Introduction: As part of this minor injuries course we have been asked to provide a 3000 word assignment utilising a case method as means of researching a patient scenario we experienced during clinical practise.
Case study method enables a researcher to investigate an individual and evaluate these findings and relate this evidence to clinical practice ( REFERENCE 1) Case studies are also often subjective and based around a personal experience or memorable patient (REFERENCE 2), whilst identified by (REFERENCE 3) that these case studies do not provide a great amount of empirical and statistical evidence, (REFERENCE 4) highlights that case study methods stimulate critical thinking and help practitioners apply theory to clinical practice.
For this case study I have chosen a patient who I treated for an Achilles tendon rupture. This assignment will aim to
document the assessment of a patient in the acute stage of injury
discuss the initial management of the injury
discuss the treatment plans available
conclude how this case study has impacted on my clinical practise
The Achilles tendon is given its name by Greek hero Achilles as the largest and strongest tendon within the human body, Patel and Haddad (2006). It connects the calf muscle (gastrocnemius) to the heel bone (calcaneus) and is located below the skin at the back of the ankle.(reference needed) As the calf muscle contracts it provides it enables the foot to be pointed downwards (plantarflexion) It is this action that enables us to walk, run, jump and to stand on our toes.(reference needed) Despite great forces applied through this tendon it is vulnerable due to its limited blood supply, the least vascularised area being 2 to 6 cm above the calcaneum. This diminished blood supply predisposes this region to chronic tendonitis and potential rupture. (reference 5)
Kerr (2005) suggests three main attributing factors are leading to an increase in rupture.
Increased sedentary lifestyle
Rising popularity of recreational sports especially in older men
An increasing proportion of people are overweight
75% of Achilles injuries occur during sporting activities, and research indicates this is occurring with patients who describe themselves as novice or beginners (Josza et al, 1989). As ENP’s it is important that we are able to differentiate between an acute tendon injury and other complaints i.e. gastrocnemius tears in order to treat, advice and refer appropriately. Misdiagnosis or delay in treatment can lead to gait dysfunction and chronic pain.
The following case study is a true event of a patient I assessed during my clinical placement. To maintain the patient’s confidentiality he will be referred to as Mr Smith.
CASE STUDY: 68 year old retired gentleman, no drug allergies, no significant past or ongoing medical problems. Mr Smith attended the emergency department at 10.00 and was booked in with a limb problem. I greeted Mr Smith, explained my role as a training Emergency Nurse Practitioner (ENP) and gained consent for his assessment.
Mr Smith had been out dancing the previous night and thought he had been kicked in the back of his right lower leg. Since, he had described difficulty walking and not been able to “bend his foot” as normal. Despite walking tentatively Mr Smith manoeuvred himself onto the examination couch. From his facial expression he appeared comfortable and his pain had been reduced having taken his own paracetamol and ibuprofen. The worst pain had been last night and the patient described an ache this morning. Further analgesia was offered but declined by the patient.
Physical examination:
This was broken down into 5 key areas described by Guly (2002)
Look (inspection)
Feel (palpation)
Movement
Specialist tests
Function
During our course we have assessed neurovascular function as a separate examination. This will be assessed between movement and specialist tests.
Look: Mr Smith was examined in a private cubicle. His trousers removed in order to expose both lower limbs for comparison. Mr Smith had no wounds, no obvious deformity, no erythema /cellulites and no bruising noted. There was noticeable swelling around the base of the calf in the soleus region on the medial aspect of the limb. Both limbs were of equal colour and warmth. No surgical scarring was observed on either limb.
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Feel: Palpation of lower leg then took place. In accordance with Gully (2002) this should take place from the joint above to the joint below. Palpation started from the knee joint downwards. From the examination of the knee joint no pain over bony land marks was elicited by the patient. The palpation moved distal towards the ankle, no bony tenderness was identified. The ankle was examined for bony tenderness. No tenderness was found at the posterior edge or tip of both the medial and lateral maleolus, the base of the 5th metatarsal or the navicular bone. Using Ottawa ankle rules (Hopkins, 2010) there was no indication to xray the ankle. Mr Smith was then asked to go into the prone position, this enabled a good comparative view of both limbs mainly the gastrocnemius muscles and the Achilles tendons. The gastrocnemius muscle was then palpated; although uncomfortable towards the distal muscle a specific tender point was not identified. The Achilles tendon was then palpated; this gave a specific origin for the pain. There was also bogginess (palpable step) in the lower third of the Achilles. Although a step was palpable Kerr (2005) indentified that not all ruptures have a palpable step, the cause of this unknown.
Movement: Ankle movements were examined both active and passive. Mr Smith had good active dorsi flexion and normal plantar flexion of both ankles. However when examined with passive resistance there was a marked deficit on his right ankle. Sterling (2001) highlighted that even though normal range of motion is witnessed during active movement it is essential passive movement is carried out, and assumptions should not be made to the integrity of the Achilles tendon. Both medial and lateral ligaments were stressed with no laxity and good end feel. Finally an anterior draw test was performed, the ankle was stable.
Neurovascular status: Mr Smith had normal sensation of his first web space, dorsum of foot and anterior and lateral aspect of lower leg. Mr Smith was able to dorsiflex and had normal toe plantar mechanism. Pedal pulse was also present.
Specialist tests: Mr Smith was then asked to kneel onto the trolley and support himself using the wall. A Thompson- Simmons (calf squeeze) test was then performed. At this time Mr Smith had no plantar flexion movement. Johnson and Morelli (2001) details this is highly suggestive of a ruptured Achilles tendon. Prior to undertaking this assignment I was not aware of any other specialist tests other than ultrasound. These shall be discussed later.
Function: Guly (2002) states the examination of a joint should include its functionality. Mr Smith was then asked to perform a calf heel raise (stand on tip-toes). He was unable to perform this task. Sterling et al (2001) summarised that a patient whose other plantar flexors are still functioning will not be able to perform this task if their Achilles is ruptured.
Treatment: Mr Smith was diagnosed and treated as an Achilles tendon rupture. He was placed in an equinas cast and was given crutches to mobilise with, which he did very well. A referral was then made to our fracture clinic where he would be followed up with the orthopaedic team. Take home analgesia was offered but declined by the patient. Mr Smith asked about the long term plan of action, would he need surgery to repair his tendon. I answered honestly and stated I didn’t know but endeavoured to find out from one of my colleagues. It was this lack of follow on care knowledge that has been one of the focuses for this case study. Having an extended knowledge base would further enable a holistic approach to care not only in the acute care environment but to also provide accurate information about the care the patient should expect to receive. This sharing of knowledge will hopefully enable the patient to make an informed choice about how they would like to proceed. The follow on from acute injury to referral to fracture clinic is currently within 3 days. The patient will be presented if suitable with two options; surgical repair or conservative management. From reviewing the literature contributing towards this assignment it is clear the orthopaedic world is divided over these two strategies of care. However the common goal summarised by Patel and Haddad (2006) is a restoration of the normal length and tension of the Achilles tendon, allowing patients to regain their functional and desired level of activity. Fotiadis et al (2007) supports this and further discusses the importance of restoring length as this will preserve strength of the gastrocnemius and the soleus muscles, again improving functionality.
Surgical repair: the procedure involves making a longitudinal incision on the medial aspect of the Achilles tendon. Normally the incision is between 8 and 10cm, the ends of the tendon are then sewn together using non-absorbable suture. Two types of stitch are favoured, Krackow or Bunnell. (see appendix A) Kerr (2005) highlights the advantages of surgical repair as
Increased strength
Reduced calf atrophy
Less likely hood of re-rupture
Faster return to sporting activities.
However with any invasive procedure there will be a risk off
Deep wound infection
Deep vein thrombosis
Delayed wound healing
Scar adhesions
Hyperesthesia or numbness of the skin
After surgery the limb is immobilised with an equinas plaster or brace for between 6 to 8 weeks followed by physiotherapy.
Non Surgical Management: Johnson and Morelli (2001) outlines that conservative management involves the patient being placed initially in an equinas cast. The immobilisation of the ankle plantar flexed between 40° and 60° enables the tendon to be stress free promoting the unification of the partial tear or rupture tendon. Having discussed the current treatment guidelines with my orthopaedic colleagues at the hospital the patient would be expected to return to fracture twice over a 6 week period. This would be to have a new POP each time and gradually have the degree of plantar flexion increased. The patient would remain on crutches, non weight bearing on the affected limb, to reduce the potential stress placed on the tendon.
Having presented the case study and outlined initial management and expected follow up care, I would now like to introduce new methods of assessing for Achilles tendon rupture as stated on page 3.
Matles Test: The patient is laid in the prone position with knees flexed at 90°. Both feet and ankles are observed for plantar flexion. The diagram below indicates the there is an increase in dorsi-flexion on the injured limb (right)
Source: foot and ankle hyperbook (2011)
The O’Brien test: the patient lies in the prone position knees flexed at 90°. A small gauge needle is then inserted 10cm form the superior border of the calcaneus into the Achilles tendon. Passive dorsiflexion and plantar flexion movements are applied; absence of movement indicates a potential rupture.
The Copeland test: the patient is laid in prone position with knees flexed at 90°. A sphygmomanometer is placed around the bulk of the calf and the pressure raised to 100mmHg with the ankle plantar flexed. When the ankle is dorsiflexed, in a non- injured Achilles tendon, pressure increases to 140mmHg. Where the Achilles is ruptured the pressure remains the same (Sterling et al, 2000).
Other specialist diagnostic procedures can be performed i.e. ultrasound or MRI. These have been highlighted by Patel and Haddad (2006) as more accurate at detecting partial tears. Ultrasound is operator dependent and requires an experienced technician and radiologist and MRI carries a high cost and limited clinical value of what has already been diagnosed clinically.
Differential diagnosis: During the initial history taking it is paramount an accurate detail history is taken leading up to the events. Majewski et al(2008) outlines 44% of Achilles injuries are misdiagnosed as ankle sprains or gastrocnemius injuries and advocates the use of the two specialists test previously identified; the calf squeeze test and the Maltes test. Majewski et al (2008) concludes along with proficient palpation of the Achilles tendon two positive tests is good evidence of a rupture. However reinforces the need for sonography (ultra-sound) to differentiate between partial and full tears.
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As ENP’s we are usually the first clinician patients see with an acute injury. We have a vital role in demonstrating accurate history taking, assessment, treatment and referral to the appropriate speciality. Despite the patient having an injury it is important that we can provide the patient with accurate education and health promotion advice. It is recognised within our department that weekends have a high increase is sporting injuries who attend the emergency department. The main sports are rugby league and football. We have a great opportunity to impart knowledge to patients with injuries in order to hopefully reduce the incidence of new or re-occurring injury. In relation to Achilles injury or Achilles tendonitis Walker (2005) promotes warm up techniques, the benefits include:
Increased blood flow to working muscles
Increased range of movements
Improved speed of contraction
Increased temperature and hence increased elasticity
Improved oxygen saturation
As previously identified there is reduced vascularisation to part of the tendon, Henry et al (1986) concludes that warming up increases the flexibility of the joint involved and best results occur from static stretching.
Another important factor to advice patients about is footwear. If possible hard backs of shoes should be padded as identified by Milroy (1994) these areas nudge the Achilles, often at the site of injury and wherever possible heels should be slightly raised to shorten the Achilles resulting in less injury from sudden lengthening.
It is this information that I will be now documenting i.e. did they warm up prior to exercise and also conveying this to patients in order to reduce further injuries.
Conclusion:
As identified there is an increase in Achilles tendon rupture injuries hence more people will be attending the Emergency Department through direct referral from General practitioners and Walk in Centres/ Minor injuries units or from self presentation. From reviewing literature it is evident there is a significant number of misdiagnosis occurring around the area of injured Achilles tendons. Despite Mr Smiths diagnosis seeming straightforward I now have a greater appreciation of differential diagnosis and the effects misdiagnosis or delay in treatment can have on the short an
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