Bilateral Achilles tendon injury in a 14-year-old adolescent: case report

Abstract

Introduction:

Achilles tendon (AT) wounds are defined as partial or complete disruptions of the tendon that create direct communication with the external environment [2] Lamah L Diallo M Tekpa JBD. The incidence of bilateral AT lacerations in children remains unknown. We report a case of simultaneous bilateral AT laceration in a 14-year-old adolescent following a domestic accident.

Case report:

A 14-year-old male adolescent with no prior medical history was admitted to the emergency department for open ankle trauma following a domestic accident. While walking backward, his heels struck a sheet of metal lying on the ground. He presented with complete functional impairment, linear wounds with a depression over both ATs. Clinical examination revealed a positive bilateral Thompson test. The diagnosis of a total, bilateral AT laceration was confirmed. Surgical debridement and tendon repair were performed, followed by immobilization of the ankles in equinus position for 3 weeks, then at 90° for another 3 weeks. Postoperative recovery was uneventful, with normal walking and return to activities by 8 months after surgery.

Discussion:

While various series of AT wounds have been described in the literature, no cases of simultaneous bilateral AT wounds have been previously reported. To our knowledge, this is the first reported case of a simultaneous, complete bilateral AT laceration in a child.

Conclusion:

This case report describes a complete transection of the AT resulting from a domestic accident. The case underscores the potential hazards associated with household injuries.

Introduction

The Achilles tendon (AT) is formed by the fusion of the tendons of the soleus and the gastrocnemius muscles. It descends into the posterior region of the ankle and inserts onto the lowest part of the posterior surface of calcaneus. There are two injuries of AT: traumatic injuries and ruptures caused by muscular contraction^[1]. Traumatic injuries can be further subdivided into two mechanisms: open injuries (or wounds), which result from penetrating trauma, and closed injuries, which are associated with blunt trauma. AT wounds are defined as partial or complete disruptions of the tendon that communicates with the external environment^[2].

AT rupture is a spontaneous subcutaneous injury of the tendon, most commonly affecting male athletes between the ages of 30 and 50^[3]. It typically occurs during a forceful jump, a sudden acceleration while running, or excessive pressure. Simultaneous bilateral AT rupture is rare in children, as are bilateral tendon wounds. The incidence of bilateral AT rupture is less than 1%^[3–5], though several case reports have been documented in the literature^[6–11]. The incidence of AT wounds in children remains unknown. In accordance with the SCARE guidelines^[12], we report a case of simultaneous bilateral AT laceration in a 14-year-old adolescent following a domestic accident. This case report has been reported in line with the SCARE checklist^[12].

HIGHLIGHTS

• Achilles tendon wounds are defined as partial or complete disruptions of the tendon that create direct communication with the external environment. The incidence of bilateral Achilles tendon rupture is less than 1%.

• The incidence of bilateral AT lacerations in children remains unknown. We report a case of simultaneous bilateral Achilles tendon laceration in a 14-year-old adolescent following a domestic accident.

• We presented this work at the 8th Congress of the Ivorian Society of Orthopedic and Traumatological Surgery, and we would be delighted to have our work accepted for publication in this journal as a clinical case.

Case report

A 14-year-old male adolescent with no significant past medical history was admitted to the emergency department with open trauma to both ankles following a domestic accident. The patient was not an athlete, had no history of clubfoot treated with the Ponseti method, and had no other relevant medical history. While walking backward, his heels reportedly struck a sheet of metal lying on the ground. He presented with complete functional impairment, horizontal wounds with depressions over both AT, and an inability to stand on his toes (Fig. 1). With the patient in the prone position and the feet hanging off the examination table, compression of the calf produced no plantar flexion of either foot. Physical examination revealed complete bilateral AT laceration. Imaging showed no associated bone lesions.

Figure 1.

Bilateral Achilles tendon section. (A) Left tendon and (B) right tendon.

A diagnosis of simultaneous bilateral AT laceration was made. Under general anesthesia, with the patient in the prone position, we performed debridement and tendon repair using slow-absorbing sutures with Kessler knots. The skin closure was done with interrupted sutures using fast-absorbing thread (Fig. 2). The ankle was immobilized in an equinus position with a plaster boot for 3 weeks, followed by immobilization at 90° for an additional 3 weeks. Rehabilitation started after removal of the second cast. Recovery was uneventful, with normal walking after four physiotherapy sessions and full return to activity without pain at 8 months postoperatively (Fig. 3).

Figure 2.

Bilateral Achilles tendon suture. (A) Left tendon and (B) right tendon.

Figure 3.

Clinical appearance 6 weeks after removal of the second cast. (A) Left tendon and (B) right tendon.

Discussion

AT rupture is a common injury among young adult male athletes aged 30–50 years^[1,13,14]. Ruptures are rare in the pediatric population, with only a few case reports found in the literature^[8–11] and Ashebo published the largest series of pediatric AT ruptures in 2023^[1]. However, Antony C et al reported a case of bilateral AT rupture in an adolescent with a history of bilateral Achilles tenotomy for clubfoot correction at 11 weeks of age^[7]. While various series of AT wounds have been described in the literature, no cases of simultaneous bilateral AT wounds have been previously reported^[1,2,15,16]. To our knowledge, this is the first reported case of a simultaneous, complete bilateral AT laceration in a child. In Ashebo’s series^[1], open laceration injuries occurred in younger patients (12 years or younger). This case highlights the dangers of domestic accidents in our setting^[17].

In adult patients with AT rupture, conservative (non-surgical) and surgical treatments are often compared, but there are no specific studies or recommendations for AT rupture management in children^[18,19]. Some authors suggest that while surgical treatment carries more complications, it reduces the risk of re-rupture^[19]. Given our patient presented with a complete tendon laceration, surgical repair was necessary to restore tendon continuity and minimize the risk of re-rupture. The postoperative course was uneventful, and the patient resumed normal activities without recurrence after an 8-month follow-up.

Conclusion

Bilateral and simultaneous AT injuries are rare in children, as are ruptures of this tendon. This case illustrates a complete bilateral AT laceration following a domestic accident. It also highlights the danger and severity of household accidents in children.

Ethical approval

Case reports do not require the approval of our institute’s ethics committee.

Consent

Written informed consent was obtained from the patient’s mother for publication of this case report and accompanying images.

Sources of funding

All authors declare that they have no financial conflicts of interest.

Author contributions

Study concept of design: A.K.S.K.D.: Data collection: R.B.O.: and J.J.O.: Data analysis or interpretation: K.A.:M.G.: and Y.L.A.: Writing the paper: A.K.S.K.D.: and N.M.:

Conflicts of interest disclosure

All authors declare that they have no personal conflicts of interest or other relationships with other people or organizations that could improperly influence this work.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Amenan Kan Sophie Kouassi-Dria.

Artificial intelligence (AI)

The authors state that they did not use AI at any stage in the preparation of this case report.