MAISONNEUVE FRACTURE

MAISONNEUVE FRACTURE

 

Maisonneuve fracture is named after Jules Germain Francois Maisonneuve, a French Surgeon who was the first person to explain the part of external rotation in the occurrence of fractures of ankle.  

Maisonneuve fracture is combination of a fracture, and instability of your ankle joint. This fracture is of spiral kind, and is found in upper third of one of the bones of your leg, known as Fibula.

This fracture is not seen alone, and is along with ankle injury (fracture of medial malleolus or deltoid ligament of ankle rupture).

This fracture is considered to be similar to Galeazzi fracture, as it is seen in relation with ligament disruption as well.

Maisonneuve fracture is caused by external rotation that is severe enough to cause such injury. On the basis of Danes-Weber classification this fracture is a type C, and according to classification of Lauge-Hansen classification, Maisonneuve fracture is an injury of pronation-external rotation type.

To further describe, and make it easier for you to understand, we will discuss about:

 

ANATOMY OF FIBULA AND ANKLE JOINT

FIBULA:

The fibula is a cylindrical bone of leg this is placed at the posterior part of the limb. It is present subsequent to other long bone referred to as the Tibia. In medical aspect, a long bone is defined as a bone who is longer than its width.

Like various long bones, the fibula possesses a proximal end (with head and a neck) a shaft, and has a distal end. The fibula and tibia run side by side to other in the leg area and are almost the same in length however the fibula is a lot thinner than the tibia itself. This indicates the contributions of weight-bearing role of every bone. In different words, the thicker tibia has a far more role to play in weight-bearing than the fibula.

Each part of fibula has different parts and different functions. Fibula has an apex proximally, it is where the styloid process is present, the head is also there which is conjoined with the lateral tibial condyle, and a neck that is short (common fibular nerve is right behind it).

Shaft of fibula has three borders and three surfaces. These borders are anterior border, interosseous border, and a posterior border. The surfaces are lateral, medial, and posterior.

Distally, it has lateral malleolus and has point where ligaments attach.

There are three joints- superior tibiofibular joint (which is a synovial joint), middle tibiofibular joint (interosseous membrane attaches it), inferior tibiofibular joint (which is a syndesmosis joint). It is seen to participate in mortise joint formation of ankle as well.

Fibula is supplied by fibular artery, but the nerve supply is different to all three parts (proximal, distal, and periosteum). The proximal end is innervated by the genicular branch of common fibular nerve, distal end is innervated by deep fibular nerve, and the periosteum is innervated by deep and superficial fibular nerves.

In an aspect seen medically, Fibula is inclined to fractures that are more related to injuries due to trauma. Fibular fracture doesn’t occur alone, and is almost always related to fracture od tibia (the adjacent bone to Fibula) or instability of ankle joint. But this does not mean isolated fibular fractures do not exist. But because fibula is thinner than the other bone (tibia) and does not bear as much weight as other bones do; hence fracture is usually seen with injury to other parts as well.

Proximal fracture of fibula also results in common fibular nerve damage. This results in a decreased sense, more so in lateral part of the foot and a weakened dorsiflexion of ankle is seen. This is also known as foot drop. When an ankle injury is followed by a fracture of proximal part of the fibula it is known as Maisonneuve fracture. This is related to the medial malleolus fracture, fracture of the proximal one third of the fibula (or its shaft), and there is also a chance of damage to distal tibiofibular syndesmosis.

THE ANKLE JOINT

Ankle joint, is also known as talocrural joint in medical aspect. It is found in lower limb and is a synovial joint in nature. It is formed by tibia and the fibula, and the foot itself. It is a hinge joint, and helps in dorsiflexion (raising one’s foot up towards the shin bone) and plantarflexion (moving foot down away from the body).

Tibia and Fibula are joined together by tibiofibular ligaments which are very strong in nature. They form a socket together, which is bracket like in shape. This socket is covered by hyaline cartilage. Together, all this is also called as mortise. Talus (a bone that is small and is located between tibia and fibula and the calcaneus- heel bone) fits in this mortise and completes the ankle joint.

Other than the bones, there are two main ligaments that arise from the malleoli (there are two malleoli present on each side of the ankle, and are two bony projections).

One of the two sets of ligaments is medial ligament which is also known as deltoid ligament, and is attached to the malleolus on the medial side of lower aspect of tibia. It itself has four ligaments that attach to different bones of foot (calcaneus, navicular, and the talus). This ligament helps protecting the foot from over-eversion. In Maisonneuve fracture, the deltoid ligament gets injured or the medial malleolus itself.

The lateral ligament arises from malleolus that is on the lateral part of lower end of fibula. It protects the foot from over-inversion. The set of lateral ligaments comprises of three different ligaments known as anterior talofibular, posterior talofibular, and calcaneofibular.

 

TYPES OF FRACTURES

There are many types of bone fractures, most of which occur because of trauma, overuse, or having conditions like osteoporosis.

On the basis of shape of the fracture, name of the fractures is set, including:

  • Stable fracture: This is the mildest kind of fracture wherein the damaged ends of a bone line up and are hardly ever out of place, so the healing process is easy.
  • Partial or incomplete fracture: This is a crack that doesn't absolutely damage the bone into more or equal to two pieces.
  • Complete fracture: This is a fracture wherein the bone is absolutely damaged into multiple separate pieces.
  • Greenstick fracture: This is an incomplete fracture wherein the bone is broken to a certain limit, bent to a certain degree of limit; it's commonly seen in children.

 

Complete fractures are further classified on the basis of the way the damage has occurred to the bone. They may be:

  • Transverse.
  • Oblique.
  • Longitudinal.
  • Comminuted.
  • Spiral.

Spiral fracture occurs when tibia or the fibula are broken in half by an extremely strong force that twists the bone. These bones are known as long bones as they are longer than wide. Another long bone is femur, which might also see spiral fracture. Spiral fractures aren’t just limited to lower limb or the leg, but to the arm as well. Humerus, radius, and ulna may also be injured.

Long bones, when broken, they get separated into two parts with uneven and rough edges making it very hard for the bones to be put back together as they were. This makes these kinds of fractures serious, with risk and possibility of complications.

Some of the causes of spiral fractures are as follows:

  • Injuries due to snowboarding. This happens when the leg is stuck in ski board while the body keeps on moving.
  • Injuries due to soccer. This occurs when two players run with great force into each other.
  • Injuries to legs or arms by twisting them in wrestling.
  • Accidents related to motor vehicles or motorcycles.
  • Child abuse.
  • Falling down in a way that legs and arms are twisted, such as falling from stairs, or falling in between rocks and trees.
  • Physical abuse.
  • Injuries due to machinery.

Spiral fractures are also known as torsion fractures, and because of extreme twist these fractures are very painful. Most spiral fractures affect the long bones of the legs, such as the femur, tibia, and fibula, but they can also affect the long bones of the arm, such as the humerus, ulna, and radius. People diagnosed with a spiral fracture are seriously injured and have risks and complications compared to the other fracture. Other than pain, spiral fractures may result in:

  • Loss of consciousness or fainting.
  • Not being able to put any weight on the injured bone.
  • No feeling or control in your feet and hands, or legs and arms as whole.
  • Tented bone (bone seems as if it is about to break loose through the skin).
  • Not being able to extend or fully straighten affected limb.
  • Bruises.
  • Redness, swelling or inflammation.
  • Weak pulse in ankle or the wrist.

Doctors will make sure you are fully examined, more so by focusing on the affected limb. You will also need to undergo tests, like X-rays and CT scan. Treatment includes pain medication and surgery. After-surgery care is very important.

 

LAUGE-HANSEN CLASSIFICATION

This classification system is named after Sir Niels Lauge-Hansen, who was a Danish physician. This classification is used for classifying injuries related to ankle on the basis of mechanism of injury with their patterns and findings on imaging. This system is used with Weber classification to diagnose and classify injuries of ankle.

This classification has names set with first word being how the foot was (the position of foot) at the time of injury due to trauma (whether it was in supination or pronation). The second word of the name describes what was the direction of damaging force (which can be external rotation, abduction, or adduction).

According to this classification, it has grouped injuries in 13 different and unique patterns, grouped in bigger 4 groups.

  1. Supination-adduction:
  • Absence of medial malleolar fracture.
  • Presence of vertical or oblique medial malleolar fracture.
  1. Supination-external rotation:
  • Stage I: tear or avulsion of anteroinferior tibiofibular ligament.
  • Stage II: displacement of the talus, which causes an oblique or a spiral fibular fracture.
  • Stage III: posteroinferior tibiofibular ligament tear, or fracture of the posterior malleolus.
  • Stage IV: deltoid ligament tear or avulsion of medial malleolus that is transverse.
  1. Pronation-abduction:
  • Stage I: disruption of deltoid ligament or transverse fracture of medial malleolus.
  • Stage II: fracture of posterior malleolus.
  • Stage III: oblique fracture of fibula.
  1. Pronation-external rotation:
  • Stage I: rupture of deltoid ligament, which may come into sight as widening of medial mortise, or avulsion fracture of medial malleolus that is transverse in nature.
  • Stage II: anterior inferior tibiofibular ligament involvement or commonly regarded to as AITFL, with a widened distal tibiofibular distance because of extension of AITFL into the interosseous membrane.
  • Stage III: Oblique or a spiral fracture of fibula (which is greater than 6cm), and is above the joint of talotibial joint.
  • Stage IV: posterior inferior tibiofibular ligament or PITFL involvement, or fracture of posterior malleolus.

 

DanIs-weber classification

It is also known as Weber classification, and is used along with lauge-hansen classification to classify injuries of ankle, more so in relation with fractures of lateral malleolus. It is broadly divided into three different groups:

  1. Type A:
  • Is infrasyndesmotic- when the level of fracture is below syndesmosis.
  • It is usually a transverse fracture.
  • In this fracture, tibiofibular syndesmosis is intact.
  • Deltoid ligament is intact in type A.
  • There is occasional fracture of medial malleolus.
  • In case the medial malleolus is intact, type A fractures are more stable.
  1. Type B:
  • It is transsyndesmotic- at the level of syndesmotic ligaments.
  • Type B fractures are usually spiral kind.
  • In type B class, tibiofibular syndesmosis is intact, but in case distal tibiofibular joint is seen widened, it indicates injury to syndesmosis.
  • Fracture of medial malleolus may be seen.
  • In case space between medial malleolus and dome of talus is seen widened, it may indicate torn deltoid ligament.
  • On the basis of status and position of medial malleolus or deltoid ligament, the variable stability. It may require an open reduction-internal fixation (ORIF).
  • Weber B fractures are further classified into:
  • B1: it is usually isolated.
  • B2: not isolated, it is usually associated with a lesion of medial malleolus or medial ligament.
  • B3: not isolated like B2, it is seen in relation with medial lesion and a posterolateral tibial fracture.
  1. Type C:
  • It is suprasyndesmotic- above syndesmosis.
  • Distal tibiofibular articulation is seen widened, with disrupted tibiofibular syndesmosis.
  • Presence of fracture of medial malleolus and injury of deltoid ligament.
  •  In case of Maisonneuve fracture where fracture is proximal to the level of neck of fibula, a full knee or full-length radiograph of tibia and fibula is required.
  • This type is unstable, and required an open reduction-internal fixation or ORIF.
  • It is subdivided into:
  • C1: simple type; diaphyseal fibular fracture.
  • C2: complex type, diaphyseal fibular fracture.
  • C3: proximal fibular fracture. This occurs because of external rotation of forceful abduction, and is associated with medial side injury usually.

 

PATHOPHYSIOLOGY

Usually a severe, forceful, external rotation of ankle brings about a tear in deltoid ligament, and/or causes a medial malleolus avulsion fracture. Ankle mortise goes through severe rotational force resulting in rupture of syndesmotic ligaments and anteromedial aspect of the joint capsule of ankle.

The rotatory force doesn’t stay there, but transfers upwards and damages the interosseous membrane in this process. This severe force causes a spiral fracture proximal fibular neck. This fracture can also sometimes be an oblique one.

Oblique fracture of lateral malleolus occurs in case anterior part of tibiofibular syndesmosis resists the mechanical force. There is a process known as diastasis, in which the lateral malleolus displaces posterolaterally from the tibia.

It is not yet clear, as is shown different in different studies whether the mechanism of injury is pronation-external rotation, or supination-external rotation.

 

SIGNS AND SYMPTOMS

There are some important signs that ankle injuries may be a Maisonneuve fracture. First, patients with Maisonneuve fractures usually have a very stressful and full of force ankle external rotation, so it is necessary to understand the mechanism of injury. This can be a sports injury or fall during normal activities.

Common symptoms of Maisonneuve fractures include swelling, pain, bruising, and tenderness around the ankle and lower (or distal) tibiofibular joints. More specifically, pronation and external rotation injuries are expected to illicit pain during external rotation of the ankle.

In addition, the mobility of the foot is limited and it is not possible to support weight due to ankle pain. Pain is also felt around the medial and lateral sides of the ankle, but less often around the upper (or proximal) tibiofibular joint. Damage to the deltoid ligament or interosseous membrane causes bleeding around the surrounding tissue and can cause localized edema.

The Syndesmotic Ligament serves to stabilize the ankle and talus joints, so interruption of this Syndesmosis can reduce the space between the distal tibia, fibula, and talus. The long-term consequence of this is painful ankle arthropathy due to direct contact between the shin and the ankle. If the Maisonneuve fracture is left untreated, it may result in valgus deformity of ankle due to instability of the entire tibial joint and deltoid ligament. As a result, the ankle is in a chronic pronation state, characterized by the medial malleolus of ankle protruding into the tissue.

 

PHYSICAL EXAMINATION

Physical examination is very important in every injury related to ankles so to rule out and being sure that Maisonneuve fracture is not missed. Patients may also take into account a twisting movement to their ankle however not always. Patients may also document ankle ache with widespread swelling, however it's far crucial to observe the joints above and underneath the ankle.

Squeeze test: in this test doctor palpates tibia and the fibula at mid-level of calf. In case of syndesmotic injuries, it turns out positive which manifests itself as tenderness.

Kleiger’s test: also known as the stress test, or external rotation stress test. It is done to examine the deltoid ligament sprains and inferior syndesmotic tibiofibular sprain thereby helping in diagnosing ankle sprains that are medial. Patient is put in sitting position, with the knee hanging 90 degrees.

Examiner stabilizes the leg on the posterior side and grasps the ankle with other hand, rotating it externally. Test is called positive when there is pain at interosseous membrane site, or on the medial side. This pain may even radiate up to the leg (which completely depends on how severe the injury is).

In case both squeeze test and Kleiger’s test are positive it indicates the presence of Maisonneuve fracture.

Also, because common peroneal nerve crosses over head of fibula, neurologic examination is very important. Any weakness in dorsiflexion of ankle, eversion of foot, numbness on the lateral part of leg or foot dorsum should also arouse further suspicion of presence of Maisonneuve fracture.

 

DIAGNOSIS

Diagnosis of a Maisonneuve fracture requires a combination of medical history, physical examination, and x-ray images. Physical examinations, such as palpation along the fibula, are effective in distinguishing between Maisonneuve fractures and isolated injuries of syndesmosis, as patients generally do not report pain near the proximal fibula. The sensation of pain near the proximal fibula during palpation is a positive sign of a Maisonneuve fracture. Patients are usually asked about the mechanism of injury because ankle instability is often associated with damage to the proximal fibula in Maisonneuve fracture.

To rule out the possibility of an isolated fibula fracture, mortise stability is examined.

Ankle x-rays are used to detect tibial syndesmosis or increased medial space. The medial free space is the area between the ankle and the medial malleolus of the ankle. Damage to the deltoid and syndesmotic ligaments leads to instability of mortise that laterally moves the talus and widens the medial space.

To confirm the diagnosis, x-rays of the entire leg are used to check for fractures of the proximal fibula and enlargement of the interosseous free space (or tibial fibula free space). The interosseous space is the area between the medial side of the fibula and the lateral side of the tibia.

Computed tomography or magnetic resonance imaging can also be used to explain the diagnosis, if desired. An MRI scan can check for damage to the interosseous or tibial tubercle if ankle instability is diagnosed. Although arthroscopy can be used to diagnose syndesmotic lesions, it is often not recommended due to surgical difficulties. Ankle radiographs are used to assess the integrity of the deltoid and tibiofibular ligaments. The size of the inner free space can also be measured using stress radiography.

 

RADIOGRAPHIC FEATURES

  1. Syndesmotic injury:
  • Decrease in tibiofibular overlap: Measured at the point of maximum overlap. Usually, >6 mm in AP view, usually >1 mm in mortise. It has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular ligament clearance or overlap measurements.
  • Increase in clear space medially: Usually ≤ 4mm in stress view. A medial clearance of more than 5 mm with an external rotational load on the dorsiflexed ankle indicates deep destruction of the deltoid structures.
  • Increase in clear space between tibia and fibula: Measure 1 cm above the joint. Usually, <6mm for both AP view and stress or mortise view.
  1. Fracture of lateral malleolus:
  • Talocrural angle: It is measured by bisecting a line through the anatomical axis of the tibia and another line through the tip of the ankle. Shortening lateral ankle fractures can lead to increased talus angle. To estimate the length of the fibula, the angle of the talus is not 100% reliable. You can also use the medial fibula ridge and readjustment of the entire tibial joint.
  1. Fracture of posterior malleolus: three signs may be seen, double contour, misty mountain, and spur sign.

 

TREATMENT

The treatment of Maisonneuve fractures has the following goals:

  • Proximal fibula and medial ankle reduction to achieve stabilization.
  • Repair of the distal tibiofibular ligament and deltoid ligament.
  • Restoration of ankle stability.

Treatment is either non-surgical (or conservative) or surgical. The main surgical treatments for Maisonneuve fractures are open reduction and closed reduction, both of which usually precede internal fixation of the injury. These steps are known as Open Internal Reduction Fixation (ORIF) and Closed Internal Reduction Fixation (CRIF).

Internal fixators:

The syndesmotic screw is the primary internal fixator used in the surgery for Maisonneuve fractures. There are two main types of syndesmotic screws. A trans- syndesmotic screw (placed at the level of syndesmosis) and a suprasyndesmotic screw (placed above syndesmosis). Based on multiple clinical findings, it is recommended that the syndesmotic screw be attached at least 1 cm proximal to tibial fibrous syndesmosis, or 4-6 cm proximal to the tibial total joint line. Instead of metal fittings, biodegradable implants such as bioabsorbable screws that do not require postoperative removal can be used. However, biodegradable implants limit ankle rotation and foot dorsiflexion.

Non-operative interventions:

If only the posterior ligament of the tibiofibular syndesmosis is partially damaged, non-surgical treatment such as a long leg cast is recommended for at least 6 weeks. Fixing techniques such as casting are often paired without weight-bearing precautions. Gradually, physiotherapy rehabilitation programs allow patients to carry weight after a plaster cast at least 8 weeks after surgery. Orthopedic surgeons give these non-surgical treatments even if the medial malleolus of ankle remains intact.

Surgical interventions

Open reduction-internal fixation:

Open repositioning surgery is usually not done at the level of the proximal fibula because an incision near the proximal end risks cutting the common peroneal nerve. Instead, it is recommended to shrink the proximal fibula at the level of distal fibular syndesmosis. The hook test is performed on a curved hook to assess the stability of the fibula. If instability is found, the fibula can be further stretched to repair all bone.

The fibula can then be put into the fibula notch of the tibia to effectively restore its length. You can then use the inward rotation of the foot to correct the anatomical alignment.

After open reduction, internal fixation is usually done to stabilize the ankle joint. To take into account that the distal fibula is slightly posterior to the distal tibia, the drill holes are at a 30 ° angle from the anteromedial side of the tibia to the posterolateral side of the fibula. In this way, transsyndesmotic screws can be inserted to ensure tibial fixation. If the fibula remains unstable after shrinking, additional supra-syndesmotic screws can be temporarily inserted for approximately 3-6 months.

Partial dorsiflexion of the foot is maintained prior to intraoperative screw fixation to reduce the fibula and restore the correct anatomical composition of the ankle. This is because in the neutral or maximum dorsiflexion position of the foot, the trochlear surface of the talus can reduce postoperative maximum dorsiflexion due to the rigidity after screwing.

Assessment of the severity of syndesmotic lesions can be done by fluoroscopic screening. Fluoroscopic guidance is also useful for fixing the syndesmotic screw. Repair of the anterior medial joint capsule of the ankle can be achieved using suturing techniques.

Closed reduction-internal fixation:

Closed reduction surgery does not require a leg incision or incision for surgery. It is most often used when a Maisonneuve fracture causes severe damage to only the anterior part of the syndesmotic ligament. That is, the posterior joint of the ankle is still stable and traction can be used to rotate the foot inward and restore the length of the fibula bone. Long leg casting or short leg casting is used postoperatively to maintain this alignment. If closure reduction is sufficient to restore bone length, it is generally recommended that surgery for medial ankle fractures is not required. Otherwise, large medial ankle fractures can be repaired with a transsyndesmotic screw, 8 wires or Kirschner wire. For smaller medial ankle fractures, a wire tension band will suffice.

 

RECOVERY

Rehabilitation after a Maisonneuve fracture can take months and depends on the severity of the injury and the surgeon's guidelines. Most surgeons fix the ankles and immobilize them for 4-6 weeks after surgery and prevent limb tension for 6-12 weeks after surgery. Some surgeons recommend a second surgery to remove the hardware used to repair the syndesmosis before tension resumes. This is controversial and can be discussed with the surgeon.

Standard postoperative recovery usually includes 6-12 weeks of putting on weight on the affected ankle. You can then use physiotherapy to regain flexibility, strength, and balance. The goal is to allow the patient to become fully active again and regain the function they had before the injury.

If the ankle is not properly positioned during the healing process, the joint is at risk of developing osteoarthritis. Ultimately, this can lead to chronic ankle pain, tenderness, stiffness and inflexibility.

 

TREATMENT AFTER SUGRERY OF SPIRAL FRACTURES

Sprints are often used after surgery or during a clean break to reinforce the correct position of the epiphysis. The sprint can be easily adjusted to accommodate inflammation.

During the first few weeks of healing, the fractured bone should be completely fixed or immobile. A cast is usually applied as soon as the swelling subsides.

The brace can be removed for cleaning, physiotherapy, and testing, so you can replace the cast after a few weeks. Wheelchairs, crutches, or pedestrians may also be needed to limit the weight of the limbs. For the first 48 hours after applying the sprint and plaster cast, the limbs should be raised to heart level. Icing and elevation should be applied regularly throughout the day as needed or as directed by your doctor.

Medicines are prescribed to relieve pain. Doctors usually prescribe antibiotics to prevent infection. Gradual exercise activity may be appropriate for 4-6 weeks after injury. However, in severe cases, it often takes more than 12 weeks for the bones to begin to support their weight. Reinforcing devices such as rods and pins are usually removed 3 to 6 months after surgery.

Most people still need to limit the movement of their affected limbs, even after removing the cast or orthotic device. For lower limb injuries, you can use walking aids or crutches for weeks or months after removing the plaster cast or brace.

Overall, complete recovery from a spiral fracture often takes 4-6 months. Serious injuries can take up to 18 months to heal properly.

 

PHYSIOTHERAPY

Rest and rehabilitation are essential to the healing process of this injury. Rest and no-load activities are recommended for a period of 6 weeks.

 During this time, the ankle is splinted to the knee  or cast to secure. If the patient changes into hiking boots, physiotherapy should be started after about 6 weeks. Physical therapy exercises include stretching and strengthening the ankle, maintaining mobility, and improving ankle mobility.

Stretching and strengthening exercise allows the patient to return to gradual exercise activity after about 8-12 weeks and to full exercise after about 16 weeks. Resumption of sports after a Maisonneuve fracture with rehabilitation usually takes place within a time frame of approximately 20-24 weeks.

Specific Physiotherapy Treatment:

  • Customized movement and stretch prescriptions to increase ankle movement freedom during exercise.
  • Conducted under the guidance of a physiotherapist.
  • Cold laser treatment to stimulate healing of damaged ligaments.
  • Cold and ice modality to improve swelling and stiffness.
  • Heat treatments such as ultrasound to improve the sensitivity of other ligaments and tendons in the feet and ankles.
  • Guide to activities such as weight management, walking, running, using hiking shoes, and returning to work-out.

 

COMPLICATIONS

Delaying diagnosis and thereby the treatment can lead to intraoperative complications. In one clinical study case, conducted in 2000 which was then published in orthopedics, the insertion of a super-syndesmotic screw further laterally displaced the lateral malleolus of the ankle, which then lead to removal of the screws.

Postoperative complications include:

•      Development of osteoarthritis of the ankle.

•      Onset of peroneal paralysis after damage to the common peroneal nerve.

•      Extraosseous (extraosseous indicates something that is outside the bone) calcification of blood vessels or tissues surrounding the tibiofibular joint.

Complications related to hardware used in surgery:

Improperly placed screws can come into contact with the articular surface and can lead to calcification around the affected area. Broken screws can also cause pain in these areas. Postoperative hardware removal can cause problems such as infection, joint stiffness, or diastasis recti if the fixation is not long enough.

In areas where residual stiffness persists, patients may report pain or a slight pain sensation. In general, it is recommended to remove the hardware 6-12 weeks after internal fixation so that the tibiofibular syndesmosis can heal properly.

The syndesmotic screw must be removed prior to rehab training. Carrying your weight without removing the hardware first can reduce your ankle dorsiflexion and can damage your screws, which can lead to stiff ankles.

Other complications that can be associated with Maisonneuve fracture or spiral fractures in general are as follows:

  • Compartment syndrome- condition where blood supply to the affected area is stopped.
  • Nerve damage, or damage of blood vessels.
  • Damage of muscle.
  • Infections- like osteomyelitis, or deep bone infection that is chronic in nature.
  • Sepsis- when the nature of an infection is extremely severe, the immune system of body starts to damage the body tissues after being stimulated by the infection.
  • Non-union/malunion- when bones do no heal, or heal abnormally.
  • Pulmonary or fat emboli- occurs when blood clots get separated and go into lungs or other body organs.

 

TAKEAWAY

Maisonneuve fractures occur as a result of rotational injuries to the ankle. In most cases, the feet are placed on the floor and the limbs rotate inward.

This puts stress on the bones and ligaments. In violent cases, this injury can overcome the strength of bones and ligaments. Energy from the injury passes through the ankle ligaments (syndesmotic Ligaments) and fibula, which are adjacent to the leg bones.

Injuries can be difficult to identify because there are often subtle fractures just below the knee joint, but there are serious ligament injuries that extend to the ankle. This ligament damage can lead to ankle instability that requires treatment.

Regular x-rays of the ankle may not clearly show damage to this ligament. To make a diagnosis, the doctor may need to take a special x-ray that stresses the ankle. Instability is noticeable when the ankle is stressed.

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