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