Extern Noon ConferencePATHARA SUKVAREE RA5402116

33 . . Chief complaint 4 .

Primary surveyA 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 RTLBEE No external wound

Secondary surveyA no known drug/food allergyM no current medicationP no underlying diseaseL NPO time 8.00 amE 4 . trauma

Head to toe examinationVital signs T 37.3 , BP 160/85 , PR 58 , RR20 HEENT not pale conjunctivae , anicteric sclera Heart normal S1S2 , no murmurLung 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+ bothIntact sensory left foot

Head to toe examinationExtremitiesSeen dimple over Rt . posterior anklePalpable gap and tender at Rt. Achilles tendon Can dorsiflexion and plantarflexion with Increase passive dorsiflexion of Rt . Ankle

Head to toe examinationLack of plantarflexion when squeeze the calf

Initial management

Dx .Achilles Tendon Rupture (Right )Subtitle

Initial managementAdmit Pre-op lab On Anterior short leg slab Pain control set OR for Achilles tendon repair

Achilles Tendon Rupture

Anatomy

Soleus muscleGastrocnemius muscleTibialis posteriorPeroneus longus/brevis

Plantarflexion

Achilles tendon rupture often misdiagnosed as an ankle sprain (missed up to 25%)Incidence = 7 : 100,000 per yearmore common in menmost common inages 30-4080% occurs during recreational sport

Pathophysiology Weak / degenerative tendonPrevious Achilles tendon problemsAgingepisodic athletes weekend warrior flouroquinoloneantibioticssteroid injections Shear stresstraumatic injury ,Sport event sudden forced plantar flexionviolent dorsiflexion in a plantar flexed foot Achilles tendon rupture4-6 cm above the calcaneal insertion

Stop-and-go sportsSprintersDecathletesSoccerJumperBasketball

Differential diagnosis of posterior heel / calf pain Ankle spain ( injury when landing )Fracture calcaneusRupture Achilles tendonBursitisCalcaneal apophysitisVascular claudication / DVTRheumatologic diseaseSoft tissue infectionMalignancy HematomaDo NOT assume rupture is absent because the patient can plantar-flex their ankle or walk

subtendinous bursitisenthesopathy or subcutaneous bursitis

Hypovascular region

Clinical presentation Symptomspatient usuallyreports a "pop , feeling stuck at back of ankleweakness and difficulty walkingpain in heel

Physical examinationInspection Increase resting ankle dorsiflexion in prone position with knee bent Calf atrophy in chronic case Palpable gap at Achilles tendon weakness to ankle plantar flexionincreased passive dorsiflexionThompson test

Investigation RadiographR/O other pathology (huglunds deformity)Ultrasound Complete vs partial rupture MRIEquivocal physical examination , negative Thompson test with high clinical suspecious

Haglund's deformityis a bony enlargement on the back of the heel. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa (a fluid-filled sac between the tendon and bone).18

Initial management of Rupture tendon

Cold compressionAnalgesias (Paracetamol / NSAIDS)Rest , NWB with crutchesImmobilization (a splint)

Treatment options Non-operative treatment Operative treatment Open repair Percutaneous repairAcute rupture (