Figure 8.1
AP, mortise, and lateral radiographs of the injury
Diagnostic Testing and Treatment Considerations
Medial clear space widening greater than 5 mm indicates a tear of the deltoid ligament with accompanying disruption of the distal tibiofibular syndesmosis, which should be surgically stabilized. An external rotation stress radiograph was performed to assess syndesmotic integrity, and frank widening of the ankle mortise was observed (Fig. 8.2).
Figure 8.2
External rotation stress view demonstrates widening of the syndesmosis and medial clear space
Treatment and Timing of Surgery
At initial evaluation, the patient was placed into a well-padded, short-leg AO splint, with radiographic confirmation of reduction of the ankle mortise. He was instructed to remain nonweightbearing on that extremity and maintain elevation of the limb as much as possible. Surgery was scheduled few days after injury (7 days) to allow decrease of swelling and improvement of the condition of the soft tissues.
Surgical Tact
Surgical intervention for Maisonneuve injuries is focused on reduction and fixation of the syndesmosis [1, 2]. This is generally accomplished with one or two 3.5 mm tri- or quadri-cortical screws. The distal screw should be placed approximately 2 cm proximal to the plafond, and the second screw should be placed 1–2 cm proximal to that. While there is debate in the literature about the number and size of screws as well as whether they should extend to the fourth cortex [3], the authors prefer a minimum of two screws of 3.5 mm diameter (tri- or quadri-cortical) for these syndesmotic injuries.
A short plate may be used to disperse the forces exerted by the screws and help with centralizing the screws on the fibula.
The proximal shaft fibula fracture does not generally require fixation unless significantly shortened and hindering syndesmosis reduction [1, 2, 4]. If needed, a small incision may be made over the fibula fracture site and length regained using a clamp before syndesmosis fixation.
Technique of Open Reduction and Internal Fixation
To accommodate the plate, an incision of approximately 3 cm was made over the fibula, and a lateral approach was made. The three-hole one-third tubular plate was centered on the fibula, and the foot was dorsiflexed. Using a large pointed reduction clamp with one tine on the fibula through the middle hole of the plate and the other tine medially on the tibia, the syndesmosis was reduced. This reduction was confirmed radiographically, as seen by normal medial and syndesmosis clear spaces. All four cortices were drilled with a 2.5 mm drill, and two tricortical 3.5 mm screws were placed (Fig. 8.3).
