"Double Maisonneuve fracture": an unknown fracture pattern

Injury to the posterior malleolus in Maisonneuve fractures

PURPOSE

The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture.

METHODS

The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula.

RESULTS

A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients.

CONCLUSION

Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.

Maisonneuve Fractures of the Ankle: A Critical Analysis Review

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Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.

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The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).

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The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.

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Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.

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Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.