Transcript 30 yo male presents with ankle pain

Alyson Wattai, PA-S
2012
 CCX: Right ankle pain x 1 hour
 HPI: 30 yo male presented to Towanda ED with right
ankle pain x 1 hour. described as constant sharp pain,
aggravated with movement and weight bearing, alleviated
with rest and elevation, moderate 6/10 in pain severity,
10/10 being previous injury to arm. Pain began after workrelated injury, patient reported having slipped on icy
surface and “twisted ankle”. No associated symptoms
of ankle edema, erythema, or ecchymosis. He denied
fever, chills, weakness, history of broken bones, DVT,
cellulitis, gout, anticoagulation medication, ankle
sprain/strain, or Achilles tendon tear.
 Allergies: NKDA
 Medications: None.
 General – AAOx3, mild distress complaining of ankle pain
 Vitals – Ht. 68 in. Wt. 195 lbs. T 98.5 F, BP 134/68, Pulse 94 RR 18,
SaO2 99% on room air
 Cardiac- RRR, no M/G/R
 Pulmonary – CTA B/L, no wheeze, rales or rhonchi
 Musculoskeletal –
 Right ankle – no sign of obvious deformity, no edema, erythemaa or
ecchymosis. Tender to palpation at level of bilateral malleloi and distal
tibia, limited ROM 5% ankle flexion/extension/inversion/eversion
compared to left ankle.
 Left ankle – Negative for edema, erythema, ecchymosis, tenderness to
palpation. Full ROM with flex/ext/inver/ever.
 Skin – No ecchymosis or lesions
 Vasc – Capilary refill < 2 seconds bilaterally
 Neuro – Light touch and dull vs. sharp sensation intact B/L in LE
 Deltoid ligament sprain
 Lateral ligament ankle sprain
 Ankle muscle strain
 Malleolar or talar ankle fracture
 Compartment syndrome
 Tibia or fibula fracture
 Maisonneuve fracture
 Achilles tendon rupture
 ED physician ordered AP and lateral views of right
ankle
 At this point, patient was diagnosed with non-
displaced distal tibial fracture and Orthopaedics was
consulted surgical repair.
 Dr. Nazar’s first question – where are the other
images?
 AP/Lateral views of lower extremity
 Patient was discharged from Towanda ED with transfer
to EMHS for emergency surgery to reduce tibia/fibula
fractures.
 Given Percocet 5/325 mg TAB 1-2 TAB PO q4H PRN
pain
 Patient presented to EMHS in ankle splint with
complaint of significant ankle pain.

Maisonneuve fracture was first classified in 1840 by Dr. Jacques Maisonneuve as a “proximal fibular fracture associataed
with an injury to the medial ankle structures” (Levy, B.A., Vogt, K.J., Herrera, D.A., Cole, P.A.) This particular type of
ankle fracture accounts for 5-7% of all ankle fractures. ((Demetriades, D., Newton, E.). The mechanism of injury
attributed to this type of fracture involves forceful external rotation of an adducted or inverted foot (Levy, B.A., Vogt,
K.J., Herrera, D.A., Cole, P.A.). The transfer of force from the impact of injury travels up through the planted foot to
disrupt the space between tibia and fibula in interosseaous membrane and exits in proximal fibula area. This provides
the explanation for proximal fibula fractures with secondary to malleolar or tibial fractures with great force radiating
through interosseous membrane and exiting pushing proximal fibular bone until it fractures. The diagnostic key to
this type of fracture is the multiple sites of fracture or ligament disruption. Classification of maisonneuve fracture is
based on presence of medial malleolar fracture, tear of deltoid ligament on medial aspect of ankle, tear of interosesous
membrane between tibia and fibula, as well as proximal fibula fracture (Demetriades, D., Newton, E.). Patients
typically present with significant ankle pain with weight bearing and malleolar tenderness on palpation during
physical examination. Due to this presentation, the proximal fibula fracture may be missed based on clinical diagnosis
alone. Plain AP and Lateral x-rays of both ankle and lower extremity to view the ankle joint as well as proximal and
distal tibia and fibula support diagnosis. Treatment for maisonneuve fractures involves open reduction and internal
fixation (ORIF) to mend malleolar fracture or decrease interossesous space between the tibia and fibula. This is done
by using 3.5 or 4.5 cm threaded screws into the tibia and fibula to anchor the joint space. (Carr, J.) No reduction is
needed for proximal fibular fracture in majority of cases because the fracture is usually nondisplaced. Significant fibula
fractures resulting in displaced or open fractures may also need to be reduced and fixated with plate and screws.
The patient incorporated into this case report was initially diagnosed with distal tibia fracture and consulted to
orthopediacs for surgical ORIF. Second order for xrays was requested to view lower extremity which idenitified
associated proximal fibular fracture.
 Mechanism of injury:
 External rotation of an adducted or inverted foot
 Diagnosis made by x-rays of ankle and lower extremity
 Most common problem in diagnosing this type of
fracture is the failure to order BOTH ankle and lower
extremity x-rays to look for proximal fibular fracture.
 Maisonneuve fractures are classified as Type C ankle
fracture under Danis-Weber classification
 Danis-Weber classification
 Type A – fibular fracture distal to ankle fracture
 Type B – fibular fracture parallel to ankle fracture
 Type C – fibular fracture proximal to ankle fracture
 Maisonneuve criteria:
 Diagnosis of Maisonneuve fracture includes following
three x-ray findings:
 Medial malleolar fracture OR deltoid ligament tear
 Stretched or torn interosseus membrane
 Fibula fracture
 Surgery of choice: ORIF of ankle joint at medial
mallelus
 Stabilize main weight bearing bone  tibia with metal
plate and screws
 Reduction of proximal fibula usually not necessary
because of the nature of the fracture (non-displaced).
Significant fibular fractures may also need to be reduced
if displaced.
 ORIF of right distal tibia
 3 threaded screws were placed in tibia
 12 hole straight 4.5 mm DCP with 12 screws
 No fixation of proximal fibula
 Immobilization
 Right lower extremity placed in leg immobilizer
 POD #4 – fiberglass cast to right lower extremity from
toes to proximal tibia/fibula
 Medications
 Medications
 Pain management - Percocet 5/325 mg PO 10 mg 1 TAB QID
 DVT prophylaxis – Aspirin 325 mg PO QHS until follow up
appointment where PT/PT INR will be re-checked
 Inflammation – Ibuprofen 600 mg PO QID x 7 days
 Patient education
 Patient instructed of side effects of medications.
 Patient told to use crutches with non-weight bearing on right
leg. Also, educated on risk and signs of DVT with leg
immobilized.
 Follow up on November 12, 2012 (in four days) to check for
infection at incision site and address pain level. Instructed
to go to ED with signs of infection, fever, severe leg pain.
 Teaching points:
 ALWAYS examine the joint above and below the area of
pain on physical exam with palpation in order to check
for tenderness in other areas that patient may not even
be aware.
 Order x-ray view of injured joint PLUS joint above and
below because patient may not even have tenderness in
a joint that may have minimal/moderate fracture.
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Levy, B.A., Vogt, K.J., Herrera, D.A., Cole, P.A. (2006). Maisonneuve Fracture Equivalent with Proximal Tibiofibular
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