extern conference ortho korat PATHARA SUKVAREE 5402116

1. Extern Noon Conference
PATHARA SUKVAREE RA5402116

2. ผู้ป่วยชายไทยคู่อายุ 33 ปี อาชีพพนักงานเทศบาล
ภูมิลาเนา อ.เมือง จ .นครราชสีมา
Chief complaint
“ปวดข้อเท้าขวา 4 ชั่วโมงก่อนมารพ.”

3. Primary survey
A  Can speak clearly , can flex neck , no midline cervical
tenderness
B  No dyspnea , no subcutaneous emphysema ,JVP not
engorge, trachea in midline , equal breath sound , no
sucking chest wound , no distant heart sound
C  BP160/85 , PR 58 bpm , no external bleeding
D  E4V5M6 , pupil 3 mm RTLBE
E  No external wound

4. Secondary survey
A  no known drug/food allergy
M  no current medication
P  no underlying disease
L  NPO time 8.00 am
E  4 ชั่วโมงก่อนมารพ. ขณะที่ผู้ป่วยกาลังเล่นฟุตบอล รู้สึกลั่นที่ข้อเท้าขวา
ในจังหวะที่กาลังจะเตะบอล แล้วรู้สึกเจ็บบริเวณข้อเท้าขวาทันที เดินได้ ขยับข้อ
เท้ากระกดขึ้นลงได้ ไม่ชา ไม่เคยเป็นเช่นนี้มาก่อน ปฏิเสธประวัติ trauma
บริเวณข้อเท้า

5. Head to toe examination
 Vital signs – T 37.3 , BP 160/85 , PR 58 , RR20
 HEENT – not pale conjunctivae , anicteric sclera
 Heart – normal S1S2 , no murmur
 Lung – normal and equal breath sound , no adventitious sound
 Abdomen – soft , not tender , no guarding , no contusion , BS +
 Tender at right posterior ankle , not warm not swelling , small
ecchymosis
 DPA 2+ both
 Intact sensory left foot

6. Head to toe examination
 Extremities
 Seen dimple over Rt .
posterior ankle
 Palpable gap and tender at
Rt. Achilles tendon
 Can dorsiflexion and
plantarflexion with Increase
passive dorsiflexion of Rt .
Ankle

7. Head to toe examination
 Lack of
plantarflexion when
squeeze the calf

8. Initial management

9. Dx .
Achilles Tendon
Rupture (Right )Subtitle

10. Initial management
Admit
Pre-op lab
On Anterior short leg slab
Pain control
set OR for Achilles tendon repair

11. Achilles Tendon
Rupture

12. Anatomy
Soleus muscle
Gastrocnemius muscle
Tibialis posterior
Peroneus longus/brevis
Plantarflexion

13. Achilles tendon rupture
 often misdiagnosed as an ankle
sprain (missed up to 25%)
 Incidence = 7 : 100,000 per year
 more common in men
 most common in ages 30-40
 80% occurs during
recreational sport

14. Pathophysiology
Weak / degenerative tendon
• Previous Achilles tendon
problems
• Aging
• episodic athletes “ weekend
warrior “
• flouroquinolone antibiotics
• steroid injections
Shear stress
traumatic injury ,Sport event
• sudden forced plantar flexion
• violent dorsiflexion in a plantar flexed foot
Achilles tendon rupture
• 4-6 cm above the calcaneal
insertion
Stop-and-go sports
• Sprinters
• Decathletes
• Soccer
• Jumper
• Basketball

15. Differential diagnosis of
posterior heel / calf pain
 Ankle spain ( injury when landing )
 Fracture calcaneus
 Rupture Achilles tendon
 Bursitis
 Calcaneal apophysitis
 Vascular claudication / DVT
 Rheumatologic disease
 Soft tissue infection
 Malignancy
 Hematoma
“Do NOT assume rupture is absent because the
patient can plantar-flex their ankle or walk”
subtendinous bursitis
enthesopathy or
subcutaneous bursitis
Hypovascular region

16. Clinical presentation
Symptoms
patient usually reports a "pop“ ,
feeling stuck at back of ankle
weakness and difficulty walking
pain in heel

17. Physical examination
Inspection
Increase resting ankle dorsiflexion in prone
position with knee bent
Calf atrophy in chronic case
 Palpable gap at Achilles tendon
weakness to ankle plantar flexion
increased passive dorsiflexion
Thompson test

18. Investigation
Radiograph
R/O other pathology (huglund’s
deformity)
Ultrasound
Complete vs partial rupture
MRI
Equivocal physical examination ,
negative Thompson test with high
clinical suspecious

19. Initial management of Rupture tendon
- Cold compression
- Analgesias (Paracetamol / NSAIDS)
- Rest , NWB with crutches
- Immobilization (a splint)

20. Treatment options
Non-operative treatment
Operative treatment
Open repair
Percutaneous repair
Acute rupture (<6 weeks)
• Complete  Operative VS Non-operative
• Partial  Non-operative
Chronic Rupture
• Non-operative management followed by
PT is reasonable

21. Non-operative treatment
functional bracing/short leg casting in
resting equinus 6-8 weeks
 Indication
 acute injuries with surgeon or patient preference
for non-operative management
 sedentary patient
 medically frail patients
Plantarflexion 20 degree
• outcomes
• plantar flexion strength
• risk of re-rupture
• wound complications

22. Operative treatment
•open end-to-end achilles tendon repair
• indications
acute ruptures (approximately <6
weeks)
• outcomes
• Re-rupture
• Plantar flexion strength
• Wound Complication / infection
(Smoking***)
• Post op
• Immobilize in 20° of plantar flexion for
4-6 weeks
•Required 3-6 month return to sport
• Percutaneous repair
• indications
concerns over cosmetic of traditional
scar
• outcomes
• higher risk of sural nerve
damage
• Wound Complication / infection

23. Surgery for Chronic Achilles tendon rupture
•reconstruction with VY advancement
•indications
•chronic ruptures with defect < 3cm
•flexor hallucis longus transfer +/- VY
advancement of gastrocnemius
•indications
•chronic ruptures with defect > 3cm
•requires a functioning tibial nerve

24. Reference
Orthobullet
Uptodate : Achilles tendinopathy and tendon rupture

25. Thank you