Missed peroneus longus tendon laceration following plate-glass injury: A pitfall in the emergency department

Abstract

A thorough exploration of traumatic wound is critical to accurately assess the severity of the injury. When it comes to glass-related injuries, the diagnosis of a glass foreign body is often prioritized over identifying any underlying damage. The authors report a case of peroneus longus tendon rupture caused by plate-glass accident that was misdiagnosed in the emergency department (ED) as a superficial laceration.

Introduction

While chronic degenerative tears are well documented, complete rupture of peroneal longus (PL) tendon caused by open injuries is a rare occurrence [1]. The article highlights a missed PL tendon laceration during the initial ED evaluation in an active male presented following a plate glass injury. Further, it provides management plan for delayed presentation due to misdiagnosis and proposes effective strategies for preventing such occurrences in the emergency department (ED).

Case

A 45-year-old man arrived at the ED with a 3-in., reverse L-shaped laceration on his left lower leg. The injury occurred when a large piece of plate glass he was carrying slipped and fell. (Fig. 1).

Fig. 1.

Patient's initial presentation to ED with laceration at the lateral aspect of left lower leg.

Plain radiographs showed no evidence of a glass foreign body. Per ED provider's note, wound was explored under local anesthetic revealing partial tendon and muscle belly transection. These were repaired using 3-0 Vicryl, and skin was closed with staples.

Plain radiographs showed no evidence of a glass foreign body. Per ED provider's note, wound was explored under local anesthetic revealing partial tendon and muscle belly transection. These were repaired using 3-0 Vicryl, and skin was closed with staples.

After two weeks, the sutures were removed, and wound healed without issues. Due to ongoing ankle pain and weakness, patient presented to us three weeks after injury. Examination showed weak eversion and limited ankle range of motion (ROM). The distal neurovascular function was preserved. A subsequent magnetic resonance imaging (MRI) scan demonstrated complete rupture of PL tendon with 3 cm retraction and partial tear of peroneus brevis (PB) tendon (Fig. 2A and B). Given the findings and active functional status, patient was recommended surgical exploration for possible primary repair versus allograft reconstruction.

Fig. 2.

Sagittal (A) and coronal (B) T2 MRI images showing full-thickness PL rupture with a 3-cm gap. C, intraoperative image showing distal extension of exposure to retrieve retracted distal stump of PL. Placement of freer elevator inside the retinaculum before opening the sheath. D, Exposure of partial-thickness split tear of PB, held with pen rose drain. The PL retracted stumps were held with allis clamps. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Operative technique

It took one month after the injury for the surgery to be carried out. Reopening the previous wound revealed full-thickness rupture of PL tendon. Additional distal exposure was required to reveal the retracted distal stump that was found to be adhered to PB tendon (Fig. 2C). The underlying PB had partial-thickness split tear at muscle-tendon junction with frayed Vicryl sutures applied in ED (Fig. 2D). It was clear that the completely severed PL injury was missed due to significant retraction of the tendon stumps. No foreign bodies or pieces of glass were detected. Following extensive debridement, the tendons demonstrated adequate mobility for a tension-free primary repair. First, the PB split tear was tubularized using 2-0 Ethibond suture (Fig. 3A).

Fig. 3.

A, Tubularization of PB tear. B, Core suture application of PL tendon stumps. C, Completed tendon repair with stable relocation in peroneal groove. D, Repair of peroneal retinaculum over Freer elevator for tension-free approximation.

For repairing PL tendon, 2-0 Ethibond was used as a core suture, followed by 3-0 Vicryl circumferential suture for added strength (Fig. 3B and C). The repaired tendons were returned to the groove, and retinaculum was repaired over a freer elevator with 3-0 Prolene (Fig. 3D). The final ROM confirmed stable repair with adequate tendons mobility. After a layered closure, the extremity was secured in short-leg splint and patient was discharged home with nonweightbearing instructions for six weeks.

Postoperative follow-up

Sutures were removed two weeks after surgery, and patient was fitted with a cast. At four weeks, the cast was replaced with boot to enable ROM, and weightbearing and therapy started at six weeks. The patient began resistance training after eight weeks and returned to previous activities after 12 weeks. He then noticed a prominent knot stack of one of the Prolene stitches behind the lateral malleolus, causing shoe wear irritation. Under local anesthesia and sedation, it was removed without difficulty and symptoms were resolved. At the final follow-up, six months after surgery, patient regained full eversion strength (5/5) without any pain at repair site and had equal ROM (Fig. 4).

Fig. 4.

Six-month follow-up visit showing the symmetrical range of ankle motion.

Discussion

It's well known that early surgical intervention is the most effective way to manage a clearly divided tendon as it allows for primary repair and maximizes outcomes [2]. Unfortunately, such injuries can go undetected and present later with chronic ankle pain and instability [7]. Little has been reported in the literature regarding missed traumatic ruptures of the peroneal tendon during ED visits. In cases of glass injuries, there is often too much focus on diagnosing a glass foreign body rather than the diagnosis of underlying damage. A delayed or missed diagnosis not only compromises outcomes but is also a leading cause of malpractice lawsuits in ED. [3] Through this case report, we sought to create awareness of early recognition and describe effective diagnostic measures as well as our surgical approach for delayed presentation.

Peroneal tendon ruptures in adults are usually a result of chronic overuse, often with an underlying deformity and instability [4]. The PB tendon is most frequently torn, as it is situated right behind the bone and exposed to mechanical friction during ROM [5]. However, PL is the first to be injured with lacerations around lower leg, as it is superficial. Due to its tendinous nature, the severed ends may retract from the injury zone, making them difficult to notice in a busy ED setting. This is what happened to our patient: only partial-thickness PB tear was identified and repaired, while the full-thickness discontinuity of PL tendon was left out. Notably, retracted tendon stumps are vulnerable to scarring and atrophy, often necessitating tendon transfer or allograft reconstruction. Despite the delay in surgery, primary repair was still feasible in this instance. However, it did require further exposure and soft tissue releases, increasing the chances of potential complications that could have been prevented with a timely diagnosis.

Realizing that tendon injuries can often go undetected if not actively sought out, we propose the following sequence of steps in the ED.

• 1.Be wary of potential tendon injuries, no matter how superficial the wound may appear.
• 2.Have low threshold to extend the wound margins for a thorough evaluation.
• 3.Follow three mandatory requirements before any wound exploration: adequate local anesthetic, optimal lighting, and a bloodless field (a simple 3-min elevation of the extremity with blood pressure cuff inflated to 20 mm above the systolic pressure is an effective measure).
• 4.Explore each tendon individually for visual continuity; move the adjacent joints to bring retracted cut ends into the field, if any, and test for each tendon function distal to the wound.
• 5.Vague terms as ‘tendons intact’ are often misleading and should be avoided. Reporting should be done separately for each tested tendon [6].
• 6.Finally, don't hesitate to consult orthopaedics when in doubt.

Conclusion

High suspicion of underlying tendon laceration is crucial to avoid misdiagnosis in open injuries, such as those caused by plate-glass trauma. This case report serves as a reminder of how important a thorough physical examination is in arriving at an accurate diagnosis. The strategies outlined could potentially be effective in preventing such incidents in the ED.

CRediT authorship contribution statement

Sreenivasulu Metikala: Conceptualization, Investigation, Resources, Writing – original draft, Writing – review & editing. Jeffrey Byrd: Writing – original draft, Writing – review & editing. Madana Vallem: Writing – original draft, Writing – review & editing. Khalid Hasan: Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare we have no competing interest or personal relationships that could have appeared to influence the work reported in this case report.