SLR - July 2020 - Nicole Spalj

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

Reference: Pyle, L, Al-Gharib, R, Kissel E. Lateral Malleolar Fracture with Concurrent Achilles Tendon Rupture: A Case Report and Literature Review. Case Reports in Emergency Medicine. 2020 Feb 11; 2020. 

Scientific Literature Review

Reviewed By: Nicole Spalj, DPM 
Residency Program: Detroit Medical Center – Detroit, MI

Podiatric Relevance: The majority of people who present to the emergency department for exercise or sports-related injuries typically have lower extremity injuries. Although most injuries occur in isolation, it is rarer to have concomitant soft-tissue and bony-related injuries. As such, the potential for missed diagnosis remains high. This article aimed to present a case of foot and ankle trauma that involved both a lateral malleolus fracture and an Achilles tendon rupture that occurred simultaneously and highlights why the potential to miss this injury remains high. 

Methods: This paper was a case report that featured a 53-year-old male who presented to the emergency department after slipping and falling down three separate steps. He was evaluated and found to have pain upon palpation of the lateral ankle as well as a palpable dell with suspicion for an Achilles tendon rupture. Imaging revealed a Weber B lateral malleolus fracture and obliteration of the fat pad proximal to the Achilles tendon consistent with an Achilles tendon rupture. The patient was splinted and told to follow up in clinic for ongoing care. He then failed to follow up until one year later. Based off the case study and rare presentation of the combined injuries, an extensive literature review was completed in order to evaluate the incidence of a combined ankle fracture and Achilles tendon rupture. 

Results: MEDLINE and Google Scholar databases were reviewed for cases involving a concomitant ankle fracture and Achilles tendon rupture. Thirteen different case reports were reviewed that met the inclusion criteria, however twelve of the thirteen cases involved a fracture of the medial malleolus which was different than the present case report. In the case reports, the majority of the authors cited a similar mechanism of injury for the Achilles ruptures which involved a sudden dorsiflexory force applied to the forefoot. However, the authors found that the mechanism for the ankle fracture was different between authors and consisted of hyperextension of the ankle, hindfoot eversion or hindfoot inversion. The authors agreed that the Achilles injury likely occurred prior to the medial malleolus fracture. The mechanism suspected for the fibula fracture with Achilles rupture was suspected to be a forced hyperdorsiflexion of the forefoot followed by axial loading of the hindfoot which led to the fibular fracture. 

Conclusions: The case report highlights an atypical injury that could potentially be missed in the emergency setting. As seen with the literature review, combined Achilles tendon rupture and ankle fractures are rarely discussed in the literature. Due to the rarity of the combined injury, the concern remains that it could potentially be easier to miss this type of trauma which could lead to devastating complications for the patient. Knowledge of this lesser-known type of dual trauma should increase physician awareness and diagnosis. 

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