Grand Rounds: Traumatic Achilles Tendon, Segment #1

Objective

At the conclusion of this blog case, participants should be able to discuss the diagnosis and treatment of the ischemic lower extremity with a limb-threatening wound; in this case, a necrotic, infected, and ischemic Achilles Tendon and contiguous soft tissues.

Introduction

• This 92 yo female was an active, independent ambulator (without assistive device) until sustaining a traumatic wound to her R Achilles tendon in her SNF.  
• The wound was cleansed by the nursing staff and the patient was immediately transferred to an emergency room and then to the affiliated wound center of that hospital.  
• Both in the ER and in the wound center the patient, and her family were told that a BKA was the only option due to LE ischemia with no vascular surgical consideration being presented to the patient and her family. Only portable doppler studies were done at that time.

History of Present Illness

Chief Complaint:

• 92 yo, well-oriented (X3) female active ambulator with painful wound of R Achilles Tendon with a complaint of mild-moderate pain since the injury

History of the Chief Complaint:  

• Trauma to R Achilles tendon in SNF while ambulating 
• Told BKA was only option due to LE ischemia with no vascular surgical consideration presented to patient and family 

Medical History:

• PVD, A-Fib, HTN, Dementia, COPD, Depression - 

Meds: 

• Spiriva, Metoprolol, Lasix, Lisinopril, Spironolactone, Cymbalta, Warfarin, Namenda 

Surgical History:

• Cataracts - Appendectomy - No previous surgical treatment of this new wound 

Family History:

• Breast CA (daughter), Lung CA (daughter) 

Social History: 

• Alcohol - None, Tobacco - 9 Pack years (Quit in 1974) 

Allergies:

• Ativan, Haldol 

Review of Systems: 

• Memory loss, Depression, Muscle weakness and pain, Stiffness, Swelling in joints, Bruises easily 

Case Segment #1

Participants’ Questions, Comments, Suggestions, Literature References and CPG Discussion

• What would you want to know from the History and Physical Examination? 
• What CPGs are you considering at this point in the case? 
• Does this patient need hospital admission? Is this patient a potential candidate for HBO?