Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Township, MI
Last reviewed: May 2026
| Feature | Maisonneuve Fracture | Standard Lateral Ankle Sprain | Bimalleolar Fracture |
|---|---|---|---|
| Fibula fracture location | Proximal fibula (upper 1/3 or near fibular head) | No fracture | Distal fibula at or near ankle joint |
| Ankle X-ray appearance | Often appears normal or shows only medial/posterior malleolus fracture — proximal fibula NOT on standard ankle film | Normal X-ray | Fracture clearly visible at ankle |
| Syndesmosis status | Disrupted — the entire interosseous membrane and syndesmotic ligaments tear as energy travels proximally | Intact or partially sprained | Variable; may be disrupted |
| Deltoid ligament | Often torn (medial ankle); may see medial clear space widening | Usually intact | May be torn or medial malleolus fractured |
| Stability | Unstable — syndesmosis disruption makes ankle mortise unstable | Stable | Variable; often unstable |
| Treatment | Usually surgical — syndesmotic screw or TightRope fixation to restore mortise stability | Conservative — RICE, brace, PT | Variable; ORIF for displaced/unstable |
| Diagnostic Step | What It Reveals | Why Critical |
|---|---|---|
| Full-length fibula X-ray (mortise + AP lower leg) | Proximal fibula fracture that is missed on ankle-only films | Standard ankle X-rays do not include the proximal fibula — must specifically request full-leg view |
| Ankle mortise view | Medial clear space widening (>4mm); lateral talar shift; posterior malleolus fracture | Mortise widening indicates syndesmotic disruption even without obvious fracture |
| Squeeze test (clinical) | Pain at ankle when fibula compressed at mid-calf | Positive squeeze test indicates interosseous membrane disruption; prompts proximal fibula imaging |
| External rotation stress test | Ankle instability and pain with external rotation of foot | Assesses syndesmotic integrity; positive test correlates with need for surgical stabilization |
| CT scan | Posterior malleolus fracture size; fracture pattern; syndesmotic assessment | Better characterizes fracture for surgical planning; identifies posterior malleolus involvement |
Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatrist | Balance Foot & Ankle, Michigan | 5,000+ patients/year
Why Maisonneuve Fractures Are Missed
The Maisonneuve fracture mechanism is a severe external rotation force that spirals from the ankle up the fibula. It disrupts the deltoid ligament (medial) or fractures the medial malleolus, then tears through the entire syndesmosis, with the fracture exiting at the proximal fibula — far above the ankle. Ankle X-rays may show only mild widening or appear near-normal, leading to incorrect diagnosis as a simple ankle sprain. The key is palpating the entire fibula — proximal fibula tenderness after an ankle injury mandates full-length fibula X-ray.
Components of the Injury
1. Medial ankle injury (deltoid ligament tear or medial malleolus fracture). 2. Complete syndesmotic disruption (AITFL, PITFL, interosseous membrane). 3. Proximal fibula fracture (at or above the fibular neck). This triad creates a completely unstable ankle mortise despite the fracture being remote from the ankle.
Diagnosis
Full-length fibula X-rays when proximal tenderness is present. Stress X-rays of the ankle show mortise widening. CT of the ankle and fibula characterizes all components. Any ankle injury with significant medial-side pain (deltoid region) should prompt suspicion for Maisonneuve.
Treatment
Surgical fixation of the syndesmosis (trans-syndesmotic screws or suture buttons) restores ankle mortise stability. The proximal fibula fracture typically does not require fixation. Medial malleolus fracture if present is fixed concurrently. Recovery: 6–12 weeks non-weight-bearing, then progressive rehabilitation over 3–6 months.
FAQs
Can a Maisonneuve fracture be treated without surgery? Rarely — because the complete syndesmotic disruption creates an unstable mortise that cannot be reliably maintained in a cast. Most cases require surgical stabilization to prevent long-term ankle widening and post-traumatic arthritis.
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Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.