Tibialis posterior tendon injury associated with a closed medial malleolus fracture—a case report

Abstract

A 25-year-old healthy male solicitor was involved in a road traffic accident, being knocked off his motorbike by a car. He presented with an abrasion over the medial aspect of the right ankle and swelling of his right foot. The ankle was diffusely tender on the medial aspect and passive ankle movements were restricted and painful. There was no distal neurological deficit and posterior tibial and dorsalis pedis pulsations were palpable. Survey for associated skeletal injuries was negative.X-ray of the right ankle revealed a fracture of the medial malleolus with wide displacement of the fragments. The fibula and syndesmosis were intact ( Fig. 1).Urgent surgery was carried out for the medial malleolar fracture. The fracture was exposed through a medial longitudinal incision and the fragments were found to be widely displaced. The tibialis posterior tendon was found to be lacerated about 2 cm proximal to the fracture site and the distal stump was found interposed in the fracture site. The tendon appeared healthy otherwise. The incision was placed anterior in order to avoid the abrasion and had to be extended to retrieve the proximal end of the severed tendon. The frayed tendon edges were freshened and repaired after fixation of the medial malleolar fracture with two partially threaded cancellous screws. The screws were positioned a little anterior in order to protect the repair. The deltoid ligament was found to be intact and there was no osteochondral injury noted in the ankle joint on exploration. The ankle and foot were immobilised in a resting plaster for four weeks postoperatively, followed by progressive weight bearing as tolerated.Radiological union of the fracture had occurred by 14 weeks and return to full activities of daily living was possible by 6 months. At the time of last review 30 months following surgery, the foot arches were well maintained and he had achieved a full range of active ankle and foot movements, although the terminal 108 of inversion and eversion were associated with some discomfort (Fig. 2). DiscussionThe tibialis posterior tendon lies close to the medial malleolus and beneath the flexor retinaculum, which binds the tendon to the bone. This location of the tendon precludes it from direct laceration. 8 The anatomic arrangement at the ankle prevents

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures

“…This type of injury is rare, with only 23 previously reported cases over the last 35 years. 1,[3][4][5][6][7][8][9][11][12][13][14][15][16][17][18] In concert with the current findings, the most common mechanism of injury includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. However, direct trauma to the tendon medially also may occur.…”

“…2,17 Most cases involve a high-energy mechanism of injury, such as a motor vehicle collision or a fall from height. [1][2][3][4][5][6][7][8][9][10][13][14][15][16][17][18] However, lower-energy athletic injuries also have been described. 11,12 Rupture frequently occurs in a relatively hypovascular segment of the tendon, corresponding approximately to the level of the fracture site posteromedi-ally, which may indicate that the tendon lacerates against it.…”

Posterior tibialis tendon rupture associated with closed medial malleolus fracture and avulsion of anterior talofibular ligament: A case report and review of the literature

“…PTT rupture without repair can ultimately lead to severe pes planovalgus deformity followed by possible degenerative changes to surrounding joints and pain. 7,8 While to the best of our knowledge, there have been a few case reports describing complete PTT rupture in association with closed ankle fracture, [9][10][11][12][13][14][15][16][17][18][19][20][21] we could not find any reports of a triad of simultaneous closed medial malleolus fracture, ATFL avulsion from the talus, and PTT tendon rupture. So we think that it would be worthy to report this case after obtaining written informed consent for his anonymized information to be published in this article.…”

Acute Tibialis Posterior Tendon Rupture Associated With a Distal Tibial Fracture

“…10,11 Few case reports have been published regarding the association of ankle fractures and tibialis posterior tendon rupture. [1][2][3][4][5][6][7][8][9] The ankle fracture pattern is typically a pronation-external rotation injury, where the tendon is ruptured due to a direct tear over the fracture fragment medially. Due to the limited clinical evaluation possible at acute injury, tendon rupture is likely to be recognized intraoperatively or missed.…”