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April 2008 Radiology Quiz
This patient is a 20 year old male who presents to the ED with the complaint of right ankle pain. The patient staes he was playing basketball and when he landed his ankle inverted and he her a pop.
Questions:
1. Describe what you see?
- Soft tissue swelling
- On the lateral view a soft tissue defect is noticed.
- Diagnosis: Achilles tendon rupture
2. What is the mechanism of injury?
- Three mechanisms result in this injury: a direct blow to the tendon, forceful dorsiflexion of the ankle, or increased tension on an already taut tendon.
3. What would you find on physical exam?
- Examine and palpate along the entire gastrocnemius-soleus musculotendinous unit to note tenderness, ecchymosis, swelling, and tendon defects. In patients with complete ruptures, a palpable gap along the Achilles tendon and 2-6 cm above its insertion may be noted. The patient will alsp have weakness on active plantar flexion. (inability to stand on toes) Some clinical tests that might help diagnosis Achilles tendon ruptutres include:
- Hyperdorsiflexion sign: While the patient is prone and has both knees flexed to 90°, maximally dorsiflex both ankles and compare the injured side to the uninjured side.
- Thompson test: While the patient is prone and the affected leg is extended, squeeze the calf muscles to indirectly plantar flex the foot. A positive Thompson test results if the foot does not plantar flex. A positive Thompson test helps confirm the diagnosis of a rupture.
- O'Brien needle test: A small-gauge needle is inserted perpendicularly through the skin into the tendon substance, approximately 10 cm proximal to the calcaneal insertion of the Achilles tendon. Motion of the hub of the needle in a direction opposite the tendon during passive ankle dorsiflexion and plantar flexion confirms an intact tendon distal to the needle level.
4. How would you manage this patient?
- It consists of NSAIDs, RICE (rest, ice, compression, and elevation), crutch use, and non-weight bearing. Apply a posterior long leg splint with the foot in 20 to 25 degrees of plantarflexion to oppose the tendon ends. Most Achilles tendon ruptures require surgical repair. Arrange follow-up with a Podiatrist or Orthopedic Surgeon within 24 to 28 hours.
5. True or False : For acute somatic dysfunctions, focus your treatment immediately on the dysfunctional area to prevent further damage to the tissues.
- False – for very acute somatic dysfunction, treat the secondary and peripheral areas first to allow access to the acute area.
Trivia: Marley was the first reggae act to headline at what famous American locale?
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