01Approach to the Critical Patient/attcp46

Triage and limb threat

›Immediate priorities

›Hemodynamic instability from alternate source

›Trauma survey for concomitant injury

›Syncope evaluation if unclear mechanism

›Open injury over Achilles region

›Broad-spectrum antibiotics per open tendon or contaminated wound

›Tetanus prophylaxis pathway

›Neurovascular compromise of foot

›Absent DP or PT pulse

›Capillary refill delay

›Progressive sensory deficit

›Compartment syndrome after high-energy ankle or leg trauma

›Pain out of proportion

›Pain with passive toe stretch

›Tense compartments

Immediate stabilization and early actions

›Early management bundle

›Analgesia plan

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400-600 mg once if no contraindications

›If severe pain, opioid titration

›Morphine IV 0.05-0.1 mg/kg

›Re-dose every 10-15 minutes to comfort and safety

›Immobilization position

›Ankle plantarflexion 20-30 degrees for suspected complete rupture

›Avoid dorsiflexion stretching

›Non-weight-bearing

02History/hx43

Mechanism and timing

›Injury context

›Sudden push-off or acceleration

›Basketball, soccer, tennis, running

›Sudden dorsiflexion with knee extended

›Misstep off curb

›Fall with foot forced up

›Direct laceration mechanism

›Sharp injury to posterior ankle

›Time since event

›<48 hours

›2-14 days

›>14 days

Symptoms and function

›Classic symptom cluster

›Sudden posterior ankle or calf pain

›Audible pop or snap

›Immediate weakness with push-off

›Difficulty walking or climbing stairs

›Function modifiers

›Ability to toe-walk

›Ability to single-leg heel raise

›Ability to drive with affected side

Risk factors and modifiers

›Patient factors

›Age 30-50 years

›Male sex

›Elevated BMI

03Physical Exam/exam42

Inspection and palpation

›Local findings

›Posterior ankle or calf swelling

›Ecchymosis tracking to heel

›Palpable tendon defect 2-6 cm proximal to calcaneal insertion

›Less reliable after swelling develops

›Resting ankle posture

›Increased dorsiflexion relative to contralateral side

›Skin and wound assessment

›Open laceration over tendon

›Skin tenting or threatened compromise

›Infection signs for delayed presentations

Functional testing

›Strength and gait

›Plantarflexion weakness

›Antalgic gait

›Loss of push-off phase

›Single-leg heel raise

›Inability suggests complete rupture

›Pain-limited attempt interpretation caveat

Special tests and diagnostic accuracy

›Calf squeeze testing

›Thompson test

›Sensitivity about 96%

›Lower in partial tears

›Specificity about 93%

›False positives uncommon

›Matles test

04Differential Diagnosis/ddx34

Posterior ankle and calf pain differentials

›Tendon and muscle injury

›Achilles tendinopathy

›ICD-10 M76.6

›Achilles partial tear

›ICD-10 S86.0

›Gastrocnemius tear

›ICD-10 S86.1

›Soleus strain

›ICD-10 S86.1

›Bony injury

›Calcaneal avulsion fracture

›ICD-10 S92.0

›Posterior malleolus fracture

›ICD-10 S82.8

›Joint and ligament injury

›Ankle sprain

›ICD-10 S93.4

›Syndesmotic injury

›ICD-10 S93.43

›Vascular and neurologic

›Deep vein thrombosis

›ICD-10 I82.4

›Acute limb ischemia

›ICD-10 I74.3

›Sural neuritis

›SNOMED CT concept for peripheral neuropathy pattern

05Laboratory Tests/lt18

Typical ED lab approach

›Minimal routine labs

›No labs for isolated closed rupture with stable patient

›Focus on analgesia and immobilization pathway

›Surgery or admission pathway labs

›CBC for operative planning or anemia concern

›Leukocytosis nonspecific

›Hemoglobin baseline for operative planning

›Electrolytes and creatinine for anesthesia planning

›Renal dosing implications for NSAIDs and LMWH

›INR for warfarin use or bleeding risk

›Reversal planning if urgent surgery

›Glucose for diabetes or infection concern

›Hyperglycemia association with wound complications

›Infection concern labs

›CRP for suspected infection in delayed presentation

›Normal value does not exclude localized infection

›ESR for chronic infectious concern

›Slow kinetics and limited ED utility

06Diagnostic Tests/dt49

Scoring Systems

›Classification and grading

›Acute vs chronic rupture timing

›Acute within 2 weeks

›Subacute 2-6 weeks

›Chronic beyond 6 weeks

›Rupture location

›Midsubstance 2-6 cm proximal to insertion

›Insertional rupture

›Myotendinous junction rupture

›Ultrasound gap estimate use

›Larger gap associated with operative consideration in some protocols

›Dynamic testing improves interpretation

Radiographs

›X-ray indications

›Mechanism with bony injury concern

›Fall from height

›Direct blow

›Suspected calcaneal avulsion

›Palpable bony prominence

›Skin tenting at posterior heel

›Open injury with foreign body concern

›Glass or metal mechanism

›Views

›Ankle 3-view series

›AP

›Lateral

›Mortise

07Disposition/dispo19

ED disposition framework

›Discharge typical pathway

›Closed injury

›Pain controlled with oral plan

›Splint or boot in plantarflexion

›Safe non-weight-bearing plan

›Reliable follow-up within 1 week

›Admission or transfer triggers

›Open rupture or contaminated wound

›Associated fracture requiring operative care

›Neurovascular compromise

›Skin compromise over posterior heel

›Inability to ambulate safely at baseline or after injury

›Uncontrolled pain despite ED regimen

›Follow-up timing

›Orthopedics or sports medicine within 3-7 days

›Earlier if open injury or skin compromise

›Work and activity restrictions

›Driving restriction for right-sided injury until cleared

›No sports and no running until cleared

08Treatment/t106

Immediate life-saving interventions

›Life threats and limb threats

›Hemorrhage and shock evaluation when mechanism suggests polytrauma

›ATLS primary survey if high-energy mechanism

›Transfusion pathway if unstable bleeding

›Open injury pathway

›Wound coverage with sterile dressing

›Antibiotics without delay

›Cefazolin IV 2 g once

›If severe penicillin allergy, clindamycin IV 600-900 mg once

›If gross contamination, add gram-negative coverage per local protocol

›Tetanus prophylaxis

›Tdap if not up to date

›TIG if unknown or incomplete immunization with dirty wound

Immobilization and Splinting

›Immobilization selection

›Posterior short leg splint in plantarflexion

›Add stirrup for rotational control if needed

›CAM boot with heel wedges

›Plantarflexion positioning maintained by wedges

›Removability for hygiene and rehab when protocol allows

›Immobilization principles

›Plantarflexion 20-30 degrees for suspected complete rupture

›Avoid dorsiflexion stretch

›Swelling-phase avoidance of circumferential cast

›Neurovascular reassessment after application

›Post-application checks

›Pain trend

›DP and PT pulses

›Capillary refill

›Sensation plantar and dorsal foot

Reduction

›Reduction considerations

›Not typically applicable for isolated tendon rupture

›If associated fracture-dislocation, follow fracture reduction pathway

›Analgesia and anesthesia for associated reduction

›Non-opioid options

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400-600 mg once if no contraindications

›Opioid titration options

›Morphine IV 0.05-0.1 mg/kg

›Fentanyl IV 0.5-1 mcg/kg

›Procedural sedation pathway for fracture-dislocation

›Monitoring and airway readiness

›Continuous pulse oximetry

›End-tidal CO2 when available

›Suction setup

›BVM and airway adjuncts

›Sedation medication examples

›Ketamine IV 1 mg/kg

›Additional 0.25-0.5 mg/kg as needed

›Propofol IV 0.5-1 mg/kg

›Additional 0.25-0.5 mg/kg titration

Open fracture medications and timing

›Open Achilles or posterior ankle laceration over tendon

›Antibiotics timing within 1 hour of recognition

›Cefazolin IV 2 g once

›Repeat dosing per operative timeline and local protocol

›If contamination risk high, broaden per local protocol

›Farm or soil contamination with anaerobe concern

›Freshwater contamination consideration

›Tetanus prophylaxis

›Tdap if not up to date

›TIG for high-risk immunization histories

›Urgent orthopedic evaluation

›Irrigation and debridement planning

›Tendon repair planning

DVT prophylaxis when relevant

›VTE risk assessment for lower limb immobilization

›Prior VTE history

›Active malignancy

›Thrombophilia

›Prolonged immobility

›Estrogen therapy

›Pregnancy or postpartum status

›Prophylaxis options aligned to local protocol

›If prophylaxis indicated, LMWH example

›Enoxaparin SC 40 mg daily

›Renal impairment dose adjustment per protocol

›If prophylaxis indicated, aspirin option per protocol

›Aspirin PO 81-160 mg daily

›Bleeding risk assessment

›Documentation essentials

›Risk factors supporting plan

›Contraindications supporting avoidance

Definitive management pathways

›Nonoperative functional rehabilitation pathway

›Indications

›Lower surgical risk preference

›Acceptable tendon apposition in plantarflexion by imaging or exam

›Ability to adhere to protocol and follow-up

›Typical protocol elements

›Boot with heel wedges

›Early protected weight-bearing per specialist protocol

›Early range of motion progression per protocol

›Operative repair pathway

›Indications

›High-demand athlete or occupational heavy labor

›Large tendon gap in neutral position on ultrasound

›Failed nonoperative course

›Open rupture

›Delayed presentation with retraction

›Complication balance

›Lower rerupture rate vs traditional casting

›Higher wound complication risk relative to nonoperative in some cohorts

›Evidence and guideline framing

›AAOS guidance

›Operative and nonoperative both reasonable options in many patients

›Shared decision-making emphasis

›Early functional rehab emphasis

›Similar rerupture rates to surgery in some modern functional rehab protocols

›Reduced stiffness and faster recovery relative to prolonged casting in many protocols

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Imaging selection

›Ultrasound preferred for tendon assessment

›Radiographs only if fracture concern with shielding

›Analgesia safety

›Acetaminophen preferred

›NSAID avoidance in later pregnancy

›VTE risk elevation

›Lower threshold for prophylaxis discussion with obstetrics

›LMWH safety considerations with delivery planning

Geriatric

›Older adult considerations

›Higher baseline fall risk with non-weight-bearing

›Mobility aid selection and training

›Home safety planning

›Skin fragility with splints and boots

›Extra padding and frequent skin checks

›Comorbidity impact on surgical risk

›Diabetes and wound risk

›Peripheral vascular disease and healing risk

›Admission threshold

›Unsafe ambulation at home

›Poor social supports

Pediatrics

›Pediatric considerations

›True rupture uncommon

›High suspicion for avulsion fracture at calcaneal apophysis in adolescents

10Background/b32

Epidemiology

›Population patterns

›Incidence range about 11-37 per 100000 population in many reports

›Variation by region and activity

›Male predominance in many cohorts

›Peak incidence in active adult males

›Sports association frequent

›Large proportion during sport and recreational activity

Pathophysiology

›Injury mechanism

›Tendon failure during eccentric loading

›Sudden dorsiflexion while contracting

›Common rupture zone

›Hypovascular midsubstance 2-6 cm proximal to insertion

›Predisposing tendon degeneration

›Chronic tendinopathy microtears

›Collagen disorganization

›Clinical implications

›Preserved plantarflexion possible via accessory muscles

›Partial tears mimic strain

Therapeutic Considerations

›Treatment tradeoffs

›Operative repair

›Lower rerupture in some studies

›Higher wound and infection risk

›Nonoperative functional rehab

›Good functional outcomes in many patients with modern protocols

›Similar rerupture rates to surgery in some functional rehab cohorts

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Discharge instructions

›Diagnosis

›Suspected Achilles tendon rupture

›Immobilization care

›Keep splint or boot on as placed

›Keep dry

›Do not remove padding or wedges unless instructed by specialist

›Avoid ankle dorsiflexion stretching

›Activity

›No weight-bearing on injured leg unless specialist says otherwise

›Use crutches or walker

›Elevate above heart as much as possible for 48-72 hours

›Ice 15-20 minutes at a time with skin protection

›Pain control

›Acetaminophen as directed on label

›Ibuprofen or naproxen as directed on label if safe for you

›Avoid mixing multiple NSAIDs

›Follow-up

›Orthopedics or sports medicine within 3-7 days

›Earlier if wound present or skin concerns

›Return to ER now for

›New numbness or weakness in foot

›Blue or pale toes

›Increasing tightness or severe pain not controlled

›Splint too tight or painful pressure points

›Fever or spreading redness

›Drainage or foul smell from wound

12References/r21

Guidelines and evidence sources

›Core guideline and society statements

›AAOS guidance on acute Achilles tendon rupture treatment options

›Operative and nonoperative both reasonable in many patients

›Shared decision-making emphasis

›AOFAS position statement on acute Achilles ruptures and early functional rehabilitation

›Nonoperative effective for select patients with early functional rehab

›Surgical repair reasonable for healthy active patients

›Diagnostic accuracy sources

›Thompson test performance estimates

›Sensitivity about 96%

›Specificity about 93%

›Physical examination diagnostic accuracy reviews for tendon injury tests

›Likelihood ratio reporting for calf squeeze testing

›Evidence synthesis and review sources

›Meta-analyses comparing operative vs nonoperative outcomes

›Rerupture and complication tradeoffs

›Impact of functional rehabilitation protocols

›Coding references

›ICD-10 S86.0 injury of Achilles tendon

›ICD-10 M76.6 Achilles tendinitis

›SNOMED CT concepts for Achilles tendon rupture and repair procedures

Evidence & Review

Evidence & Review