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
Patient Discharge Instructions
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
Swelling or tightness inside the splint
Fever above 38.5 degrees Celsius
Wound discharge, increased redness, or warmth around any wound
Pain management at home
Acetaminophen 500-1000 mg every 4-6 hours as needed
Maximum 4000 mg per 24 hours
Do not exceed recommended dose
Ibuprofen 400-600 mg every 6 hours with food as needed
Avoid if you have kidney problems or stomach ulcers
Avoid before surgery without discussion with your surgeon
Take prescribed medications as directed
Activity and recovery expectations
Expected recovery time 3-6 months for return to full activity
Operative outcomes are good to excellent in approximately 86-89% of patients
Strict non-weight-bearing compliance is essential for a good outcome
Smoking cessation is strongly recommended as smoking significantly impairs bone healing
References
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
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
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