achilles tendon rupture is defined as being neglected if the diagnosis is made at least 4  weeks after the trauma .
all of the cases described in the literature were adult patients , and they were treated with various surgical techniques using different tissues for augmentation .
the authors report the case of a 7  year old girl with posttraumatic neglected rupture of the achilles tendon treated 8  weeks after the trauma with a tenorrhaphy using the bunnell technique augmented with the plantaris gracilis tendon .
a 7  year old girl was seen at our clinic for pain at the right calf with limping and weakness during plantar flexion of the right foot .
her mother stated that she had started to limp about 8  weeks before after a swinging door hit her on the back of the leg while she was running . at that time she complained of a small cut on the skin that was over her achilles mid - tendon .
she was then taken to the emergency department of the closest hospital , where the skin was sutured .
she was allowed to walk but she started to limp on her right lower limb and to feel a kind of weakness during plantar flexion .
she was seen again by a pediatrician after 6  weeks , who then referred her to us .
physical examination showed an achilles tendon gap under the skin at inspection and upon palpation of the area ( fig .  1 ) and an inability to raise her heel off the ground on the right side .
a swollen mass was also present during palpation at the proximal part of the calf muscle , and a positive thompson squeezing test was noted .
magnetic resonance imaging ( mri ) showed a chronic full - thickness tear of the right achilles tendon with a gap of 5  cm ( fig . 
2a chronic full - thickness tear of the right achilles tendon with a gap of 5  cm was present on mri an achilles tendon gap was present under the skin at physical examination a chronic full - thickness tear of the right achilles tendon with a gap of 5  cm was present on mri she was then taken to the operating room . under general anesthesia and in the prone position , the right foot showed slight dorsiflexion due to the prevalence of the extensor muscles ( fig .  3 ) .
after the right lower limb was exanguinated , a medial para - achilles tendon incision was made just over the gap .
the proximal part of the tendon appeared to be severely proximally retracted , while a small stump of the distal insertion was present over the posterior calcaneal tuberosity .
the proximal part of the tendon was released from all of the scar tissue and the plantaris gracilis tendon was found to be intact ( fig . 
a termino - terminal tenorrhaphy was then possible , but only with the foot flexed in the full equinus position , utilizing the plantaris gracilis tendon as an augmentation ( fig . 
a non - weight - bearing short leg cast in the equinus position was then used for 2  weeks , followed by a new short leg cast in a less equinus position to recover the plantigrade position for three  weeks .
after the cast was removed , a physical therapy program was prescribed for 3  weeks to recover the correct plantigrade position as well as tip - toed walking .
she was able to return to normal activities within a month after cast removal.fig . 
3under general anesthesia and in the prone position , the right foot showed slight dorsiflexion due to the prevalence of the extensor musclesfig . 
4the proximal part of the tendon appeared to be severely proximally retracted , while a small stump of the distal insertion was present over the posterior calcaneal tuberosity .
5a termino - terminal tenorrhaphy was then possible , but only with the foot flexed in the full equinus position , utilizing the plantaris gracilis tendon as an augmentation ( grasped with the clamp ) under general anesthesia and in the prone position , the right foot showed slight dorsiflexion due to the prevalence of the extensor muscles the proximal part of the tendon appeared to be severely proximally retracted , while a small stump of the distal insertion was present over the posterior calcaneal tuberosity .
the plantaris gracilis tendon was found to be intact a termino - terminal tenorrhaphy was then possible , but only with the foot flexed in the full equinus position , utilizing the plantaris gracilis tendon as an augmentation ( grasped with the clamp ) the patient was completely asymptomatic at 3  years follow - up .
the parents of the young patient gave informed consent prior to their daughter being included in the study .
acute traumatic rupture of the achilles tendon of a child has rarely been described in the literature .
more frequently , children are affected by spontaneous avulsion of the achilles tendon due to the effects on the calcaneus of various conditions such as inflammatory and autoimmune diseases , infectious diseases , or neurological and genetically determined collagen abnormalities . to our knowledge
, there are only 2 cases in the literature of a posttraumatic acute rupture at the middle third of the achilles tendon ( the typical localization of an achilles rupture in an adult ) in a young patient . in one case ( a 14  year old girl ) , the tendon , which was initially only partially damaged , was totally ruptured in a subsequent trauma 2  weeks later .
she was then operated on , and went on to achieve a full clinical recovery .
the second patient , a 7 year old girl , who was the first case of acute achilles tendon rupture in a child under the age of 10  years to be described in the literature , was successfully treated conservatively for an acute tear of her achilles tendon after she had fallen on her plantar - flexed foot .
she was struck across the mid - tendon sideways by a swinging door , but the lesion at the achilles tendon was not diagnosed immediately . neglected traumatic achilles tendon ruptures in children are not reported in the literature .
nonoperative treatment can be successful only if the tendon is immobilized in the full equinus position .
surgical treatment is often recommended for older and relatively athletic patients , or in cases where treatment has been delayed . in this case , the patient was allowed to walk for 6  weeks after the trauma , even though she was limping due to weakness during plantar flexion . at the operation , we found an large gap between the two edges of the tendon .
reconstruction using the bunnell technique   was difficult and was only possible in the fully equinus position .
skin closure was also very difficult , with delayed healing of the central part of the scar was present , probably because of ischemia due to the tension at the edges of the skin .
several different techniques have been described for the treatment of chronic or neglected achilles tendon ruptures in adults , such as bridging approximation procedures , v 
y slide lengthening of the tendon , gastrocnemius advancement , fascial turndown flaps , local tendon transfers , free tissue transfer , and the use of synthetic grafts [ 68 ] .
the results of all these procedures have only been reported for skeletally mature patients , and their long - term effects in children are unknown . in our young patient , we decided to perform a more anatomical procedure : a termino - terminal tenorrhaphy .
we used the plantaris gracilis tendon as an augmentation because it is inconstant and its absence does not influence the function of the ankle .
a physical therapy program was needed after cast removal to recover the full range of ankle motion .
excellent functional results were observed by 3  months after the surgery . the incision had healed completely and the foot was plantigrade
, the patient could walk on tip toes , and she was able to perform 20 repetitive single - leg heel - raise maneuvers . the aofas score for
the ankle and hindfoot was 96 points ( out of a maximum possible score of 100 points ) , due to moderate restriction of the sagittal motion . at follow - up 3  years after surgery , the patient had recovered full range of motion of the ankle and full ankle function . to our knowledge , this is the first neglected rupture of the achilles tendon in a child described in the literature .
we believe that in patients under the age of 10  years , nonoperative treatment of acute lesions is safe and offers satisfactory results after a relatively short period of immobilization . in neglected cases ,
several well - validated techniques are available for adults , but their long - term effects in skeletally immature patients are unknown .
problems with closing the tendon gap and skin closure are always possible for gastrocnemius muscle and skin retraction .
 posttraumatic neglected achilles tendon ruptures in a young patient have not been described in the literature to our knowledge ; indeed , neglected ruptures of the achilles tendon have only rarely been described in adults . 
 we present the case of a 7  year old girl with posttraumatic neglected rupture of the achilles tendon that was operated on 8  weeks after the trauma . 
Introduction
Case report
Discussion