Above and below…
Presentation
A 32 year old male, with past medical history of nephrolithiasis, is brought in by ambulance as a level B trauma activation for evaluation after MVA on motorcycle. Per EMS report, the patient was coming out of gas station onto the main road, when his bike fell leftwards. The patient was under the bike after the fall and was wearing a helmet. EMS notes the majority of damage to the helmet was on the nasal region. Loss of consciousness was reported at the scene and the patient does not remember details of the accident. The patient complains of right shoulder pain and facial pain.
On initial presentation, the patient was hemodynamically stable, was protecting his airway, and had clear breath sounds bilaterally with a normal oxygen saturation. His GCS is 15.
Physical Exam
General: Alert, in no acute cardiopulmonary distress. Moving air well.
Mental Status: Oriented to person, place and time. Normal affect. GCS15
Head: Normocephalic. Atraumatic. Scalp palpated without lacerations/deformity
Eyes: Pupils are 3 mm equal, round and reactive to light. Extraocular muscles intact.
Ear, Nose and Throat: Oropharynx clear, mucous membranes moist. Tongue/uvula midline. Midface and palate stable. No malocclusion of jaw. Trachea midline. TMs clear bilaterally. Trachea midline. Blood in the nares, no active bleeding noted.
Neck: Supple, Full range of motion. No step off or tenderness. No crepitus
Chest: Chest expansion equal and symmetric bilaterally, no tenderness, crepitus, ecchymosis or deformity noted
Respiratory: Regular rate and effort, clear to auscultation
Cardiovascular: Regular rate and rhythm. No rubs or murmurs
Gastrointestinal: Abdomen soft, non-tender, non-distended. No hepatosplenomegaly.
Neurologic: No focal neurological deficits. Moves all extremities spontaneously. Sensation intact bilaterally.
Skin: Superficial abrasions bilateral knees, and bilateral elbows.
Musculoskeletal: No gross deformities. Normal range of motion. Pelvis stable.
Back: No tenderness, no step offs noted of C/T/L spine. Normal ROM
Extremities: Warm, DP and radial pulses 2+ bilaterally, cap refill <2 secs, neurovasc intact, TTP left dorsal area of left foot, TTP right shoulder
Patient stripped & log rolled, anterior & posterior skin surfaces examined
Digital rectal exam deferred
Workup/ED Course
Imaging results:
-CT head: no evidence of acute intracranial abnormalities.
-CT cervical spine: no evidence of fracture
-CT lumbar spine: no evidence of fracture
-CT thoracic spine: no evidence of fracture
-CT chest/abdomen/pelvis: no acute findings
-Chest x-ray: no acute disease.
-Pelvis x-ray: no fracture.
-R wrist/hand x-rays: no evidence of fracture.
-L foot x rays: Comminuted fracture mildly displaced second and third metatarsals. Possible Nondisplaced fracture at the base of the fourth metatarsal.
-L tibula/fibula x-rays : comminuted nondisplaced proximal fibular fracture mortise of ankle is subluxed medially. No tibia fracture seen.
-L ankle x-rays: Moderate widening of the mortise medially; no fracture seen.
ED Course
The patient’s cervical spine was assessed. Patient complained of no further pain or tenderness at C-spine, and cervical collar was removed.
Per trauma note, “Patient was found to have a left fibular fracture and second and third metatarsal fracture.”
Orthopedic surgery was consulted. Recommendations: “Hard soled shoe and weightbearing as tolerated. Okay for patient to follow-up outpatient if able to mobilize.”
A road test was attempted in the ED. However, the patient could not bear weight and complained of excruciating pain. The patient was admitted to the trauma service for pain control and further orthopedic surgery evaluation.
The patient was diagnosed with an orthopedic finding the next day, do you see what was found?
XR Left ankle- Oblique view
XR L tibula/fibula- AP view
Outcome/Discussion
This patient’s imaging findings are consistent with a Maisonneuve fracture, which is a “fracture of the proximal third of the fibula with associated fracture and/or disruption of the interosseous membrane and distal tibiofibular syndesmosis at the ankle.” While the diagnosis of “Maisonneuve fracture” was not noted in the radiology X-ray interpretations, the findings of a proximal fibula fracture, widened mortise, and the patient’s inability to bear weight should raise a high suspicion for this diagnosis.
The next day, orthopedic surgery took the patient to the OR for open reduction and internal fixation of the left ankle syndesmosis. He was later discharged with recommendations for outpatient follow up.
While patients often do not require admission for this injury, patients should be placed in a posterior long leg splint and made nonweightbearing, with outpatient orthopedic surgery follow up within one week. Urgent orthopedic consultation should be sought if there are concerns for neurovascular injury or compartment syndrome.
Reference: Ring Joshua, Shaheen Stephen. Maisonneuve Fracture. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recTZd3hAnrPgxDR3/Maisonneuve-Fracture#h.2vbslhbhi6tp. Updated April 29, 2022. Accessed January 2, 2024.
Takeaway Points
Know presentations of commonly missed orthopedic conditions- many diagnoses require combining two X-ray series together!
Trauma patients often have distracting injuries and may not have a reliable reports of area of pain. Thorough secondary surveys and tertiary exams should be performed.
Review all images personally before clearing patients.
If patients were ambulatory prior to arrival, have a high suspicion for occult injury if patients are unable to bear weight.
Accurate physical exams and imaging results should be communicated for every consult.
Always evaluate “above and below” the site of an orthopedic injury!
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