Complete Anterior Tibial Tendon Rupture After Closed Tibial Shaft Fracture: A Case Report

Acute anterior tibialis tendon (ATT) rupture is a rare injury that may go unrecognized in the acute trauma setting, particularly when it co-occurs with a closed tibial shaft fracture. We report a case of complete ATT rupture in a 25-year-old male following a motorcycle accident causing a distal tibial shaft fracture. The rupture was identified intraoperatively; during distal locking screw placement, tendon-like fibers were observed through the surgical incision. Given this unexpected finding, the incision was extended to allow further exploration. Careful dissection revealed a complete rupture of the anterior tibial tendon, which had not been identified preoperatively. Because of significant soft-tissue edema at the time of fracture fixation, a staged surgical approach was adopted: temporary proximal stump fixation to the superior extensor retinaculum followed by definitive end-to-end repair 10 days later using Krakow and modified Kessler sutures. At 6 months, MRI confirmed tendon continuity, dorsiflexion strength was 4/5, and the AOFAS score was 90 (excellent). This case illustrates the diagnostic challenge of ATT rupture concurrent with tibial fracture and highlights that opportunistic visualization of the tendon may occur during distal locking procedures when the fracture apex is anteriorly oriented-an anatomical coincidence that, when recognized, enables timely repair. The principal clinical lessons are as follows: (1) the importance of including ATT integrity in the assessment of tibial fractures with anterior apex angulation or dorsiflexion deficit; (2) a staged approach is feasible and effective when soft-tissue conditions preclude immediate repair; and (3) early surgical repair, when stumps are viable, is associated with excellent functional outcomes.