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

Trimalleolar Fracture Associated with Subcutaneous Rupture of the Achilles Tendon and Traumatic Peroneal Dislocation: A Case Report and Review of the Literature

CASE

We report the case of a 44-year-old man who sustained an Achilles tendon rupture with an associated trimalleolar fracture and traumatic peroneal dislocation of the left ankle after a snowboarding injury. These injuries have been surgically repaired; the patient has returned to all his activities 18 months after surgery.

CONCLUSION

The possibility of such injuries occurring in combination should be considered. A thorough history, physical examination, and plain radiographs should be performed in higher energy trauma to the ankle. Additional diagnostic tests such as ultrasonography or magnetic resonance imaging may be used to supplement treatment.

LEVELS OF EVIDENCE

Level 5.

High-Energy Achilles Tendon Rupture With Associated Medial Malleolus Fracture and Traumatic Peroneal Dislocation: A Case Report

Fracture, Achilles tendon rupture, or traumatic dislocation of the peroneal tendons are often seen in isolation after a trauma or sports-related injury. However, in rare circumstances, a combination of these injuries can occur simultaneously. Multiple previous case reports describe a combination of 2 of these injuries. Missed or delayed diagnosis is common in these combination injuries and can lead to significant patient morbidity and result in long-term consequences. We report a case of a 35-year-old man who sustained an Achilles tendon rupture with an associated medial malleolus fracture and traumatic peroneal dislocation after a snowboarding injury. These injuries were treated surgically, and at 9 months postoperatively, the patient had returned to all activities. Clinicians should have a high index of suspicion for concomitant injuries with higher-energy trauma to the ankle and should perform a thorough history, physical examination, and plain radiographs at a minimum.Levels of Evidence: LEVEL 5.

Gustilo IIIA Open Bimalleolar Fracture Dislocation of Ankle with Ipsilateral Achilles Tendon Rupture: A Case Report and Review of Literature

CASE

Although rare, a medial malleolus fracture plus ipsilateral Achilles tendon rupture has been described in previous case reports. We present a unique case of an open bimalleolar fracture dislocation with ipsilateral Achilles tendon rupture after a motorcycle crash. His Achilles injury was diagnosed intraoperatively during external fixator placement. He presented in a delayed fashion to our institution, where he underwent open reduction internal fixation and Achilles tendon reconstruction.

CONCLUSION

Although most commonly described with isolated medial malleolus fractures, Achilles tendon injuries can also be associated with bimalleolar ankle fractures. These associated injuries are frequently missed.

The Reliability of Kager's Triangle in Detecting Acute Achilles Tendon Ruptures

The Achilles tendon is a common site of anatomical injury among athletes and those participating in recreational sporting activities. Acute Achilles tendon ruptures are often misdiagnosed as a sprained ankle and are more common in the male population. Mechanism of injury is often a noncontact injury, resulting from sudden forced plantar flexion or violent dorsiflexion in a plantar flexed foot. Delays in diagnosis and treatment may complicate the clinical outcome. Because findings may be subtle on history and physical examination, the use of readily available adjunctive studies is important for practitioners. One method is the analysis of Kager's triangle on lateral ankle radiographs. Obscuration of Kager's triangle has been described as a radiographic indicator of Achilles tendon rupture, but the sensitivity and specificity of this finding have been poorly reported. [Orthopedics. 2020; 43(2): e91-e94.].

Lateral Malleolar Fracture with Concurrent Achilles Tendon Rupture: A Case Report and Literature Review

Achilles tendon and malleolar fractures are commonly seen in isolation, but only a few cases of combined injuries have been reported. In this case, we present a 53-year-old male who sustained an isolated lateral malleolus fracture with an Achilles tendon rupture. Emergency Medicine physicians should consider the possibility of these injuries in combination.

Tendon healing in the context of complex fractures

Tendons connect muscle to bone and play an integral role in bone and joint alignment and loading. Tendons act as pulleys that provide anchorage of muscle forces for joint motion and stability, as well as for fracture reduction and realignment. Patients that experience complex fractures also have concomitant soft tissue injuries, such as tendon damage or rupture. Tendon injuries that occur at the time of bone fracture have long-term ramifications on musculoskeletal health, yet these injuries are often disregarded in clinical treatment and diagnosis for patients with bone fractures as well as in basic science approaches for understanding bone repair processes. Delayed assessment of soft tissue injuries during evaluation of trauma can lead to chronic pain, dysfunction, and delayed bone healing even following successful fracture repair, highlighting the importance of identifying and treating damaged tendons early. Treatment strategies for bone repair, such as mechanical stabilization and biological therapeutics, can impact tendon healing and function. Because poor tendon healing following complex fracture can significantly impact the function of tendon during bone fracture healing, a need exists to understand the healing process of complex fractures more broadly, beyond the healing of bone. In this review, we explored the mechanical and biological interaction of bone and tendon in the context of complex fracture, as well as the relevance and potential ramifications of tendon damage following bone fracture, which has particular impact on patients that experience complex fractures, such as from combat, automobile accidents, and other trauma.

Trimalleolar fracture and associated Achilles tendon rupture: Ten year follow up of an unusual water-skiing injury

A 49 year old professional fitness instructor sustained a high velocity rotational injury to his right ankle while waterski-ing. The ski bindings did not release, exacerbating the injury. This resulted in a trimalleolar fracture and a rupture of his Achilles tendon.

A trimalleolar fracture in association with a rupture of the Achilles tendon has not been previously reported.

This combination of injuries posed a dilemma in treatment options and postoperative management.

The authors felt that ensuring that the Achilles tendon healed with no shortening was the priority for future function in this professional athlete.

It was decided to treat the Achilles tendon rupture by open repair and to place the ankle in equinus postoperatively.

It was also decided to openly reduce and internally fix the medial and lateral malleolar fractures before immobilising the ankle in equinus.

Any residual stiffness in the ankle, subtalar and midtarsal joints would be treated with aggressive physiotherapy.

It was felt that the rotational forces may have resulted in a degree of degloving around the ankle. Care was therefore taken in the choice and placement of the surgical incisions.

In spite of this, the lateral surgical wound broke down postoperatively, needing treatment with a fasciocutaneous flap.

When reviewed at ten years following the injury, the patient was continuing to work as a fitness instructor with a view to continuing to retirement in five years at the age of 65.

There was a slight decrease in dorsiflexion of the right ankle but flexion was full and movement of the subtalar and midtarsal joints were also full.

There remained 1 cm of wasting of the right calf.

Radiology of the ankle showed no joint space narrowing or evidence of degenerative change at ten years following the injury.

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.

Chronic Achilles tendon rupture associated with rupture of the peroneus brevis tendon. A clinical case

The treatment of a chronic rupture of the Achilles tendon remains difficult. Different techniques such as augmentation or plasties are used for restoring the gap in these ruptures. The combination of Achilles tendon rupture with other tendon ruptures may increase the difficulty in their treatment. We present a rare combination of a delayed Achilles tendon rupture and a peroneus brevis tendon rupture and its management. The importance of the presented case is the combination of both ruptures that adds difficulty to the surgical technique. A thorough analysis should be made of the magnetic resonance findings when planning a tendon transposition. To our knowledge, there are no reports of a simultaneous combination of an Achilles tendon rupture and a peroneus brevis tendon rupture.

Medial malleolus fracture of the ankle combined with rupture of the Achilles tendon

A 59-year-old man fell off a 60-cm-high step, with his ankle in a twisted position, and sustained a closed fracture of the medial malleolus, with an ipsilateral complete Achilles tendon (TA) rupture. The TA rupture was initially missed but diagnosed by ultrasound examination, 2 weeks post-operatively. The ankle fracture was diagnosed from routine radiographs. Such a combination of injuries has been reported infrequently in the literature, but significant similarities have been described in the mechanism of injury and fracture patterns. Nevertheless, three of five reported cases with combined medial malleolus fractures were initially misdiagnosed.

Unrecognised Acute Rupture of the Achilles Tendon in Severe Ankle Sprain

Inversion ankle sprain is a common sport injury. It commonly refers to the injury of lateral collateral ligaments of the ankle. Failure to detect the concomitant injuries would lead to inappropriate treatment and suboptimal result. A case of unrecognised rupture of the Achilles tendon in a patient with severe inversion ankle sprain is reported.

Missed Medial Malleolar Fracture Associated With Achilles Tendon Rupture: A Case Report and Literature Review

A 45-year-old man sustained an Achilles tendon rupture while playing futsal. A concomitant medial malleolar fracture was not diagnosed until the patient underwent an operation for Achilles tendon repair. A routine postoperative radiograph showed a minimally displaced medial malleolar fracture. Conservative treatment was chosen for the fracture. The function of the Achilles tendon recovered well, and the fracture was united. A medial malleolar fracture can be missed when an Achilles tendon rupture occurs simultaneously. Thus, surgeons should consider the possibility of medial malleolar fracture associated with an Achilles tendon rupture.

Achilles tendon rupture with open distal tibia and fibula fracture

The authors present a previously unreported case of an open fracture of the distal tibia and fibula with associated Achilles tendon rupture in a 27-year-old motorcyclist. Management followed established trauma principles of wound exploration, debridement, and stabilization of the fracture with reamed locked intramedullary nailing of the tibia. The injury to the Achilles tendon was not identified until surgical exploration for fixation of the fracture. This required a 2-stage operative approach, involving initial debridement and fracture fixation followed by Achilles tendon repair during the second-look wound review procedure. The authors believe this to be the first reported case of Achilles tendon rupture in association with an open transverse distal tibia fracture. Prior to surgical exploration of the wound, Achilles tendon rupture was not suspected, emphasizing the need for clinical suspicion, thorough examination, and adequate wound exploration at operation for fracture fixation.

Acute calcaneus tendon rupture associated with ipsilateral malleolar fracture: case report and literature review

Malleolar fractures are rarely associated with lesions of the adjacent tendons or neurovascular structures. The association of ankle fractures with Achilles tendon rupture is even more infrequent, although both of these injuries are very common in and of themselves. To our knowledge, fracture of the lateral malleolus in association with an acute rupture of the ipsilateral calcaneus tendon has not been previously described. In this article, we describe a female patient who sustained an acute rupture of the Achilles tendon in conjunction with fracture of the ipsilateral lateral malleolus.

End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures

We prospectively analyzed the functional and clinical results of patients who underwent a single end-to-end suture and an augmented tendon repair with plantaris tendon at middle-term follow-up. From January 2003 to May 2005, 30 consecutive patients were operated on for the treatment of acute Achilles' tendon rupture by means of 2 different methods. No cases required adjunctive procedures to allow for acceptable end-to-end apposition. All ruptures were acute and repairable. The patients were divided into 2 groups. In group 1, augmentation with plantaris tendon was performed in addition to the Krakow end-to-end suturing technique in 16 patients, and in group 2, only the Krakow end-to-end suturing technique was used in 14 patients. The average age of the patients was 40.6 years. Patients in the study groups were followed up at a mean of 17.8 months after surgery. At the end of the follow-up, functional and subjective outcome scores were evaluated. The American Orthopaedic Foot and Ankle Society hindfoot clinical outcome scores were 96.7 in group 1 and 98.8 in group 2. Although there was a numerical increase in group 2, no significant difference was determined between the 2 study groups statistically. The surgical outcome concerning local tenderness, skin adhesion scar, and tendon thickness was better in group 2 than in group 1 without a statistical significance. Although functional outcomes of both treatment groups were the same, the end-to-end suturing technique provided a safer and more reliable treatment with a low risk of complications in the treatment of acute Achilles' tendon ruptures compared with the plantaris tendon augmentation technique.

Subcutaneous rupture of the Achilles tendon and ipsilateral fracture of the medial malleolus

Background

Although ankle fractures and an Achilles tendon rupture are relatively frequent in isolation, their association in the same injury is uncommon.

Case presentation

A 38 year old male tree surgeon fell six meters from a tree, sustaining a subcutaneous rupture of the Achilles tendon and an ipsilateral closed fracture of the medial malleolus. The injuries were diagnosed following clinical examination and imaging.

Conclusion

This injury combination is infrequent, and management of the Achilles tendon rupture should take into account the necessity not to secondarily displace the fracture of the medial malleollus.

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.