Maisonneuve injury with no fibula fracture: A case report

Abstract

Background: Ankle syndesmosis injury is difficult to diagnose accurately at the initial visit. Missed diagnosis or improper treatment can lead to chronic complications. Complete syndesmosis injury with a concomitant rupture of the interosseous membrane (IOM) is more unstable and severe. The relationship between this type of injury and Maisonneuve injury, in which the syndesmosis is also injured, has not been discussed in the literature previously.

Case summary: A 16-year-old patient sustained left medial malleolar fracture, and the associated inferior tibiofibular syndesmotic instability was overlooked. After open reduction and internal fixation of the medial malleolar fracture, inferior tibiofibular syndesmosis diastasis with IOM rupture was detected by auxiliary imaging. Secondary surgical intervention was performed to reduce anatomically and fix with two trans-syndesmosis screws. Twelve weeks later, the screws were removed. At the 6-mo follow-up, the patient gained full range of motion of the ankle.

Conclusion: Complete syndesmosis injury with IOM rupture should be considered Maisonneuve-type injury. Open reduction and internal fixation could obtain good outcomes.

Keywords: Case report; Classification; Interosseous membrane; Maisonneuve; Stress test; Syndesmosis injury.

Figure 1

Left ankle radiographs (from another hospital) of anteroposterior and lateral views showing medial malleolar fracture.

Figure 2

Postoperative radiograph showing the enlarged tibiofibular clear space and medial clear space.

Figure 3

Calf magnetic resonance imaging. A: Sagittal magnetic resonance imaging (MRI) showing high-signal intensity (orange arrow) indicating injury of the interosseous membrane (IOM); B: Coronal MRI showing IOM injury (orange arrow) compared with the contralateral uninjured calf; C: Axial MRI showing IOM rupture (orange arrow) compared with the contralateral uninjured calf, torn from the fibular interosseous crest.

Figure 4

Assessment of inferior tibiofibular syndesmosis in computed tomography scans. A: Bartoníček et al[6]’s evaluation method: The anterior aspect of the distal fibula and tibia was continuous, similar to the posterior aspect, “star” area of higher density of the subchondral cancellous bone; B: The distance between the Tillaux-Chaput tubercle and Gifford and Lutz[7]’s tibiofibular line did not exceed 2 mm at the level of 10 mm superior to the tibial plafond.

Figure 5

Computed tomography scans indicating complete injury of inferior tibiofibular syndesmosis. A: Rupture of the interosseous membrane (IOM) torn from fibular interosseous crest; B: Avulsion fracture of the anterior inferior tibiofibular ligament (AITFL) in the soft tissue window of computed tomography (CT) scan; C: Avulsion fracture of the posterior inferior tibiofibular ligament (PITFL) in the soft tissue window of CT scan; D: The intact IOM at the proximal part of the calf; E: Avulsion fracture of the AITFL was hardly caught in the bone window of the CT scan (the same B plane); F: Avulsion fracture of the PITFL was hardly caught in the bone window of the CT scan (the same C plane).

Figure 6

Ankle radiographs of anteroposterior and lateral views after secondary surgery. A: Anteroposterior; B: Lateral.