The Journal of Foot & Ankle Surgery 54 (2015) 268–272
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Irreducible Ankle Fracture-Dislocation Due to Tibialis Anterior Subluxation: A Case Report Roman M. Natoli, MD, PhD 1, Hobie D. Summers, MD 2 1 2
Senior Resident, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Irreducible ankle fracture-dislocations are rare. Several cases of irreducible ankle fracture-dislocation have been reported in published studies secondary to the tibialis posterior tendon, deltoid ligament, or extensor digitorum longus tendon blocking the reduction. We report a case of irreducible ankle fracture-dislocation resulting from posteromedial subluxation of the tibialis anterior tendon around a medial malleolar fracture fragment. Ultimately, the ankle required open reduction of the incarcerated tendon to reduce the joint and proceed with internal fixation of the associated fracture. The patient’s postoperative course was uncomplicated, and the tibialis anterior tendon was functioning at 10 months postoperatively, after which he did not return for follow-up examinations. To our knowledge, this is the first reported case of the tibialis anterior tendon blocking closed reduction of an ankle fracture-dislocation. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle dislocation dorsiflexion fracture tibialis anterior
Although the number of ankle fractures has been increasing (1), ankle fracture-dislocations remain a small subset (2). Most of these injuries will be reducible using closed methods and treated with subsequent internal fixation. Thus, sparse data is available on the recognition and management of irreducible ankle fracture-dislocations. Nonetheless, several cases of irreducible ankle fracture-dislocations have been reported. These cases differed in the obstruction to obtaining a closed reduction, such as tibialis posterior tendon interposition under an intact medial malleolus (3,4), within the medial malleolar fracture site (3), and between the tibia and fibula in the syndesmosis (5–8). Additionally, the deltoid ligament (9) or extensor digitorum tendon trapped in the distal tibiofibular joint (9), medial malleolar fragment (10), and fibular dislocation (11–14) have all been reported as causes of incomplete closed reduction of ankle fracture-dislocations. To our knowledge, we report the first case of tibialis anterior tendon displacement as the cause of incomplete closed reduction of an ankle fracture-dislocation. Case Report An otherwise healthy 33-year-old male was demolishing a brick wall. When the brick wall started to fall, he jumped from a height of Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Hobie D. Summers, MD, Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Maguire Center, Suite 1700, Maywood, IL 60153. E-mail address: [email protected] (H.D. Summers).
approximately 5 ft and sustained a twisting injury to his left ankle. He presented to a local emergency department with a closed ankle fracture-dislocation (Fig. 1). At the outside hospital, 2 reduction attempts were made with the patient under conscious sedation, without success (Fig. 2). At that point, the patient was transferred to our institution. On presentation, the ankle skin was closed, ecchymotic, and swollen but without evidence of open or bullous compromise. He had minimal active dorsiflexion and plantar flexion of his ankle. The extensor hallucis longus tendon was functioning normally. His sensation to light touch was absent over the distal most aspect of the plantar surface of the foot but was otherwise normal. The dorsalis pedis was palpable. Palpation of the posterior tibial artery was not possible given the swelling; however, the foot and toes had normal capillary refill. Reduction was again attempted on his arrival at our institution after an intra-articular injection of 10 mL of 1% plain lidocaine. This last reduction attempt was an improvement over the previous attempts (Fig. 3) but still left the patient’s ankle incompletely reduced. However, the patient’s plantar surface sensation had returned to normal after the final closed reduction attempt. The patient was admitted to our hospital and prepared for operative intervention, scheduled for the next day. Surgery was performed with the patient under general anesthesia with complete muscle paralysis in the supine position with a bump under the ipsilateral hip. A proximal thigh tourniquet was used to aid in hemostasis and visualization. Before the incision, it was noted that the ankle could not be completely reduced in the medial direction. A curvilinear incision was created over the medial malleolus and distal tibia. On inspection of the medial malleolar fracture site, the tibialis anterior tendon was
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.012
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
269
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of the left ankle injury taken at the outside facility.
identified posteriorly, trapped around the medial malleolar fracture fragment (Fig. 4). The medial malleolar fragment was delivered posteriorly behind the tibialis anterior tendon, releasing the tibialis anterior tendon back to its anatomic position. With the tibialis anterior tendon reduced, the ankle was likewise reducible, and the medial malleolar fragment could be returned to its normal position. Subsequent fixation of the fibula, medial malleolus, and Chaput fragment of the distal tibia were performed in a routine manner (Fig. 5). A syndesmotic screw was placed to augment the Chaput fragment fixation.
Postoperatively, the patient was kept non-weightbearing for 10 weeks owing to the syndesmotic injury, for which he was placed in a cast for the first 6 weeks to prevent equinus. At the 10-month postoperative visit, he could actively dorsiflex to approximately 5 past neutral, demonstrating a functional tibialis anterior tendon. His fixation was stable and the ankle mortise maintained (Fig. 6). He had returned to normal shoe wear by 4.5 months postoperatively and, ultimately, had returned to work in drywall installation by 6.5 months postoperatively in his normal work boots.
Fig. 2. Anteroposterior (A) and lateral (B) radiographs of the ankle taken at the outside facility after 2 attempts at closed reduction with the patient under conscious sedation.
270
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
Fig. 3. Anteroposterior (A) and lateral (B) radiographs of the ankle taken at our facility after the third reduction attempt with sedation provided by an intra-articular block.
Discussion Ankle fracture-dislocations that cannot be satisfactorily reduced using a closed technique are rare. However, patients with this injury have a poorer prognosis than those with ankle fractures without dislocation (15). Although several case reports of irreducible ankle
fracture-dislocations have been previously published (3–14), we found no published report of the tibialis anterior tendon as the cause of closed reduction failure. Several case reports of the tibialis anterior tendon blocking reduction of Lisfranc dislocations have been published (16). Others have reported tibialis anterior tendon laceration with distal tibia shaft fractures (17,18). Otherwise, the tibialis anterior
Fig. 4. Schematic depiction of the tibialis anterior subluxation such as was encountered during surgery.
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
271
Fig. 5. (A and B) Immediate postoperative mortise and lateral radiographs.
tendon has remained unmentioned as the causative disturbance in fractures and dislocations of the ankle joint. It is interesting to contemplate how displacement of the tibialis anterior tendon might have occurred. It is unknown whether
displacement of the tendon occurred at the injury or during the few reduction maneuvers attempted, although the inability to reduce the injury from the outset indicates the presence of the displacement at the initial presentation to the emergency room. The tibialis anterior
Fig. 6. (A and B) Weightbearing mortise and lateral radiographs at 10.5 months postoperatively.
272
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
tendon inserts into the medial cuneiform of the tarsus and the base of the first metatarsal. It acts to dorsiflex and invert the foot. It is possible that the tibialis anterior tendon slipped medially around the medial malleolus at the point of maximum displacement and then fell posterior to the medial malleolus fracture fragment as the ankle spontaneously returned to its prehospital position (Fig. 4). The tendon might then have become stuck in that position, preventing closed reduction. In conclusion, irreducible ankle fracture-dislocations are very rare. We have reported the case of tibialis anterior tendon subluxation that blocked closed reduction. Intraoperatively, it was necessary to approach the medial side of the ankle first. After reduction of the tibialis anterior tendon to its anatomic position, open reduction and internal fixation of the ankle fracture proceeded routinely. At approximately 10.5 months postoperatively, the patient was doing well, with a functioning tibialis anterior tendon. Acknowledgments The medical illustration was provided by Patrick Carrico at Medical Imagery. References 1. Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 31:430–433, 2002. 2. Yang NP, Chen HC, Phan DV, Yu IL, Lee YH, Chan CL, Chou P, Renn JH. Epidemiological survey of orthopedic joint dislocations based on nationwide insurance data in Taiwan, 2000-2005. BMC Musculoskelet Disord 12:253, 2011. 3. Coonrad RW, Bugg EI Jr. Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures about the ankle joint. J Bone Joint Surg Am 36A:744–750, 1954.
4. Lee HG, Horan TB. Internal fixation in injuries of the ankle. Surg Gynecol Obstet 76:593, 1943. 5. Walker RH, Farris C. Irreducible fracture-dislocations of the ankle associated with interposition of the tibialis posterior tendon: case report and review of the literature of a specific ankle fracture syndrome. Clin Orthop Relat Res 160:212–216, 1981. 6. Parrish TF. Fracture-dislocation of the ankle: an unusual cause of failure of reduction: a case report. J Bone Joint Surg Am 41-A:749–751, 1959. 7. Ermis MN, Yagmurlu MF, Kilinc AS, Karakas ES. Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition. J Foot Ankle Surg 49:166–171, 2010. €hler, William Wood, 8. The Treatment of Fractures, English ed 4, edited by L Bo Baltimore, 1936. 9. Hsiao KC, Tu CH. Irreducible fracture dislocation of the ankle: report of two cases. J Formos Med Assoc 93(suppl 3)):S161–S165, 1994. 10. Lee BJ, Lee SR, Kim ST, Park WS, Kim TH, Park KH. Irreducible fracture-dislocation of the ankle caused by an entrapped medial malleolus at the syndesmosis. J Orthop Trauma 22:209–212, 2008. 11. Chan D, Jones D. Irreducible syndesmosis due to an entrapped posterior fragment. Injury 26:569–571, 1995. 12. Mayer PJ, Evarts CM. Fracture-dislocation of the ankle with posterior entrapment of the fibula behind the tibia. J Bone Joint Surg Am 60:320–324, 1978. 13. Schatzker J, Johnson RG. Fracture-dislocation of the ankle with anterior dislocation of the fibula. J Trauma 23:420–423, 1983. 14. Schatzker J, McBroom R, Dzioba R. Irreducible fracture dislocation of the ankle due to posterior dislocation of the fibula. J Trauma 17:397–401, 1977. 15. Bagger J, Holmer P, Nielsen KF. The prognostic importance of primary dislocated ankle joint in patients with malleolar fractures. Acta Orthop Belg 59:181–183, 1993. 16. Karaindros K, Arealis G, Papanikolaou A, Mouratidou A, Siakandaris P. Irreducible Lisfranc dislocation due to the interposition of the tibialis anterior tendon: case report and literature review. Foot Ankle Surg 16:e68–e71, 2010. 17. Givissis P, Christodoulou A, Karataglis D, Terzidis I, Pournaras J. Laceration of tibialis anterior tendon complicating a closed tibial fracture: a case report. J Foot Ankle Surg 43:426–429, 2004. 18. Ebrahimi FV, Tofighi M, Khatibi H. Closed tibial fracture associated with laceration of tibialis anterior tendon. J Foot Ankle Surg 49:86.e19–86.e22, 2010.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Irreducible Ankle Fracture-Dislocation Due to Tibialis Anterior Subluxation: A Case Report Roman M. Natoli, MD, PhD 1, Hobie D. Summers, MD 2 1 2
Senior Resident, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Irreducible ankle fracture-dislocations are rare. Several cases of irreducible ankle fracture-dislocation have been reported in published studies secondary to the tibialis posterior tendon, deltoid ligament, or extensor digitorum longus tendon blocking the reduction. We report a case of irreducible ankle fracture-dislocation resulting from posteromedial subluxation of the tibialis anterior tendon around a medial malleolar fracture fragment. Ultimately, the ankle required open reduction of the incarcerated tendon to reduce the joint and proceed with internal fixation of the associated fracture. The patient’s postoperative course was uncomplicated, and the tibialis anterior tendon was functioning at 10 months postoperatively, after which he did not return for follow-up examinations. To our knowledge, this is the first reported case of the tibialis anterior tendon blocking closed reduction of an ankle fracture-dislocation. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle dislocation dorsiflexion fracture tibialis anterior
Although the number of ankle fractures has been increasing (1), ankle fracture-dislocations remain a small subset (2). Most of these injuries will be reducible using closed methods and treated with subsequent internal fixation. Thus, sparse data is available on the recognition and management of irreducible ankle fracture-dislocations. Nonetheless, several cases of irreducible ankle fracture-dislocations have been reported. These cases differed in the obstruction to obtaining a closed reduction, such as tibialis posterior tendon interposition under an intact medial malleolus (3,4), within the medial malleolar fracture site (3), and between the tibia and fibula in the syndesmosis (5–8). Additionally, the deltoid ligament (9) or extensor digitorum tendon trapped in the distal tibiofibular joint (9), medial malleolar fragment (10), and fibular dislocation (11–14) have all been reported as causes of incomplete closed reduction of ankle fracture-dislocations. To our knowledge, we report the first case of tibialis anterior tendon displacement as the cause of incomplete closed reduction of an ankle fracture-dislocation. Case Report An otherwise healthy 33-year-old male was demolishing a brick wall. When the brick wall started to fall, he jumped from a height of Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Hobie D. Summers, MD, Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Maguire Center, Suite 1700, Maywood, IL 60153. E-mail address: [email protected] (H.D. Summers).
approximately 5 ft and sustained a twisting injury to his left ankle. He presented to a local emergency department with a closed ankle fracture-dislocation (Fig. 1). At the outside hospital, 2 reduction attempts were made with the patient under conscious sedation, without success (Fig. 2). At that point, the patient was transferred to our institution. On presentation, the ankle skin was closed, ecchymotic, and swollen but without evidence of open or bullous compromise. He had minimal active dorsiflexion and plantar flexion of his ankle. The extensor hallucis longus tendon was functioning normally. His sensation to light touch was absent over the distal most aspect of the plantar surface of the foot but was otherwise normal. The dorsalis pedis was palpable. Palpation of the posterior tibial artery was not possible given the swelling; however, the foot and toes had normal capillary refill. Reduction was again attempted on his arrival at our institution after an intra-articular injection of 10 mL of 1% plain lidocaine. This last reduction attempt was an improvement over the previous attempts (Fig. 3) but still left the patient’s ankle incompletely reduced. However, the patient’s plantar surface sensation had returned to normal after the final closed reduction attempt. The patient was admitted to our hospital and prepared for operative intervention, scheduled for the next day. Surgery was performed with the patient under general anesthesia with complete muscle paralysis in the supine position with a bump under the ipsilateral hip. A proximal thigh tourniquet was used to aid in hemostasis and visualization. Before the incision, it was noted that the ankle could not be completely reduced in the medial direction. A curvilinear incision was created over the medial malleolus and distal tibia. On inspection of the medial malleolar fracture site, the tibialis anterior tendon was
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.012
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
269
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of the left ankle injury taken at the outside facility.
identified posteriorly, trapped around the medial malleolar fracture fragment (Fig. 4). The medial malleolar fragment was delivered posteriorly behind the tibialis anterior tendon, releasing the tibialis anterior tendon back to its anatomic position. With the tibialis anterior tendon reduced, the ankle was likewise reducible, and the medial malleolar fragment could be returned to its normal position. Subsequent fixation of the fibula, medial malleolus, and Chaput fragment of the distal tibia were performed in a routine manner (Fig. 5). A syndesmotic screw was placed to augment the Chaput fragment fixation.
Postoperatively, the patient was kept non-weightbearing for 10 weeks owing to the syndesmotic injury, for which he was placed in a cast for the first 6 weeks to prevent equinus. At the 10-month postoperative visit, he could actively dorsiflex to approximately 5 past neutral, demonstrating a functional tibialis anterior tendon. His fixation was stable and the ankle mortise maintained (Fig. 6). He had returned to normal shoe wear by 4.5 months postoperatively and, ultimately, had returned to work in drywall installation by 6.5 months postoperatively in his normal work boots.
Fig. 2. Anteroposterior (A) and lateral (B) radiographs of the ankle taken at the outside facility after 2 attempts at closed reduction with the patient under conscious sedation.
270
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
Fig. 3. Anteroposterior (A) and lateral (B) radiographs of the ankle taken at our facility after the third reduction attempt with sedation provided by an intra-articular block.
Discussion Ankle fracture-dislocations that cannot be satisfactorily reduced using a closed technique are rare. However, patients with this injury have a poorer prognosis than those with ankle fractures without dislocation (15). Although several case reports of irreducible ankle
fracture-dislocations have been previously published (3–14), we found no published report of the tibialis anterior tendon as the cause of closed reduction failure. Several case reports of the tibialis anterior tendon blocking reduction of Lisfranc dislocations have been published (16). Others have reported tibialis anterior tendon laceration with distal tibia shaft fractures (17,18). Otherwise, the tibialis anterior
Fig. 4. Schematic depiction of the tibialis anterior subluxation such as was encountered during surgery.
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
271
Fig. 5. (A and B) Immediate postoperative mortise and lateral radiographs.
tendon has remained unmentioned as the causative disturbance in fractures and dislocations of the ankle joint. It is interesting to contemplate how displacement of the tibialis anterior tendon might have occurred. It is unknown whether
displacement of the tendon occurred at the injury or during the few reduction maneuvers attempted, although the inability to reduce the injury from the outset indicates the presence of the displacement at the initial presentation to the emergency room. The tibialis anterior
Fig. 6. (A and B) Weightbearing mortise and lateral radiographs at 10.5 months postoperatively.
272
R.M. Natoli, H.D. Summers / The Journal of Foot & Ankle Surgery 54 (2015) 268–272
tendon inserts into the medial cuneiform of the tarsus and the base of the first metatarsal. It acts to dorsiflex and invert the foot. It is possible that the tibialis anterior tendon slipped medially around the medial malleolus at the point of maximum displacement and then fell posterior to the medial malleolus fracture fragment as the ankle spontaneously returned to its prehospital position (Fig. 4). The tendon might then have become stuck in that position, preventing closed reduction. In conclusion, irreducible ankle fracture-dislocations are very rare. We have reported the case of tibialis anterior tendon subluxation that blocked closed reduction. Intraoperatively, it was necessary to approach the medial side of the ankle first. After reduction of the tibialis anterior tendon to its anatomic position, open reduction and internal fixation of the ankle fracture proceeded routinely. At approximately 10.5 months postoperatively, the patient was doing well, with a functioning tibialis anterior tendon. Acknowledgments The medical illustration was provided by Patrick Carrico at Medical Imagery. References 1. Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 31:430–433, 2002. 2. Yang NP, Chen HC, Phan DV, Yu IL, Lee YH, Chan CL, Chou P, Renn JH. Epidemiological survey of orthopedic joint dislocations based on nationwide insurance data in Taiwan, 2000-2005. BMC Musculoskelet Disord 12:253, 2011. 3. Coonrad RW, Bugg EI Jr. Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures about the ankle joint. J Bone Joint Surg Am 36A:744–750, 1954.
4. Lee HG, Horan TB. Internal fixation in injuries of the ankle. Surg Gynecol Obstet 76:593, 1943. 5. Walker RH, Farris C. Irreducible fracture-dislocations of the ankle associated with interposition of the tibialis posterior tendon: case report and review of the literature of a specific ankle fracture syndrome. Clin Orthop Relat Res 160:212–216, 1981. 6. Parrish TF. Fracture-dislocation of the ankle: an unusual cause of failure of reduction: a case report. J Bone Joint Surg Am 41-A:749–751, 1959. 7. Ermis MN, Yagmurlu MF, Kilinc AS, Karakas ES. Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition. J Foot Ankle Surg 49:166–171, 2010. €hler, William Wood, 8. The Treatment of Fractures, English ed 4, edited by L Bo Baltimore, 1936. 9. Hsiao KC, Tu CH. Irreducible fracture dislocation of the ankle: report of two cases. J Formos Med Assoc 93(suppl 3)):S161–S165, 1994. 10. Lee BJ, Lee SR, Kim ST, Park WS, Kim TH, Park KH. Irreducible fracture-dislocation of the ankle caused by an entrapped medial malleolus at the syndesmosis. J Orthop Trauma 22:209–212, 2008. 11. Chan D, Jones D. Irreducible syndesmosis due to an entrapped posterior fragment. Injury 26:569–571, 1995. 12. Mayer PJ, Evarts CM. Fracture-dislocation of the ankle with posterior entrapment of the fibula behind the tibia. J Bone Joint Surg Am 60:320–324, 1978. 13. Schatzker J, Johnson RG. Fracture-dislocation of the ankle with anterior dislocation of the fibula. J Trauma 23:420–423, 1983. 14. Schatzker J, McBroom R, Dzioba R. Irreducible fracture dislocation of the ankle due to posterior dislocation of the fibula. J Trauma 17:397–401, 1977. 15. Bagger J, Holmer P, Nielsen KF. The prognostic importance of primary dislocated ankle joint in patients with malleolar fractures. Acta Orthop Belg 59:181–183, 1993. 16. Karaindros K, Arealis G, Papanikolaou A, Mouratidou A, Siakandaris P. Irreducible Lisfranc dislocation due to the interposition of the tibialis anterior tendon: case report and literature review. Foot Ankle Surg 16:e68–e71, 2010. 17. Givissis P, Christodoulou A, Karataglis D, Terzidis I, Pournaras J. Laceration of tibialis anterior tendon complicating a closed tibial fracture: a case report. J Foot Ankle Surg 43:426–429, 2004. 18. Ebrahimi FV, Tofighi M, Khatibi H. Closed tibial fracture associated with laceration of tibialis anterior tendon. J Foot Ankle Surg 49:86.e19–86.e22, 2010.
