Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up

Abstract

Rationale: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture.

Patient concerns: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility.

Diagnoses: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS).

Interventions: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits.

Outcomes: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification.

Lessons: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

Figure 1.

Typical imaging of the patient. (A–E) Radiography and CT scans at the first visit: (A) and (E) represented the non-stress and stress views, respectively; the width of the inferior tibiofibular space was 5.29 mm and 5.54 mm, respectively; (B) showed 5.27 mm in width of inferior tibiofibular space; (C) showed a fracture of the Volkmann tuberosity; (D) showed proximal tubular fracture. (F)–(I) Radiography and CT scans in 14th week after injury: (F) and (G) showed the width of the inferior tibiofibular space was 4.22 mm and 4.17 mm, respectively; (H) revealed the union of Volkmann fracture; (I) showed partial union of proximal tubular fracture, as the fracture line got obscure. (J)–(N) Radiography and CT scans at the 41st month follow-up after injury: (J) and (N) represented that the width of the inferior tibiofibular space on the non-stress and stress views was 4.57 mm and 4.84 mm, respectively; (K) showed 4.53 mm in width of inferior tibiofibular space in a cross section view of CT scans; (L) showed the total union of Volkmann fracture; (M) showed total union of proximal tubular fracture. CT = computed tomography.