![]() Several techniques for surgical repair exist, the most common being repair of the medial flexor retinaculum with or without retromalleolar groove deepening. The literature has demonstrated conservative management of tibialis posterior dislocation to be inadequate in most or all cases. If clinical concern for tibialis posterior dislocation were to arise in the future, surgical treatment would be considered. Medial flexor retinacular avulsion injury in the absence of tendon dislocation does not necessarily require surgical management, and this component of our patient's injuries was thus managed nonoperatively. The ankle tendons are routinely evaluated and described on CT at our institution. Soft tissue algorithm CT, as in our case, is quite good at evaluating gross integrity and position of the tibialis posterior. Magnetic resonance imaging exam is most sensitive for subluxation of the tibialis posterior, but has been known to miss dynamic subluxations because of positioning. Therefore, this finding is equivocal for tibialis posterior fibro-osseous tunnel injury.Īxial CT demonstrates partial medial subluxation of the tibialis posterior tendon (arrow). The posterior tibial tendon is slightly, but not frankly, subluxed in the medial direction ( Fig. In our case, the posteromedial tibia fibrocartilaginous avulsion fragment is seen in a classic and easily recognizable position, and is attached to the avulsed and redundant flexor retinaculum ( Fig. It is the largest, most medial, and most anterior of the tarsal tunnel structures. The tibialis posterior normally courses in the retromalleolar groove of the posteromedial tibia. ![]() Injury to the medial flexor retinaculum can contribute to medial subluxation of the tibialis posterior tendon, but injury to the tendon fibro-osseous tunnel is usually also required for frank dislocation to occur. Medial flexor retinaculum tears usually occur at the insertion of the ligament on the posteromedial tibia. In fact, approximately one third of acute superficial deltoid ligament injuries have an associated medial flexor retinaculum injury. Medial flexor retinaculum injuries are also usually associated with deltoid ligament injuries. Lateral radiograph with graphic overlay demonstrating position of flexor retinaculum.įorced ankle eversion and forced dorsiflexion with a contracted tibialis posterior tendon is the most common mechanism of tendon subluxation, though the phenomenon is also seen with medial malleolar fractures. 4).įorty-three-year-old male with medial ankle flexor retinaculum avulsion fracture. Three days later a computed tomography (CT) scan was performed, which among other injuries demonstrated an unusual medial flexor retinacular avulsion fracture from the medial aspect of the posterior malleolus, with associated avulsion fragment ( Fig. He was then taken to the operating room, where he underwent joint irrigation, removal of numerous small osseous and cartilaginous fragments, and external ankle fixation. The patient was reduced in the emergency department under conscious sedation. Radiographs demonstrated markedly displaced and overlapping subtalar dislocation, posterior talar process avulsion fragment, other scattered smaller ossific bodies, foreign body debris, open wound, and soft tissue gas ( Fig. Initial physical exam demonstrated intact flexor hallucis function, with limited assessment of the other ankle tendons due to joint deformity. Medial ankle injuries can damage the above structures in a predictable manner, with implications for treatment.Īn otherwise healthy 43-year-old male tumbled a long distance while hiking and landed in a swamp, sustaining an open and contaminated ankle fracture-dislocation. The deep and superficial deltoid ligament components are additional important and commonly injured medial ankle soft tissue structures. Small fibrous septa arising from the medial retinaculum undersurface and extending to the calcaneal periosteum subdivide the tarsal tunnel. The medial and anterior borders of the tarsal tunnel are the posteromedial tibia including the retromalleolar groove, as well as the sustentaculum tali. The tarsal tunnel is medially and posteriorly enclosed by the flexor retinaculum, a thin fibrocartilaginous structure similar in shape and composition to other anatomic retinacula. These structures course distally beyond the medial ankle to the foot. The tarsal tunnel transmits the tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial vessels and nerves, and flexor hallucis longus tendon. In this case report, the medial flexor retinaculum and associated medial ankle structures will be discussed. ![]() While less common than lateral ankle injury, medial ankle pathology is a significant cause of disability.
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