What is the initial management and treatment for a Maisonneuve fracture?

Initial Management and Treatment of Maisonneuve Fracture

The initial management of a Maisonneuve fracture should include immobilization, pain control, and prompt surgical fixation to restore ankle stability and prevent long-term complications such as post-traumatic arthritis.

Initial Assessment and Stabilization

• Imaging studies:

  • Plain radiographs of the ankle AND proximal fibula (crucial to avoid missing the proximal fibular fracture)
  • CT scan to assess:
    • Posterior malleolar involvement (present in ~80% of cases)
    • Distal fibular position in the fibular notch
    • Syndesmotic injury extent

• Initial stabilization:

  • Immobilization with a short leg splint
  • Elevation to reduce swelling
  • Ice application
  • Appropriate analgesia (multimodal approach with paracetamol as baseline)
  • Non-weight bearing status

Definitive Treatment

Surgical Management (Primary Recommendation)

Surgical fixation is strongly recommended for most Maisonneuve fractures to ensure anatomical reduction of the distal fibula in the fibular notch and restore syndesmotic stability 1.

1. Timing of surgery:

   • Early definitive fixation within 24 hours for hemodynamically stable patients 2
   • Delayed fixation for patients with severe associated injuries or hemodynamic instability 2

2. Surgical approach:

   • If posterior malleolar fracture present: Reduce and fix first via posterolateral approach 1
   • Open reduction of distal fibula via anterolateral approach (preferred over closed reduction which has up to 50% malposition rate) 1
   • Syndesmotic fixation with screws or suture button devices
   • Consider fixation of the proximal fibular fracture in cases with significant instability 3

3. Post-surgical verification:

   • Postoperative CT scan to confirm accurate reduction 1, 3
   • This step is critical as malreduction can lead to poor outcomes and need for revision surgery

Conservative Management (Limited Indications)

Conservative treatment may be considered in select cases with:

• Minimal syndesmotic disruption
• Stable ankle mortise on stress views
• Patient factors that preclude surgery

This approach includes:

• Non-weight bearing short leg cast for 6-8 weeks
• Regular radiographic follow-up to ensure maintenance of reduction
• Progressive weight bearing after evidence of healing

Potential Pitfalls and Complications

1. Missed diagnosis:

   • Always examine the proximal fibula when evaluating ankle injuries
   • Failure to obtain proximal fibula imaging can lead to missed Maisonneuve fractures

2. Syndesmotic malreduction:

   • Improper clamp placement during surgery can cause malreduction 3
   • Oblique clamp placement is particularly problematic
   • Changes in proximal fibular fracture alignment during reduction may indicate syndesmotic malreduction

3. Inadequate assessment:

   • Relying solely on intraoperative fluoroscopy without postoperative CT can miss malreductions 1, 3

Rehabilitation Protocol

1. Early postoperative phase (0-2 weeks):

   • Non-weight bearing
   • Elevation and ice for swelling control
   • Active toe movements and ankle pumps

2. Intermediate phase (2-6 weeks):

   • Continued non-weight bearing
   • Progressive range of motion exercises if fixation is stable

3. Late phase (6-12 weeks):

   • Progressive weight bearing as tolerated
   • Physical therapy focusing on proprioception, strength, and gait training

Long-term Follow-up

• Regular radiographic assessment to monitor healing and detect early signs of post-traumatic arthritis
• Consideration for syndesmotic screw removal (if used) at 8-12 weeks
• Long-term follow-up to monitor for late complications

While some recent case reports suggest successful conservative management in select cases 4, the preponderance of evidence supports surgical management to restore anatomic alignment and prevent long-term complications for most Maisonneuve fractures.