Irreducible Fracture Dislocation of the Ankle Caused by Tibialis Posterior Tendon Interposition

A patient with severe irreducible open fracture dislocation of the ankle was admitted to our emergency department. After wound irrigation and debridement, skeletal traction was applied to the calcaneus to minimize soft tissue injury and swelling. The patient was followed in traction for 1 week, after which reduction and fixation of the fibula was attempted but not achieved. We extended the incision distally, visualized the ankle, and located the tibialis posterior tendon between the distal tibia and fibula, thereby inhibiting the reduction. The tendon coursed into the tibiotalar joint anteriorly and pushed the talus anterolaterally. After manipulation of the tendon to its anatomically correct location, the ankle was easily reduced. The wound at the medial side was closed with a fasciocutaneous rotational flap. The ankle was then immobilized for 6 weeks postoperatively. The patient regained her full range of motion, and there were no problems with the tibialis posterior tendon, such as rupture or insufficiency. Isolated tibialis posterior tendon interposition between the distal tibiofibular and tibiotalar joints has rarely been reported, and can inhibit anatomical reduction of the fractured ankle.     

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report.

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.     

Talus Fracture of the Medial Tubercle of the Posterior Process: Interposition of the Flexor Hallucis Longus Tendon

Talus fracture of the medial tubercle of the posterior process is rare. This type of fracture can be easily missed, because it is difficult to identify on plain radiographs of the ankle. Oblique radiographs with external rotation, computed tomography, and magnetic resonance imaging (MRI) of the ankle are useful for making an accurate diagnosis. However, even with an early diagnosis, the treatment guidelines for talus fractures of the posterior medial tubercle have not yet been established. The flexor hallucis longus (FHL) tendon, which passes through the groove between the medial and lateral tubercles of the posterior process of the talus, can interpose between the fracture sites and interrupt fracture reduction. MRI might be the best imaging modality for the identification of the interposed FHL tendon. We report a case in which talus fracture of the posterior medial tubercle was treated by open reduction and internal fixation owing to an interposed FHL tendon that was confirmed by MRI. MRI is the recommended imaging study of choice for talus fractures of the posterior medial tubercle owing to the possibility of an interposed FHL tendon.     

Tibialis Posterior Tendon Rupture Associated with a Closed Medial Malleolar Fracture: A Case Report and Review of the Literature

We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient’s progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.     

Traumatic rupture of the tibialis posterior tendon after ankle fracture: three cases and a review of the literature

We report three cases of complete traumatic tibialis posterior tendon rupture which occurred after ankle fracture. Diagnosis was established at surgery. Repair of the non-degenerative tendon was achieved during the procedure for osteosynthesis of the malleolar fracture. Fractures healed a few months after surgery. The posterior tibialis muscle tendon functioned plantar arch was normal, except in one patient with multiple injuries who died in intensive care thirteen days after the accident. Although exceptional, injury of the tibialis posterior tendon should not be overlooked after ankle fracture. These injuries become apparent only at surgery for the malleolar fracture since pain hinders clinical examination. Primary suture best guarantees a good functional outcome. Residual pain, deficit in active inversion of the foot, modified medial longitudinal arch, or progression to planovalgus are retrospective diagnostic signs.     

Rupture of the tibialis posterior tendon in a closed ankle fracture: a case report

Rupture of the tibialis posterior tendon may occur during a trauma in pronation-external rotation of the foot or, less commonly, during a direct trauma of the ankle. When an isolated fracture of the medial malleolus is present, it is more likely that a direct trauma has occurred. A 36-year-old man with a non-displaced medial malleolar fracture was evaluated. Repair of the tendon and reduction of the fracture were performed. Twenty-four months after the operation, the fracture was completely healed, the patient was asymptomatic, he had a normal ankle range of motion, and the function and strength of the tibialis posterior tendon were equal to those on the contralateral side. Early surgical repair of the tibialis posterior tendon combined with malleolar fracture reduction is recommended to avoid progression to a plano-valgus foot.     

Irreducible dislocation of the subtalar joint: a report of two cases

Two patients with irreducible lateral dislocation of the subtalar joint are reported. In both patients the injury was closed and associated with a lateral calcaneal fracture. Open reduction confirmed the tendon of tibialis posterior was located around the lateral aspect of the neck of the talus and prevented reduction.     

Ruptured tibialis posterior tendon in a closed ankle fracture

Interposition of a ruptured tibialis posterior tendon between the medial malleolar fracture fragments in a closed pronation-eversion ankle fracture occurred in a 21-year-old woman. The tendon rupture was not diagnosed before surgery but was recognized at the time of open reduction. the tendon was repaired and the fracture internally fixed. Twelve months after the operation, the patient had a nearly full range of pain-free ankle movements and a normal longitudinal arch.     

Open Ankle Dislocation Without Fractures With Tibialis Posterior Tendon Interposition Through the Interosseous Space

Open ankle dislocations without fracture are rare injuries. Dislocation or interposition of adjacent tendons are a rare associated feature of ankle fracture-dislocation. We report an extremely unusual case of open ankle dislocation without fracture with concurrent tibialis posterior tendon interposition through the interosseous space that was detected incidentally on computed tomography. We highlight the clinical, radiologic, and intraoperative features to avoid missing similar diagnoses.     

Concomitant Talar Neck Fracture and Achilles Tendon Rupture

A 56-year-old man fell down 1 m from a ladder and sustained a forced dorsiflexion injury to his right ankle when his foot contacted a lower rung, which resulted in the rare combination of a Hawkins II fracture of the neck of the talus and a concomitant rupture of the Achilles tendon. Clinical examination and diagnostic imaging confirmed the injuries, and surgical fixation of the fracture and repair of the Achilles tendon were achieved by means of a posterior approach. Healing proceeded unremarkably, and, at 18 months postoperatively, the patient had regained full function despite a 5 degrees limitation of subtalar joint range of motion.     

Severe ligamentous injury of the ankle with ruptured tendo Achillis and fractured neck of talus

Severe tendon and ligament rupture of the ankle associated with a fracture of the talus were successfully treated by surgical repair followed by cast immobilization. We suggest that the mechanism of injury was forced dorsiflexion with initial rupture of the Achilles tendon, followed by rupture of the ankle ligaments and fracture of the neck of the talus.     

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 Medial Tubercle of the Posterior Process of the Talus: Magnetic Resonance Imaging Appearance with Clinical Follow-Up

Fractures of the medial tubercle of the posterior process of the talus are rare injuries. They are often misdiagnosed, resulting in increased morbidity and symptoms of chronic ankle pain and instability. When undetected, these fractures may become displaced, with potential additional injuries such as to the flexor hallucis longus tendon which may become interposed between the fracture fragments. We report a case of a clinically unsuspected fracture of the medial tubercle of the posterior process of the talus seen on magnetic resonance imaging, treated conservatively, with interval satisfactory healing of the fracture at 6 weeks follow-up.     

Avoiding pitfalls in ankle fracture-dislocations: A case report of a dislocated tibialis posterior tendon causing persistent ankle subluxation

Tibialis posterior tendon dislocation, a rare complication in ankle fracture-dislocations, can impede anatomical reduction of the ankle mortise. We report on a 59-year-old healthy male with an open fracture-dislocation of the right ankle. Despite multiple attempts under direct vision of the anterior syndesmosis, anatomical reduction of the ankle mortise was not possible. Soft tissue windows in a computed tomography (CT) scan revealed the dislocated tibialis posterior tendon to be the impeding structure. At the level of the fibula fracture the tendon passed through the interosseous membrane anterior to the distal tibia and was then incarcerated in the medial talocrural joint before returning to the flexor retinaculum and its insertion on the navicular bone. Understanding the trauma mechanism and the course of the dislocated tendon as well as correct interpretation of CT and magnetic resonance images of the ankle enable surgeons to early diagnose and correctly treat this condition.     

Simultaneous rupture of the tibialis posterior and flexor digitorum longus tendons in a closed tibial fracture

An interposition of ruptured tendons of the tibialis posterior and flexor digitorum longus occurred between the lower third tibial fracture fragments in a closed tibial fracture in a 26-year-old man. The tendon ruptures were not diagnosed preoperatively but were recognized at the time of open reduction. The tendons were repaired and the fracture internally fixed. Six months postoperatively, the patient had a 10 degree dorsal extension deficit in the ankle joint, the motion was painless, and the strength of the posterior tibial compartment muscles was grade 5.     

Interosseous transfer of tibialis posterior for common peroneal nerve palsy

The interosseous route remains popular for tibialis posterior tendon transfer for drop-foot. It leaves a smaller range of movement than the circumtibial route, but lengthening the calcaneal tendon may improve this. The results of this present series indicate that, in order to predict a good functional result, the ankle must be held in at least 20 degrees of dorsiflexion at the time of tendon transfer.     

Interposition of Tibialis Posterior and Flexor Digitorum Longus Tendons Resulted in Irreducible Ankle Fracture-Dislocation

Irreducible ankle fracture-dislocations are very rare entities. The present case report demonstrates an unusual finding of tibialis posterior and flexor digitorum longus tendons interposed in the tibiofibular joint impairing successful closed reduction of ankle fracture-dislocation. A 45-year-old patient presented with a bimalleolar pronation-external rotation ankle fracture-dislocation after a motorcycle accident. Attempts to perform closed reduction before surgery were unsuccessful. Subsequent urgent open reduction and internal fixation surgical management revealed interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint. In irreducible fracture-dislocation of the ankle with severe lateral displacement of the talus, one should be aware of the possibility of soft tissue interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint.     

Traumatische Luxation der Tibialis posterior Sehne

Traumatic dislocations of the tibialis posterior tendon are a rare entity compared to other injuries of the ankle joint. It should be considered if the patient presents with the mechanism of an ankle sprain in combination with severe pain in the region of the internal malleolus. We report of two cases of a traumatic dislocation of the tibialis posterior tendon and discuss the clinical image and the operative treatment.     

Recurrent dislocation of tibialis posterior tendon

We successfully treated two patients with recurrent dislocation of the tibialis posterior tendon by creating a bone block. Sudden resistive contraction of the tibialis posterior muscle is considered to be the mechanical cause of the initial traumatic injury, and a shallow tibialis posterior tendon sulcus may be the predisposing factor. Once the flexor retinaculum is torn during the initial trauma, recurrent dislocation is inevitable, and surgical treatment is mandatory. When treating patients with a complaint of long-standing pain around the medial malleolus, we must bear in mind the possible diagnosis of recurrent dislocation of the tibialis posterior tendon. If the patient can voluntarily dislocate the tendon by active plantar flexion and inversion of the ankle, the diagnosis is definitive. Received: 1 April 1997     

Diagnosis of medial tubercle fractures of the talar posterior process using oblique views

Fracture of the medial tubercle of posterior process of talus is a very rare injury. Often, these fractures are not seen on the AP and lateral radiographs of the ankle joint resulting in them being misdiagnosed as an ankle sprain. This study examines 10 ankle specimens simulated with a posteromedial fracture in varying planes, by multiple X-ray views in varying angles of external rotation in order to increase the sensitivity of oblique views to diagnose a fracture of the posteromedial tubercle. True AP and lateral views (0 degrees and 90 degrees of external rotation) of the ankle joint were unable to detect the fracture simulated in the posteromedial tubercle of the posterior process in any specimens. The fractures in all the specimens were clearly visible when the X-ray beam was parallel to the plane of osteotomy. The fractures could still be identified when the plane of X-ray beam was within +/-10 degrees from the plane of osteotomy. Any further increase or decrease in plane of the X-ray beam could not identify the fracture. Two oblique views at 45 degrees and 70 degrees of external rotation could identify the fractures of the posteromedial tubercle at all planes. These oblique views can be used before resorting to the CT scan.