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Lesiones Ligamentarias del Tobillo: Esguinces y Tendn de Aquiles

Francisca Pacheco Donoso Residente Ortopedia y Traumatologa Diciembre 2011

Esguinces de Tobillo

Esguince de Tobillo
Introduccin
Lesin musculo esqueltica mas frecuente: 40% consultas TMT urgencia EEUU: 1 por cada 10.000 hab/da. UK: 16.9 por cada 10.000 hab/ao. H:M : 50.3 : 49.7% Pacientes jvenes: Mecanismo rotacional Practica deportiva 49.3%

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Mecanismo
Lateral:
Inversin + RI del retropi Pierna en RE

Lesin complejo ligamentario lateral:


LTFA 100% LCF 50-75% LTFP <10%

Medial:
Stress en inversin 5%

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Clasificacin

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Examen fsico
AVO Equimosis Puntos dolorosos Cajn anterior: LTFA

S:73% E:97%

Tilt talar: LCF Sindesmosis


Squeeze test Test RE

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Radiologa: Criterios de Ottawa
Criterios de Ottawa para Tobillo Incapacidad de cargar extremidad (4 pasos) Dolor en borde posterior y punta del malolo externo Dolor en borde posterior y punta del malolo interno

Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.

Esguince de Tobillo
Radiologa
Diagnostico: CLNICO Rx Tobillo AP-Lat-Mortaja

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Radiologa
Proyecciones de Stress
Tilt talar > 15 Shift talar > 2 mm

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Tratamiento
PRICE
Proteccin Reposo Ice Compresin Elevacin

Disminuir edema Evitar rigidez Rehabilitacin


B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Tratamiento
Evitar en lo posible la inmovilizacin Taping Brace Yeso BC: Periodo menor a 3 semanas en G III Uso de soporte externo: Feedback (+) a paciente y ayuda a rehabilitacin Reintegro precoz a actividades Descarga indicada por 10 das en esguinces G III Crioterapia intermitente por 72 hrs
B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Rehabilitacin
Diversos protocolos ROM Fortalecimiento eversores Propiocepcin

Recupera balance y control postural

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Esguince de Tobillo
Complicaciones

B.R. Waterman et al. The Epidemiology of Ankle Sprains in the United States . J Bone Joint Surg Am. 2010;92:2279-84 N. Malfulli. Management of Acute an Chronic Ankle instability. J am Acad Orthop Surg 2008; 16:608-615 N.Malfulli. Focus on: Lateral Ankle Instability. JBJB Br 2010

Inestabilidad Tobillo

Inestabilidad de Tobillo
Introduccin
Inestabilidad mayor a 6 meses post trauma 20% de pacientes con esguince tobillo Inestabilidad funcional: Giving away
Laxitud aumentada Deficit propiocepcin post KNT Debilidad musculos peroneos:

Disminucin de tiempo de reaccin ante inversion en EMG

Inestabilidad subtalar Objetivable mediante cajon anterior y Rx stress


J.Bell et al. Chronic Lateral Ankle Instability: The Bostrm Procedure. Oper Tech in Sports Med 13: 176-182. 2005 R. Krips. Ankle Instability. Foot and Ankle Clinics. N Am. 11 (2006) 311 32

Inestabilidad mecanica

Inestabilidad de Tobillo
Diagnostico Diferencial
Extrarticulares:
Pellizcamiento anterior de Tobillo Ruptura / subluxacin de peroneos

Intrarticulares:
Lesiones osteocondrales del Talo / Tibia Cuerpos libres intrarticulares

J.Bell et al. Chronic Lateral Ankle Instability: The Bostrm Procedure. Oper Tech in Sports Med 13: 176-182. 2005 R. Krips. Ankle Instability. Foot and Ankle Clinics. N Am. 11 (2006) 311 32

Inestabilidad de Tobillo
Tratamiento
Conservador: Soporte KNT
Fortalecimiento peroneos Coordinacin

50% con buenos resultados luego de 3 meses Malos resultados con laxitud mecnica severa

Considerar Ciruga precozmente

J.Bell et al. Chronic Lateral Ankle Instability: The Bostrm Procedure. Oper Tech in Sports Med 13: 176-182. 2005 R. Krips. Ankle Instability. Foot and Ankle Clinics. N Am. 11 (2006) 311 32

Inestabilidad de Tobillo
Tratamiento Quirrgico
10% casos Reconstruccin Anatmica

Uso del tejido previamente daado

Bostrm

Modificacin de Gould

Modificacin de Karlsson

J.Bell et al. Chronic Lateral Ankle Instability: The Bostrm Procedure. Oper Tech in Sports Med 13: 176-182. 2005 R. Krips. Ankle Instability. Foot and Ankle Clinics. N Am. 11 (2006) 311 32

Inestabilidad de Tobillo
Introduccin
Reconstruccin no Anatmica:

Sacrifica otros tendones (P. Brevis) o porciones de ellos

Watson-Jones

Evans

Chrisman-Snook

J.Bell et al. Chronic Lateral Ankle Instability: The Bostrm Procedure. Oper Tech in Sports Med 13: 176-182. 2005 R. Krips. Ankle Instability. Foot and Ankle Clinics. N Am. 11 (2006) 311 32

Lesiones Sindesmales

Lesiones Sindesmales
Anatoma
Complejo sindesmal

C. Zalavras, D. Thordarson. Ankle Syndesmotic Injury. J Am Acad Orthop Surg 2007; 15:330-339

Lesiones Sindesmales
Generalidades
Mecanismo: RE +/- dorsiflexin Lesin ligamentaria PURA Asociacin con Fx

Fx LH PRE (Weber C)


30% 70%

Fx LH SER (Weber B)


Maisonneuve

Squeeze test Test de RE


C Zalavras, D Thordarson. Ankle Syndesmotic Injury. J Am Acad Orthop Surg 2007; 15: 330-339

Lesiones Sindesmales
Radiologa
Rx Tobillo AP-Lateral-Mortaja Rx pierna AP-Lateral Rx en proyecciones de stress:
Mortaja: Lateral Lateral: Posterior

TAC: Distasis 2-3 mm no evidente en Rx RM:

S:100% E:93% para rotura de LTFA

Artroscopia
C. Zalavras, D. Thordarson. Ankle Syndesmotic Injury. J Am Acad Orthop Surg 2007; 15:330-339

Lesiones Sindesmales
Tratamiento Quirrgico
Distasis tibio-peronea > 2mm Fx fibula 4,5 cm sobre el plafn + lesin deltodea Luego de RAFI malolo medial con Fx peron 15 cm sobre el plafn Segn medicin intraoperatoria (Hook Test)

No necesaria luego de fijacin en Fx tobillo bimaleolar

C Zalavras, D Thordarson. Ankle Syndesmotic Injury J Am Acad Orthop Surg 2007; 15: 330-339

Lesiones Sindesmales
Tornillo Sindesmal
Tcnica Quirrgica: Pie en dorsiflexin Tornillos corticales 3,5 4,5 mm 2-3 cm de plafn 25 - 30 de PL a AM 3-4 corticales

C Zalavras, D Thordarson. Ankle Syndesmotic Injury. J Am Acad Orthop Surg 2007; 15: 330-339

Lesiones Sindesmales
Manejo Postoperatorio
Descarga por 6 semanas Yeso BC Brace Eventual retiro tornillo al 3 mes

C. Zalavras, D. Thordarson. Ankle Syndesmotic Injury. J Am Acad Orthop Surg 2007; 15:330-339

Rotura Tendn de Aquiles

Rotura Tendn de Aquiles


Anatoma
Hipocrates Polaillon (1888): Reparacin Quirrgica Tendn mas largo y fuerte del cuerpo Porciones tendineas:
Gastrocnemios Soleo

Compartimiento posterior pierna, superficial 2 bursas: anterior y posterior


D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37, N. No 6;1223-34 Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Anatoma
Irrigacion: 3 zonas Proximal y distal:

A. Tibial Posterior

Media:
A. Peroneal Watershed area

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Mecanismos
Arner O, Lindholm A. (1959) Subcutaneous rupture of the Achilles tendon: A study of 92 cases. Acta Chir Scand. (Suppl.239):1 51.

53 %: Durante la marcha con carga del peso en antepie cuando se extiende la rodilla.

Sprint, salto Cada en un agujero o por escaleras. Cada de altura.


D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34

17 %: Dorsiflexin subita de tobillo

10 %: Dorsiflexin subita del pi en flexin plantar

N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Etiopatogenia
Irrigacin Teoria mecanica: microtrauma repetitivo Disfuncin gastrocnemio-sleo Edad / Gnero Cambios en patrn de entrenamiento Lesiones previas Enfermedades autoinmunes o inflamatorias Fluoroquinolonas, Corticoides
D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Clinica
Dolor sbito: Sensacin de golpe

Chasquido / Piedrazo

Incapacidad para cargar Debilidad y rigidez Edema, equmosis Gap palpable

2-6 cm proximal a insercin

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Clinica
Calf Squeeze test: Thompson-Simmonds (+): Rotura Tendon Aquiles

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Clinica
Matles test: (+) pie neutro o en dorsiflexion Copeland test
Esfigmomanometro 100 mm Hg Dorsiflexion pie Tendon intacto: Presion >

OBrien Test

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Radiologa
Rx Tobillo lateral: Triangulo de Kager

Disminucin o desaparicin

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Radiologa
Ecografa: Mtodo diagnostico de eleccin
Medicin de Gap Vacio acstico Irregularidad y engrosamiento de bordes

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Radiologa
RM: T1:

Disrupcin de seal dentro de tendn

T2:
Aumento de intensidad de seal Edema y hemorragia

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Ortopdico: Segn ecografa:
Gap <5 mm en flexin plantar mxima Gap <10 mm en posicin neutra Aposicin >75% en flexin plantar de 20

Comorbilidades DM Tabaquismo Enfermedad vascular


D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Ortopdico:

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Ortopdico: KNT rehabilitacin a las 8 semanas
Retorno a practica deportiva 4-6 meses Hasta 12 meses en lograr mxima fuerza en flexin plantar

Tasa de re-rotura variable:10-20%

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Quirrgico: Abierto

Mayor tasa infeccion, re-rotura y dao de partes blandas

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 A.Cretnik.Percutaneous Versus Open Repair of the Ruptured Achilles Tendon. Am J Sport Med, Vol. 33, No. 9

Rotura Tendn de Aquiles


Tratamiento
Quirrgico: Abierto + Augmentacin con vaina Triceps Sural

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Percutneo Achillon

(2002)

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005 J. Tan. Non-Surgical Management of Achilles Tendon Ruptures. Foot Ankle Clin N Am 14 (2009) 675 68

Rotura Tendn de Aquiles


Tratamiento
Percutneo con instrumento de Dresdner: Indicacion en rotura aguda de tendn de Aquiles Contraindicado en:
Rotura cronica Re-rotura Uso de corticoides Aquilodinia cronica

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner:
Decubito prono Anestesia raquidea Matles Test

Colocacion de instrumentos Demarcacion de cabos

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Apertura de fascia

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Divulsion Colocacion de instrumento

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Se coloca instrumento a 1 cm de insercin Aguja enhebrada con material irreabsorbible

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Se lleva instrumento 1 cm a proximal 2 aguja enhebrada: Marcar cabos!!!

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Retiro de instrumento Traccin de suturas Pie en flexin plantar mxima

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner: Sutura desde periferia al centro 5 mm de distancia entre puntos Cierre por planos

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Tratamiento
Percutneo con Instrumento de Dresdner:

D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34 N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

Rotura Tendn de Aquiles


Postoperatorio
Primeras 2 semanas:

Yeso BC en equino en descarga Yeso BC en equino (3 cm) con carga parcial

2-4 semana:

4-6 semanas:
Yeso BC en equino (1 cm) Carga parcial ejercicios de propiocepcin y bicicleta.

6 semanas: Retiro de yeso y marcha con apoyo

Talonera + KNT
D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34

Retorno a practica deportiva 4-6 meses


N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005

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