Maisonneuve Fractures

A Maisonneuve fracture is a fracture of the proximal fibula with disruption of the distal tibiofibular syndesmosis and injury to the medial ankle structures, either a medial malleolus fracture or a deltoid ligament rupture. It is named after Jules Germain François Maisonneuve (1809-1897), the French surgeon who described the pattern in 1840.

Where the fibula breaks, because sources differ. English-language teaching usually says the proximal third, whereas the two dedicated series cited on this page, Kašper and Bartoníček, define the injury by a fracture of the proximal quarter of the fibula, and Bartoníček's definition further requires rupture of the anterior and interosseous tibiofibular ligaments with all other injuries variable. In Kašper's 70 patients the fracture was subcapital in 64 and involved the fibular head in 6. Nothing clinical turns on third versus quarter; what matters is that the fibular fracture is far enough proximal that the syndesmosis must be assumed disrupted and formally assessed.

The key concept. The energy of the external rotation injury is transmitted through the interosseous membrane, so the fibula fractures proximally rather than at the ankle. What results is a Weber C equivalent: the syndesmosis is completely disrupted, the ankle mortise is unstable, and the injury requires surgical stabilisation. The proximal fibula fracture itself does not require fixation.

Epidemiology. About 5% of all ankle fractures, with a peak incidence at 20-50 years, an equal male-female distribution, and an association with sports injuries and falls. It is often missed initially, up to 20% in some series, and a missed Maisonneuve leads to chronic ankle instability.

The syndesmosis. Four ligaments stabilise the distal tibiofibular joint:

1. Anterior inferior tibiofibular ligament (AITFL) - runs obliquely from the anterolateral tibia to the anterior fibula and prevents anterior fibular translation. It is the first syndesmotic structure to fail in external rotation.
2. Posterior inferior tibiofibular ligament (PITFL) - the strongest of the four, running from the posterolateral tibia to the posterior fibula, and including the posterior malleolus component.
3. Interosseous ligament - the thickened distal portion of the interosseous membrane and the primary restraint to syndesmotic widening. In a Maisonneuve injury it is disrupted along its entire length.
4. Transverse tibiofibular ligament - the deep component of the PITFL, its inferior continuation.

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The interosseous membrane. It connects the tibia and fibula along their entire length and transfers 10-15% of axial load from tibia to fibula. In a Maisonneuve fracture it is torn from the ankle to the level of the fibula fracture, which is the route by which the injury energy migrates proximally. This is complete syndesmotic disruption, the most severe form of syndesmotic injury.

The medial side. For the ankle to become unstable the medial structures must fail as well, in one of two ways: the medial malleolus fractures, a transverse pattern visible on X-ray, or the deltoid ligament ruptures, which shows only as medial tenderness with no fracture visible.

Mechanism. The foot is planted and pronated (everted) and the body rotates externally, the same mechanism as a Weber C fracture; the talus rotates externally in the mortise. Pronation combined with external rotation puts maximum stress on the medial structures first, so the medial malleolus fractures or the deltoid ruptures, and the injury then spirals round to the lateral side. The AITFL tears, allowing the fibula to shift laterally, and instead of the fibula fracturing at ankle level the energy propagates up the interosseous membrane, which tears sequentially. The membrane injury stops when the fibula fractures proximally, usually at the junction of the proximal and middle thirds.

Why the fibula fails proximally. The interosseous membrane is more easily torn than the fibula, so the energy travels up the leg through membrane disruption until it finds a weak point in the bone, typically the proximal third where the fibula is thinnest.

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History. A fall, a twisting injury or a sports injury, with an external rotation force on the planted foot. The patient may describe a "pop" or "snap" at the time of injury, has pain at the ankle and may also have calf or proximal leg pain, and is unable to weight bear.

Examination. Swelling and ecchymosis reflect the energy of the injury; the diagnostic findings are where the leg is tender.

Special tests. Three tests interrogate the syndesmosis:

1. Squeeze test (Hopkinson test) - compress the tibia and fibula at mid-calf level; pain at the ankle is positive and indicates syndesmotic injury. Highly sensitive but not specific.
2. External rotation stress test - stabilise the tibia and externally rotate the foot; pain at the syndesmosis is positive, and stress fluoroscopy may show widening.
3. Cotton test under fluoroscopy - apply a lateral translation force to the talus; a visible lateral shift of the fibula from the tibia is positive, greater than 3-4mm compared with the contralateral side. This is the definitive test for syndesmotic instability.

The suspicion algorithm.

1. Isolated medial malleolus fracture seen on ankle films
2. OR medial tenderness without lateral fracture
3. → Palpate proximal fibula
4. → If tender, order full-length tibia/fibula films
5. → If proximal fibula fracture seen = Maisonneuve fracture

Imaging confirms the Maisonneuve pattern, assesses the medial malleolus fracture and the syndesmotic widening, and plans the surgery.

Ankle series. AP, lateral and mortise views:

Read the thresholds as conventions, and know their two weaknesses. They are measured 1 cm above the tibial plafond, published cut-offs vary between sources (tibiofibular clear space appears as under 5mm and under 6mm), and none has an established sensitivity or specificity, so a normal measurement does not exclude the injury. Do not confuse the two clear spaces: tibiofibular clear space under 5mm, medial clear space under 4mm. Most importantly, this page's own evidence shows how insensitive plain films are: in Kašper's series of 70 Maisonneuve fractures, tibiofibular clear space widening was demonstrated radiographically in only 40 of 70 cases. If the mechanism and examination suggest a Maisonneuve injury, normal measurements are a reason for CT rather than reassurance.

Full-length tibia/fibula films. Essential for the diagnosis. They show the proximal fibula fracture, usually a spiral pattern and typically at the junction of the proximal and middle thirds, and the extent of interosseous membrane disruption is inferred from its level. Ask for two views of the leg: in Kašper's series the fibular fracture was seen only on the lateral lower-leg radiograph in 24%.

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CT. It measures the tibiofibular distance precisely, shows fibular rotation (malreduction) and identifies osteochondral lesions of the talus, an associated injury. CT is often obtained but may not change management if the plain films already show the Maisonneuve pattern with a widened syndesmosis. The indications are:

• Posterior malleolus involvement (size, fragment pattern)
• Complex fracture patterns
• Subtle syndesmotic widening on plain films
• Post-reduction assessment of mortise congruity

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MRI. Not routinely needed: clinical and plain-film diagnosis is usually sufficient, and MRI adds cost and rarely changes the surgical plan once syndesmotic instability is confirmed clinically or radiographically. It earns its place in a few situations:

• Medial malleolus intact but the deltoid injury is in question (clinical examination, medial tenderness and stress views, is usually sufficient; MRI confirms an equivocal rupture)
• Planning a deltoid ligament repair
• Assessing the syndesmotic ligaments in detail or ruling out occult injury patterns
• Medicolegal documentation
• Research, mapping the extent of injury

Intraoperative stress testing. Stability is tested before and after fixation. The Cotton test is repeated after syndesmotic fixation to confirm stability, and a gravity stress test, a lateral view with the stress applied by gravity, assesses talar tilt and anterior drawer. Stress testing under anaesthesia is more reliable than awake examination because the awake patient guards.

Algorithm

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The principle that organises everything else. The problem is the syndesmosis, not the fibula. Four rules follow:

1. The fibula fracture does not need fixation. The proximal fibula is far from the ankle joint and not intra-articular, it is usually stable, it has a good blood supply and heals well without surgery, and nonunion at this level is rare. Fixing it gives no mechanical advantage, adds morbidity, and would need an additional proximal incision with peroneal nerve risk.
2. Syndesmotic fixation is mandatory. Complete disruption means an unstable ankle mortise, and without fixation chronic instability and arthritis develop. The options are syndesmotic screws or a suture button.
3. Fix the medial malleolus if displaced, by standard ORIF with screws or a plate through a separate medial incision.
4. The deltoid ligament may not need repair if the syndesmosis is stabilised and the mortise congruent. Some surgeons explore and repair it, it is repaired directly if the mortise stays incongruent or if it is explored open, and the evidence on the benefit of routine repair is unclear.

Nonoperative management is not appropriate. Complete syndesmotic disruption creates an unstable mortise, and without fixation the result is chronic lateral talar shift, post-traumatic arthritis, chronic instability and poor functional outcomes. The only exception is a non-ambulatory patient or severe medical comorbidity precluding surgery, which is rare; every other patient is counselled for surgical stabilisation of the syndesmosis.

Surgical goals and timing. The operation restores an anatomic ankle mortise, stabilises the distal tibiofibular syndesmosis, fixes the medial malleolus if it is fractured and displaced, and allows the interosseous membrane to heal. Operate ideally within 1-2 weeks of injury; severe swelling may force a staged approach (wrinkle test), and delay increases the difficulty because of early callus and scarring.

Screws or suture button. Most surgeons use syndesmotic screws (1-2 screws) or a suture button device, and both produce good outcomes when properly positioned.

What the randomised evidence adds is in the cards below. Andersen's trial against a single quadricortical screw found higher functional scores with the suture button and no symptomatic recurrent diastasis against 7 in the screw group, but the screws were routinely removed at a mean of 85.9 days and the screw arm carried more posterior malleolar injuries at baseline. Onggo's meta-analysis of five trials concluded that the two constructs give similar clinical outcomes, the suture button's clear advantage being fewer implant failures, so the choice rests on implant failure, cost, soft tissues and experience.

Syndesmotic malreduction. The most important complication to avoid. The fibula ends up externally rotated in the incisura, posteriorly translated, or over- or undercompressed, and even 1-2mm of malreduction increases contact pressures and leads to arthritis. Intraoperative CT may detect a subtle malreduction that fluoroscopy misses.

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The proximal fibula. It typically heals without intervention and the problems are rare: delayed union (very rare), painful hardware if it was inadvertently fixed, and peroneal nerve injury if a surgical approach was attempted.

Most protocols keep the patient non-weightbearing for 6 weeks after syndesmotic fixation, which allows the membrane to heal; some surgeons allow earlier weightbearing with a suture button because of its dynamic fixation. Markolf's cadaveric data give the rationale for what is restrained: axial weight-bearing barely moved the fibula, whereas external foot torque produced ten to twenty times more displacement, so it is torsional loading rather than weight-bearing that should be restrained to limit screw bending and breakage.

Screw removal. Many surgeons remove syndesmotic screws at 3-4 months, which allows a return to full activity without the risk of breakage; if a screw breaks after union the fragments can be left. A suture button avoids the question altogether.

Return to work and sport

• Sedentary work: 2-4 weeks (with limitations)
• Manual labour: 3-6 months
• Running/jogging: 4-6 months
• Contact sports: 6 months minimum
• Full recovery: 6-12 months

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What decides the result. Anatomic reduction of the mortise is the single most important factor, and intraoperative vigilance is what secures it.

Favourable

• Accurate syndesmotic reduction
• Early surgical treatment
• Anatomic medial malleolus fixation
• Compliant patient with rehabilitation

Unfavourable

• Syndesmotic malreduction
• Delayed diagnosis/treatment
• Associated cartilage damage
• Persistent mortise widening
• Older age, obesity, smoking

In the long term. With proper treatment most patients achieve a good functional outcome. Some stiffness may persist, especially in dorsiflexion; radiographic arthritis may develop but is often asymptomatic; and chronic instability is rare with adequate fixation.

Global epidemiology. Maisonneuve fractures account for roughly 5 to 7% of all ankle fractures and represent the most proximal expression of a pronation-external-rotation injury. In the largest dedicated series (70 patients, mean age 48 years; PMID 32349489) men predominated, the female share rose after age 50, a posterior malleolus fracture accompanied 77% of cases, a medial malleolus fracture 39% and a complete deltoid rupture 51%, with intact medial structures in only 10%. Contemporary CT-based reviews report posterior malleolar involvement in about 80% of cases (PMID 37185026). The pattern is consistent worldwide; differences between centres reflect imaging access and reduction technique rather than true biological variation.

Major guidance, side by side. No society publishes a Maisonneuve-specific guideline; recommendations are extrapolated from syndesmotic and ankle-fracture guidance.

Registry and high-level evidence. Joint registries do not track syndesmosis implants discretely, so the evidence base is randomised rather than registry-derived. A Level I RCT (PMID 29298255) and a meta-analysis of five RCTs (PMID 30503612) both show dynamic suture-button fixation gives equal-or-better function, less late tibiofibular widening and far fewer implant failures than a static screw, while a cadaveric study (PMID 23405026) shows screw diameter and number of cortices have little mechanical effect. Across all constructs, malreduction is the dominant driver of poor outcome (PMID 22357084).

Global practice variation. High-resource settings increasingly favour open reduction of the distal fibula, suture-button or screw fixation, and post-operative CT to confirm reduction. Limited-resource settings rely more on closed reduction and screw fixation under fluoroscopy; because closed reduction is malreduced in up to 50% of cases (PMID 37185026), low-cost screws remain widely used where suture-button devices or CT are unavailable. Hardware-removal practice also differs (routine versus selective screw removal) - an issue largely avoided by suture-button constructs.