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Pronation External Rotation
Hallmark:
- Spiral fracture of the fibula ABOVE the syndesmosis
Stage I
- Rupture of the deltoid ligament OR
- Fracture of the medial malleolous
Stage II
- Rupture of the anterior syndesmosis including the interosseous membrane with or without fracture
Stage III
- Fracture of the fibula ABOVE the syndesmosis
Stage IV
- Rupture of the posterior tibio-fibular ligament OR
- Fracture of the posterior malleolous
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Maisonneuve fracture
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Short, spiral fracture
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Maisonneuve fractures only account for <25% of all the PER injuries.
Fracture is routinely missed because we rarely order long leg xrays.
The fracture may not be tender initially, so don't be fooled by a negative squeeze test.
These fractures never need to be fixated, because the fracture is protected by so much muscle mass.
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Typical midshaft fracture
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Often these fractures will have butterfly fragments or be comminuted
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Syndesmotic screw not necessary in this case
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Avoid plating when fracture is midshaft or higher
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That's a long plate!
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That is a nice butterfly fragment
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Worst dislocations of all the fracture patterns
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Often see significant cartilage damage within the joint
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Fix the medial malleolar fracture first to help determine fibular length
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