Alyson Wattai, PA-S

2012

30 yo male presents with ankle pain

CCX: Right ankle pain x 1 hourHPI: 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 work-related 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: NKDAMedications: None.

Initial Presentation

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

Physical Exam

Deltoid ligament sprainLateral ligament ankle sprainAnkle muscle strainMalleolar or talar ankle fractureCompartment syndromeTibia or fibula fractureMaisonneuve fractureAchilles tendon rupture

Differential Diagnosis

ED physician ordered AP and lateral views of right ankle

ED Orders

AP View 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

Consult Orthopaedics

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.

Transfer to EMHS

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.

Abstract

Mechanism of injury: External rotation of an adducted or inverted

footDiagnosis made by x-rays of ankle and lower

extremityMost 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

Maisonneuve fractures are classified as Type C ankle fracture under Danis-Weber classificationDanis-Weber classification

Type A – fibular fracture distal to ankle fractureType B – fibular fracture parallel to ankle fractureType 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 tearStretched or torn interosseus membrane Fibula fracture

Classification of Maisonneuve Fracture

X-rays of Maisonneuve Fracture

Surgery of choice: ORIF of ankle joint at medial mallelus Stabilize main weight bearing bone tibia with

metal plate and screwsReduction 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.

Treatment for Maisonneuve Fracture

ORIF of right distal tibia3 threaded screws were placed in tibia12 hole straight 4.5 mm DCP with 12 screwsNo fixation of proximal fibula

ImmobilizationRight lower extremity placed in leg immobilizerPOD #4 – fiberglass cast to right lower

extremity from toes to proximal tibia/fibula Medications

Patient’s treatment

Post-Op X-rays

MedicationsPain management - Percocet 5/325 mg PO 10 mg 1 TAB QIDDVT 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.

Discharge Instructions

POD #13 X-rays

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.

Take Home Messages

Carr, J. (2008). Brown: Skeletal trauma. (4th ed.). Philadelphia: W.B. Saunders Company.

Demetriades, D., Newton, E. (2011). Color Atlas of Emergency Trauma. (2nd ed.). Cambridge: Cambridge University Press.

 Levy, B.A., Vogt, K.J., Herrera, D.A., Cole, P.A. (2006). Maisonneuve Fracture Equivalent with

Proximal Tibiofibular Dislocation: A Case Report and Literature Review. Journal of Bone & Joint Surgery, 88(5):1111-1116 doi: 10.2106/JBJS.E.00954

 Magee, D. (2008). Orthopedic physical assessment. (5th ed.). St. Louis: Saunders. Mattu, A., Chanmugam, A., & Tibbles, C. (2010). Avoiding common errors in the emergency

department. Philadelphia: Lippincott Williams & Wilkins. Rockwood, C.A., Green, D. (2010). Rockwood and Green’s Fractures in Adults: Sect. III. Spine. 41.

Principles of spine trauma care. Lippincott Williams & Wilkins

Wiss, D. (2006). Master techniques in orthopaedic surgery. (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.

Wolfson, A. (2010). Harwood-nuss' clinical practice of emergency medicine. (5th ed.). Philadelphia: Lippincott Williams & Wilkins.

References