Figure 1. Anteroposterior radiograph of the right ankle.
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Figure 2. Anteroposterior radiograph of the tibia and fibula.
A 46-year-old man presents to the emergency department with severe pain in his right ankle after he slipped on icy stairs. Radiographs of the right ankle and the tibia and fibula show a proximal fibular fracture with medial clear space widening at the ankle (Figures 1 and 2).
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The patient has a proximal fibular fracture with medial clear space widening indicating a syndesmosis injury; this injury pattern is described as a Maisonneuve fracture.1 The mechanism of injury is pronation and external rotation of the foot that results in a fracture of the medial malleolus or disruption of the deltoid ligaments.1,2
The goal of treatment is anatomic reduction of the tibiotalar joint as a small shift in the talus increases joint contact forces and predisposes patients to early arthritis. Any patient presenting with unexplained medial clear space widening must undergo radiographic examination of the proximal tibia and fibula to rule out a Maisonneuve fracture. The proximal fibular fracture confirms that the syndesmosis is ruptured from the proximal fibular fracture down through the ankle.1,2
Maisonneuve fractures with medial clear spaced widening require surgery with syndesmosis fixation. Syndesmosis fixation involves compressing the tibia and fibular bones back together with a bone clamp followed by placing 2 horizontal screws across the distal tibia and fibula to maintain reduction. Patients are instructed to limit weight-bearing for 2 months while the syndesmosis heals. Screws are removed at 2 to 3 months from injury to prevent them from breaking when the patient resumes full weight-bearing.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants.
1. Levy BA, Vogt KJ, Herrera DA, Cole PA. Maisonneuve fracture equivalent with proximal tibiofibular dislocation. A case report and literature review. J Bone Joint Surg Am. 2006;88(5):1111-1116.
2. Jones CB, Gilde A, Sietsema DL.Treatment of syndesmotic injuries of the ankle: a critical analysis review. JBJS Rev. 2015;3(10).