Escolar Documentos
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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
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%
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
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
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:
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
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
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:
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
Lesiones Sindesmales
Radiologa
Rx Tobillo AP-Lateral-Mortaja Rx pierna AP-Lateral Rx en proyecciones de stress:
Mortaja: Lateral Lateral: Posterior
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)
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
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
53 %: Durante la marcha con carga del peso en antepie cuando se extiende la rodilla.
N. Malfulli , P. Renstrm, W. Leadbetter. Tendon Injuries: Basic Science and Clinical Medicine. Springer-Verlag London 2005
Chasquido / Piedrazo
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
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
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
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
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
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
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
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
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
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
(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
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
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
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
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
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
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
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
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
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
2-4 semana:
4-6 semanas:
Yeso BC en equino (1 cm) Carga parcial ejercicios de propiocepcin y bicicleta.
Talonera + KNT
D. Heckman et al. Achilles Tendn Disorders. Am J Sport Med. Vol 37,No 6;1223-34