The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Unrecognized Pediatric Partial Achilles Tendon Injury Followed by Traumatic Completion: A Case Report and Literature Review William Kelton Vasileff, MD, Vasilios Moutzouros, MD Department of Orthopaedic Surgery, Center For Athletic Medicine, Henry Ford Hospital, Detroit, MI
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Achilles tendon ruptures are a relatively common athletic injury but are exceedingly rare in the pediatric population. We describe the case of a 10-year-old ice hockey player who experienced an Achilles tendon injury from a laceration to the posterior leg from a skate blade that led to a partial tendon laceration. This tendon injury was initially unrecognized despite an emergency department evaluation. The patient continued to complain of weakness and paresthesia after the skin laceration had healed. A traumatic dorsiflexion injury while running several weeks later led to a traumatic complete tendon rupture. The clinical, operative, and physical therapy records were reviewed to complete the history, treatment, and rehabilitation progress. The initial laceration injury had occurred 6 weeks before presentation, and the traumatic dorsiflexion injury had occurred 2 days before referral to an acute orthopedics clinic. Open repair was performed several days after the traumatic completion of the laceration, and the patient was immobilized in a cast for 5 weeks. The patient had weaned off crutches by 10 weeks postoperatively and had returned to some activities and light skating at 5.5 months. A full return to running and ice hockey had been achieved by 8 months postoperatively. The optimal repair for this injury has not been well established in published studies. We have concluded that laceration injuries have the potential to mask tendon injuries and that prolonged symptoms after a laceration should suggest occult pathologic features. Open tendon repair is a viable treatment option in the pediatric patient with Achilles tendon ruptures. A return to activities within a reasonable period can be expected with robust physical therapy. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ice hockey laceration surgical repair
Achilles tendon ruptures are a relatively common injury, particularly in those in their fourth decade and older but are quite rare in the pediatric population. Most pediatric patients who experience this injury have usually sustained an avulsion from the calcaneal insertion of the tendon. We describe a 10-year-old male ice hockey player who sustained a laceration to his calf that we believe caused a partial Achilles tendon laceration. This was followed by a forced dorsiflexion injury 6 weeks later, completing the rupture. The patient was treated successfully with surgical approximation and repair of the tendon and had returned to sports activities by 8 months postoperatively. Case Report A 10-year-old male was referred to our acute care orthopedics clinic after an injury sustained at school the previous day. While he Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: William Kelton Vasileff, MD, Department of Orthopaedic Surgery, Center For Athletic Medicine, Henry Ford Hospital, 6525 Second Avenue, Detroit, MI 48202. E-mail address: [email protected] (W.K. Vasileff).
was playing in the schoolyard, he had slipped and sustained a forced dorsiflexion injury to his right ankle, at which time he described having felt a popping sensation followed by excruciating pain in his ankle. The patient was taken to visit his primary care pediatrician later that same day, where magnetic resonance imaging was ordered. The patient referred to our office the next day. Complicating his history was an injury sustained while playing ice hockey approximately 6 weeks earlier. The child had been playing in a hockey game, approaching the boards, when he sustained a laceration to the posterior medial aspect of his right distal calf from his own left skate blade. He was evaluated after that injury in the pediatrics hospital emergency department. A physical examination and direct inspection of the wound showed an apparently intact Achilles tendon at that time. The laceration was subsequently closed in 2 layers. After that injury, the patient had returned to his activities, including hockey, with minimal difficulty other than persistent complaints of subjective weakness in plantarflexion and paresthesia distal to the laceration. The physical examination at his referral to the orthopedics clinic revealed some mild swelling about his right distal calf. Also visualized was a well-healed, 5.5-cm laceration on the posterior right leg, with no signs of infection. The wound began proximally in the midline and
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.016
2
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. Posterior ankle photograph of pediatric patient. Black line indicates location of laceration sustained from ice hockey skate blade.
extended obliquely in an inferior and medial direction toward its distal termination (Fig. 1). He was able to actively plantarflex, dorsiflex, invert, and evert his foot. However, a definite decrease in plantarflexion strength was noted. The Thompson test was nonreactive, with decreased plantarflexion of the foot compared with the contralateral side. A defect in his Achilles tendon was palpable just distal to the area of the healed hockey skate laceration. The magnetic resonance imaging scan obtained after the most recent dorsiflexion injury was reviewed and demonstrated a complete rupture of the Achilles tendon (Figs. 2 and 3).
Fig. 2. Representative T2-weighted proton density turbo spin echo sagittal magnetic resonance image illustrating complete rupture of Achilles tendon.
The patient was taken to the operating room the next day for surgical repair of his Achilles tendon. After he was placed on the operating table in the prone position, a vertical incision was made from the distal gastrocnemius musculotendinous junction to the insertion of the Achilles tendon at the posterior calcaneus tuberosity. The sural nerve was identified, found to be in continuity, and protected throughout the case. Distally, a hematoma in the area of the ruptured tendon was recognized, extending obliquely proximally to distally. With additional visualization, it appeared that 2 distinct portions of the Achilles tendon had ruptured. The medial and superficial region showed signs of old injury, including scarring and tendon fiber contracture and widening. A separate area of a newer fresh rupture was present that was more lateral and deep and appeared to constitute one quarter of the total tendon area. Some minimal tendon debridement was done in an effort to not reduce the tendon length. A roll was placed under the leg to decrease tension on the tendon by flexing the knee and plantarflexing the ankle. A Martin bandage was applied to the gastrocnemius to push the heads of the muscle as distally as possible. A No. 1 Ethibond suture was passed into the proximal tendon using the modified Bunnell technique and then through the distal portion of the tendon after the ends had been approximated. Next, a no. 0 Ethibond suture was used to close the periphery of the tendon at the approximation site to further align the ruptured tendon. Finally, a no. 1 Vicryl suture was placed through the tendon transversely, proximally and distally to the Bunnell suture and external to the tendon to act as a backup or check rein. The ankle could be placed in a neutral position with negligible stress on the repair construct. After the repair had been completed, the subcutaneous tissue and skin were closed in layers, and a long leg Robert-Jones splint dressing was applied, with the knee in 30 of flexion to restrict strain on the repair. The patient was seen for a follow-up examination 1 week after surgery and was placed in a long leg cast with the knee in 30 of flexion and the ankle in a neutral position. At 1 month after surgery, the patient had active plantarflexion, and palpation of the tendon indicated continued healing of the repaired tendon. At that time, molds were created for a hinged ankle foot orthosis (AFO) with dorsiflexion restricted to 10 , and the patient was placed in a short leg walking cast. He was fitted with the brace 1 week later. He was instructed that full weightbearing was allowed and that the AFO should be worn for any significant walking, although he could
Fig. 3. Representative T1-weighted turbo inversion recovery magnitude sagittal magnetic resonance image illustrating complete rupture of Achilles tendon.
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
perform some limited ambulation around his home without the brace. In addition, physical therapy was initiated twice per week, and he was to wean off of the use of the crutches and focus on plantarflexion strength and range of motion. At 10 weeks postoperatively, the patient had weaned off of crutch use and had continued to use his AFO when out of the house and at school. Numbness from the initial injury had persisted along the distribution of the lateral plantar nerve from the midfoot distally but was continuing to improve. He was allowed to wean out of the AFO and continued his physical therapy and home exercise program. The patient was seen in the clinic 5.5 months postoperatively and was continuing to improve his range of motion. His strength was nearing normal, and the previously noted numbness was also steadily improving. At that time, he was instructed to continue his formal physical therapy and home regimen. It was also discussed that he could begin a gradual return to skating but that competitive ice hockey would be allowed at a later point. At 8 months postoperatively, the patient had returned to running and ice hockey and was doing well without pain. The operative leg remained slightly weak, in particular with plantarflexion activities; however, the patient was instructed on a continued home exercise program and discharged from formal physical therapy. Discussion Very few cases of Achilles tendon ruptures involving skeletally immature patients have been reported in published studies. Our case was unique in that it involved an athletic pediatric patient who had sustained a laceration injury, with later traumatic completion leading to a delayed diagnosis. Little has been written about Achilles tendon injuries in the pediatric population; however, classic texts have referred to avulsions from the calcaneal insertion to be more common than midsubstance disruptions in pediatric patients compared with their adult counterparts (1). Through an extensive search, several case reports regarding similar injuries were reviewed. A report from 2004 described a 7-year-old female who had sustained a midsubstance rupture after a fall of 1 m onto a plantarflexed foot. That patient was treated conservatively in a cast for 6 weeks and went on to complete healing and full activity (2). A report from 1971 described a 14-year-old patient who had presented with a history more similar to that of our patient (3). She had been struck by a swinging door across the posterior aspect of her distal lower leg in the area of her Achilles tendon and had complained of a slight limp and calf weakness for 1 week. Three weeks later, she had sustained a complete rupture while running on the beach. She was treated by open repair and had also healed well and returned to her activities. A 2003 publication described the treatment of a 5-year-old male with congenital insensitivity to pain who developed calcaneal osteomyelitis and subsequently an Achilles avulsion with significant contracture (4). The patient was treated using an Ilizarov technique for lengthening of the tendon and repair and had resolution of his infection and successful reconstruction of his heel cord. A report from 1992 described a collegiate hockey player who had sustained an injury to his Achilles tendon in a similar fashion to our patient. The player had been struck by a skate blade on the posterior aspect of his lower leg; however, he had sustained a complete laceration injury during that index event (5). The postoperative care of our patient was individualized on the basis of his subacute delayed presentation. At surgery, some chronically damaged nonviable tendon tissue was identified that had to be debrided, along with the more acute ruptured segment. Despite this, the tendon edges were well approximated at the repair, with minimal tension. Because of his age and activity level and the nature of his injury, it was decided that long leg immobilization in slight flexion was appropriate for the immediate postoperative period to most effectively protect the repair. His advancement in activity level,
3
including the prolonged use of the AFO and delayed return to sports activities, was deliberately conservative for several similar reasons, including the nature of his injury and the delayed surgical repair. The patient had a somewhat slow return of strength, and his continued neurologic symptoms were also slightly concerning because he might not have been able regulate his own activity levels appropriately. Additionally, the patient had been more active than prescribed on several occasions and had been performing training and sports activities at an earlier point, despite our recommendations. Multiple reports have been written recently regarding the differences between operative and nonoperative treatment of Achilles tendon injuries and differences among repair techniques when operative intervention has been elected (6–11). Disagreement has continued regarding the optimal treatment; however, none of these reports addressed patients in the pediatric population. The most common cited differences between operative and nonoperative treatment have included the increased complications associated with surgical care and an associated decrease in the repeat rupture rate. With nonoperative care, a slight residual decrease in plantarflexion strength has been reported (12). Owing to the lack of clear evidence directing the treatment choices in this situation, in particular, with skeletally immature patients, the treatment decision will be up to the discretion of the provider and the patient’s family. Because of the acute on chronic nature of this specific injury, surgical intervention was recommended after discussing the potential benefits and risks of surgical and nonsurgical treatment, and the family agreed with the plan of care. Several issues arose with the diagnosis and treatment of our patient that could alter the clinical care for this type of injury. The first was that clinicians can, on occasion, be misled by the physical examination findings of Achilles tendon injuries. Our patient most likely sustained a partial laceration to his Achilles tendon but had presented to the emergency department with physical examination findings suggestive of an intact tendon, despite his subjective weakness (13). After an injury such as this, if a patient continues to complain of weakness and other symptoms, clinical suspicion should be elevated for Achilles tendon rupture, and additional evaluation should be pursued. This would likely be in the form of additional imaging such as magnetic resonance imaging or ultrasonography. Several healthcare providers could have encountered the patient and been alerted by his prolonged symptoms, including the athletic trainer, school nurse, emergency medicine physicians, primary care pediatrics physician, and orthopedic surgeons. Had his injury been identified at an earlier point before traumatic completion of the rupture, protecting the patient from additional injury by activity modification and restricted weightbearing, brace wear, or casting in an equinus position might have been appropriate and adequate treatment. Our patient has done well with surgical treatment, despite his delayed diagnosis and prolonged recovery. We believe that most pediatric patients, in particular those who have sustained a laceration and later traumatic complete injury, such as did our patient, would benefit from surgical repair of the Achilles tendon. Healthcare providers should maintain vigilance when addressing these types of injuries to prevent a delay in diagnosis and associated treatment. References 1. Azar FM. Traumatic disorders. In: Campbell’s Operative Orthopaedics, pp. 2737– 2788, edited by ST Canale, JH Beaty, eds, Mosby Elsevier, Philadelphia, 2008. 2. Eidelman M, Nachtigal A, Katzman A, Bialik V. Acute rupture of Achilles tendon in a 7-year-old girl. J Pediatr Orthop B 13:32–33, 2004. 3. Ralston EL, Schmidt ER Jr. Repair of the ruptured Achilles tendon. J Trauma 1:15–21, 1971. 4. Shea KG, Showalter L. Iliziarov method of repair of Achilles tendon rupture in a patient with congenital insensitivity to pain: a case report. J Bone Joint Surg Am 85:1816–1818, 2003.
4
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
5. Kelly TF, Ryan JB. Lacerated Achilles tendon in a collegiate hockey player: a case report. Am J Sports Med 20:84–87, 1992. 6. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 9:1369–1379, 2005. 7. Hohendorff B, Siepen W, Spierling L, Staub L, Schmuck T, Boss A. Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture. J Foot Ankle Surg 5:392–399, 2008. n E, Karlsson J. Acute rupture of tendon 8. Moller M, Movin T, Granhed H, Lind K, Faxe Achillis: a prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 6:843–848, 2001. 9. Uchiyama E, Nomura A, Takeda Y, Hiranuma K, Iwaso H. A modified operation for Achilles tendon ruptures. Am J Sports Med 10:1739–1743, 2007.
10. Yatsumoto T, Miymamoto W, Uchio Y. Novel approach to repair of acute Achilles tendon rupture: early recovery without postoperative fixation or orthosis. Am J Sports Med 2:287–292, 2010. 11. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 17:2767–2775, 2010. 12. Moller M, Lind K, Movin T, Karlsson J. Calf muscle function after Achilles tendon rupture: a prospective, randomised study comparing surgical and non-surgical treatment. Scand J Med Sci Sports 1:9–16, 2002. 13. Ufberg J, Harrigan RA, Cruz T, Perron AD. Orthopedic pitfalls in the ED: Achilles tendon rupture. Am J Emerg Med 22:596–600, 2004.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Unrecognized Pediatric Partial Achilles Tendon Injury Followed by Traumatic Completion: A Case Report and Literature Review William Kelton Vasileff, MD, Vasilios Moutzouros, MD Department of Orthopaedic Surgery, Center For Athletic Medicine, Henry Ford Hospital, Detroit, MI
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Achilles tendon ruptures are a relatively common athletic injury but are exceedingly rare in the pediatric population. We describe the case of a 10-year-old ice hockey player who experienced an Achilles tendon injury from a laceration to the posterior leg from a skate blade that led to a partial tendon laceration. This tendon injury was initially unrecognized despite an emergency department evaluation. The patient continued to complain of weakness and paresthesia after the skin laceration had healed. A traumatic dorsiflexion injury while running several weeks later led to a traumatic complete tendon rupture. The clinical, operative, and physical therapy records were reviewed to complete the history, treatment, and rehabilitation progress. The initial laceration injury had occurred 6 weeks before presentation, and the traumatic dorsiflexion injury had occurred 2 days before referral to an acute orthopedics clinic. Open repair was performed several days after the traumatic completion of the laceration, and the patient was immobilized in a cast for 5 weeks. The patient had weaned off crutches by 10 weeks postoperatively and had returned to some activities and light skating at 5.5 months. A full return to running and ice hockey had been achieved by 8 months postoperatively. The optimal repair for this injury has not been well established in published studies. We have concluded that laceration injuries have the potential to mask tendon injuries and that prolonged symptoms after a laceration should suggest occult pathologic features. Open tendon repair is a viable treatment option in the pediatric patient with Achilles tendon ruptures. A return to activities within a reasonable period can be expected with robust physical therapy. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ice hockey laceration surgical repair
Achilles tendon ruptures are a relatively common injury, particularly in those in their fourth decade and older but are quite rare in the pediatric population. Most pediatric patients who experience this injury have usually sustained an avulsion from the calcaneal insertion of the tendon. We describe a 10-year-old male ice hockey player who sustained a laceration to his calf that we believe caused a partial Achilles tendon laceration. This was followed by a forced dorsiflexion injury 6 weeks later, completing the rupture. The patient was treated successfully with surgical approximation and repair of the tendon and had returned to sports activities by 8 months postoperatively. Case Report A 10-year-old male was referred to our acute care orthopedics clinic after an injury sustained at school the previous day. While he Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: William Kelton Vasileff, MD, Department of Orthopaedic Surgery, Center For Athletic Medicine, Henry Ford Hospital, 6525 Second Avenue, Detroit, MI 48202. E-mail address: [email protected] (W.K. Vasileff).
was playing in the schoolyard, he had slipped and sustained a forced dorsiflexion injury to his right ankle, at which time he described having felt a popping sensation followed by excruciating pain in his ankle. The patient was taken to visit his primary care pediatrician later that same day, where magnetic resonance imaging was ordered. The patient referred to our office the next day. Complicating his history was an injury sustained while playing ice hockey approximately 6 weeks earlier. The child had been playing in a hockey game, approaching the boards, when he sustained a laceration to the posterior medial aspect of his right distal calf from his own left skate blade. He was evaluated after that injury in the pediatrics hospital emergency department. A physical examination and direct inspection of the wound showed an apparently intact Achilles tendon at that time. The laceration was subsequently closed in 2 layers. After that injury, the patient had returned to his activities, including hockey, with minimal difficulty other than persistent complaints of subjective weakness in plantarflexion and paresthesia distal to the laceration. The physical examination at his referral to the orthopedics clinic revealed some mild swelling about his right distal calf. Also visualized was a well-healed, 5.5-cm laceration on the posterior right leg, with no signs of infection. The wound began proximally in the midline and
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.016
2
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Fig. 1. Posterior ankle photograph of pediatric patient. Black line indicates location of laceration sustained from ice hockey skate blade.
extended obliquely in an inferior and medial direction toward its distal termination (Fig. 1). He was able to actively plantarflex, dorsiflex, invert, and evert his foot. However, a definite decrease in plantarflexion strength was noted. The Thompson test was nonreactive, with decreased plantarflexion of the foot compared with the contralateral side. A defect in his Achilles tendon was palpable just distal to the area of the healed hockey skate laceration. The magnetic resonance imaging scan obtained after the most recent dorsiflexion injury was reviewed and demonstrated a complete rupture of the Achilles tendon (Figs. 2 and 3).
Fig. 2. Representative T2-weighted proton density turbo spin echo sagittal magnetic resonance image illustrating complete rupture of Achilles tendon.
The patient was taken to the operating room the next day for surgical repair of his Achilles tendon. After he was placed on the operating table in the prone position, a vertical incision was made from the distal gastrocnemius musculotendinous junction to the insertion of the Achilles tendon at the posterior calcaneus tuberosity. The sural nerve was identified, found to be in continuity, and protected throughout the case. Distally, a hematoma in the area of the ruptured tendon was recognized, extending obliquely proximally to distally. With additional visualization, it appeared that 2 distinct portions of the Achilles tendon had ruptured. The medial and superficial region showed signs of old injury, including scarring and tendon fiber contracture and widening. A separate area of a newer fresh rupture was present that was more lateral and deep and appeared to constitute one quarter of the total tendon area. Some minimal tendon debridement was done in an effort to not reduce the tendon length. A roll was placed under the leg to decrease tension on the tendon by flexing the knee and plantarflexing the ankle. A Martin bandage was applied to the gastrocnemius to push the heads of the muscle as distally as possible. A No. 1 Ethibond suture was passed into the proximal tendon using the modified Bunnell technique and then through the distal portion of the tendon after the ends had been approximated. Next, a no. 0 Ethibond suture was used to close the periphery of the tendon at the approximation site to further align the ruptured tendon. Finally, a no. 1 Vicryl suture was placed through the tendon transversely, proximally and distally to the Bunnell suture and external to the tendon to act as a backup or check rein. The ankle could be placed in a neutral position with negligible stress on the repair construct. After the repair had been completed, the subcutaneous tissue and skin were closed in layers, and a long leg Robert-Jones splint dressing was applied, with the knee in 30 of flexion to restrict strain on the repair. The patient was seen for a follow-up examination 1 week after surgery and was placed in a long leg cast with the knee in 30 of flexion and the ankle in a neutral position. At 1 month after surgery, the patient had active plantarflexion, and palpation of the tendon indicated continued healing of the repaired tendon. At that time, molds were created for a hinged ankle foot orthosis (AFO) with dorsiflexion restricted to 10 , and the patient was placed in a short leg walking cast. He was fitted with the brace 1 week later. He was instructed that full weightbearing was allowed and that the AFO should be worn for any significant walking, although he could
Fig. 3. Representative T1-weighted turbo inversion recovery magnitude sagittal magnetic resonance image illustrating complete rupture of Achilles tendon.
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
perform some limited ambulation around his home without the brace. In addition, physical therapy was initiated twice per week, and he was to wean off of the use of the crutches and focus on plantarflexion strength and range of motion. At 10 weeks postoperatively, the patient had weaned off of crutch use and had continued to use his AFO when out of the house and at school. Numbness from the initial injury had persisted along the distribution of the lateral plantar nerve from the midfoot distally but was continuing to improve. He was allowed to wean out of the AFO and continued his physical therapy and home exercise program. The patient was seen in the clinic 5.5 months postoperatively and was continuing to improve his range of motion. His strength was nearing normal, and the previously noted numbness was also steadily improving. At that time, he was instructed to continue his formal physical therapy and home regimen. It was also discussed that he could begin a gradual return to skating but that competitive ice hockey would be allowed at a later point. At 8 months postoperatively, the patient had returned to running and ice hockey and was doing well without pain. The operative leg remained slightly weak, in particular with plantarflexion activities; however, the patient was instructed on a continued home exercise program and discharged from formal physical therapy. Discussion Very few cases of Achilles tendon ruptures involving skeletally immature patients have been reported in published studies. Our case was unique in that it involved an athletic pediatric patient who had sustained a laceration injury, with later traumatic completion leading to a delayed diagnosis. Little has been written about Achilles tendon injuries in the pediatric population; however, classic texts have referred to avulsions from the calcaneal insertion to be more common than midsubstance disruptions in pediatric patients compared with their adult counterparts (1). Through an extensive search, several case reports regarding similar injuries were reviewed. A report from 2004 described a 7-year-old female who had sustained a midsubstance rupture after a fall of 1 m onto a plantarflexed foot. That patient was treated conservatively in a cast for 6 weeks and went on to complete healing and full activity (2). A report from 1971 described a 14-year-old patient who had presented with a history more similar to that of our patient (3). She had been struck by a swinging door across the posterior aspect of her distal lower leg in the area of her Achilles tendon and had complained of a slight limp and calf weakness for 1 week. Three weeks later, she had sustained a complete rupture while running on the beach. She was treated by open repair and had also healed well and returned to her activities. A 2003 publication described the treatment of a 5-year-old male with congenital insensitivity to pain who developed calcaneal osteomyelitis and subsequently an Achilles avulsion with significant contracture (4). The patient was treated using an Ilizarov technique for lengthening of the tendon and repair and had resolution of his infection and successful reconstruction of his heel cord. A report from 1992 described a collegiate hockey player who had sustained an injury to his Achilles tendon in a similar fashion to our patient. The player had been struck by a skate blade on the posterior aspect of his lower leg; however, he had sustained a complete laceration injury during that index event (5). The postoperative care of our patient was individualized on the basis of his subacute delayed presentation. At surgery, some chronically damaged nonviable tendon tissue was identified that had to be debrided, along with the more acute ruptured segment. Despite this, the tendon edges were well approximated at the repair, with minimal tension. Because of his age and activity level and the nature of his injury, it was decided that long leg immobilization in slight flexion was appropriate for the immediate postoperative period to most effectively protect the repair. His advancement in activity level,
3
including the prolonged use of the AFO and delayed return to sports activities, was deliberately conservative for several similar reasons, including the nature of his injury and the delayed surgical repair. The patient had a somewhat slow return of strength, and his continued neurologic symptoms were also slightly concerning because he might not have been able regulate his own activity levels appropriately. Additionally, the patient had been more active than prescribed on several occasions and had been performing training and sports activities at an earlier point, despite our recommendations. Multiple reports have been written recently regarding the differences between operative and nonoperative treatment of Achilles tendon injuries and differences among repair techniques when operative intervention has been elected (6–11). Disagreement has continued regarding the optimal treatment; however, none of these reports addressed patients in the pediatric population. The most common cited differences between operative and nonoperative treatment have included the increased complications associated with surgical care and an associated decrease in the repeat rupture rate. With nonoperative care, a slight residual decrease in plantarflexion strength has been reported (12). Owing to the lack of clear evidence directing the treatment choices in this situation, in particular, with skeletally immature patients, the treatment decision will be up to the discretion of the provider and the patient’s family. Because of the acute on chronic nature of this specific injury, surgical intervention was recommended after discussing the potential benefits and risks of surgical and nonsurgical treatment, and the family agreed with the plan of care. Several issues arose with the diagnosis and treatment of our patient that could alter the clinical care for this type of injury. The first was that clinicians can, on occasion, be misled by the physical examination findings of Achilles tendon injuries. Our patient most likely sustained a partial laceration to his Achilles tendon but had presented to the emergency department with physical examination findings suggestive of an intact tendon, despite his subjective weakness (13). After an injury such as this, if a patient continues to complain of weakness and other symptoms, clinical suspicion should be elevated for Achilles tendon rupture, and additional evaluation should be pursued. This would likely be in the form of additional imaging such as magnetic resonance imaging or ultrasonography. Several healthcare providers could have encountered the patient and been alerted by his prolonged symptoms, including the athletic trainer, school nurse, emergency medicine physicians, primary care pediatrics physician, and orthopedic surgeons. Had his injury been identified at an earlier point before traumatic completion of the rupture, protecting the patient from additional injury by activity modification and restricted weightbearing, brace wear, or casting in an equinus position might have been appropriate and adequate treatment. Our patient has done well with surgical treatment, despite his delayed diagnosis and prolonged recovery. We believe that most pediatric patients, in particular those who have sustained a laceration and later traumatic complete injury, such as did our patient, would benefit from surgical repair of the Achilles tendon. Healthcare providers should maintain vigilance when addressing these types of injuries to prevent a delay in diagnosis and associated treatment. References 1. Azar FM. Traumatic disorders. In: Campbell’s Operative Orthopaedics, pp. 2737– 2788, edited by ST Canale, JH Beaty, eds, Mosby Elsevier, Philadelphia, 2008. 2. Eidelman M, Nachtigal A, Katzman A, Bialik V. Acute rupture of Achilles tendon in a 7-year-old girl. J Pediatr Orthop B 13:32–33, 2004. 3. Ralston EL, Schmidt ER Jr. Repair of the ruptured Achilles tendon. J Trauma 1:15–21, 1971. 4. Shea KG, Showalter L. Iliziarov method of repair of Achilles tendon rupture in a patient with congenital insensitivity to pain: a case report. J Bone Joint Surg Am 85:1816–1818, 2003.
4
W.K. Vasileff, V. Moutzouros / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
5. Kelly TF, Ryan JB. Lacerated Achilles tendon in a collegiate hockey player: a case report. Am J Sports Med 20:84–87, 1992. 6. Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 9:1369–1379, 2005. 7. Hohendorff B, Siepen W, Spierling L, Staub L, Schmuck T, Boss A. Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture. J Foot Ankle Surg 5:392–399, 2008. n E, Karlsson J. Acute rupture of tendon 8. Moller M, Movin T, Granhed H, Lind K, Faxe Achillis: a prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 6:843–848, 2001. 9. Uchiyama E, Nomura A, Takeda Y, Hiranuma K, Iwaso H. A modified operation for Achilles tendon ruptures. Am J Sports Med 10:1739–1743, 2007.
10. Yatsumoto T, Miymamoto W, Uchio Y. Novel approach to repair of acute Achilles tendon rupture: early recovery without postoperative fixation or orthosis. Am J Sports Med 2:287–292, 2010. 11. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 17:2767–2775, 2010. 12. Moller M, Lind K, Movin T, Karlsson J. Calf muscle function after Achilles tendon rupture: a prospective, randomised study comparing surgical and non-surgical treatment. Scand J Med Sci Sports 1:9–16, 2002. 13. Ufberg J, Harrigan RA, Cruz T, Perron AD. Orthopedic pitfalls in the ED: Achilles tendon rupture. Am J Emerg Med 22:596–600, 2004.
