Focused Ultrasound for Traumatic Ankle Pain in the Emergency Department

Focused Ultrasound for Traumatic Ankle Pain in the Emergency Department

The Journal of Emergency Medicine, Vol. 44, No. 2, pp. 476–477, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/...

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The Journal of Emergency Medicine, Vol. 44, No. 2, pp. 476–477, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2012.02.047

Visual Diagnosis in Emergency Medicine

FOCUSED ULTRASOUND FOR TRAUMATIC ANKLE PAIN IN THE EMERGENCY DEPARTMENT Wei-Jing Lee, MD, MS,* Wen-Shiang Tsai, MD,* and Reng-Hong Wu, MD† *Department of Emergency Medicine and †Department of Radiology, Chi-Mei Medical Center, Tainan, Taiwan Reprint Address: Wen-Shiang Tsai, MD, Department of Emergency Medicine, Chi-Mei Medical Center, 901 Zhonghua Road, Yongkang District, Tainan 710, Taiwan

studies include radiography, magnetic resonance imaging (MRI), and ultrasonography. Ankle radiography is primarily used in ruling out fractures. An MRI scan can provide detailed information, but is too expensive, time consuming, and impractical in the ED. Bedside ultrasound, however, is useful in confirmation of tendon injuries, is easily accessible, inexpensive, and involves no radiation (2). Treatment options include surgical and non-surgical treatments, and depend on the severity of the Achilles tendon injury and the patient’s general condition (3).

CASE REPORT A 74-year-old man was brought to the Emergency Department (ED) with right ankle pain after a motorcycle accident. Physical examination revealed swelling of the right ankle, with loss of plantar flexion and a positive Thompson’s test. X-ray studies showed no obvious fracture (Figure 1). Bedside ultrasound of the ankle was obtained and revealed a hypoechoic gap of 0.48 cm in width (Figure 2), suggesting an Achilles tendon rupture. The consulting orthopedic surgeon discussed the treatment alternatives with the family and they decided upon non-surgical treatment with short leg cast.

DISCUSSION The Achilles tendon is the strongest tendon in the human body and has high resilient properties. It connects the gastrocnemius muscle to calcaneus. Risk factors for an Achilles tendon rupture include direct trauma, being an athlete, sudden forced plantar flexion or dorsiflexion of the foot, and use of medications (fluoroquinolone antibiotics and corticosteroids). Patients who are ‘‘weekend warriors,’’ of advanced age, or are poorly conditioned, are also at risk. Diagnosis can be made by physical examination through palpation of a gap in the tendon, or squeezing the calf muscle (Thompson test) (1). Imaging

Figure 1. Lateral X-ray study of right ankle reveals soft tissue swelling of the right ankle (arrow).

RECEIVED: 29 August 2011; FINAL SUBMISSION RECEIVED: 29 October 2011; ACCEPTED: 26 February 2012 476

Focused Ultrasound for Traumatic Ankle Pain in the ED

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Figure 2. Ultrasound of the right ankle shows hypoechoic gap of 0.48 cm in width with minimal fluid collection, suggesting right Achilles tendon tear (arrow) and part of normal Achilles tendon (bold arrow).

REFERENCES 1. Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019–36.

2. Grechenig W, Clement H, Bratschitsch G, et al. Ultrasonography of the Achilles tendon. Orthopade 2002;31:319–25. 3. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures. J Bone Joint Surg Am 2010;92:2767–75.