跟腱撕裂

1 Rebecca Aspden, HMS III Gillian Lieberman, MD Achilles Tendon RuptureAchilles Tendon Rupture Rebecca Aspden, Harvard Medical School Year III Gillian Lieberman, MD November 15, 2004 2 Rebecca Aspden, HMS III Gillian Lieberman, MD Achilles tendon: •Largest tendon in body. •Formed from conjoined tendons of gastrocnemius and soleus muscles. •Inserts on calcaneus. •Contributes to plantar flexion of foot. www.medicalmultimediagroup.com 3 Rebecca Aspden, HMS III Gillian Lieberman, MD Types of Achilles Tendon Types of Achilles Tendon InjuryInjury z Peritendinosis (peritendinitis) – Edema and scarring of paratenon (fatty areolar tissue around tendon). – Acute pain and swelling. – Seen in runners who increase their training or run on uneven surfaces. z Tendinosis – Intrasubstance degeneration of tendon itself. z Tears (partial or complete) – Vulnerable zone of avascularity 2-6 cm above calcaneal insertion. 4 Rebecca Aspden, HMS III Gillian Lieberman, MD Who gets tears?Who gets tears? • Average age 35-40. • Sports act is often triggering factor. • “Weekend Warrior” • In elderly underlying systemic disease or long-term corticosteroid medication may contribute. • Chronic degeneration of tendon (tendinosis) may be predisposing factor. 5 Rebecca Aspden, HMS III Gillian Lieberman, MD Our patientOur patient Mr. S is a 37 year-old man who was playing basketball at the local YMCA on Saturday afternoon. Even though Mr. S was a serious athlete in college, in the years since graduation he only makes it to the gym once a week for a pick-up game with his buddies from the office. As he was starting to chase after the ball, Mr. S felt a sudden pain in his left calf and heard a snap. He thought he had been shot! He could not walk and immediately limped to the sideline. 6 Rebecca Aspden, HMS III Gillian Lieberman, MD DiagnosisDiagnosis • Look for: – Palpable gap in tendon – Positive Thompson test – Difficulty standing on toes – Tenderness UpToDate Diagnosis of Achilles Tendon rupture can almost always be made clinically. 7 Rebecca Aspden, HMS III Gillian Lieberman, MD Imaging OptionsImaging Options z Plain films are not very helpful. z In questionable cases ultrasound can provide definitive diagnosis (particularly good in differentiating partial from complete rupture). z MRI helpful in planning surgery and in identifying intratendon abnormalities such as tears, tendinosis, and retrocalcaneal bursitis. – Helps surgeon decide whether to approximate tendon ends or use allograft. 8 Rebecca Aspden, HMS III Gillian Lieberman, MD Plain film of torn AchillesPlain film of torn Achilles PACS, BIDMC 9 Rebecca Aspden, HMS III Gillian Lieberman, MD Longitudinal sonogram showing Longitudinal sonogram showing partialpartial--thicknessthickness teartear Hartgerink et al. Tendon is markedly thickened and hypoechoic. 10 Rebecca Aspden, HMS III Gillian Lieberman, MD Longitudinal sonogram showing Longitudinal sonogram showing fullfull--thicknessthickness teartear Hartgerink et al. This ultrasound shows posterior shadowing (due to sound beam refraction at frayed tendon ends) and 9 mm of retraction with tendon debris between calipers. Another sign of tear on ultrasound is fat herniation. 11 Rebecca Aspden, HMS III Gillian Lieberman, MD Tendons on MRITendons on MRI Proton Density T2 Normal DARK DARK Degenerated (tendinosis) BRIGHT DARK Torn BRIGHT BRIGHT 12 Rebecca Aspden, HMS III Gillian Lieberman, MD NORMAL NORMAL -- axialaxial Proton density T2 PACS, BIDMC PACS, BIDMC Achilles tendon 13 Rebecca Aspden, HMS III Gillian Lieberman, MD NORMAL NORMAL -- sagittalsagittal Proton density T2 PACS, BIDMC PACS, BIDMC Achilles tendon 14 Rebecca Aspden, HMS III Gillian Lieberman, MD Tendons on MRITendons on MRI Proton Density T2 Normal DARK DARK Degenerated (tendinosis) BRIGHT DARK Torn BRIGHT BRIGHT 15 Rebecca Aspden, HMS III Gillian Lieberman, MD DEGENERATED DEGENERATED -- axialaxial Proton density T2 PACS, BIDMC PACS, BIDMC slightly increased signal 16 Rebecca Aspden, HMS III Gillian Lieberman, MD DEGENERATED DEGENERATED -- sagittalsagittal Proton density T2 PACS, BIDMC PACS, BIDMC thickened tendon 17 Rebecca Aspden, HMS III Gillian Lieberman, MD Tendons on MRITendons on MRI Proton Density T2 Normal DARK DARK Degenerated (tendinosis) BRIGHT DARK Torn BRIGHT BRIGHT 18 Rebecca Aspden, HMS III Gillian Lieberman, MD TEAR TEAR -- axialaxial Proton density T2 PACS, BIDMC PACS, BIDMC intact plantaris tendon tear 19 Rebecca Aspden, HMS III Gillian Lieberman, MD TEAR TEAR -- sagittalsagittal Proton density T2 PACS, BIDMC PACS, BIDMC avulsed piece of bone 20 Rebecca Aspden, HMS III Gillian Lieberman, MD PACS Proton Density Images PACS, BIDMC PACS, BIDMC PACS, BIDMC Normal Degenerated Torn Summary - sagittal 21 Rebecca Aspden, HMS III Gillian Lieberman, MD Proton Density Images PACS, BIDMC PACS, BIDMC PACS, BIDMC Normal Degenerated Torn Summary - axial 22 Rebecca Aspden, HMS III Gillian Lieberman, MD Treatment for Achilles tendon ruptureTreatment for Achilles tendon rupture z Surgery followed by early mobilization has had better results than just immobilizing tendon with cast for 8 weeks. z Active rehabilitation phase after surgery is 6 months long. zMost patients can return to pre-injury activity including sports. 23 Rebecca Aspden, HMS III Gillian Lieberman, MD ConclusionConclusion •Achilles tendon rupture is often seen in middle-aged men who exercise infrequently. •Diagnosis is usually made without imaging but US can be used in questionable cases. •MRI is used in surgical planning. www.home.zonnet.nl 24 Rebecca Aspden, HMS III Gillian Lieberman, MD ReferencesReferences Anderson, J., J.W. Read, and J. Steinweg. Atlas of Imaging in Sports Medicine. Sydney: McGraw-Hill Australia, 1998. Andrews, J.R., B. Zarins, and K.E. Wilk, ed. Injuries in Baseball. New York: Lippincott-Raven Publishers, 1998. Halpern, B., S.A. Herring, D. Alcheck, and R. Herzog. Imaging in Musculoskeletal and Sports Medicine. Malden, MA: Blackwell Science, 1997. Hartgerink. P. et al. Full- versus Partial-Thickness Achilles Tendon Tears: Sonographic Accuracy and Characterization in 26 Cases with Surgical Correlation. Radiology 220: 406-412, 2001. Kerr, Roger. Magnetic Resonance Imaging of the Foot and Ankle. Seminars in Roentgenology 35(3): 306-318, 2000. Kjaer, M. et al, ed. Textbook of Sports Medicine. Malden, MA: Blackwell Science, 2003. Moore, K.L. and A.F. Dalley. Clinically Oriented Anatomy. New York: Lippincott Williams & Wilkins, 1999. Southmayd, William and Marshall Hoffman. Sports Health. New York: Quick Fox, 1981. 25 Rebecca Aspden, HMS III Gillian Lieberman, MD AcknowledgementsAcknowledgements Thanks to Larry Barbaras, Gillian Lieberman, Pamela Lepkowski, Alice Fisher, and Mary Hochman. Without their encouragement, inspiration, and technical help, this presentation would not have been possible. Achilles Tendon Rupture Slide Number 2 Types of Achilles Tendon Injury Who gets tears? Our patient Diagnosis Imaging Options Plain film of torn Achilles Longitudinal sonogram showing partial-thickness tear Longitudinal sonogram showing full-thickness tear Tendons on MRI NORMAL - axial NORMAL - sagittal Tendons on MRI DEGENERATED - axial DEGENERATED - sagittal Tendons on MRI TEAR - axial TEAR - sagittal Slide Number 20 Slide Number 21 Treatment for Achilles tendon rupture Conclusion References Acknowledgements