Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures

Abstract

Tibialis posterior tendon rupture in the setting of pronation-type ankle fractures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a medial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accordance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated ruptures. [Orthopedics.2016; 39(5):e970-e975.].

Posterior tibialis tendon rupture concomitant with a closed medial malleolar fracture: A case report and literature review

“…Traumatic mechanisms of pronation and external rotation, redundant edema on the medial side of the ankle, the irreducibility of the dislocation or fracture, and the appearance of "bone flakes" separated from the distal medial metaphysis of the tibia are suspicious clinical signs that should be considered for PTT lesions. 1,2,9,11,18,21,22 Due to the limitations of clinical examinations, the use of MRI and preoperative ultrasound can be helpful in diagnosing this lesion. 23 Because these techniques are not always available, careful examination of the tendon rupture should be performed during surgery.…”

“…18 In the literature, we found only limited articles that reported complete posterior tibialis rupture associated with a closed ankle fracture. [1][2][3]5,7,8,11,12,16,18,[20][21][22][23][26][27][28][29][30][31][32][33][34][35] Giblin et al 31 first described the PTT rupture associated with a closed medial malleolar fracture in 1980. Most of the articles reported complete rupture of the PTT with medial malleolus involvement.…”

Rupture of posterior tibial tendon in a bimalleolar ankle fracture: A case report

“…The pain associated with the injury limits the clinical examination, making it difficult to diagnose the injury [3] . Lauge-Hansen pronation and external rotation ankle fractures with a forced dorsiflexion moment are the most commonly reported mechanisms of injury because this position places maximal stress on the tibialis posterior tendon [6] . Posterior tibialis tendon rupture without repair can ultimately lead to severe pes planovalgus deformity followed by possible degenerative changes to surrounding joints and pain [7] .…”

Fibular insufficiency fracture: an under-reported complication of advanced tibialis posterior dysfunction

“…They do discuss whether this may be an indication for surgery in these patients. There are reports of acute tibialis posterior tendon rupture with associated pronation-type ankle fracture requiring surgical repair of the torn tendon along with ankle fracture fixation,2 but these are acute traumatic, unstable fractures rather than insufficiency fractures presenting subacutely.…”