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Closed rupture of the musculotendinous junction of extensor hallucis longus
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No. 6
378
1. 29.10.86
2. 12.02.87
3. 14.02.87
Figure 1. Composite photograph of a series of radiographs of the right tibia.
This case is unlike McMaster’s series in that it followed direct trauma, which presumably caused a tear in the interosseous membrane. The resulting synostosis produced severe symptoms and a late recurrence despite adequate initial resection and the use of gelfoam block for haemostasis. This case illustrates that excision of the fibula may be necessary to prevent recurrent tibiofibular synostosis.
Gamble B. (1984) Proximal tibiofibuku synostosis, a case report. J. Pediatr. Or&p. 4, 243. McMaster J. and Scranton P. (1975) Tibiofibular synostosis, a cause of ankle disability. C/in. orthop. 111,172. Wong K. and Weiner D. Proximal tibiofibular synostosis. Clin. orthop. 135,45.
Paper accepted 22 June 1989.
References Andrisano A. and CapeJJi A. (1982) Le sinostosi tibio-peroneal dish& post-traumatiche. Chir. Organi Mov. 58, 713.
Requests for reprints shouM be ahirtsed to: Mr D. J. Harbome, Accident and Emergency Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester CL1 3NN.
Closed rupture of the musculotendinous extensor hallucis longus
junction of
P. Menz and W. J. S. Nettle Department
of Plastic Surgery, Flinders Medical Centre, Adelaide, South Australia
Introduction A case of closed rupture of the musculotendinous junction of the extensor haJlucis longus is reported. This unusual injury was sustained by rapid, powerful forced flexion of the great toe against resistance. This type of injury has not previously been reported in the literature. The injury is postulated to be 0 1989 Buttenvorth & Co (Publishers) Ltd 0020-1383/89/0603784 $03.00
a late complication damage sustained blood supply at the successful outcome dition
of fracture of the distal tibial shaft, with to the segmental muscle and tendon time of fracture. This case demonstrates of surgical management of this con-
Case reports
Figure 1. Demonstrating after football injury.
inability to dorsiflex
the right hallux
Case report
Figure 2. Plain radiographs showing spiral fracture of the distal tibiaI shaft and associated fibuIar shaft fracture sustained 4 years before presentation.
A fit, 16-year-old male was unable to extend his right large toe 6 weeks after trauma sustained while playing football. He had attempted to kick the football, but had succeeded only in kicking the ground with the dorsal aspect of his right hallux before connecting with the ball. He was immediately unable to extend the toe. On examination he had a clinically obvious closed rupture of his right extensor hallucis longus (Fi~re I). There were no other injuries revealed on clinical examination. Relevant past history included a closed spiral fracture of the right distal tibial shaft with an associated oblique fracture of the distal fib&r shaft (Figure 2). He had sustained this fracture some 4 years before presentation following a fall down a rock-face. This was managed by closed reduction and full leg plaster immobilization with early weight bearing. Bony union was obtained with a fully functional and painless lower limb. At operation an isolated complete rupture of the extensor hallucis longus musculotendinous junction was found (Figure3). This area was excised. Histology showed ischaemic changes in the skeletal m&e, as weII as a centraI fibrous tissue fragment also showing ischaernic changes. There was no bony callus or bony spur interfering with muscle or tendon function. Primary repair was not possible. The tendon of peroneus tertius was mobilized and directly attached to the trimmed extensor hallucis longus tendon above the ankle (Figure 4). A woven tendon repair using S/O monofilament nylon was used. The repair was followed by 3 weeks immobilization in plaster with the large toe dorsiflexed, and by subsequent physiotherapy. Healing proceeded unevenMy. Six months after surgery, extension of the hallux was almost the same as the opposite side (Figure 5). Plantarflexion remained unaffected. No functional disability could be elicited.
Discussion Closed rupture of the musculotendinous junction of extensor hallucis longus (EHL) is an unusual injury not previously reported in the literature. One case of closed rupture of the extensor hallucis longus tendon distal to the musculotendinous junction has been reported by Sim and De Weerd (1977). They reported closed rupture of the EHL tendon in the midfoot of a 17-year-old snow-skier, with the postulated aetiology being sustained forced extension of the great toe against the ski boot. Other previously reported injuries to
Figure 3. Complete rupture of the musculotendinous extensor
junction of
hallucis longus.
the EHL tendon have been direct traumatic laceration of the tendon (Lipscomb and Kelly, 1955; Anzel et al., 1959). In the region of the ankle, closed rupture of tibialis
380
Injury: the British Journal of Accident Surgery (1989) Vol.ZO/No.6
Figure 5. Extension of the right hallux compared opposite side 6 months after repair.
Figure 4. Peroneus tertius tendon directly attached shortened distal extensor hallucis longus tendon.
with
the
to the
anterior tendon has been described; this tends to occur in diabetics aged over 45 years (Dooley et al., 1980). Kashyap and Prince (1987) note that spontaneous rupture of the tendon in these cases normally occurs at the musculotendinous junction, as occurred in our case. However, our patient was young and not diabetic. In our case, trauma to the segmental blood supply of the EHL musculotendinous junction caused by previous distal tibial/fibular shaft fracture is the proposed mechanism of closed rupture. The origin of the extensor hallucis longus is the mid-anterior fibula and adjoining interosseous membrane and it inserts into the dorsal aspect of the proximal and distal phalanx of the hallux (Williams and Warwick, 1980). Its vascular supply consists of five or six arterial pedicles from the anterior tibial artery which enter the medial border of the muscle &Lathes and Nahai, 1979) (Figure6). We propose that these vessels were damaged 4 years prior to presentation when the patient sustained a closed distal tibiabfibular shaft fracture, causing critical musculotendinous devasculari&ion. The resulting weakening of the EHL musculotendinous junction was not evident until severely strained playing football. M&laster (1933) in his classic experiments showed that normal healthy tendon under stress does not rupture, but rupture occurs elsewhere in the musculotendinous unit. He also demonstrated that obstruction to the blood supply of 1 cm of normal tendon will predispose to tendon rupture.
Figure 6. Segmental blood supply of extensor hallucis longus from the anterior tibia1 artery with proposed disruption caused by tibial shaft fracture 4 years before presentation.
Many local and systemic conditions are known to predispose to weakening of the tendon, in turn predisposing to closed rupture in situations of less than maximal strain, or even everyday use. Conditions which have been described
381
Case reports
include rheumatoid arthritis, overuse, lipoma, steroid therapy, uraemia, gonorrhoea and tuberculous synovitis (Miki et al., 1986). A simii weakening or attrition occurs when tendons rub over rough bony surfaces or screws used in fracture fixation. There was no evidence of bony interference with muscular or tendinous function in our case, despite the previous fracture. Peroneus tertius muscle and tendon was chosen for repair. This muscle and tendon satisfied the principles of tendon transfer, namely muscular synergy, appropriate length of transferred tendon, adequate muscle strength and absence of critical preoperative muscle function (Verdan, 1979). The peroneus tertius is part of the extensor digitorum longus, and could be described as its fifth tendon. It is not always present (Williams and Warwick, 1980). Both extensor hallucis longus and peroneus tertius function in toe extension, hence muscular synergy is maintained. Peroneus tertius is not of critical importance in joint stability, and so may be utilized in this way without undue consequence. As shown by our case, excellent range of movement is returned by this tendon transfer, with no functional disability.
rupture of the tendon of tibialis anterior. 1. Bone]oint Surg. 62% 471. Kashyap S. and Prince R. (1987) Spontaneous rupture of tibialis anterior tendon. Clin. Orthop. 216,159. Lipscomb P. R. and Kelly P. J. (1955) Injuries of the extensor tendons in the distal part of the leg and in the ankle. J. BoneJoinf surg. 37A,1206. Mathes S. J. and Nahai F. (1979) Clinical Alhs of Muscle and Musculocutaneous Flaps.St Louis: C. V. Mosby Co. McMaster P. E. (1933) Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. 1. ‘BoneJoint Surg. 15,705. Miki T., Yamamuro T., Kotoura, Y. et al. (1986) Rupture of extensor tendons of fingers. 1, BoneJoint Surg. 68A, 160. Sim F. H. and De Weerd J. H. (1977) Rupture of the extensor hallucis longus tendon while skiing. Minn. Med. 60, 789. Verdan C. (1979) The general principles of tendon transfer in the hand and forearm. In: Verdan C. (ed.) TendonSurgery oftheHanA. Edinburgh: Churchill Livingstone, ch. 19. Williams P. L. and Warwick R. (1980). Gray’s Anatomy. 36th
Edition. Edinburgh: Churchill Livingstone.
Paper accepted 23 July 1989.
References Anzel S. H., Covey K. W., Weiner A. D. et al. (1959) Disruption of
muscles and tendons: a report of 1014 cases. Surgery 45, 406. Dooley B. J., Kudelka P. and Menelaus M. B. (1980) Subcutaneous
RequestsfurreprintsshouMbe addressedto: Mr P. Menz, Department of Plastic Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042.
Blunt injury to the spinal accessory nerve Nabil H. Aziz and David T. Shakespeare Orthopaedic
Deptient,
South Warwickshire
General Hospital, Warwick, UK
Introduction Injuries to the accessory nerve are uncommon and are usually due to injuries of the neck or lymph node biopsy (King and Motta, 1983; Vastamaki and Solonen, 1984). Rarely, blunt injury such as by biting is involved (Paljarvi and Partanen, 1980). We present two such cases, together with a review of the anatomy and functions of the nerve.
Case report Two men attended a night club and on descending
the stairs they an inebriated individual who greeted them by biting each in turn on the right side of the neck. Both men experienced severe pain in the neck and noticed weakness of the right shoulder; no wounds were sustained. When examined some weeks later both men were found to have obvious wasting of the right trapezius muscle (figures I, 2). Abduction was limited to 80". Electromyogram (e.m.g.) studies revealed damage to the accessory nerve as it crossed the posterior triangle of the neck. Six months after injury, symptoms had settled and power had returned, but some wasting remained. encountered
0 1989 Butterworth & Co (Publishers) Ltd OOZO-1383/89/060381-02 $03.00
Anatomical considerations The accessory nerve lies superficially in the posterior triangle (Figure 3). This makes it vulnerable to biting, amorous or otherwise. The spinal accessory nerve emerges from the posterior border of the sternomastoid muscle after supplying it on its deep surface. It then passes obliquely beneath the deep fascia on the levator scapulae muscle where it receives contributions from C2 and 0. Beneath the anterior border of the trapezius it receives contributions from C3 and C4 to form a plexus. There are three functional sections of the trapezius: The superior section passively supports the shoulder girdle and actively elevates the shoulder with the levator scapulae. The middle section stabilizes the scapula to the chest wall during scapular rotation and controls the scapular rotation around the chest wall in forward flexion. The inferior section provides the lower force couple for rotation with the serratus anterior muscle.
378
1. 29.10.86
2. 12.02.87
3. 14.02.87
Figure 1. Composite photograph of a series of radiographs of the right tibia.
This case is unlike McMaster’s series in that it followed direct trauma, which presumably caused a tear in the interosseous membrane. The resulting synostosis produced severe symptoms and a late recurrence despite adequate initial resection and the use of gelfoam block for haemostasis. This case illustrates that excision of the fibula may be necessary to prevent recurrent tibiofibular synostosis.
Gamble B. (1984) Proximal tibiofibuku synostosis, a case report. J. Pediatr. Or&p. 4, 243. McMaster J. and Scranton P. (1975) Tibiofibular synostosis, a cause of ankle disability. C/in. orthop. 111,172. Wong K. and Weiner D. Proximal tibiofibular synostosis. Clin. orthop. 135,45.
Paper accepted 22 June 1989.
References Andrisano A. and CapeJJi A. (1982) Le sinostosi tibio-peroneal dish& post-traumatiche. Chir. Organi Mov. 58, 713.
Requests for reprints shouM be ahirtsed to: Mr D. J. Harbome, Accident and Emergency Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester CL1 3NN.
Closed rupture of the musculotendinous extensor hallucis longus
junction of
P. Menz and W. J. S. Nettle Department
of Plastic Surgery, Flinders Medical Centre, Adelaide, South Australia
Introduction A case of closed rupture of the musculotendinous junction of the extensor haJlucis longus is reported. This unusual injury was sustained by rapid, powerful forced flexion of the great toe against resistance. This type of injury has not previously been reported in the literature. The injury is postulated to be 0 1989 Buttenvorth & Co (Publishers) Ltd 0020-1383/89/0603784 $03.00
a late complication damage sustained blood supply at the successful outcome dition
of fracture of the distal tibial shaft, with to the segmental muscle and tendon time of fracture. This case demonstrates of surgical management of this con-
Case reports
Figure 1. Demonstrating after football injury.
inability to dorsiflex
the right hallux
Case report
Figure 2. Plain radiographs showing spiral fracture of the distal tibiaI shaft and associated fibuIar shaft fracture sustained 4 years before presentation.
A fit, 16-year-old male was unable to extend his right large toe 6 weeks after trauma sustained while playing football. He had attempted to kick the football, but had succeeded only in kicking the ground with the dorsal aspect of his right hallux before connecting with the ball. He was immediately unable to extend the toe. On examination he had a clinically obvious closed rupture of his right extensor hallucis longus (Fi~re I). There were no other injuries revealed on clinical examination. Relevant past history included a closed spiral fracture of the right distal tibial shaft with an associated oblique fracture of the distal fib&r shaft (Figure 2). He had sustained this fracture some 4 years before presentation following a fall down a rock-face. This was managed by closed reduction and full leg plaster immobilization with early weight bearing. Bony union was obtained with a fully functional and painless lower limb. At operation an isolated complete rupture of the extensor hallucis longus musculotendinous junction was found (Figure3). This area was excised. Histology showed ischaemic changes in the skeletal m&e, as weII as a centraI fibrous tissue fragment also showing ischaernic changes. There was no bony callus or bony spur interfering with muscle or tendon function. Primary repair was not possible. The tendon of peroneus tertius was mobilized and directly attached to the trimmed extensor hallucis longus tendon above the ankle (Figure 4). A woven tendon repair using S/O monofilament nylon was used. The repair was followed by 3 weeks immobilization in plaster with the large toe dorsiflexed, and by subsequent physiotherapy. Healing proceeded unevenMy. Six months after surgery, extension of the hallux was almost the same as the opposite side (Figure 5). Plantarflexion remained unaffected. No functional disability could be elicited.
Discussion Closed rupture of the musculotendinous junction of extensor hallucis longus (EHL) is an unusual injury not previously reported in the literature. One case of closed rupture of the extensor hallucis longus tendon distal to the musculotendinous junction has been reported by Sim and De Weerd (1977). They reported closed rupture of the EHL tendon in the midfoot of a 17-year-old snow-skier, with the postulated aetiology being sustained forced extension of the great toe against the ski boot. Other previously reported injuries to
Figure 3. Complete rupture of the musculotendinous extensor
junction of
hallucis longus.
the EHL tendon have been direct traumatic laceration of the tendon (Lipscomb and Kelly, 1955; Anzel et al., 1959). In the region of the ankle, closed rupture of tibialis
380
Injury: the British Journal of Accident Surgery (1989) Vol.ZO/No.6
Figure 5. Extension of the right hallux compared opposite side 6 months after repair.
Figure 4. Peroneus tertius tendon directly attached shortened distal extensor hallucis longus tendon.
with
the
to the
anterior tendon has been described; this tends to occur in diabetics aged over 45 years (Dooley et al., 1980). Kashyap and Prince (1987) note that spontaneous rupture of the tendon in these cases normally occurs at the musculotendinous junction, as occurred in our case. However, our patient was young and not diabetic. In our case, trauma to the segmental blood supply of the EHL musculotendinous junction caused by previous distal tibial/fibular shaft fracture is the proposed mechanism of closed rupture. The origin of the extensor hallucis longus is the mid-anterior fibula and adjoining interosseous membrane and it inserts into the dorsal aspect of the proximal and distal phalanx of the hallux (Williams and Warwick, 1980). Its vascular supply consists of five or six arterial pedicles from the anterior tibial artery which enter the medial border of the muscle &Lathes and Nahai, 1979) (Figure6). We propose that these vessels were damaged 4 years prior to presentation when the patient sustained a closed distal tibiabfibular shaft fracture, causing critical musculotendinous devasculari&ion. The resulting weakening of the EHL musculotendinous junction was not evident until severely strained playing football. M&laster (1933) in his classic experiments showed that normal healthy tendon under stress does not rupture, but rupture occurs elsewhere in the musculotendinous unit. He also demonstrated that obstruction to the blood supply of 1 cm of normal tendon will predispose to tendon rupture.
Figure 6. Segmental blood supply of extensor hallucis longus from the anterior tibia1 artery with proposed disruption caused by tibial shaft fracture 4 years before presentation.
Many local and systemic conditions are known to predispose to weakening of the tendon, in turn predisposing to closed rupture in situations of less than maximal strain, or even everyday use. Conditions which have been described
381
Case reports
include rheumatoid arthritis, overuse, lipoma, steroid therapy, uraemia, gonorrhoea and tuberculous synovitis (Miki et al., 1986). A simii weakening or attrition occurs when tendons rub over rough bony surfaces or screws used in fracture fixation. There was no evidence of bony interference with muscular or tendinous function in our case, despite the previous fracture. Peroneus tertius muscle and tendon was chosen for repair. This muscle and tendon satisfied the principles of tendon transfer, namely muscular synergy, appropriate length of transferred tendon, adequate muscle strength and absence of critical preoperative muscle function (Verdan, 1979). The peroneus tertius is part of the extensor digitorum longus, and could be described as its fifth tendon. It is not always present (Williams and Warwick, 1980). Both extensor hallucis longus and peroneus tertius function in toe extension, hence muscular synergy is maintained. Peroneus tertius is not of critical importance in joint stability, and so may be utilized in this way without undue consequence. As shown by our case, excellent range of movement is returned by this tendon transfer, with no functional disability.
rupture of the tendon of tibialis anterior. 1. Bone]oint Surg. 62% 471. Kashyap S. and Prince R. (1987) Spontaneous rupture of tibialis anterior tendon. Clin. Orthop. 216,159. Lipscomb P. R. and Kelly P. J. (1955) Injuries of the extensor tendons in the distal part of the leg and in the ankle. J. BoneJoinf surg. 37A,1206. Mathes S. J. and Nahai F. (1979) Clinical Alhs of Muscle and Musculocutaneous Flaps.St Louis: C. V. Mosby Co. McMaster P. E. (1933) Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. 1. ‘BoneJoint Surg. 15,705. Miki T., Yamamuro T., Kotoura, Y. et al. (1986) Rupture of extensor tendons of fingers. 1, BoneJoint Surg. 68A, 160. Sim F. H. and De Weerd J. H. (1977) Rupture of the extensor hallucis longus tendon while skiing. Minn. Med. 60, 789. Verdan C. (1979) The general principles of tendon transfer in the hand and forearm. In: Verdan C. (ed.) TendonSurgery oftheHanA. Edinburgh: Churchill Livingstone, ch. 19. Williams P. L. and Warwick R. (1980). Gray’s Anatomy. 36th
Edition. Edinburgh: Churchill Livingstone.
Paper accepted 23 July 1989.
References Anzel S. H., Covey K. W., Weiner A. D. et al. (1959) Disruption of
muscles and tendons: a report of 1014 cases. Surgery 45, 406. Dooley B. J., Kudelka P. and Menelaus M. B. (1980) Subcutaneous
RequestsfurreprintsshouMbe addressedto: Mr P. Menz, Department of Plastic Surgery, Flinders Medical Centre, Bedford Park, South Australia 5042.
Blunt injury to the spinal accessory nerve Nabil H. Aziz and David T. Shakespeare Orthopaedic
Deptient,
South Warwickshire
General Hospital, Warwick, UK
Introduction Injuries to the accessory nerve are uncommon and are usually due to injuries of the neck or lymph node biopsy (King and Motta, 1983; Vastamaki and Solonen, 1984). Rarely, blunt injury such as by biting is involved (Paljarvi and Partanen, 1980). We present two such cases, together with a review of the anatomy and functions of the nerve.
Case report Two men attended a night club and on descending
the stairs they an inebriated individual who greeted them by biting each in turn on the right side of the neck. Both men experienced severe pain in the neck and noticed weakness of the right shoulder; no wounds were sustained. When examined some weeks later both men were found to have obvious wasting of the right trapezius muscle (figures I, 2). Abduction was limited to 80". Electromyogram (e.m.g.) studies revealed damage to the accessory nerve as it crossed the posterior triangle of the neck. Six months after injury, symptoms had settled and power had returned, but some wasting remained. encountered
0 1989 Butterworth & Co (Publishers) Ltd OOZO-1383/89/060381-02 $03.00
Anatomical considerations The accessory nerve lies superficially in the posterior triangle (Figure 3). This makes it vulnerable to biting, amorous or otherwise. The spinal accessory nerve emerges from the posterior border of the sternomastoid muscle after supplying it on its deep surface. It then passes obliquely beneath the deep fascia on the levator scapulae muscle where it receives contributions from C2 and 0. Beneath the anterior border of the trapezius it receives contributions from C3 and C4 to form a plexus. There are three functional sections of the trapezius: The superior section passively supports the shoulder girdle and actively elevates the shoulder with the levator scapulae. The middle section stabilizes the scapula to the chest wall during scapular rotation and controls the scapular rotation around the chest wall in forward flexion. The inferior section provides the lower force couple for rotation with the serratus anterior muscle.