Extern noon conference orthokorat Pathara PP
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Transcript of Extern noon conference orthokorat Pathara PP
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 (