Open Journal of Orthopedics, 2013, 3, 224-226 Published Online September 2013 (
Achilles Tendon Rupture with Isolated Medial Malleolar
Fracture in Ipsilateral Ankle: A Case Report
Fatih Türkmensoy1, Ismail Türkmen1, Yalçın Turhan2, Korhan Özkan1, Mehmet Akif Akçal3
1Department of Orthopaedics and Traumatology, Göztepe Training and Research Hospital, İstanbul Medeniyet University, İstanbul,
Turkey; 2Department of Orthopaedics and Traumatology, Düzce Atatürk State Hospital, Düzce, Turkey; 3Department of Ortho-
paedics and Traumatology, Kilis State Hospital, Kilis, Turkey.
Received July 15th, 2013; revised August 15th, 2013; accepted August 29th, 2013
Copyright © 2013 Fatih Türkmensoy et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Achilles tendon ruptures and malleol fractures are commonly seen injuries in orthopaedic and traumatology practice,
but what is rare is their concomitant. In this report, we aimed to present a rare case of a patient who has isolated medial
malleolar fracture and achilles tendon rupture in ipsilateral ankle after an ankle sprain due to a fall from stairs and
mechanism of injury.
Keywords: Achilles Tendon Rupture and Malleol Fracture; Injury Mechanism
1. Introduction
Achilles tendon is the strongest tendon in the human
body which occurs with incorporation of M. Gastrocne-
mius and M. Soleus tendons. Acute rupture of this tendon
is one of the commonest injuries in adults [1].
Malleol fractures are also frequently seen in orthopae-
dics and traumatology practice, which usually occur after
ankle sprain [2]. Medial malleol fractures are sometimes
seen as isolated, but they are often together with fractures
of lateral and/or posterior malleolus. Although acute
Achilles tendon rupture and medial malleolar fractures
are relatively frequent, the concomitant association of
those two injuries in ipsilateral ankle is rare with only six
single cases having been reported in the English speaking
literature [2].
In this report, we aimed to present a patient with acute
Achilles tendon rupture and isolated medial malleol frac-
ture and tried to present the possible injury mechanism.
2. Case Presentation
A 42 years old male who fell down from stairs was seen
in our emergency unit with pain and tenderness over his
right ankle joint. He was wearing a shoe and his injury
happened while he was going up the stairs. He inverted
his right foot and fell down four stairs. He had heard a
“pop-up” sound before inverting his ankle.
In his detailed physicial examination the pain was
localized posterior and medial aspect of his ankle joint
and a three centimetres gap was palpable four centime-
tres proximal to the distal insertion of his Achilles ten-
The patient could not plantar flexion his foot actively
and the Thompson test was positive. His ankle roentge-
nograpies and CT images revealed a non displaced me-
dial malleolar fracture (Figure 1) while MRI of the same
ankle revealed an Achilles tendon rupture (Fig ure 2). He
was hospitalized with the acute Achilles tendon rupture
and isolated medial malleolar fracture in his ipsilateral
The patient underwent surgery next day. Prone posi-
tion was choosen and thigh tourniquet was used to
Figure 1. Preoperative X-ray and CT of the right ankle.
Copyright © 2013 SciRes. OJO
Achilles Tendon Rupture with Isolated Medial Malleolar Fracture in Ipsilateral Ankle: A Case Report 225
provide a bloodless field. Under fluroscopic guidence
medial malleol fracture was fixed by a malleolar screw
percutaneously first (Figure 3). Then, repair of Achilles
tendon was made. The tendon exposed using medial
approach with an end-to-end repaired using the well
known Krakow technique and it was strengthened with
the circumferential surgery knots. Subcutaneus fat closed
with absorbable sutures and to close the skin non-absor-
bable sutures were used. After the procedure a long-leg
cast was applied with slightly equines position. He was
encouraged to mobilise with crutches when he reached
his room. At his third postoperative day he was dis-
charged after his wound was controlled.
Twelve days later the sutures was removed and one
month later his cast was changed with short-leg cast in
naturel position and he was encouraged to full-weight-
bear on his ankle. The cast was removed on the second
month of the surgery and mobilised under directions of
physiotherapist. He was walking without crutches, but
there was two heel height on operation side. In the third
mounth he could walk with full-weight-bear. In the eight
mounth follow up he was asymptomatic with full range
of active-passive ankle motion and fully weight bearing,
so he was discharged from follow-up.
3. Discussion
Acute Achilles tendon rupture is the most common ten-
don injury in adults, especially in man. It occurs fre-
Figure 2. Preoperative MRI of the right ankle.
Figure 3. Postoperative X-ray of the right ankle.
quently in sports action. Treatments of this condition in-
clude surgery or non-surgery treatment [3]. Open reduc-
tion and primary repair of tendon are gold Standard and
various surgical techniques have been described [4]. Com-
bined with medial malleolar fracture, acute Achilles ten-
don is rare and injury mechanism generally consists of
suddenly loading energy to ankle and forefoot [2]. Six
cases have been reported in the literature up to this date,
and the causes of these concominant injuries were motor
vehicle accident in one case, sports injuries in two cases
and fall or false step on stairs or ladder in three cases.
Detailed history of these patients revealed that injuries
consist of hyperextansion of forefoot which might cause
Achilles tendon rupture and then hindfoot inversion with
resultant medial malleolar fracture.
The mechanism of injury in our case was consistent
with the previus reports of concominant Achilles tendon
rupture with isolated medial malleolar fracture. Assal at
al recommended that patients with a supination adduction
ankle injury should have an examination of Achilles
tendon integrity although this is also true for eversion
injuries [5]. Lugger at al found 5.3% insidance of medial
malleolar fracture in Alpine skiers who sustained an
Achilles tendon rupture due to eversion type injuries [6].
Six cases have been reported in the literature up to this
date, but we belive that its insidance is more than that.
4. Conclusion
Routine antero-posterior and lateral X-rays should be
taken in acute Achilles tendon injuries to identify bone
lesion and in ankle injuries systemic examination should
be made to show the soft tissue condition for acute Ach-
illes tendon rupture, especially if injury mechanism in-
cludes hindfoot inversion and hyperextension of forefoot.
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Achilles Tendon Rupture with Isolated Medial Malleolar Fracture in Ipsilateral Ankle: A Case Report
Copyright © 2013 SciRes. OJO
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