Achilles tendon rupture. Occurrence with a closed ankle fracture

A 61-year-old man, involved in an automobile accident, sustained a complete Achilles tendon rupture with an ipsilateral, closed slightly displaced medial malleolus ankle fracture. The tendon rupture was not diagnosed before operation but was recognized at the time of open reduction of the ankle. This rare combination of injuries was apparently secondary to hyperdorsiflexion of the foot. The tendon rupture would have been missed had surgical treatment not been required. Unrecognized tendon ruptures associated with closed ankle fractures may be a cause of residual ankle-foot weakness, pain, loss of motion, or a combination thereof.     

Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report

Although extensor pollicis longus tendon ruptures have been noted as a complication of distal radius fractures, flexor tendon ruptures in association with acute fractures of the distal radius are rare. We report a rupture of the flexor carpi radialis tendon as a complication of an acute distal radius fracture that was discovered during operative management of the fracture.     

Displaced malleolar fractures associated with spiral fractures of the tibial shaft

A displaced fracture of the lateral malleolus, of the posterior tibial margin (posterior malleolus), or of both requiring open reduction and internal fixation was observed in association with ipsilateral spiral tibial shaft fracture in five patients. The malleolus fracture components all were managed using AO (ASIF) instrumentation. The tibial shaft fracture was treated nonoperatively in three patients and with interfragmentary screw fixation in two with more severe initial displacement. The bony healing of all fractures was uneventful. These combined injuries amounted to 0.9% of all admitted tibial shaft fractures and 3.9% of those with spiral configuration. An associated displaced malleolar fracture in tibial shaft fractures, sometimes even indiscernible in the anteroposterior view, may be overlooked unless roentgenograms are focused on the ankle joint. Examination of the joints above and below the fracture is of particular importance in clinics advocating functional treatment of tibial shaft fractures.     

Traumatic rupture of the tibialis posterior tendon after closed ankle fractures: A report of two cases

Summary We report two cases of posttraumatic complete rupture of the tibialis posterior tendon that occurred during closed fractures of the medial malleolus. A low located fracture of the medial malleolus and an intense forced pronation, external rotation and dorsiflexion of the foot have been involved in the physiopathogeny of that rupture. At each intervention, the tibialis posterior tendon had been disrupted above the upper edge of the groove of the medial retinaculum of the ankle. After tendon suture concomitant with osteosynthesis, the evolution was favourable. Failing to appreciate this tendon rupture, although rare, can be at the origin of residual pains and a functional deficit of foot reversion.     

Fracture of the ankle associated with rupture of the Achilles tendon: case report and review of the literature

SUMMARY: A thirty-five-year-old man fell two meters from a ladder and sustained a closed fracture of the medial malleolus with an ipsilateral complete Achilles tendon rupture. The Achilles tendon rupture was diagnosed by means of the patient's complaints and physical findings. The ankle fracture was diagnosed incidentally on routine radiographs. Such a combination of injuries has been reported infrequently in the literature, and striking similarities have been described in the mechanism of injury and fracture pattern. Remarkably, in three of four reports the combined injury was initially misdiagnosed.     

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.     

Ankle Fracture Associated With Rupture of the Achilles Tendon: Case Report and Review of the Literature

Solitary ankle fracture or Achilles Tendon (AT) rupture might not be an uncommon injury. However, concomitant ipsilateral ankle fracture with AT rupture is rare. The present report discusses this rare combination. A 30-year-old female had fallen while rock climbing and sustained a closed fracture of the medial malleolus with an ipsilateral complete AT rupture. Most of the reported cases had similar patterns, not only in terms of history, but also in terms of a similar fracture pattern. This rare combination of orthopedic injuries tends to occur when an abrupt excessive force is applied to the forefoot, with subsequent ankle hyperextension or hindfoot inversion. Imaging studies are useful both for confirming the injuries and for medicolegal and research purposes. Definitive treatment of the AT rupture is usually surgical in young active patients. Concomitant malleolar fractures can be managed conservatively or surgically, depending on the fracture configuration and degree of displacement. The importance of a thorough clinical examination in assessing the musculoskeletal and neurovascular structures in ankle injuries cannot be overemphasized. Knowledge of these injury patterns is crucial to reducing the incidence of residual morbidity such as ankle and foot weakness and loss of motion.     

外踝骨折后三角韧带损伤程度的X线与MRI比较研究

目的 探讨急性外踝骨折后X线片与MRI评价三角韧带损伤程度的影像学诊断价值.方法 总结医院PACS系统中41例急性外踝骨折(排除合并内踝骨折病例)的X线片和MR影像资料,于踝穴位X线片上测量踝内侧间隙(medial clear space,MCS)宽度,应用MR影像对三角韧带深层(胫距后韧带)及浅层(胫弹簧韧带和胫跟韧带)损伤进行评价分级,统计分析MCS与三角韧带损伤程度的相关性;分别记录以X线片和MRI为参考的全部病例Lauge-Hansen分型.结果 MCS与三角韧带损伤等级呈正相关,经ROC曲线分析,判定三角韧带完全断裂(深层和浅层同时)的MCS最适临界值和深层单独完全断裂的MCS最适临界值均为7.85 mm;而判断浅层完全断裂的MCS最适临界值是6.48mm;以MRI为金标准,所有病例Lauge-Hansen分型的准确性为58.5％,但预测三角韧带断裂的准确性达82.9％,只是难以区分深层和(或)浅层断裂.结论 急性外踝骨折后即使未出现内踝骨折,也常伴有三角韧带损伤,X线片仍是踝关节骨折评价的首选检查技术,而MR检查是明确三角韧带损伤程度的敏感辅助检查技术.     

Lateral subtalar dislocation associated with a lateral malleolus and a nutcracker cuboid fracture: Case report of a rare pattern of lesion

Introduction and importanceCombined fracture of the lateral malleolus and cuboid due to a lateral subtalar dislocation is an uncommon injury. Literature is scarce on this trauma association. To the best of our knowledge, this represents a new lesion pattern. Hereby we describe its mechanism, management and outcomes.Case presentationWe report a case of a 58-year-old woman, who fell from the stairs and presented with pain and an acute deformity of the left foot and ankle. Plain radiographs and CT scan revealed a lateral subtalar dislocation with a lateral malleolus and cuboid fractures. After a failed closed reduction, the patient underwent an open reduction and fixation of the talonavicular joint. An external fixator was applied to address the cuboid fracture. The lateral malleolus was treated conservatively with 5.5 weeks of immobilization. At 38 months of follow-up, the patient scored 87% on the AOFAS ankle-hindfoot scale and returned to normal daily activity. Radiographs demonstrate signs of posttraumatic arthritis at the subtalar and talonavicular joints.Clinical discussionAfter reduction of the lateral subtalar dislocation, addressing the nutcracker cuboid fracture was essential, since it can contribute to a flatfoot deformity. Although the patient progressed to posttraumatic arthritis, the sequelae are usually well tolerated and a good outcome was achieved.ConclusionThe rarity of this pattern of lesion is related to the necessary multidirectional forces. Correct management of the associated fractures is essential.Our study demonstrates a new lesion pattern of lateral subtalar dislocations, its mechanism, management and outcomes.     

Achilles tendon rupture associated with injury of the calcaneofibular ligament

A 49-year-old man collided against an infielder when he slid into second base during a recreational baseball game. He was unable to continue in the game due to diffuse pain and swelling of his hindfoot. A rupture of the Achilles tendon was diagnosed incidentally on palpation and observation of a positive Thompson's squeeze test. Subcutaneous hemorrhage at the lateral aspect of the heel and a small bone fragment under the lateral malleolus on an anteroposterior plain radiograph indicated a fracture of the calcaneal wall. At surgery, a complete rupture of the Achilles tendon and an avulsion of the calcaneofibular ligament from the calcaneal wall were seen. Both injuries were surgically repaired, and the patient subsequently did well. The mechanism of injury was thought to be impact hyperdorsiflexion of the ankle with rupture of the Achilles tendon accompanied by an inversion injury. Using a literature search, it was found that this combination of injuries has not been previously reported.     

Late rupture of the extensor pollicis longus tendon: The case against attrition

The authors report the case of a 23-year-old man who sustained ipsilateral volar Barton's and scaphoid fractures which were complicated by a late rupture of the extensor pollicis longus tendon. The anatomy of the injury precluded attrition as the cause of the tendon rupture and the alternative theory of ischaemic rupture is examined. Clinicians should be aware that injuries other than the Colles' fracture may be complicated by rupture of extensor pollicis longus.     

Posterior tibial tendon rupture in pronation-external rotation ankle fractures

We have recently treated two patients with closed pronation-external rotation bimalleolar ankle fractures. During the surgical explorations, an avulsion type rupture of the posterior tibial tendon was observed. Open reduction and internal fixation of the fracture in conjunction with primary tendon repair has produced excellent clinical results. We wish to report these two cases of this uncommon injury. More important, we wish to point out the association of the tendon rupture in conjunction with a particular type of fracture pattern.     

S-Type Posterolateral Approach for Open Reduction and Internal Fixation of Pronation External Rotation Ankle Fractures: Improved Visualisation of the Posterior Joint and the Lateral Malleolus

Pronation external rotation (PER) fractures are unstable ankle fractures that require anatomically stable fixation. However, due to the long distance between the fibula and the posterior malleolus in PER IV, existing approaches may make it difficult for the fixation of the associated posterior joint and the lateral malleolus. We describe an S-type posterolateral approach for the open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture in PER IV.     

Traumatic rupture of the tibialis posterior tendon after ankle fracture: a case report

Degenerative tears of the posterior tibial tendon associated with chronic disease are well documented in the literature. Traumatic ruptures of this tendon, however, are much less common and consequently have received little attention. An association has been shown between pronation-external rotation ankle fractures and tears of the tendons that cross the medial aspect of the ankle, most commonly the posterior tibial tendon. In the present case report, we share our unique experience of an open-ankle fracture associated with the traumatic rupture of the posterior tibial tendon. This injury illustrates that soft-tissue injury must always be suspected concomitantly in the treatment of certain fractures on the basis of both mechanism of injury and fracture pattern.     

Rupture of the quadriceps tendon: an association with a patellar spur

We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis.     

The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures

The treatment of isolated lateral malleolar fractures with deltoid ligament rupture remains controversial. We prospectively analysed 35 patients with isolated lateral malleolar fractures during 2006–2013. Radiography and magnetic resonance imaging (MRI) were performed to assess the degree of reduction, ligament damage, and stability. Internal fixation was performed for all unstable valgus fractures with unacceptable fracture parameters. Fractures with residual valgus instability after fixation underwent anterior deltoid repair. The mean anterior deltoid ligament grade based on MRI was significantly different between the high-grade unstable group and the stable and low-grade unstable groups (p = 0.037 and 0.004, respectively). Postoperative medial clear space measurements were not significantly different between groups. MRI was shown to be a useful tool in the preoperative identification of isolated lateral malleolus fractures prone to valgus instability. In the case of high-grade unstable fractures of the lateral malleolus, repair of the anterior deltoid ligament is adequate for restoring medial stability.     

The ANK device: a new approach in the treatment of the fractures of the lateral malleolus associated with the rupture of the syndesmosis

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow. We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24-124). The fractures were evaluated according to the Lauge-Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.     

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.     

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.     

腓骨远端干骺端钢板固定外踝和后踝治疗三踝骨折

目的探讨腓骨远端干骺端钢板用作支撑钢板固定外踝和后踝治疗三踝骨折的疗效及预后。方法 2008年1月至2010年1月,采用腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折23例,男10例,女13例;年龄20～65岁,平均45岁。左侧12例,右侧11例。根据Lange-Hansen分型,Ⅲ、Ⅳ度旋后-外旋型14例,Ⅳ度旋前-外旋型9例。直视下行骨折复位内固定,骨折复位固定顺序为外踝、后踝、内踝、下胫腓联合。术后随访观察骨折愈合及钢板稳定情况。结果所有病例得到随访,随访时间12～36个月,平均28.4个月。患肢均无畸形愈合,无骨不连,无钢板外露、松动、断裂,无伤口感染。根据Baird-Jackson评分系统进行评估,优17例,良4例,可2例,优良率为91%。结论腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折,其操作简便、对骨折固定可靠、踝关节功能恢复满意、并发症少,是治疗三踝骨折的有效方法。