Orthopedics

Achilles Tendon Rupture

CASE

A 41 year-old male without significant past medical history presents to the emergency department after sudden onset right leg pain while playing soccer. The patient reports jumping for the ball, landing on his feet, and immediately feeling sharp pain in his right ankle.  On exam, he has mild swelling to the posterior ankle overlying the Achilles tendon, and the area is tender to palpation. Plantarflexion is absent with calf squeeze, neurovascular exam is normal, and the remainder of patient’s exam is unremarkable. Bedside ultrasound is used to confirm the suspected diagnosis (Figure 1):

Figure 1: Ultrasound showing Achilles tendon rupture. Image courtesy of Dr. Timothy Boardman.

Figure 1: Ultrasound showing Achilles tendon rupture. Image courtesy of Dr. Timothy Boardman.


Why ultrasound?

  • US is useful to determine complete vs. partial rupture

  • It is not necessary for diagnosis

Provocative Testing: The Thompson Test (Figure 2)

  • Lack of plantar flexion when calf is squeezed with patient in prone position (sensitivity 0.96; specificity 0.93)

Figure 2: Diagram illustrating The Thompson Test. http://www.aidmyachilles.com/

Figure 2: Diagram illustrating The Thompson Test. http://www.aidmyachilles.com/

CASE OUTCOME

The diagnosis of Achilles tendon rupture was made. The patient was evaluated by orthopedics in the ED. He was placed in a posterior splint in resting equinus and discharged with instructions for non-weight-bearing with crutches. Orthopedic follow-up in 7-10 days was advised.

 

OVERVIEW OF ACHILLES TENDON RUPTURES

Anatomy:

  • Largest tendon in the body

  • Formed by the soleus, medial gastrocnemius, and lateral gastrocnemius tendons

  • Blood supply from the posterior tibial artery

Epidemiology:

  • Incidence: 18:100,000 per year

  • Demographics:

    • Men > Women

    • Ages 30-40 most common

    • Most often secondary to overuse and/or mechanical overload

  • Risk factors:

    • Intermittent athletes, “weekend warrior”

    • Older age

    • Fluoroquinolone use

    • Local steroid injection

Mechanism:

  • Sudden forced plantar flexion

  • Violent dorsiflexion in a plantar flexed foot

Symptoms:

  • Patient may report a “pop” or describe a feeling like being kicked in the leg

  • Weakness and difficulty walking, especially with plantar flexion

  • Heel pain

  • Patient usually cannot perform a single heel raise

The presence of at least two physical exam findings establishes the diagnosis:

  • Positive Thompson test

  • Palpable defect in the tendon

  • Decreased ankle plantar flexion strength and increased ankle dorsiflexion

Imaging:

  • Not necessary for diagnosis

  • MRI may be useful in cases of equivocal physical exam findings or chronic ruptures, but is not necessary in the ED setting

  • Ultrasound can help differentiate between complete and partial ruptures

Management: nonoperative vs. operative management is controversial.

  • Nonoperative

    • For acute injury; patient/provider preference; elderly/frail patients

      • Splint or cast in resting equinus

      • Early range of motion exercises

      • Re-rupture rates similar to those of tendon repair with fewer complications

  • Operative: End-to-end Achilles tendon repair

    • For acute injury (<6weeks); patient/provider preference

      • Improved strength

      • Higher percentage of patients who return to sports

TAKE HOME POINTS

  • Achilles tendon rupture tends to occur in older men who participant in strenuous activities on an occasional basis

  • Often a clinical diagnosis. Imagining is generally unnecessary for diagnosis but may help differentiate between partial and complete tears.

  • Patients can be discharged in splint or cast in resting equinus with close orthopedic follow-up.

  • Management is controversial and may be surgical or nonoperative based on several factors.

Faculty Reviewer: Jeffrey P. Feden, M.D.


REFERENCES:

  1. Karadsheh M. Achilles Tendon Rupture. Orthobullets [Internet]. Available from http://www.orthobullets.com/foot-and-ankle/7021/achilles-tendon-rupture. Accessed June 2017.

  2. Egol KA, Koval KJ, Zuckerman, JD. Handbook of Fractures, 5th ed. Wolters Kluwer Health, 2015. 490-493 p.

  3. Kadakia AR, Dekker RG, Ho BS. Acute Achilles Tendon Ruptures: An Update on Treatment. Journal of the American Academy of Orthopaedic Surgeons: January 2017;25(1): 23-31.

  4. Chiodo CP, Glazebrook M, Bluman EM, et al. Diagnosis and Treatment of Acute Achilles Tendon Rupture. Journal of the American Academy of Orthopaedic Surgeons: August 2010; 18(8): 503-510.

  5.  Tintinalli JE. Achilles Tendon Rupture, Chapter 272. Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill, 2011. 1867 p.

Give 'Em the Old One-Two: Boxer's Fracture

Case

A healthy 22-year-old right-handed man presents to the ED with right hand pain. He reluctantly endorses punching a concrete wall with an ungloved fist. On exam, the patient is holding his hand with fingers in partial flexion. There is mild swelling over the third through fifth MCPs with mild erythema and intact skin. Neurovascular exam is normal. Plain films were obtained.

Courtesy of Radiopedia.com

Courtesy of Radiopedia.com


What is the Diagnosis?

Fractured neck of fifth metatarsal. AKA, Boxer’s fracture

Overview

Boxer’s Fractures are a very common injury seen in the ED. Highest incidence are in men 10-19 years followed by men 20-29 years. The two most common mechanisms of injury are falls or direct blows with high axial loads (i.e. punching a fixed, inelastic object). Interestingly, despite the name, these fractures are not typically seen in experienced boxers, as boxing training aims to teach one to lead with the first and second knuckles, aligning the forces of impact into an axial load that transmits and distributes force through the larger bones and joints of the forearm and upper arm. Studies have suggested roughly 30% of hand fractures are metacarpal fractures and they account for nearly 19% of ER fracture visits. The metacarpal neck is the most commonly fractured site. The fifth metacarpal is the most commonly fractured metacarpal. Fractures to the first metacarpal are less common and are often managed operatively. First metacarpal fractures include Bennett’s fractures (fracture-dislocation of the base of the first metacarpal), and Rolandos fractures (comminuted version of Bennett’s fracture) and can also occur as a result of an axial load mechanism such as punching.

Evaluation 

Typical symptoms include tenderness or pain focally over the distal metacarpal. Physical examination should include careful inspection for possible “fight bites” given the common potential mechanism of injury. Comparing to the uninjured hand can help highlight distorted anatomy. Evaluate for possible rotational misalignment of the metacarpals by observing convergence of the finger tips with flexed MCPs and PIPs. Note that in this position, phalanxes should point to the scaphoid. Evaluate for extensor mechanism injuries. Due to the intrinsic pull of the interosseus muscles, metacarpal neck fractures typically result in dorsal angulation of the apex of the fracture, resulting in a clinical appearance of a depressed MCP joint. 

Radiology

Obtain AP, oblique, and lateral hand films

Special views: 

Brewerton View

Brewerton View

Roberts View

Roberts View

Indications for CT:

  • Inconclusive plain films with high clinical suspicion for injury

  • Complex fractures of metacarpal head

  • Multiple CMC dislocations

Associated injurieS:

Given the mechanism, skin break or lacerations over the knuckle may not only represent a potential open fracture, but should also lend themselves to a high degree of suspicion for a “fight bite,” with associated microbiological concern, and managed accordingly. Other fight-related injuries should also be considered and evaluated for as well.

Management:

Not all metacarpal fractures are managed the same. Important factors in management include degrees of shaft angulation and length of metacarpal shaft shortening, dependent on which metacarpal is injured, neurovascular status, and whether the injury is open or closed.

METACARPAL ACCEPTABLE DEGREE OF SHAFT
ANGULATION (degrees)
2nd 10
3rd 20
4th 30
5th 40

Operative indications:

  • Unacceptable degree of angulation (per table above)

  • Unacceptable shaft shortening >5 mm regardless of metacarpal

  • Rotational deformity of any digit >10 degrees

  • Multiple fractures

  • Intraarticular fracture or involvement of metacarpal head

  • Most first metacarpal fractures (Bennett’s and Rolando)

Non-Operative Treatment:

  • Analgesia

    • Consider an ulnar nerve block!

  • Reduction 

    • Using a c-arm for real-time X-ray feedback may be helpful. 

    • Jahss technique: 90 degrees flexion of MCP and the PIP (AKA 90-90 approach). Apply dorsal pressure to the proximal phalanx while stabilizing metacarpal shaft.

Jahss Technique

Jahss Technique

  • Splint 

    • Ulnar gutter for immobilization of the fourth and fifth metacarpals

    • Volar splint for immobilization of the second and third metacarpals.

  • Ice

  • Elevation

  • Tylenol/NSAIDs

  • Referral to hand surgeon for follow-up

Take home points:

  • Boxer’s Fractures are a common injury, most often seen in young men.

  • Consider wounds associated with these fractures as potential fight bites given the mechanism

  • The more radial the metacarpal involved, the less degree of angulation is acceptable without surgical intervention, while there is no degree of acceptable malrotation

Faculty Reviewer: Dr. Nicholas Asselin

References: 

  1. Nakashian et al. Incidence of metacarpal fractures in the US population. Hand. 2012. 7(4):426. 

  2. Ashkenaze and Ruby. Metacarpal fractures and dislocations. Orthopedic Clin North Am. 1992 23:19. 

  3. Haughton et al. Principles of hand fracture management. Open Orthop Journal. 2012. 6;43-55. 

Non-Accidental Trauma

Case

A hypothetical 7 month-old infant presents to the emergency department for mild respiratory distress. There is no recent illness or symptoms to explain the infant’s tachypnea and mild hypoxia. There is no visible bruising on exam. The parent states that the infant is starting to pull to stand but does not yet cruise. They have had several falls onto their tile kitchen floor. The CXR (below) is read by the radiologist left posterior rib fractures in ribs 4-8.

Case courtesy of Dr. George Harisis, Radiopaedia.org. From the case Non-Accidental Injury

Case courtesy of Dr. George Harisis, Radiopaedia.org. From the case Non-Accidental Injury

Highly Specific Fracture Patterns for Non-Accidental Trauma

A helpful adage: “Those that don’t cruise rarely bruise.” Approximately 80% of NAT occur in children less than 18 months old. A study evaluating bruising in normal infants demonstrated that only 0.01% (6 of 465) of pre-cruisers had ecchymoses. Soft tissue findings, like bruises, may tip you off to underlying or fractures either underlying or elsewhere. Pierce et al. (2010) highlighted the value of the TEN 4 FACES mnemonic to highlight concerning bruises that should prompt a workup for NAT: bruises to the Torso, Ears, and Neck in children < 4, any bruising on immobile children < 4 months, or bruising to the Frenulum, Angle of the mandible, Cheek, Eyelid, or Sclera. 

Fractures are the second most common finding in pediatric non-accidental trauma after bruising or other soft-tissue injuries. Although there are often similar fracture patterns seen in both accidental and non-accidental trauma, the fractures described below are the most highly specific for non-accidental trauma and should heighten your suspicion for intentional physical abuse:

Metaphyseal Fracture (aka “Corner” or “Bucket Handle” fractures)

A metaphyseal fracture is made up of microfractures perpendicular to the long axis of the bone, most commonly the distal ends of the tibia, femur, humerus. These microfractures are caused by the shearing forces of ligaments when a child who cannot control their limbs is shaken forcefully while held around their torso. It is highly specific fracture and is almost universally considered pathognomonic for non-accidental trauma.

Case courtesy of Dr. Basab Bhattacharya, Radiopaedia.org. From the case Non-Accidental Injuries

Case courtesy of Dr. Basab Bhattacharya, Radiopaedia.org. From the case Non-Accidental Injuries

Case courtesy of Dr. JR Dwek. From the The Radiographic Approach to Child Abuse.

Case courtesy of Dr. JR Dwek. From the The Radiographic Approach to Child Abuse.

Posterior Rib Fractures

Posterior rib fractures occur when enough anteroposterior chest compression is generated to cause movement of the posterior rib that acts as a lever over the transverse spinal process. This, like with metaphyseal fractures, can be caused by holding and shaking an infant with two hands around the ribcage. Other mechanisms include “marked forward decceleration into a solid object” in MVCs or in other non-accidental trauma. Biomechanically, the amount of force needed to cause leverage against the transverse process cannot be replicated when the patient is lying with their back against a flat surface, as is the case in CPR. A small post-mortem study of infants that had received even two-handed CPR supports this: they found anterolateral fractures but no occurrences of posterior rib fractures. In studies by Kleinman et al. (1997) and by Barsness et al. (2003) Posteromedial rib fractures have a very high positive predictive value (95%) for NAT and have the highest specificity for NAT.

Case courtesy of Dr. Paula Brill, Radiopaedia.org. From the case Non-Accidental Trauma.

Case courtesy of Dr. Paula Brill, Radiopaedia.org. From the case Non-Accidental Trauma.

The Three S’s: Spinous Process, Scapular, and Sternal Fractures

Though seen less often, spinous process, scapula, and sternum fractures round out the top most specific fractures for non-accidental trauma. Sternum and scapular fractures occur in the setting of a direct blow of unusual amounts force and are unexplained in the normal handling of most infants. As with other fractures, it is important to determine if the provided history matches the mechanism.

Other Specific Fracture Findings

  • Clavicular fractures (after the period explained by birth trauma)

  • Epiphyseal separations

  • Vertebral body fractures/separations

  • Digital fractures

  • Complex skull fractures

Next Steps

  • Mandatory reporting to Child Protective Services

  • Per the American Academy of Pediatrics, all patients undergoing workup for non-accidental trauma should be admitted to the hospital.

  • Complete a skeletal survey, which involves approximately 21 x-rays focusing on each individual limb or body part.

  • Order a CT brain to evaluate both the skull and underlying brain. Reconstructions of specific CTs may allow rotation of images and better identification of fractures.  

What Are We Missing?

In the most recent data published by the National Child Abuse and Neglect Data System, there were 1,585 fatalities due to child abuse and neglect in 2015. Approximately 44% percent of those suffered death due to physical abuse and almost 75% were children <3 years old.

A small study comparing known instances of child abuse fatalities with local medical records found that 30% of children who subsequently died from non-accidental trauma had interactions with health care for reasons other than well-child checks. Nearly 20% of those visits occurred within one month of their death. Albeit brief, emergency department visits may be the only interaction these children have with the health care system represent a critical opportunity for intervention.

 

Faculty Reviewer: Dr. Adam Aluisio

References

  1. Baldwin K, Pandya NK, Wolfgruber BA, et al. Femur Fractures in Pediatric Population: Abuse or Accidental Trauma? Clin Orthop Relat Res. 2011 Mar; 469(3):798-804.

  2. Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54:1107–1110.

  3. Bechtel K. Physical Abuse of Children: Epidemiology of Child Abuse in the United States. Emergency Medicine Reports. 2003 Mar.

  4.  Child Welfare Information Gateway. (2017). Child abuse and neglect fatalities 2015: Statistics and interventions. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.

  5. Christian CW. Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015; 135(5):1337-1354. 

  6. Dwek JR. The Radiographic Approach to Child Abuse. Clinical Orthopaedics and Related Research. 2011;469(3):776-789.

  7. King WK, Kiesel EL, Simon HK. Child Abuse Fatalities: Are We Missing Opportunities for Intervention? Pediatric Emerg Care. 2006;22(4):211-214.

  8. Kleinman PK, Perez-Rossello JM, Newton AW, et al. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 2011 Oct;197(4):1005-8.

  9. Kleinman PK, Schlesinger AE. Mechanical factors associated with posterior rib fractures: laboratory and case studies. Pediatr Radiol. 1997(27): 87-91.

  10.  Leaman LA, Hennrikus WL, Bresnahan JJ. Identifying non-accidental fractures in children aged <2 years . Journal of Children’s Orthopaedics. 2016;10(4):335-341.

  11. Matshes EW, Lew EO. Two-Handed Cardiopulmonary Resuscitation Can Cause Rib Fractures In Infants. Amer Journal of Forensic Med and Pathology. 2010 Dec; 31(4): 303-307.

  12. Paddock M, Sprigg A, Offiah AC. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton. Clinical Radiology. 2017 Mar;72(3):179-188

  13. Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenza DJ. Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma. Pediatrics. 2019;125(1):67-74.

  14. Sugar NF, Taylor JA, Feldman KW, and the Puget Sound Pediatric Research Network. Bruises in Infants and Toddlers Those Who Don't Cruise Rarely Bruise. Arch Pediatr Adolesc Med. 1999;153(4):399–403.