A proximal fibular fracture associated with rupture of the tibiofibular syndesmosis and the anterior fibers of the deltoid ligament caused by external rotation mechanism was described for the first time in 1840 on the basis of experiments by the French surgeon Jules Germain Francois Maisonneuve 1, which are rare in clinic, accounting for about 5% of the ankle fractures treated by surgery 2. Maisonneuve fracture is a special type of ankle injury. The manifestations of typical Maisonneuve fracture including that the fibular fracture located in proximal one-third diaphysis and the fracture line was from anterosuperior to posteroinferior. Pronation–external rotation is the main injury mechanism. Maisonneuve fracture is characterized by fractures of the proximal fibula and the complete rupture of the anterior inferior tibiofibular ligament. All 41 patients had injury of the anterior inferior tibiofibular ligament. The fracture of the medial malleolus was in 30 patients (30/41, 73.17%), rupture of the deltoid ligament was in 10 patients (10/41, 24.39%), and medial structures intact were in one patient (1/41, 2.44%). There were 20 patients with type I fracture, four patients with type II fracture, and 10 patients with type III fracture according to the Haraguchi classification of posterior malleolus fracture. Thirty-five patients (35/41, 85.37%) with injury of posterior structures, 34 patients had posterior malleolar fracture (34/41, 82.93%), and one patient had posterior inferior tibiofibular ligament rupture (1/41, 2.44%). Resultsįorty-one patients had proximal one-third fractures of the fibula including six patients with fracture involving the fibular neck, 30 with proximal one-third fractures of the fibular shaft, and five with proximal–medial one-third junction fracture of the fibular shaft. The features of proximal fibular fracture, injuries of the medial and posterior structures of the ankle, injuries of the anterior inferior tibiofibular ligament and the interosseous membrane were recorded and analyzed. Forty patients were treated with open reduction and internal fixation. MRI examination of the ankle and calf was performed in 28 and five patients, respectively. CT scan of the ankle was performed in 38 patients, including three-dimensional reconstruction in 33 patients. All patients underwent posteroanterior and lateral X-ray examinations of the ankle and calf. The cause of injuries were traffic accident in five patients, sprain injury in 20 patients, and falling injury from height in 16 patients. There were 32 males and nine females, the average age was 37.9 years (range, 18 to 61 years), the fractures occurred on the left side in 20 patients and on the right side in 21 patients. The data of 41 patients with Maisonneuve fracture from April 2014 to September 2019 were retrospectively analyzed. The aim of this study is to describe the pathoanatomical features of typical Maisonneuve fracture on the basis of radiographs, computed tomography (CT) scans, magnetic resonance imaging (MRI), and intraoperative exploration findings, and to investigate the injury mechanism of this variety. The manifestation of such fractures is variable. Following stabilization of the lower leg, a supination/external rotation force is then applied to the ankle.Maisonneuve fracture is a special type of injury which are rare in clinic. A mechanical stress view is performed with the patient supine/sitting upright with the lower leg in 15-20° internal rotation.A “ stress” view of the ankle joint can assist in identifying injury to the deep deltoid ligament with associated ankle joint instability.Ankle radiographs can appear “normal” (may only have an occult deep deltoid ligament injury with minimal medial clear space widening and/or isolated posterior tubercle disruption).In addition to imaging of the ankle, tib-fib x-rays should also be obtained to evaluate the entire length of tibia/fibula.Weakness of ankle dorsiflexion/subtalar joint (foot) eversion and/or numbness along the lateral lower leg/dorsum of the foot should raise clinical suspicion for a Maisonneuve injury. The common peroneal nerve courses over fibular head, thus a meticulous neurologic exam is critical.Tibia/fibula elicits pain in the ankle/lower leg.
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