The Journal of Foot & Ankle Surgery xxx (2017) 1–4

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The Journal of Foot & Ankle Surgery

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Case Reports and Series

Incarceration of the Posterior Tibial Tendon in an Isolated Comminuted

Medial Malleolus Fracture
David Jaffe, MD, Matthew W. Christian, MD, Annie Weber, MD, R. Frank Henn III, MD
Orthopaedic Surgeon, Department of Orthopaedics, University of Maryland, Baltimore, MD

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not
Keywords:
universally accepted, although many have agreed that any displacement warrants anatomic reduction and
ankle trauma fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary
medial malleolus fracture to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention.
posterior tibial tendon The patient was treated with prompt open reduction and internal fixation and had an excellent functional
tendon incarceration outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough
exploration of the zone of injury is required to identify and adequately address any surrounding pathologic
features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never
been previously reported and emphasizes the importance of understanding the local anatomy and how
restoration of the distorted anatomy is vital to optimize patient function.
Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.

Although ankle fractures are common injuries, investigators have Case Report
reported that 60% to 70% of these injuries are unimalleolar, and the
vast majority of these unimalleolar injuries will be isolated to the We present the case of a 26-year-old female who was the
lateral malleolus (1). Because medial malleolus fractures are more restrained driver in a motor vehicle accident who had presented to
frequently observed in the setting of bimalleolar fractures, the current the emergency department complaining of isolated right ankle pain.
body of published orthopedic data is limited regarding isolated injury She denied pain in any other location, had no medical or surgical
to the medial malleolus. It has been generally accepted that displaced history, and took no daily medications. She had no known allergies.
medial malleolar fractures should be treated with open reduction and She had no family history of problems with anesthesia or hematologic
internal fixation to restore the ankle mortise with anatomic reduction disease. She worked as a secretary and denied a history of tobacco,
to prevent nonunion and posttraumatic arthritis. However, some alcohol, or illicit drug use.
evidence has shown that isolated medial malleolus injuries can be On physical examination, the patient appeared her stated age and
treated conservatively even in the setting of some initial displacement had a body mass index of 24 kg/m2. The patient was in no acute
(2). distress and was hemodynamically stable. A full skeletal survey was
We present a case report of an incarcerated posterior tibialis performed, and no bony injury was identified, with the exception of
tendon in an isolated, comminuted medial malleolus fracture. To the the right ankle. The right ankle had diffuse edema that was increased
best of our knowledge, such an injury has not been previously on the medial side. The skin was intact with no blistering. Tenderness
reported. The tibialis posterior tendon poses a potential block to to palpation was present over the medial ankle. A complete range of
anatomic reduction of the medial malleolus and must be appropri- motion and motor examination was deferred because of the patient’s
ately reduced to allow anatomic reduction of the fracture and restore pain and the likelihood of fracture. The dorsalis pedis pulse was
the patient’s preinjury anatomy with optimal return of function. palpable, and sensation was intact to light touch in all dermatomal
distributions.
Ankle, foot, and leg radiographs were obtained by the emergency
Financial Disclosure: None reported. department. The ankle radiographs demonstrated an isolated,
Conflict of Interest: None reported. displaced, comminuted medial malleolus fracture (Fig. 1). No evidence
Address correspondence to: Matthew W. Christian, MD, Department of Ortho-
of a high fibula fracture was seen on the leg radiographs. Because of the
paedics, University of Maryland, 110 South Paca Street, Sixth Floor, Suite 300, Balti-
more, MD 21201. comminution of the medial malleolar fracture and the unusual pattern
E-mail address: [email protected] (M.W. Christian). of displacement, a computed tomography scan was performed to

1067-2516/$ - see front matter Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2017.05.016
2 D. Jaffe et al. / The Journal of Foot & Ankle Surgery xxx (2017) 1–4

Fig. 1. (A) Anteroposterior, (B) mortise, and (C) lateral radiographs demonstrating an isolated, displaced, and comminuted medial malleolus fracture.

further evaluate the bony injury and ensure the absence of a retinaculum and posterior tibialis tendon sheath were torn. The pos-
concomitant posterior malleolar fracture. The imaging study confirmed terior tibial tendon was displaced and incarcerated in between 2 main
the bony injury to be isolated to the medial malleolus and identified the fracture fragments (Fig. 3). The tendon was reduced by inverting the
posterior tibialis tendon was entrapped within the fracture fragments ankle and gently dislodging the tendon from the fragments with a freer
(Fig. 2). elevator. The tendon appeared healthy, and no tear was identified. A
Because of the fracture displacement and entrapment of the small comminuted, posterolateral fracture piece was excised. The
posterior tibialis tendon, open reduction and internal fixation was tibiotalar joint was irrigated and inspected, confirming the absence of
recommended. The patient provided informed consent, and she chondral lesions and loose bodies. The posterior fragment was reduced
was taken to the operating room for surgical intervention. The patient first using a Kirschner wire as a joystick, and the reduction was adjusted
was placed supine on a radiolucent table, and general anesthesia was and maintained with a pointed reduction clamp. This was held provi-
administered. A tourniquet was applied to the right thigh. The patient sionally in place with a smooth wire. The anterior fragment was then
was prepared and draped in standard fashion. The tourniquet was reduced to its anatomic location. A minifragment T-plate was cut and
inflated to 250 mm Hg, and a curvilinear incision was made, centered shaped to buttress the 2 fragments to the tibia. This was secured using
over the medial malleolus. After careful dissection through the appropriately sized 1.5-mm cortical screws. Another guidewire was
subcutaneous tissue, the fracture site was identified. The medial placed through the anterior fragment, carefully placed to avoid the
minifragment screw. A 2.7-mm cannulated drill was passed over the 2
guidewires. A countersink was used before inserting 4.0-mm cannu-
lated screws over the guidewires. Fluoroscopy confirmed acceptable
placement of the instrumentation, and the results of a fluoroscopic
stress examination confirmed the stability of the construct.
The medial retinaculum was then repaired with interrupted 0-0
Vicryl sutures, securing the posterior tibial tendon in its anatomic
location. The ankle could be moved freely, demonstrating a stable

Fig. 2. Sagittal computed tomography image demonstrating entrapment of the posterior

tibial tendon between the medial malleolus fracture fragments. Fig. 3. Intraoperative photograph displaying the entrapped posterior tibial tendon.
 D. Jaffe et al. / The Journal of Foot & Ankle Surgery xxx (2017) 1–4 3

Fig. 4. Postoperative (A) anteroposterior, (B) mortise, and (C) lateral radiographs after open reduction and internal fixation.

posterior tibialis tendon and stable fracture fixation. The wound was was instructed to slowly progress her weightbearing in her walking
then irrigated and closed in a layered fashion. A sterile dressing was boot. At the 6-month follow-up visit, the patient had no complaints of
applied, and the patient was placed in a short leg plaster splint with pain and her range of motion was equivalent to that of the noninjured
the ankle in neutral position. Postoperative radiographs are shown side. At 1 year, the patient continued without pain and denied activity
in Fig. 4. limitations. No detectable difference was found in the strength of her
The patient was instructed to be non-weightbearing and was posterior tibial tendon compared with the contralateral extremity (5
discharged home after training in using crutches with physical ther- of 5 on standard physical examination scoring). The patient was very
apy. At the 2-week postoperative visit, the patient was doing well satisfied with her outcome.
with minimal pain. Her incision had healed well, and she had 10 of
dorsiflexion and 30 of plantarflexion. Radiographs confirmed main- Discussion
tenance of her operative fixation. She was transitioned to a walking
boot and kept non-weightbearing. She was instructed on ankle range The posterior tibial tendon is a medially based structure that has
of motion and strengthening exercises. been implicated as a block to anatomic reduction in injuries such as
At 6 weeks, the patient denied any medial-sided pain and had no lateral subtalar dislocations or high-energy ankle fracture dislocations
tenderness to palpation over her medial malleolus (Fig. 5). The patient (3–5). It has also been identified as a block to reduction in pediatric
had increased range of motion, with 10 of dorsiflexion and 50 of ankle fractures (6). A recent case report demonstrated the posterior
plantarflexion. She had intact posterior tibial tendon strength. She tibial tendon was dislocated and blocking a medial malleolar

Fig. 5. (A) Anteroposterior, (B) mortise, and (C) lateral radiographs obtained 6 weeks after surgery demonstrating interval healing of the fracture and maintenance of fixation.
4 D. Jaffe et al. / The Journal of Foot & Ankle Surgery xxx (2017) 1–4

reduction in the setting of an ipsilateral Achilles tendon rupture (7). mechanical attenuation of the tendon. We also recommend inspec-
The injury described in that case report represented a comminuted tion of the posterior tibial tendon during open reduction and internal
medial malleolus fracture that could not be closed reduced owing to fixation of medial malleolar fractures to ensure injuries to this critical
entrapment of the posterior tibial tendon. structure are not missed.
In the present case, the posterior tibial tendon sheath was
ruptured, allowing the tendon to dislocate and become entrapped
between the 2 main fracture fragments. Dislocation of the posterior References
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