Have You Ever Heard of the Maisonneuve Injury?
For every orthopedic injury, surgeons must know the mechanism (how it occurred), details about the anatomy (part affected) and pathology (exactly what's wrong), and how to treat it. Treatment must be evidence-based meaning studies have shown what works best to give patients optimum results.
The authors of this review article on Maisonneuve injuries of the ankle provide all of that information plus more: potential complications, goals of treatment, management strategies, and the results referred to as functional outcomes of 61 cases reported from four published studies.
You probably haven't heard of Maisonneuve injuries. The name comes from the French physician who first reported this problem. Basically, the term refers t a spiral fracture of the upper one-third of the fibula. The fibula is one of two bones in the lower leg. It is the smaller bone situated on the outside or lateral side of the leg. The tibia is the other (larger) bone in the lower leg.
But there's more to the injury than just the fracture. The force of the injury pushes the ankle into a flat-footed position with intense stretch pressure along the inside of the foot and ankle. The lower leg is externally (outwardly) rotated with the foot planted on the ground.
Associated injuries can also include fractures of the malleolus (bump on either side of the ankle that we usually point to and call our ankle bone) and tears or ruptures of the surrounding ankle ligaments or joint capsule.
In severe Maisonneuve injuries, the connective tissue between the two bones (tibia and fibula) is completely torn. This is called a syndesmotic disruption. Without this strong, fibrous interconnecting ligament, one bone can shift up or down in relation to the other causing a difference in leg length from one leg to the other.
The real dilemma with Maisonneuve injuries is that they aren't painful so they can go undetected. The injuries in the lower ankle are more painful and get all the attention. No one thinks to X-ray the upper end of the fibula. People of all ages can experience a Maisonneuve injury as a result of slipping on ice, tripping and falling, falling from a height, car accidents, or sporting events.
Treatment isn't standard because the injuries can vary widely in severity and involvement of the surrounding soft tissue structures. Most of the time, surgery is required because the injury is so severe. Without reconstructive surgery, the ankle remains unstable and at risk for further injury. Reduction of the fracture and fixation of the syndesmotic tear is essential in order to restore normal function and biomechanics of the leg.
Reduction means the surgeon puts the fractured ends of the bone back together. Plates and screws may be needed to hold the bones in place until they knit back together. Fixation of the syndesmosis is also accomplished with similar hardware called syndesmotic screws. The screws can be left in place or taken out according to the surgeon's preferences and the patient's wishes.
Surgery may not be needed for less severe Maisonneuve ankle injuries. The patient is placed in a cast for six weeks. This approach is acceptable when there are no soft tissue injuries of ligaments, syndesmosis, or joint capsule. In all cases, the goal is to restore normal ankle alignment and movement.
How do patients fare after treatment for Maisonneuve injuries? According to the authors of this article who reviewed all of the studies published on this injury -- the majority of patients (88 per cent) have good-to-excellent results. Pain is eliminated and motion and function return to normal levels during daily activities. Functional outcomes are equal to before the injury within six months of treatment.
The authors would like to see more studies on this topic to look at two things: long-term results and results for each treatment approach. The hope is to find better ways to diagnose and treat this complex injury without significant delays that can negatively affect outcomes.
Bharati S. Kalyani, MD, et al. The Maisonneuve Injury: A Comprehensive Review. In Orthopedics. March 2010. Vol. 33. No. 3. Pp. 190-195.