Here’s Dr. Alsup with today’s Morning Report!
Tendon Rupture
Background:
-Galen described in 130-201 CE. In which he described a young man injured during a wrestling match
-Young people: trauma/sports
-40-60 yo: chronic inflammation
Sx: pain, swelling, loss of assoc muscle function.
– frequently is an immediate ‘pop’ or tearing sensation.
Risk factors
PMH
-SLE, Ankylosing spondylitis, RA
-DM
-CRF
-Hyperparthyroidism
-Gout/ chronic synovitis
-Leukemia/ solid tumors
-Infection
-Obesity
-Repetitive motion (jumper’s knee)
-Iatrogenic (post-op after tendon repair/ joint work, steroid injections)
Meds
-Fluroquinolones (alter cytoarchitechure of tendons)- at least 3x relative risk, 5 to 20 per 100,000 patients
-Steroids: (po or in cases of patella rupture- injection for patella tendonitis)
-Statins ?
Workup: Ultrasound! –> MRI. Sometimes Xrays.
ULTRASOUND
- Hypoechogenicity is associated with acute tears, while thickening of the tendon at the rupture site and disruption of the normal echo pattern is observed with chronic tears.
MRI
- “If the diagnosis cannot be established based on clinical and radiographic examination, an MRI is the imaging study of choice.”
Biceps tendon rupture
Rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures and almost exclusively involves the long head.
Generally chronic inflammation with acute truama
-Catching/lifting a heavy object
-weightlifting, sporting activities (eg, snowboarding, football).
Sx
-Swelling of muscle as it retracts (popeye deformity)
-pain and weakness to flexion of the elbow
Complications of compartment syndrome- v. rare
Tx:
Conservative management includes rest, nonsteroidal anti-inflammatory drugs, and ice packs in the acute phase, and range-of-motion and strengthening exercises subsequently.
- Lose 8–16% of their flexion strength
- Lose 11–21% of supination strength
- Generally does not significantly affect adl’s
Surgical treatment (anatomic reattachment) is generally recommended for young or athletic patients requiring full supination strength or for patients with cosmetic concerns
Achilles
- Incidence 7 and 13/100,000 per year
- Recent increases in recreational sport and exercise participation
- Highest incidence in the 30–39-year age group
- 1 and 16.7 times more common in males
- Up to 75% of acute injuries can be attributed to sports activity
HPI
-Sudden snap/pop
-“I was shot/kicked/hit”
-unable to plantar flex affected foot, unable to stand on toes
-Thompson test (sens/spec (0.96 and 0.88, respectively))
Treatment:
surgical reattachment vs plantar splint for 4+ weeks
-meta-analysis of 5 studies comprising 421 patients in 2002 (Bhandari et al., 2002) reported no significant difference in surgical patients returning to normal function (71%) compared to those managed non-operatively (63%).
Quadriceps & Patellar tendon rupture:
The quadriceps is a short tendon is formed by the convergence of all 4 muscles just proximal to the superior patella.
-Quads: distal 0-2 cm from the superior pole of the patella, through pathologic tissue.
-Patellar- Mostly assoc with sports but also s/p ACL autograft surgery
HPI
-Typical mechanism is a sudden eccentric contraction of the quadriceps, usually with the foot planted and the knee flexed
(extensor mechanism has been reported to be as high as 17.5 times body weight)
-Position of patella
-quads-low riding
-patella- high riding
-Unable to extend at knee with otherwise stable joint
“Testing for full, active extension against gravity is the most important aspect of the examination.”
Dx:
Plain radiographs (anteroposterior [AP], lateral, axial)
-can have other direct injuries, evaluate patella
Contralateral films- if equivocal- can compare patellar height
Tx:
1887, McBurney reported on the first surgical repair in the United States. The injury was a direct blow to the knee, and the tendon was repaired using catgut and silver wire.
– Inability to walk needs to be fixed. –> to OR non-emergently
References
- Patella tendon rupture emedicine (accessed 9/1/14) http://emedicine.medscape.com/article/1249472
- Quadracepts tendon rupture http://emedicine.medscape.com/article/1249621
- Biceps tendon rupture http://emedicine.medscape.com/article/327119
- Rajpal S et al. Acute Achilles tendon rupture .Trauma p67-81 14(1)2011
Jay Khadpe MD
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