CASE REPORT

The Frenchman's Fibular Fracture (Maisonneuve Fracture)

Jorge del Castillo, MD Evanston, Illinois

Joel M. Geiderman, MD Los Angeles, California

Two patients with injuries to the ankle sustained by rotational trauma com- plained only of pain in the ankle. Careful examination revealed tenderness over tbe proximal fibula. Subsequent radiographic studies revealed high helical frac- ture of the fibula, as originally described by Maisonneuve. The Maisonneuve fracture is produced by diastasis m a separation of bones resulting from rup- ture of ligaments around the ankle. According to classification of fibula injuries by mechanism of injury, the Maisonneuve fracture is due to external rotation of the foot relative to the tibia but it is not clear whether the foot is in pronation or supination or moves during injury, del Castillo J, Geiderman JM" The French- man's f ibular fracture (Maisonneuve fracture). JACEP 8:404-406, October 1979. fracture, fibu/a; ankle injuries, fracture, Maisonneuve

INTRODUCTION

Fracture of the proximal fibula associated with injury to the ankle may occur as a result of external rotation of the foot in relation to the tibia. The French surgeon Maisonneuve 1 first described this "fracture by diastasis" after a series of experiments in cadavers. Recent studies 2 have further elucidated the mechanism of this injury and have demonstrated a higher incidence than might be expected. The Maisonneuve fracture may be easily overlooked if it is not kept in mind when an injured ankle is evaluated.

CASE REPORTS

Case Number One. A 40-year-old man came to the emergency department complaining of left ankle pain and swelling. One day prior to admission, he had twisted his ankle while sliding into a base during a baseball game. He said that he heard a "snap" and could not bear weight on the extremity after the accident.

Physical examination of the left lower extremity revealed soft tissue swell- ing and ecchymosis over both medial and lateral malleoli. The mortise was also tender. Radiologic examination of the ankle revealed soft tissue swelling over both maiieoli with diastasis of the ankle mortise. Widening of the space between the tibia and talus was also noted. There were no fractures evident on these films. Subsequently, the patient was re-examined and tenderness was noted over the area of the proximal fibula. Radiologic examination of the t ibia and fibula showed a nondisplaced spiral fracture of the proximal fibula (Figure !).

The patient was taken to surgery for repair of the deltoid l igament and the l eg was immobilized in plastic for six weeks. He is currently doing well after undergoing physical therapy.

From the Division of Emergency Medicine, Department of Surgery, Evanston Hospital, Evanston, Illinois; Northwestern University Medical School, Chicago, Illinois.

Address for reprints: Joel M. Geiderman, M D, Department of Emergency Medicine, Cedars-Sinai Medical Center, Box 48750, Los Angeles, California 90048.

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Fig . 1. Maisonneuve fracture of the proximal fibula. This patient com- plained only of ankle pain.

Fig . 2. Maisonneuve fracture - heli- cal fracture of the proximal fibula. The direction of the fracture line may re- semble either supination-external ro- tation (SE) or a pronation-external rotation (PE) injury.

C a s e N u m b e r T w o . A 50-year- old woman s l ipped on ice, sus ta in ing a twis t ing in jury to he r r igh t ankle . She s ta ted t ha t she felt sudden pain, h e a r d a s n a p p i n g sound, and sub- sequent ly noted deformity of the me- dial aspect of the ankle . The pa t i en t did not complain of pa in in the prox- imal aspect of the leg.

P h y s i c a l e x a m i n a t i o n of t h e r i g h t lower e x t r e m i t y r e v e a l e d an an te r io r dislocation of the t ib ia over the talus. The media l aspect of the

F ig . 3. Fibular fracture in a SE type injury (after Lauge-Hansen 4) AP (left) and lateral (right) views.

a n k l e was m a r k e d l y swol len . The foot was he ld in e x t e r n a l ro ta t ion . D o r s a l i s ped is a n d pos te r io r t i b i a l pulses were both present . There was p a l p a b l e c r e p i t u s a n d t e n d e r n e s s over the r igh t p roximal f ibula.

Rad io log ic e x a m i n a t i o n of t he ank le demons t r a t ed an an te r ior dis- locat ion of the t i b i a over the t a lus and f r ac tu re of the pos te r ior t ib ia l malleolus. Ano the r rad iograph of the t ib ia and f ibula demons t ra t ed a spi- ral f rac ture of the proximal f ibula.

The pa t i en t was t r ea ted by open reduct ion and in t e rna l f ixat ion of the ankle injuries . A non-weight bea r ing cast was appl ied to the leg and the pa t i en t did well.

DISCUSSION

In 18401 t h e F r e n c h s u r g e o n J. G. Maisonneuve f i rs t described the h igh he l i ca l f r a c t u r e of the f ibu la tha t now bears his name (Figure 2). He classif ied f ractures of the f ibula accord ing to m e c h a n i s m of in jury . The M a i s o n n e u v e f r ac tu re was de- scr ibed as a 'Tracture by dias tas is ." ~'Diastasis" refers to a separa t ion of bones as a resul t of rup tu re of l iga- ments about the ankle. Accordingly, if the t ib io-f ibular l igament breaks , the f i rs t effect is s epa ra t i on of the f ibula and t ib ia a t the inferior tibio- f i b u l a r jo in t ; t h i s is fol lowed by a f racture . The f racture a lways affects an unusua l si te, ie, the super ior pa r t of the bone. 8

A cen tury la te r , Lauge-Hansen 4 • proposed a now widely accepted clas- s if icat ion of ank le in jur ies based on the mechan i sm of injury. This clas-

s i f ica t ion pred ic t s l i g a m e n t o u s and osseous in jur ies o f the ank le and leg based on the posi t ion of the foot at the t ime of in jury and the forced di- rec t ion of the ank le . 5 According to Lauge-Hansen , 4 the f ibular f r a c t u r e assoc ia ted wi th a sup ina t ion-ex te r - nal ro ta t ion in jury (SE II type) is a sp i ra l oblique f rac ture of the distal a spec t of the f ibu la (F igu re 3). In p rona t ion-ex te rna l ro ta t ion injuries, the f ibu la r f rac ture is character ized by a shor t spi ra l oblique fracture of the f i b u l a approx imate ly 7 or 8 cm above the ankle jo in t 5 (PE III type, F igu re 4).

Pankovich 2 repor ted a series of 17 Mai sonneuve f rac tures wi th de- t a i l ed cl inical and opera t ive findings. He found t h a t the f i bu l a r f racture showed two pa t t e rns . In t en cases, the f rac ture was s imi la r to t ha t de- scr ibed for a p rona t ion-ex te rna l rota- t ion fracture. In two, the fracture re- sembled a sup ina t ion-ex te rna l rota- t ion fracture. Whi le the mechanism t h a t produces the Maisonneuve frac- tu re mus t be ex te rna l ro ta t ion of the foot in relation" to the t ibia , i t is not c lear whether the foot is in pron~/tion or sup ina t i on d u r i n g the injury. A th i rd possibi l i ty, for which there is some expe r imen ta l evidence, 2 is that the foot changes posi t ion while the in jury is occurring.

In our two cases, ne i the r patient compla ined of pa in in the region of the p rox imal f ibula, probably due to the presence of a more pa infu l injury in t h e r e g i o n of t h e a n k l e . Pan- kovich 2 found pa in in the region of the proximal f ibula to be a ra re com- p l a in t as well. Because of this , a high

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Fig. 4. Fibular fracture in a PE type injury. AP (left) and lateral (right) views.

index of suspicion should be main- tained so t ha t th is f rac ture is not overlooked. Once the d i agnos i s is suspected, t ende rnes s to pa lpa t ion over the proximal fibula is a constant finding. Crepitus may also be pres- ent.

The M a i s o n n e u v e f r a c t u r e should be sought, especially when 2

1) There is an isolated fracture of the p o s t e r i o r t i b i a l t u b e r c u l e ,

e s p e c i a l l y i n the p r e s e n c e of an - teromedial capsule tenderness.

2) The deltoid l igament is rup- tu red or there is fracture of the me- dial mal leo lus in the absence of a la tera l mal leolar fracture.

3) There is tenderness over the anteromedial capsule or the syndes- mosis.

One radiologic pr inc ip le s calls for the examina t ion of both ends of a

long bone when fracture of one end is present. If this is done, the Maison- neuve fracture will never be missed. However , the cost -effect iveness of this approach is questionable, espe- cially when careful examina t ion and a high index of suspicion could ob- v i a t e t h e n e e d for t hese e x t r a roentgenograms.

The authors would like to sincerely thank Allison Good and Laura Balin for their help in preparing this manuscript.

REFERENCES 1. Maisonneuve MJG: Recherches sur la fracture du perone. Arch Gen Med 7:165- 187, 1840.

2. Pankovich AM: Maisonneuve fracture of the fibula. J Bone and Joint Surg 58A:337-342, 1976.

3. Bonnin JG: Injuries to the Ankle. Lon- don, Heineman Medical Books, Ltd, 1950, pp 1-45, 75-83, 147-165.

4. Lauge-Hansen N: Fracture of the ankle, H. Combined experimental surgi- cal and experimental-roentgenologic in- vestigations. Arch Surg 60:957-985, 1950.

5. McDade WC: Treatment of ankle frac- tures. AAOS Instructional Course Lec- tures 24:251-287, 1975.

6. Ryan J: Musculoskeletal trauma, in Walt AJ, Wilson RF (eds), Management of Trauma: Pitfalls and Practice, London, Lea & Febiger, 1975, p 251.

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