Content uploaded by Noman Niazi
Author content
All content in this area was uploaded by Noman Niazi on Jun 08, 2020
Content may be subject to copyright.
Human Journals
Case Report
May 2020 Vol.:15, Issue:3
© All rights are reserved by Noman Shakeel Niazi et al.
Atraumatic Os Peroneum Fracture and Retraction of Peroneus
Longus Tendon – Case Report and Review of Literature
www.ijsrm.humanjournals.com
Keywords: Os peroneum fracture, peroneus longus tendon
rupture, lateral ankle pain
ABSTRACT
Background: Spontaneous fracture of os peroneum with
proximal retraction of peroneus longus tendon is a rare
problem and the possibility of delayed or missed diagnosis
arises. If left untreated it can be a cause of chronic lateral
hindfoot pain. Case Report: This paper reports a 41 years old
lady with 4 years history of lateral foot pain. Ultrasound and
magnetic resonance imaging (MRI) revealed tendinitis of
peroneus longus tendon (PLT) and she was treated with
steroid injection. She presented to us with new pain over the
lateral ankle. During surgery, fracture of os peroneum with
retraction of PLT to level of lateral malleolus was found. The
diseased tendon along with fractured fragment were excised
and tenodesis with peroneus brevis was performed. Patient
showed good symptomatic recovery. Conclusion: We aim to
share our successful experience of surgical management of
atraumatic os peroneum fracture which was retracted up to
level of lateral malleolus. Fragmentation of os peroneum
leading to fracture is not mentioned in literature, although
there are very few reported cases of post traumatic os
peroneum fractures. In patients with os peroneum syndrome
with representation and remote symptoms, a high degree of
suspicion should be considered for os peroneum fracture and
proximal migration of fractured fragment.
Noman Shakeel Niazi*1, Amirul Islam2, Ahmed
Aljawadi3, Khadija Khamdan4, Anand Pillai5
Manchester University NHS foundation trust,
Manchester, United Kingdom
Submission: 23 April 2020
Accepted: 30 April 2020
Published: 30 May 2020
www.ijsrm.humanjournals.com
Citation: Noman Shakeel Niazi et al. Ijsrm.Human, 2020; Vol. 15 (3): 142-147.
143
INTRODUCTION
Atraumatic fractures of os peroneum and retraction of peroneus longus tendon (PLT) is rare.
PLT contributes to eversion and plantar flexion of the foot. It originates from proximal tibia
and fibula and intermuscular septum then it travels within the posterior fibular groove, passes
under peroneal tubercle of calcaneum and after reflecting against cuboid it inserts medially at
the base of 1st metatarsal (1). An os peroneum is a small accessory bone, located close to
cuboid and within the substance of PLT as it arches around the cuboid. It is a very anatomical
variant, seen in up to 26% of feet(2). Like most accessory ossicles, os peroneum detected
incidentally on imaging. Osperoneum can be bipartite or multipartite and can be a rare source
of lateral foot and ankle pain (2). Spontaneous fractures of os peroneum (2,3) with proximal
retraction of peroneus longus tendon is a rare problem with possibility of delayed or missed
diagnosis.
CASE REPORT
We report a case of 41 years old lady who has been having conservative treatment for right
lateral foot pain for 4 years. She is normally fit and well with no comorbidities. She had
history of atraumatic right lateral foot pain and was diagnosed as os peroneum syndrome on
ultrasound scan. Her initial MR scan showed Osperoneum syndrome with peroneus longus
tendinopathy. She had two courses of ultrasound guided steroid injections which gave her
relief from symptoms. Patient was represented to us with new symptoms. This time her pain
was moreover the lateral aspect of ankle and not over os peroneum. Her MR scan showed
peroneus longus tendon moderately tendinopathic and full thickness peroneal tendon tear
retracted to level of lateral malleolus (Figure 1). There was a palpable lump above the level
of lateral malleolus, behind fibula (Figure 2).
Surgery: Curved lateral incision was given along the course of peroneal brevis. Fracture of
Osperoneum and complete rupture of PLT was identified and retracted proximal to lateral
malleolus (Figure 3). The fractured fragment was excised along with tendinopathic tendon
and tenodesis was done with peroneal brevis (Figure 4). Patient was discharged same day and
kept nonweight bearing in cast for 6 weeks. At six weeks she was started full weight bearing
in a boot for two weeks and physiotherapy was started to improve range of motion and
strength. She showed good progress in range of motion and complete symptomatic recovery.
www.ijsrm.humanjournals.com
Citation: Noman Shakeel Niazi et al. Ijsrm.Human, 2020; Vol. 15 (3): 142-147.
144
DISCUSSION
Low incidence and non-specific symptoms make a diagnostic challenge to diagnose PLT
pathologies (4). In a patient with posterolateral hindfoot pain peroneal tendon pathology
should be considered. Painful os peroneum syndrome (5) is mentioned in literature with
spectrum of conditions including os peroneum fracture leading to diastasis of PLT tendon,
stenosing peroneal tendon synovitis, partial rupture of PLT and frank rupture of PLT. PLT
dysfunction may be acute or chronic. Acute dysfunction can occur as a result of PLT rupture
at the time of the injury. Chronic dysfunction is related to degeneration and tearing associated
with frictional forces along the tendon. Nonoperative measures include casting, dressing and
steroid injections.
Surgical excision of fracture fragments with repair of associated peroneal longus tendon
abnormalities is recommended in the acute setting or if conservative treatment fails (6).
Spontaneous fracture of os peroneum is rarely mentioned in literature. Peacock in 1986 (7)
reported post traumatic case of osperoneum fracture in which primary repair and surgical
approximation of the fractured os peroneum was performed. Jari et al (3) mentioned a case
report of PLT rupture with osperoneum fracture while playing squash and was managed with
surgical repair. Peterson et al (2) reported a case report in which osperoneum fracture was
noted surgically and excision of osperoneum fragment and repair of PLT tendon was
performed. Koh et al (8) reported post traumatic case of lateral ankle pain with rupture of
PLT distal to os peroneum. Favinger et al (9) reported an os peroneum fracture after multiple
eversion injuries leading to progressive retraction of os peroneum and PLT which was
managed conservatively in the presence of multiple comorbidities.
Our patient was initially treated conservatively as tendinopathy of peroneal longus. She did
not have any history of trauma to her ankle. On her recent MR scan, retraction of os
peroneum was noted which was confirmed per operatively as retraction of fractured fragment
up to the level of lateral malleolus. Fragmentation of os peroneum is the possible explanation
of fractured os peroneum. Osperoneum syndrome may lead to fragmentation and fracture
leading to proximal migration of PLT. In patients with os peroneum syndrome with
representation and remote symptoms, a high degree of suspicion should be considered for os
peroneum fracture and proximal migration of fractured fragment. This paper demonstrates
www.ijsrm.humanjournals.com
Citation: Noman Shakeel Niazi et al. Ijsrm.Human, 2020; Vol. 15 (3): 142-147.
145
how a rare case of PLT rupture and os peroneum fracture was managed with tenodesis to
intact peroneal brevis tendon leading to successful outcome.
CONFLICT OF INTEREST
1. No benefits in any form have been received or will be received from a commercial party
related directly or indirectly to the subject of this article.
2. The author(s) received no financial support for the research, authorship, and/or publication
of this article.
REFERENCES
1. Stefano Bianchi S, Bortolotto C, Draghi F. Osperoneum imaging: normal appearance and pathological
findings. Insights Imaging (2017) 8:59–68 DOI 10.1007/s13244-016-0540-3
2. Peterson JJ, Bancroft LW. Osperoneal fracture with associated peroneus longus tendinopathy. AJR Am J
Roentgenol. 2001;177 (1): 257-8. doi:10.2214/ajr.177.1.1770257
3. S Jari, J Warner, T. H Meadows. Spontaneous rupture of the peroneus longus tendon with an associated
osperoneum fracture: a case report and review of literature. Foot & Ankle Surg. Volume3, Issue4 Dec.
1997.Pages 205-208
4. Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective
review. J Foot Ankle Surg 2003; 42: 250-258 [PMID: 14566716 DOI: 10.1016/S1067-2516(03)00314-4]
5. Sobel M, Pavlov H, Geppert MJ, Thompson FM, DiCarlo EF, Davis WH. Painful os peroneum syndrome: a
spectrum of conditions responsible for plantar lateral foot pain.Foot Ankle Int. 1994 Mar;15(3):112-24.
6. Bessette BJ, Hodge JC. Diagnosis of the acute os peroneum fracture. Singapore Med J 1998; 39:326-327
7. Peacock KC, Resnick EJ, Thoder JJ. Fracture of the os peroneum with rupture of the peroneus longus tendon.
A case report and review of the literature. Clinical Orthopaedics and Related Research, 01 Jan 1986, (202):223-
226
8. Koh D,, Liow L, Cheah J, Koo K. Peroneus longus tendon rupture: A case report. World J Orthop. 2019 Jan
18; 10(1): 45–53.
9. Favinger JL, Richardson ML, Chew FS. Progressive retraction of a fractured os peroneum suggesting
repetitive injury to the peroneus longus tendon. Radiol Case Rep. 2018 Feb; 13(1): 216–219.
www.ijsrm.humanjournals.com
Citation: Noman Shakeel Niazi et al. Ijsrm.Human, 2020; Vol. 15 (3): 142-147.
146
Figure No. 1: Sagittal MR scan of ankle showing proximal retraction of os peroneum
and peroneal longus tendon.
Figure No. 2: Lateral ankle showing the lateral malleolus and 5th metatarsal tuberosity.
Arrow is pointing at retracted fragment of os peroneum.
www.ijsrm.humanjournals.com
Citation: Noman Shakeel Niazi et al. Ijsrm.Human, 2020; Vol. 15 (3): 142-147.
147
Figure No. 3: Showing PLT with retracted end of os peroneum
Figure No. 4: Tenodesis of peroneallongus tendon with peroneal brevis after excision of
diseased tendon.
