![]() In this case, the displacement of the talus and lateral malleolus indicate that the posterior tibio-fibular ligament has been disrupted, making this P-ER, Stage 4. Under the Lauge-Hansen system, this injury would be classified as Pronation-External Rotation (P-ER), which has the following stages: medial malleolar fracture or deltoid ligament rupture (Stage 1), anterior tibio-fibular ligament disruption (Stage 2), fibular fracture above syndesmosis (Stage 3), and posterior malleolar fracture or posterior tibio-fibular ligament disruption (Stage 4). This fracture would be classified as a Weber C. There is an abnormally large space between the medial malleolus and the talus (long arrow), consistent with deltoid ligament disruption, and the talus is shifted laterally with respect to the tibia. The syndesmosis itself is widened (arrowhead). There is a laterally displaced oblique fracture of the distal fibular shaft that is entirely above the level of the distal tibio-fibular syndesmosis. AP (A), mortise (B), and lateral (C) radiographs of the left ankle. This case fits the S-ER mechanism.ĥ0-year-old woman with ground-level fall. To restore the fibular length, the distal end of the fibula is elongated into its anatomical position for trans-syndesmotic fixation. The most common stage is S-ER, with four stages of severity: anterior tibiofibular ligament tear (Stage 1), oblique fracture of the lateral malleolus extending distally to the level of the plafond (anteroinferior to posterosuperior Stage 2), posterior malleolar avulsion fracture or posterior tibial-fibular ligament tear (Stage 3), and transverse medial malleolar avulsion fracture or deltoid ligament rupture (classic trimalleolar Stage 4). The proximal fibular fracture is not directly stabilized, but instead indirectly stabilized through fixating the distal fibula to the tibia with trans-syndesmotic screws (Figures 5a-f). ![]() Each mechanism is a combination of foot position and direction of force, with multiple stages of severity: Supination-Adduction (S-A), Supination External Rotation (S-ER), Pronation-Abduction (P-A), and Pronation-External Rotation (P-ER). Based on cadaver studies, Lauge-Hansen described four mechanisms for ankle fractures. The overlying soft tissues are swollen, but the ankle mortise appears intact. The fracture extends from the posterior cortex inferiorly to the level of the syndesmosis. Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. There is an oblique fracture of the distal fibula (arrow) with minimal displacement. Lateral (A), AP (B), and mortise (C) radiographs of the right ankle. It is named after Jules Germain Francois Maisonneuve, French surgeon (1809-1897) 1,4.30-year-old man injured his ankle playing soccer. reduction and stabilization of the fibular fractureįracture involving distal 2/3 of the fibula may compromise ankle mortise, and so may benefit from surgery 6įracture involving proximal 1/3 fibula often managed non-operatively ligamentous injuries may be managed non-operatively Reduction and stabilization of medial malleolus fracture and/or ligamentous injuries 6 Fibular fractures, particularly those involving the ankle and the shaft just proximal, are common. In some cases, internal fixation of a posterior malleolar fracture fragment may result in sufficient stabilizationįixation screws may or may not be removed after several weeks of healing 6 bioabsorbable constructs, syndesmotic staples, hooks, or cerclage wires) commonly achieved by trans-syndesmotic screws. Alternative stabilization mechanisms exist (e.g. Internal fixation of the distal tibiofibular syndesmosis 6 Treatment and prognosisĪlthough management is variable depending on the complexity of injuries, this type of fracture pattern is generally managed by operative treatment. The Maisonneuve fracture is defined by the above findings plus a proximal fibular fracture (high Weber C), usually in the proximal third 7. When these ankle injury types are seen without a fracture of the lateral malleolus, further imaging of the entire fibula is recommended. Ankle views may show a fracture of the medial malleolus or widening of the medial ankle joint space due to deltoid ligament injury, as well as widening of the distal tibiofibular syndesmosis.
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