Gastrocnemius Muscle Tear (Calf Tear)

The patient was a 46 year old man, referred from his neighborhood GP.

The story was that he was helping a friend push a stalled car. While doing so, he heard a "snapping" sound from the back of his right leg. This was accompanied by pain; however he still managed to limp back. Back home, he applied some ice onto the leg (good for him), the swelling and bruising didn't appear until the next morning.

He related the story to me on the initial visit, nine days after the injury. Why nine days? Well apparently I was the fourth medical professional he has sought, the 3rd one being the GP who finally referred him here.

Listening to his story carefully, my initial suspicion was that he may have torn his achilles tendon. However a complete tear would render him almost incapable to walk; he was limping to my clinic, sure, but not to the extent that he had to be wheeled into the room.

Examination of his leg showed some swelling of his lower leg, with bruising around the ankle and foot. Tenderness could be felt around the calf muscles. There was no palpable defect on his achilles tendon indicating a torn tendon nor was Simmons test positive for achilles cut.

So that rules out an achilles tendon injury.

Hmmm...

Bruising lower leg

with swelling of the lower leg

An ultrasound or MRI scan would help in this matter. I promptly sent him across the hallway to see the radiologist requesting for an ultrasound of his calf muscle, failing which we may proceed on to do a MRI scan.

The ultrasound report noted fluid/blood collection within the medial gastrocnemius (calf) muscle, which in the light of the patients history, confirmed the patient's diagnosis:

Gastrocnemius muscle tear (calf tear)

A tear of the gastrocnemius muscle  most commonly occurs in the middle-aged, male athlete (the "weekend warrior") when the muscle actively contracts against a foot which is dorsiflexed with an extended knee, as may occur in tennis or jogging; in this particular case, the patient was loading the calf muscles while pushing the car.

As in this patient, the diagnosis can be confused with an achilles tendon rupture. However as explained above, palpation of the achilles tendon should demonstrate an intact tendon. In any case, imaging studies such as ultrasound and magnetic resonance imaging (MRI) can be useful to ascertain the diagnosis.

Only conservative management is required to treat ruptures of the gastrocnemius muscle. 

RICE (Rest, Ice, Compression , Elevation) therapy together with adequate analgesics are the mainstay of treatment for the first 24-72 hours after injury . Ambulation with crutches is advised with gradual weight bearing in the following weeks. A walker-type brace can be used. Physiotherapy is initiated as soon as the patient feels comfortable out of the walker.

A walker type brace - patient would need a longer version

Swelling and bruising should gradually decrease over the next couple of weeks. Recovery may take up to 6 weeks or more depending on the severity of the injury. Patients can expect a full recovery provided that the rehabilitation protocol is followed.

- the BomohTulang -

SAFETY AT THE PLAYGROUND

Due to its location in a residential area, the hospital sees a fair amount of injuries involving children. The numbers seen in the emergency room usually correspond to the school holidays, where we see an increase in the number of children being brought in due to some kind of injury, usually due to a fall while playing.  I suppose the holidays are the time children are given more freedom to play outdoor, free from the pressures of homework and tuition.

The neighbourhood playground is a natural spot for children to congregate, interact and play; at the same time it helps to build their physical skills, co-ordination and strength. It is also a wonderful place for families to get some fresh air and exercise.  It may look like a safe place, but hidden dangers do lurk. The hospital had a “Smart Parent Safe Kids” campaign earlier this year where I gave a talk on prevention of playground injuries.  Why playground injuries? Well, apart from the home, accidents occur more frequently on the playground than any other places. 
In the US, more than 200,000 playground-related injuries occur annually. Similarly in Malaysia, a recent study has shown that 17% of childhood fractures occur in the parks, second only to the home (35%). Now scrapes and bruises are a normal part of growing up, but injuries that are brought to the hospital are usually of a more severe kind. We see sprains, fractures, dislocations, and rarely, amputated fingertips.

Children can injure themselves at the playground in a variety of ways.  As I have explained above, the majority of the injuries result from a fall from playground equipment. They might slip, lose their grip while climbing, or lose balance while playing on the “monkey bars”. Another way is by improper usage of equipment.

The onus is on parents and caregivers to create a safe environment for children to play. One should firstly choose a safe playground based on the location and surrounding hazards. Watch out for open drains, exposed electrical wires and busy roads among other things.

Close supervision by a responsible adult may be the most important factor in preventing playground injuries.  For young children, adults should be with them the whole time they are playing on play equipment. The word is “Active supervision” – one should not be distracted by other activities such as reading a book, talking on the phone or texting.  Although I do agree that  sometimes  adult supervision might be a problem in urban areas as both parents may be working, delegating this responsibility to the grandparents, housemaids or elder children might not be as effective.  Educating the child on the correct usage of play equipment not only decreases the chance of injuries but also goes a long way in preserving the lifespan of the play equipment.

All these might sound frightening, so should you stop sending your children to the playground? My thoughts are that the benefits of fresh air and exercise far outweigh the danger, and so long as mummy and daddy keep an eye and play an actively supervise, time spent at the playground need not end up a tearful experience.

-The BomohTulang 

ACHILLES TENDON CUT due to TOILET BOWL INJURY

The patient slipped in the bathroom and his foot crashed into the toilet bowl. (no he was not squatting on the edge of the toilet seat - see bottom pic)

He sustained a deep laceration over his calf and a clinical examination showed that the achilles tendon was torn.
This was confirmed intra-operatively, where an emergency debridement, exploration and tendon repair was done the same day.

Intra-op findings

Wound blurred out as deemed too gory for public viewing :

Post operatively, a backslab with the ankle in equinus was applied so as to relieve the tension on the operated tendon. This will be replaced later with a special walking boot allowing range of motion exercises to the ankle, with partial weight bearing of the affected limb. Total rehabilitation would take about 4-6 weeks

Apparently a group of doctors reported on this seemingly "rare" case and got it published in the foot and ankle journal.

On another related note, have you been to the toilets in the malls? you would probably come across this sign:

The bottom right symbol is an apt reminder of what not to do if one wishes to avoid getting the injury that our friend above had... perhaps the mall management might want to use the picture above to illustrate the consequences of slipping into a toilet bowl.. hmm...

- the Bomoh Tulang -

reference:

the AAOS Clinical Practice Guideline on the Diagnosis and Treatment of Acute Achilles Tendon Rupture 2009

STACK THEM UP - The Mallet finger splint

A finger has a mallet finger deformity when the distal phalanx droops down, with the patient unable to actively extend the joint.

It is also known as the baseball finger, in which the ball hits the distal phalanx and forcibly flexes the joint. This will usually result in an avulsion of the attachment of extensor tendon to the distal phalanx, usually accompanied with a flake of bone. 

It can be an open (ie with a wound  - in which case the tendon is cut) or closed (ie no wound - implying an avulsion injury) injury.

For closed injuries, the usual treatment is non-surgical. The patient will need to use a splint -  a so-called STACK splint, to keep the joint in extension (or hyperextension even) so as to allow the avulsed flake of bone to heal and to prevent stretching of the tendon.

a custom made Stack splint made by the Occupational therapy dept

another Stack splint. bought off the shelf. nice.

One needs to use the splint diligently for 6 to 8 weeks to allow adequate time for healing. There is a chance of relapse if the splint is taken out for an extended period of time. At the end of the treatment period, one might find that the finger may be stiff in which case physiotherapy might help.


 - the BomohTulang -