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Subcutaneous rupture of the Achilles tendon and ipsilateral fracture of the medial malleolus
© Maffulli and Richards; licensee BioMed Central Ltd. 2006
Received: 15 April 2006
Accepted: 27 July 2006
Published: 27 July 2006
Although ankle fractures and an Achilles tendon rupture are relatively frequent in isolation, their association in the same injury is uncommon.
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.
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.
Although ankle fractures and an Achilles tendon rupture are relatively frequent in isolation [1, 2], their association in the same injury is uncommon [3–7]. The tendon of the long flexors  can be trapped the fracture site and thus rupture. These injuries are usually diagnosed at the time of open reduction and internal fixation of the ankle fracture. A different mechanism of injury may cause the association between the Achilles tendon rupture and an ankle fracture, and this injury can be initially undiagnosed [4–7].
The patient initially elected to be managed conservatively, and received an above knee plaster of Paris cast with the foot in maximal equines. He was kept non-weight bearing for one week, and was referred to our unit, where he was seen after two weeks following the original injury. At that time, the above clinical findings were confirmed, and the patient requested to undergo surgery.
At surgery, the patient was placed prone on a fracture table in a bloodless field furnished by a thigh tourniquet. The medial malleolar fracture was visualised under image intensifier: it was undisplaced, and it was decided to manage it conservatively if still undisplaced by the end of the Achilles tendon repair. The tendon was exposed using a slightly curvilinear medial approach. An end-to-end repair was performed using a single modified Kessler suture with No 1 Vicryl (Polyglactin 910 braided absorbable suture, Johnson & Johnson, European Logistics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium). A running circumferential suture with 3-0 Vicryl reinforced the core suture. The repair was thicker than the original tendon, and the paratenon could not be sutured over it. Continuous 4-0 Vicryl reabsorbable sutures were used for the subcutaneous fat, and the skin was closed with subcuticular 4-0 Vicryl reabsorbable suture. At the end of the procedure, the fracture of the medial malleolus was undisplaced, and it was decided to leave it alone. The skin wound was dressed with gauze, sterile plaster wool was applied, followed by a below knee synthetic cast without increasing the natural minimal equinus of the ankle.
When the cast had dried, the patient was encouraged to mobilise with the use of crutches, under the direction of a physiotherapist. The patient was discharged the day after the operation. He was allowed to bear weight on the tip toes of the operated leg as tolerated, but was told to keep the leg elevated as much as possible for the first two post-operative weeks. Two weeks after the operation, a synthetic anterior below knee slab was applied, with the ankle in the natural minimal equinus. The synthetic slab was secured to the leg with three or four removable Velcro (Velcro USA Inc., Manchester, NH, USA) straps for four weeks. The patient was encouraged to weight bear on the operated limb as soon as he felt comfortable, and to gradually progress to full weight bearing. The patient was seen by a trained physiotherapist who taught him gentle mobilisation exercises of the ankle, isometric contraction of the gastrosoleus complex, and gentle concentric contraction of the calf muscles. The patient was encouraged to perform mobilisation of the involved ankle several times per day after unstrapping the two most distal Velcro straps. The patient was given an appointment six weeks from the operation, when the anterior slab was removed .
Forceful overload of the forefoot may well have preceded the malleolar fracture, and produced the Achilles tendon rupture, instead of a syndesmosis injury or high fibular fracture. Assal et al  recommend that patients presenting with a supination-adduction ankle injury (Weber Type A fracture) should have a thorough examination of the Achilles tendon. Additionally, patients presenting with a traumatic Achilles tendon rupture should have routine antero-posterior and lateral radiographs of the ankle to rule out an associated bony lesion. Good clinical practice would dictate that thorough systematic examination should be continued even though a lesion has already been identified [3, 6]. We agree with this suggestion.
Written consent was obtained from the patient or their relative for publication of study. No funding was required for this study.
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