What is the recommended treatment for a Maisonneuve fracture?

Treatment of Maisonneuve Fracture

Surgical fixation of the medial malleolus (or deltoid ligament complex) and syndesmosis stabilization is the recommended treatment for Maisonneuve fractures, while the proximal fibular fracture does not require direct fixation. 1

Surgical Management Algorithm

Medial Side Treatment

• Fix the medial malleolus fracture with standard internal fixation techniques if present, as this is a critical component of restoring ankle stability 1
• If the deltoid ligament is torn without medial malleolar fracture, direct ligament repair is not necessary—syndesmotic fixation alone provides adequate stability 1
• Consider arthroscopic-assisted medial ligament repair as a minimally invasive alternative that provides elastic fixation more consistent with syndesmotic biomechanics 2

Syndesmotic Stabilization

• Stabilize the syndesmosis using one or two screws engaging 3 or 4 cortices, which can be placed percutaneously 1
• Ensure anatomic reduction of the distal fibula within the tibial incisura before screw placement—malreduction is a critical pitfall 3
• Avoid using obliquely placed reduction clamps during closed reduction, as this can cause syndesmotic malreduction 3
• Verify reduction with intraoperative fluoroscopy and consider postoperative CT scan within 2 weeks to confirm accurate syndesmotic reduction 3

Proximal Fibular Fracture Management

• The proximal fibular fracture does not require direct internal fixation in most cases 1
• However, in patients with critically destabilized ankles (large body habitus, severe displacement), consider open reduction and internal fixation of the proximal fibula to prevent syndesmotic malreduction 3
• Worsening alignment of the proximal fibular fracture on intraoperative fluoroscopy should alert you to possible syndesmotic malreduction 3

Conservative Treatment Considerations

While surgery is the standard recommendation, conservative treatment with short leg cast immobilization may be feasible in highly select cases with:

• Minimal syndesmotic separation (<2-3mm)
• Intact lateral collateral ligaments
• Patient refusal of surgery
• Close radiographic follow-up capability 2, 4

Eight weeks of cast immobilization can yield excellent outcomes in stable injuries with only partial syndesmotic disruption 2, 4. However, this approach requires careful patient selection and is more stable than traditionally assumed only when syndesmotic disruption is partial 4.

Critical Pitfalls to Avoid

• Overemphasis on minimally invasive techniques can lead to inadequate reduction assessment—consider partial syndesmotic exposure in complex cases 3
• Intraoperative fluoroscopy and standard radiographs may miss syndesmotic malreduction—obtain postoperative CT if any concern exists 3
• Failure to examine neighboring joints can result in missed diagnosis—always perform physical examination extending two joints proximal and distal 2
• Nerve injuries can occur from fracture fragments, hematoma, or surgical approach—be aware of potential deep and superficial peroneal nerve involvement 5

Expected Outcomes

With appropriate treatment, 89% of patients achieve good or excellent outcomes, with only 11% experiencing fair or poor results 1. Complete healing typically occurs with full range of motion restoration and no post-traumatic arthritis when properly managed 2.