achilles tendon injury
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Transcript of achilles tendon injury
Orthopedics CaseConference
Issara Chandrsawang
Demographic data
• ผปวยหญงไทย อาย 64 ป
• อาชพ รบจางท วไป
• ภมล าเนา จงหวดนครราชสมา
Chief complaint
• ปวดบวมแผลบรเวณขอเทาดานหลงขางขวามากขน 1 วนกอนมา รพ.
(refer มาจาก รพ.โชคชย)
Present illness
• 8 วน กอนมา รพ. อบตเหต ถกอฐกอบอปลาหลนทบขอเทาขวาดานหลง มแผลฉดขาด
เลอดออก ลกถงเอน ไมเดนเองไมไหว สามารถกระดกขอได
จงไป รพ. แพทยเยบแผล ฉดยาฆาเชอ และใสเฝอกออนให
( ATB : ceftriaxone 2 g. iv OD
+ clindamycin 600 mg iv q 8 hr. )
• 1 วน กอนมา รพ. นดมาดแผล บวม แดง มหนอง และมกลนเหมน ยงคงมอาการปวดมาก
บรเวณหลงขอเทาขวา ไมมไข สามารถกระดกขอเทาได ไมชา
Past history
• U/D : HT, DLP
• มประวตอบตเหตกอนหนาน
• ปฏเสธประวตแพยา/อาหาร
Personal history
• ปฏเสธประวตดมสรา
• ปฏเสธประวตสบบหร
• Current medication
– Amlodipine (5) 2*1
– Simvastatin (10) 2*1
Physical examination
• V/S BT 36.7 C BP 145/86 mmHg
PR 69 /min RR 20 /min
• GA : good consciousness
• HEENT : not pale conjunctivae, anicteric sclerae
• Heart : normal s1 s2, no murmur
• Lung : clear, equal breath sound, no adventitious sounds
• Abdominal : soft, not tender, normoactive bowel sound
Physical examination
• Neuro : E4V5M6, pupil 3 mm RTLBE, grossly intact
• Ext. :
– Right foot : closed wound size 2 cm. at Achilles tendon area, swelling, erythema, warmth, tenderness, pus from wound, full ROM motor power at least gr.IV neurovascular intact, DPA 2+, capillary refill <2 sec., no numbness
Investigations
• Film x-ray right ankle AP , lateral
Diagnosis
• Infected wound at Achilles tendon area R/O Achilles tendon tear
Management
• Admit
• Pre-op evaluation
• Antibiotic
– Cefazolin 1 g iv q 6 hr.
– Gentamicin 240 mg iv OD
– PGS 3 MU iv q 6 hr.
Management
• Set OR for debridement ± repair tendon
– Intra-op finding : - partial tear Achilles tendon right ankle 70%
- infected wound , pus 3 ml.
- not extend to joint
Post-op diagnosis : - partial tear Achilles tendon right ankle
- infected wound right ankle
• On short leg slab
Achilles tendon rupture/tear
Achilles tendon
• the largest and strongest tendon in the body
• contributions of the gastrocnemius and soleus muscles
• spirals 30-150° until it inserts into the calcaneal tuberosity.
• Function : plantar flexion
Achilles tendon promblem
Achilles tendon rupture/tear
• The most common mechanisms of injury include sudden, forced plantar flexion of the foot, unexpected dorsiflexion of the foot, and violent dorsiflexion of a plantar-flexed foot
• approximately 2-6 cm above the calcaneal insertion of the tendon
• direct trauma and, less frequently, attrition of the tendon as a result of longstanding paratenonitis
• sharp intense pain in the back of their heel, feel like struck in the back of the heel, swelling
Achilles tendon rupture/tear
• Achilles tendon rupture resulting from forced dorsiflexion during active plantar flexion is commonly seen in basketball, diving, tennis, and other sports that require forceful push off from the foot.
• Risk factors for Achilles tendon rupture : sex, age, systemic illness, blood group O, Fluoroquinolone antibiotic use, Corticosteroid use, smoking
Physical examination
• substantial defect in the Achilles 2-5 cm before it inserts into the heel bone
• Thompson test
– Sensitivities in acute 93%, chronic 23%
• STAMP test (Stand and maintain plantarflexion)
• TAR test (Tendo-Achilles rise)
Investigation
• Plain x-rays will be negative unless the Achilles injury involves pulling off (avulsion) part of the heel bone (calcaneus)
• can be seen on ultrasound or MRI
Treatment
• operative versus non-operative treatment
Non-operative treatment
• For elderly and/or inactive, as well as for those with comorbidities
• On splint in plantarflexion position for 1-2 wks
• On short leg cast in plantarflexion position for 6-8 wks
• On extra heel shoes 2 cm for 1 month after remove cast And 1 cm 1 month later
• Progressive weight bearing in 4th-6th wk after injury
• Progressive exercise of cuff muscle in 8th -10th wk
Operative treatment
• Suture Achilles tendon by slow absorbing suture
• On short leg cast for 6-8 wk
• progressive excercise in 8th -10th wk
• Avoid excessive exercise in 6th -8th wk