-term use

›NSAIDs use restriction

›Avoid in first trimester (teratogenesis risk)

›Avoid after 20 weeks (fetal renal effects, premature ductus arteriosus closure)

›Opioids

›Use lowest effective dose for shortest duration

›Neonatal opioid withdrawal syndrome risk with prolonged use

›Surgical and anesthesia considerations

›General anesthesia risk is higher in pregnancy

›Coordinate with obstetrics and anesthesia

›Regional anesthesia preferred when possible

›Non-weight-bearing compliance

›Additional challenges in late pregnancy

›Physiotherapy and mobility aids essential

Geriatric

›Injury characteristics in older adults

›Peak incidence in women in the 6th decade

›May occur with lower-energy mechanisms due to osteoporosis

›Falls from standing height rather than sports mechanism

›Surgical risk assessment

›Cardiac and pulmonary pre-operative clearance

›ECG for patients with cardiac comorbidities

›Anaesthesia review for complex medical history

›Anticoagulation management

›Common in geriatric patients

›Requires bridging or reversal planning pre-operatively

›Increased bleeding risk

›Bone quality

›Osteoporosis increases fixation failure risk

›Augmented fixation techniques may be required

›Analgesia considerations

›NSAIDs used with caution

›Renal impairment risk

›GI bleeding risk

›Avoid if GFR < 30 ml/min

›Opioid sensitivity

›Increased risk of delirium

›Start at lower doses

›Morphine 0.05 mg/kg IV for severe pain in elderly

›Fall risk with analgesics and immobilization aids

›Rehabilitation and compliance

›Non-weight-bearing compliance more challenging

›Home safety assessment

›Social support evaluation

›Physiotherapy early engagement

›Prolonged recovery expected

›Increased risk of post-operative complications

›Deep vein thrombosis risk particularly elevated

Pediatrics

›Skeletally immature considerations

›Physeal (growth plate) injury concern

›Proximal fibula physis present until approximately 16-18 years

›Salter-Harris classification if growth plate involved

›Orthopedic consultation essential for physeal injuries

›Ligamentous laxity in children

›May mask findings compared to adult presentations

›Stress radiographs may be needed to demonstrate instability

›Radiographic interpretation

›Normal physeal lucency may mimic fracture

›Comparison views of contralateral leg may assist

›Pediatric radiology review recommended if uncertain

›Dose minimization

›Limit radiation exposure in children

›Use minimum required projections

›Avoid CT unless essential for surgical planning

›Analgesia in children

›Weight-based dosing

›Ibuprofen 10 mg/kg PO every 6-8 hours (maximum 600 mg per dose)

›Acetaminophen 15 mg/kg PO or PR every 4-6 hours (maximum 1000 mg per dose)

›Intranasal fentanyl 1.5 mcg/kg for severe pain in acute setting

›Procedural sedation if reduction required

›Ketamine 1-2 mg/kg IV or 4-6 mg/kg IM for procedural sedation

›Midazolam 0.05 mg/kg IV as adjunct

›Growth and outcome considerations

›Physeal arrest rare but possible with proximal fibula physeal injury

›Generally favorable outcomes in skeletally immature patients

›Serial follow-up with orthopedics to monitor growth

10Background/b73

Epidemiology

›Incidence and demographics

›Accounts for up to 7% of all ankle fractures

›One of the most commonly missed fractures in the emergency department

›Peak incidence in the 5th decade overall

›In women, peak incidence shifts to the 6th decade

›Common in active and sporting populations

›Football, basketball, soccer, skiing are high-risk sports

›Missed diagnosis burden

›Frequently missed because primary complaint is ankle pain

›Proximal fibula fracture is clinically silent in many presentations

›Complications of missed diagnosis

›Lateral talar shift

›Progressive ankle instability

›Post-traumatic osteoarthritis

›Even 1 mm of lateral talar displacement reduces tibiotalar contact area by approximately 42%

›Associated injury prevalence

›Posterior malleolus fracture in approximately 80% of cases

›Deltoid ligament rupture in approximately 50% of cases

›Medial malleolus fracture in approximately 37% of cases

›Medial structures intact in approximately 13% of cases

Pathophysiology

›Injury mechanism

›Lauge-Hansen pronation-external rotation (PER) classification

›External rotation force applied to a pronated foot

›Most severe ankle fracture pattern in the Lauge-Hansen classification

›Sequential ligament and bone failure

›Stage 1: Anterior inferior tibiofibular ligament rupture

›Stage 2: Interosseous membrane disruption (propagates proximally)

›Stage 3: Posterior inferior tibiofibular ligament rupture

›Stage 4: Medial ankle failure (deltoid ligament tear or medial malleolus fracture)

›Proximal fibula fractures when force propagates to proximal fibula

›Structural anatomy involved

›Syndesmosis complex

›Anterior inferior tibiofibular ligament (AITFL)

›Posterior inferior tibiofibular ligament (PITFL)

›Interosseous membrane

›Transverse tibiofibular ligament

›Medial ankle structures

›Deltoid ligament (deep and superficial layers)

›Medial malleolus

›Proximal fibula

›Spiral fracture pattern characteristic of rotational force

›Does not require fixation as it is not the primary stabilizer

›Instability mechanism

›Syndesmotic disruption allows lateral displacement of the talus

›Ankle mortise widening results

›Loss of normal tibiotalar articulation

›Injury ranges from stable to highly unstable

›Stability depends on extent of associated injuries

›Combined bony and ligamentous disruption creates maximum instability

Therapeutic Considerations

›Evidence base for surgical treatment

›ORIF is standard of care for most Maisonneuve fractures

›Cochrane review (Donken et al. 2012) supports surgical over conservative treatment for unstable ankle fractures

›Sproule et al. 2004 reported good to excellent outcomes in 86-89% after operative treatment

›Syndesmotic fixation options

›Transsyndesmotic screw fixation

›1-2 screws, 3.5 or 4.5 mm cortical

›3-cortical or 4-cortical fixation

›Traditional standard, requires planned removal

›Suture-button (TightRope) device

›Allows physiologic syndesmotic motion

›Does not routinely require removal

›Increasingly preferred in active patients

›Open reduction superiority

›Closed reduction of the fibula into the fibular notch has up to 50% malposition rate

›Open reduction of the distal fibula is preferred to ensure anatomic reduction

›Postoperative CT recommended to verify reduction accuracy

›Key teaching points

›Proximal fibula palpation is mandatory in every ankle injury

›This single maneuver prevents the most commonly missed fracture pattern in emergency medicine

›Ottawa Ankle Rules do not exclude Maisonneuve fracture

›Specific proximal fibula assessment required beyond standard rules

›Medial clear space widening without distal fibula fracture mandates proximal imaging

›Full-length tibia/fibula films are mandatory in this scenario

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Diagnosis explanation

›You have been diagnosed with a Maisonneuve fracture

›This is a fracture of the upper part of the calf bone (fibula) combined with a tear of the ligaments connecting the two bones of your lower leg

›This is an unstable ankle injury that requires specialist care

›Follow-up requirement

›You MUST follow up with an orthopedic surgeon within 5-7 days

›This fracture almost always requires surgery to stabilize the ankle

›Weight-bearing restrictions

›Strict non-weight-bearing on the injured leg

›Do not put any weight on the foot until cleared by orthopedics

›Use crutches or a walker at all times when moving

›Keep the leg elevated above heart level as much as possible to reduce swelling

›Ice application

›Apply ice wrapped in a towel for 20 minutes every 2 hours for the first 48 hours

›Do not apply ice directly to skin

›Splint care

›Keep the splint dry at all times

›Cover with a plastic bag when showering or bathing

›Do not remove or modify the splint

›Inspect around the splint edges

›Check for skin irritation, sores, or breakdown

›Return if pressure sores develop

›Return to emergency department immediately for

›Increasing pain that is not controlled by prescribed medication

›May indicate compartment syndrome, which is a surgical emergency

›Numbness, tingling, or weakness developing in the foot or toes

›Toes become cold, pale, blue, or white

12References/r16

Guidelines and key sources

›Primary evidence sources

›Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The Proximal Fibula Should Be Examined in All Patients With Ankle Injury: A Case Series of Missed Maisonneuve Fractures. Journal of Emergency Medicine. 2013. PMID 23079149

›Bartonicek J, Rammelt S, Tucek M. Maisonneuve Fractures of the Ankle: A Critical Analysis Review. JBJS Reviews. 2022. PMID 35180143

›Bartonicek J, Rammelt S, Kasper S, Malik J, Tucek M. Pathoanatomy of Maisonneuve Fracture Based on Radiologic and CT Examination. Archives of Orthopaedic and Trauma Surgery. 2019. PMID 30552509

›Stufkens SA, van den Bekerom MP, Doornberg JN, van Dijk CN, Kloen P. Evidence-Based Treatment of Maisonneuve Fractures. Journal of Foot and Ankle Surgery. 2010. PMID 21172642

›Sproule JA, Khalid M, O'Sullivan M, McCabe JP. Outcome After Surgery for Maisonneuve Fracture of the Fibula. Injury. 2004. PMID 15246803

›Lock TR, Schaffer JJ, Manoli A. Maisonneuve Fracture: Case Report of a Missed Diagnosis. Annals of Emergency Medicine. 1987. PMID 3592337

›Imaging guidelines

›Smith SE, Chang EY, Ha AS, et al. ACR Appropriateness Criteria Acute Trauma to the Ankle. Journal of the American College of Radiology. 2020. doi:10.1016/j.jacr.2020.09.014

›Hinds RM, Tran WH, Lorich DG. Maisonneuve-Hyperplantarflexion Variant Ankle Fracture. Orthopedics. 2014. PMID 25361368

›Systematic reviews and guidelines

›Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. Surgical Versus Conservative Interventions for Treating Ankle Fractures in Adults. Cochrane Database of Systematic Reviews. 2012

›Herring SA, Kibler WB, Putukian M, et al. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Medicine and Science in Sports and Exercise. 2024

›Kasper S, Bartonicek J, Kostlivy K, Malik J, Tucek M. Maisonneuve Fracture. Rozhledy v Chirurgii. 2020. PMID 32349489

›Richmond RR, Henebry AD. A Maisonneuve Fracture in an Active Duty Sailor: A Case Report. Military Medicine. 2018. PMID 29415223

›Kasper S, Bartonicek J, Rammelt S, Kamin K, Tucek M. Double Maisonneuve Fracture: An Unknown Fracture Pattern. European Journal of Trauma and Emergency Surgery. 2022. PMID 34519863

Evidence & Review

Evidence & Review