Presentation
Mechanical fall with twisting and inversion injury of the left ankle.
Patient Data
Fracture-dislocation of the tibiotalar joint, with anterolateral dislocation of the tibia relative to the talar dome. Comminuted fracture of the distal fibula shaft. Displaced fracture of the medial malleolus, with the fracture fragment lying medial to the talar dome. Non-displaced fracture of the lateral malleolus.
Post-reduction radiographs obtained through plaster also demonstrate a minimally displaced fracture of the posterior malleolus. There is widening of the tibiofibular syndesmosis.
Internal fixation performed through a hindfoot nail fusion (tibio-talar calcaneal arthrodesis) of the ankle joint. Minimally displaced proximal fibula shaft fracture noted. Total knee arthroplasty noted.
Case Discussion
Trimalleolar fractures are unstable fractures often associated with significant ligamentous injury and almost always require internal fixation.
In this case, the proximal fibula shaft (diaphysis) fracture was not detected until imaging of the hindfoot nail fusion. The addition of the proximal fibula shaft fracture to the radiological findings above would classify this pattern of injury as a Maisonneuve fracture (high Weber C). As such, clinical examination of the proximal lower leg, along with a knee radiograph if indicated, should always be performed in a suspected distal tibiofibular syndesmotic injury. This can be performed through the syndesmosis squeeze test.
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