Rosen & Barkin's 5-Minute Emergency Medicine Consult (702 page)

Trigger Finger

• Proximal portion of the palmar flexor tendon sheath becomes stenosed and catches as the finger is moved.
  
• Symptoms vary from pain to locking in flexion.
  

Ankle

• Achilles tendinopathy:
  
  • Overuse injury commonly seen in males
    
  • Trauma or systemic disease causing inflammation
    
  • With repeated stress, scar tissue formation and degeneration of the tendon will occur.
    
  • Patient will have pain, reduced range of motion, or morning stiffness
    
• Achilles tendon rupture
  
  • Seen more commonly in 30–40-yr-old recreational athletes
    
  • “Popping sensation”
    
  • Acute weakness, inability to continue activity
    
  • Feels like being kicked or hit in back of leg
    
  • May initially have a gap by palpation, followed by ecchymosis and a boggy sensation
    
  • Inability to plantar flex the foot with complete rupture
    
  • Thompson test:
    
    • Patient lies prone with the feet hanging over the edge of the bed.
      
    • Physician squeezes the calf muscles and looks for plantar flexion
      
    • 20–30% of Achilles tendon ruptures are missed at the initial visit because the clinician was falsely reassured by the patient’s ability to plantar flex or walk.
      
    • The Matles Test: the patient lies prone with knees flexed to 90°. Observe whether the affected foot is dorsiflexed or neutral (both are abnormal) compared to the uninjured side, where the foot should appear plantarflexed.
      

• Apophysitis occurs in children at an ossification center subject to traction:
  
  • Little League elbow at the medial epicondyle
    
  • Osgood–Schlatter syndrome at tibial tubercle
    
• Avascular necrosis (AVN):
  
  • Presents with pain and swelling around a joint
    
  • Can occur at various locations
    
  • Well-recognized sites:
    
    • Capitellum of the humerus
      
    • Head of the femur
      
    • Tarsal navicular
      
    • Metatarsal head
      
    • Diagnosis is made by plain radiographs.
      
    • Radiographs are often required to rule out fracture, AVN, osteochondritis dissecans, or bony tumor.
      

Physical exam

CBC, C-reactive protein (CRP), ESR only if more serious infection suspected

• Radiographs:
  
  • Extra-articular from articular etiologies
    
  • “SECONDS”:
    
    • Soft tissue swelling
      
    • Erosions
      
    • Calcifications
      
    • Osteoporosis
      
    • Narrowing
      
    • Deformity
      
    • Separation
      
• Ultrasound
  
  • Evaluate joint effusions
    
  • More sensitive than MRI
    
  • Used more frequently in the emergency setting
    
  • Focal tendon thickening
    
  • Focal hypoechoic areas
    
  • Irregular and ill-defined borders
    
  • Peritendinous edema
    
• MRI:
  
  • Internal morphology of the tendon and the surrounding structures
    
  • Helps diagnose retrocalcaneal bursitis and insertional tendonitis
    
  • Reveals tendon thickening and increased signal with chronic tendon abnormalities
    
• Scintigraphy:
  
  • 99 Technetium pertechnetate phosphate (binds with plasma protein) and concentrates in joint space (bursitis)
    

• Septic arthritis
  
• Fracture
  
• Osteoarthritis
  

TREATMENT

Immobilize injured extremity as indicated.

Ice, immobilization pending work-up

• General:
  
  • Rest
    
  • NSAIDs
    
  • Ice (10–20 min intervals)
    
  • Range of motion exercises
    
  • Eccentric exercise is the application of a load (i.e., muscular exertion) to a lengthening muscle.
    
  • Local injection for pain control
    
  • Outpatient management
    
  • Admit only for surgery or severe disability
    
  • Allow 6–12 wk to heal
    
  • Recent studies have described successful investigational therapies
    
  • Prolotherapy, an ultrasound-guided injection of dextrose and lidocaine to stimulate repair.
    
  • Sclerotherapy injections of Polidocanol, a sclerosing substance to reduce neovascularity
    
  • Aprotinin
    is a broad-spectrum protease and matrix metalloproteinase (MMP) inhibitor, injected peritendinously
    
• Calcific tendonitis
  
  • Low-energy radio shock-wave therapy has recently shown significant pain relief:
    
    • Thought to increase the resorption of calcium
      
  • Cimetidine has been used to decrease pain and calcium deposits.
    
• Trigger finger:
  
  • Conservative treatments such as rest, splinting (thumb spica) and NSAIDs for most
    
  • Some physicians suggest cortisone injections, (84–91% cure rate).
    
  • Surgical release of A-1 Pulley may be required.
    
• De Quervain tenosynovitis
  
  • Rest, ice, NSAIDs
    
  • Thumb spica splint for 3–5 days often helps
    
• Achilles tendonitis:
  
  • Rest, ice, NSAIDs
    
  • Orthotics or heel wedges
    
  • Cryotherapy has shown to be useful in controlling inflammation.
    
  • Achilles rupture should be splinted posteriorly in slight plantar flexion:
    
    • Refer to orthopedics, as patients often need surgery
      

• Ibuprofen: 400–800 mg PO q6–8h (max. 2,400 mg per day); peds: 5–10 mg/kg/dose PO q4–6h (max. 50 mg/kg/d)
  
• Acetaminophen: 10–15 mg/kg/dose every 4–6 hr as needed; do not exceed acetaminophen 4 g/24 h (peds: Do not exceed 5 doses of 10–15 mg/kg acetaminopen in 24 hr)
  

FOLLOW-UP

Admit patients if require surgery or other more serious illness/injury

Most patients may be managed as outpatients with appropriate referral.

• All complete tendon ruptures merit referral for surgical consultation.
  
• Partial tendon tears and chronic tendinopathy that fail to improve with 3–6 mo of conservative treatment may benefit from consultation with a specialized runners’ clinic, physical medicine and rehabilitation specialist, physical therapist, or orthopedic surgeon
  

Prevention of reinjury is central to follow-up care.

• Fluoroquinolones
  
• Tendinopathy and tendon rupture have been reported uncommonly in adults given fluoroquinolones but have been reported with most fluoroquinolones.
  

• Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: Aetiology and management.
  J R Soc Med
  . 2004;97(10):472–476.
  
• Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy.
  Br J Sports Med
  . 2006;40:81–85.
  
• Wilder RP, Sethi S. Overuse injuries: Tendinopathies, stress fractures, compartment syndrome, and shin splints.
  Clin Sports Med
  . 2004;23:55–81.
  
• Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: Effectiveness of eccentric exercise.
  Br J Sports Med
  . 2007;41:188–198.
  

See Also (Topic, Algorithm, Electronic Media Element)

Tenosynovitis

CODES

• 726.0 Adhesive capsulitis of shoulder
  
• 726.10 Disorders of bursae and tendons in shoulder region, unspecified
  
• 726.90 Enthesopathy of unspecified site
  

BASICS