Перелом Мейссоннёва: описание, классификация и лечение

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament of the ankle. This type of injury can be difficult to detect. The Maisonneuve fracture is typically a result of excessive, external rotative force being applied to the deltoid and syndesmotic ligaments. Due to this, the Maisonneuve fracture is described as a pronation external rotation injury according to the Lauge Hansen classification system. It is also classified as a Type C ankle fracture according to the Danis Weber classification system. The Maisonneuve fracture is similar to the Galeazzi fracture in the sense that there is an important ligamentous disruption in association with the fracture. The fracture is named after the surgeon Jules Germain François Maisonneuve.

Forceful, external rotation of the ankle joint is the main cause of a Maisonneuve fracture. Engaging in high intensity sports or falling over can increase the risk of tearing the deltoid ligament or cause an avulsion fracture of the medial malleolus from external rotation of the foot.

Common symptoms of a Maisonneuve fracture are pain, swelling, tenderness, and bruising around the ankle joint and inferior (or distal) tibiofibular joint. More specifically, as a pronation external rotation injury, pain during external rotation of the ankle joint is expected. Additionally, there is a reduced range of motion of the foot and an inability to weight bear due to ankle pain. Damage to the deltoid ligament or interosseous membrane can cause haemorrhaging around the surrounding tissues, resulting in a localised oedema. If a Maisonneuve fracture is left untreated, instability of the tibiotalar joint and deltoid ligament can cause a valgus deformity of the ankle. This leaves the ankle joint in a state of chronic pronation, characterised by a protrusion of the medial malleolus into the subcutaneous tissue. Forceful, external rotation of the ankle joint results in the tearing of the deep deltoid ligament and/or an avulsion fracture of the medial malleolus. The ankle mortise is subjected to excessive torque, rupturing the syndesmotic ligaments and anteromedial ankle joint capsule. Rotative energy is transferred upwards along the interosseous membrane, damaging it in the process. The force results in a spiral, sometimes an oblique, fracture at the neck of the proximal fibula. In cases where the anterior aspect of the tibiofibular syndesmosis can resist mechanical stress, only an oblique fracture of the lateral malleolus is produced. Diastasis of the lateral malleolus may also occur, in which it is posterolaterally displaced from the tibia. Stress radiographs of the ankle are used to assess the integrity of the deltoid ligament and tibiofibular syndesmosis. Based on several clinical results, syndesmotic screws are recommended to be fixed at least 1 centimetre proximal to the tibiofibular syndesmosis or 4 to 6 centimetres proximal to the tibiotalar joint line. Cadaveric analyses, from a comparative study published in Foot & Ankle International in 1997, suggest that screw fixation at 2 centimetres proximal to the tibiotalar joint line is also adequate. Biodegradable implants such as bioabsorbable screws, which do not require postoperative removal, may be used as an alternative to metallic hardware. However, biodegradable implants still limit rotation of the ankle and dorsiflexion of the foot. Immobilisation techniques such as casting are often paired with non weight bearing precautions. Gradually, physiotherapy rehabilitation programs allow patients to weight bear after at least 8 weeks of postoperative casting. Orthopaedic surgeons also administer these non operative treatments for cases where the medial malleolus remains intact.

Open reduction surgery is typically not performed at the level of the proximal fibula, as dissection near the proximal end may risk severing the common peroneal nerve. Instead, reducing the proximal fibula at the level of the distal tibiofibular syndesmosis is recommended. A hook test is performed, using a curved hook, to assess the stability of the fibula. If instability is detected, further distraction of the fibula can be done to repair the full bone. The fibula can then be guided into the fibular notch located on the tibia, effectively restoring its length. Internal rotation of the foot may then be used to correct anatomical alignment. Following open reduction, internal fixation is usually performed to stabilise the ankle mortise. To account for the distal fibula being slightly posterior to the distal tibia, drill holes are angled at 30° from the anteromedial aspect of the tibia to the posterolateral aspect of the fibula. Trans syndesmotic screws can be inserted in this way to ensure tibia fixation. Additional supra syndesmotic screws may be temporarily inserted, for approximately 3 to 6 months, if instability is still present after fibular reduction. To reduce the fibula and restore the ankle mortise to its proper anatomical configuration, partial dorsiflexion of the foot is maintained prior to intraoperative screw fixation. This is because, in a neutral or maximally dorsiflexed position of the foot, the trochlear surface of the talus may reduce maximal postoperative dorsiflexion due to rigidity after screw fixation. Assessing the severity of syndesmotic lesions can be performed with fluoroscopic screening. Guidance under fluoroscopy can also assist with syndesmotic screw fixation. Restoration of the anteromedial joint capsule of the ankle can be achieved with suturing techniques.

Closed reduction surgery requires no dissection or incisions being made into the leg to operate. It is most commonly applied in cases where the Maisonneuve fracture has only extensively damaged the anterior portion of the syndesmotic ligaments. That is, the posterior hinge of the ankle is still stable, and the foot can be internally rotated using traction to restore fibular bone length. Long leg casting or short leg casting is applied postoperatively to maintain this alignment. It is generally recommended that medial malleolar fractures do not require surgical intervention if closed reduction is sufficient enough for the restoration of bone length. Otherwise, large medial malleolar fractures can be fixed using trans syndesmotic screws, figure of 8 wires, or Kirschner wires. For smaller medial malleolar fractures, repair with a wire tension band is sufficient enough.

Incorrectly positioned screws can potentially make contact with articular surfaces, which can cause calcification around the affected area. Screw breakage can also cause pain in these areas. Postoperative hardware removal can cause problems such as infection, joint rigidity, or diastasis if fixation was not sufficiently long enough. In areas where residual stiffness has persisted, patients may report feeling pain or a mild aching sensation. Generally, it is recommended that hardware removal should be done anywhere from 6 weeks to 12 weeks after internal fixation to allow the tibiofibular syndesmosis to properly heal. Syndesmotic screws should be removed prior to rehabilitative training; bearing weight without prior hardware removal may result in ankle stiffness due to reduced dorsiflexion of the foot and potential screw breakage.

Postoperative follow ups are done to ensure that treatment has produced satisfactory results, such as checking if malreduction of any of the associated structures in a Maisonneuve fracture has occurred. Follow ups may be performed from 6 months to 2 years after the surgery and are applicable for both non operative and operative treatments.

Exact incidence rates are unknown, but it is believed that the Maisonneuve fracture accounts for 5% of all ankle injuries treated in surgery. The Maisonneuve fracture has been reported in patients as young as 17–19 years old, and up to 42–70 years old. The injury is mostly seen in male patients. A clinical article on studies conducted between 2014 and 2019, published in Orthopaedic Surgery in 2020, reported that 78% of admitted patients with a Maisonneuve fracture were male. Sporting injuries are the most common risk factor of causing a Maisonneuve fracture. Sport related injuries were associated with 50% of all Maisonneuve fracture cases examined in one clinical study. Comorbidity of the Maisonneuve fracture and other health conditions, such as hypertension, obesity, and psoriatic arthritis, have been identified in patient medical histories.