Maisonneuve Fracture: Causes, Symptoms & Treatment

What Is a Maisonneuve Fracture?

A Maisonneuve fracture is a specific type of ankle injury first described in 1840 by the French surgeon Jules Germain François Maisonneuve. It is characterized by a fracture of the proximal third of the fibula (the smaller lower leg bone), caused by a rotational force transmitted through the ankle joint. The injury is almost always accompanied by significant damage to the ligaments of the ankle and to the interosseous membrane, the connective tissue sheet connecting the tibia and fibula along their length.

This fracture is frequently missed on initial assessment because the pain is centered at the ankle while the actual bone break occurs high up on the fibula. X-rays limited to the ankle alone will often fail to reveal the injury.

Causes and Mechanism of Injury

A Maisonneuve fracture results from an external rotation force applied to a pronated foot at the ankle. Common situations include:

• Sports injuries, especially in football, skiing, or snowboarding
• Twisting the ankle on uneven ground
• Low-energy falls with rotational loading of the lower leg
• Traffic accidents involving torsional forces on the ankle and lower leg

The injuring force travels from the ankle joint upward through the interosseous membrane until it fractures the proximal fibula. This mechanism almost always produces associated injuries to the medial malleolus, the anterior syndesmosis, or the deltoid ligament.

Symptoms

The symptoms of a Maisonneuve fracture can be misleading and are often initially mistaken for a simple ankle sprain. Typical complaints include:

• Ankle pain, particularly along the inner side or at the syndesmosis (the joint between the tibia and fibula above the ankle)
• Swelling and bruising around the ankle
• Tenderness on pressing the upper fibula -- an important diagnostic clue
• Reduced range of motion and inability to bear weight
• A feeling of instability when standing or walking

Clinically, it is essential to palpate the entire length of the fibula up to the knee, as the fracture site may only be painful proximally.

Diagnosis

Diagnosing a Maisonneuve fracture requires a combination of clinical examination and targeted imaging:

Clinical Examination

The physician palpates the full length of the fibula to identify proximal tenderness. Specific tests such as the external rotation stress test and the fibula squeeze test are used to assess syndesmotic instability.

Imaging

• X-ray: Radiographs of the ankle (two views) and the entire lower leg including the proximal fibula are mandatory. Without a full-length fibula view, the fracture is easily overlooked.
• MRI (Magnetic Resonance Imaging): Provides detailed assessment of ligamentous injuries, especially to the syndesmosis and deltoid ligament.
• CT (Computed Tomography): Useful for preoperative planning and precise evaluation of fracture morphology.

Classification

In clinical practice, the Maisonneuve fracture is classified under the Lauge-Hansen system as a pronation-external rotation injury grade III or IV. Under the Weber classification, it corresponds to a Type C fracture (above the syndesmosis), which by definition implies syndesmotic instability.

Treatment

Conservative Treatment

Non-surgical management is only appropriate in rare cases where the ankle joint remains stable and syndesmotic disruption is absent or minimal. It includes:

• Immobilization in a below-knee cast or walking boot for 6 to 12 weeks
• Non-weight-bearing with crutches
• Regular follow-up X-rays to monitor alignment

Surgical Treatment

Because of the associated syndesmotic instability, most Maisonneuve fractures require surgical stabilization. The goal is to restore the integrity of the ankle mortise. Surgical options include:

• Syndesmotic screw fixation: One or two screws are placed between the tibia and fibula to hold the syndesmosis in correct alignment.
• Tight-rope (suture-button) fixation: A flexible implant that allows more physiological micro-motion at the syndesmosis compared to a rigid screw.
• Ligament repair: Torn ligaments such as the deltoid ligament may be sutured or reconstructed.
• Fibula fixation: The proximal fibula fracture itself typically does not require direct plating, as syndesmotic stabilization alone provides adequate indirect reduction.

Rehabilitation and Prognosis

Following surgical repair, structured rehabilitation is key to a successful recovery:

• Partial weight-bearing for 6 to 8 weeks, followed by gradual loading
• Physiotherapy to restore strength, coordination, and range of motion
• Removal of syndesmotic screws after 8 to 12 weeks (if applicable)
• Return to sport typically after 3 to 6 months

With timely and appropriate treatment, the prognosis is generally good. However, missed or untreated cases can result in chronic ankle instability, post-traumatic osteoarthritis, and long-term functional impairment.

References

1. Zwipp H, Rammelt S. Tscherne Unfallchirurgie: Fuß und Sprunggelenk. Springer Verlag, Berlin, 2014.
2. Lauge-Hansen N. Fractures of the ankle. Archives of Surgery. 1950;60(5):957-985.
3. van Dijk CN, Longo UG, Loppini M, et al. Conservative and surgical management of acute isolated syndesmotic injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24(4):1217-1227.