World Rural Health Conference
Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 1012
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents 
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 257-260  

Quadriceps tendon rupture


Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai; Department of Rehabilitation Medicine, Queens Health Network, Elmhurst and Queens Hospital Centers, USA

Date of Web Publication30-Apr-2018

Correspondence Address:
Dr. Subhadra Nori
Department of Rehabilitation Medicine, Elmhurst Hospital Center, Broadway 79-01 Queens N.Y 11373
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_341_16

Rights and Permissions
  Abstract 


Acute knee pain is a frequently encountered problem in the clinical settings. In 2003, American Orthopedic Association recorded that 19.4 million people visited a physician because of a knee problem. Knee pain due to injuries is increasing even among the older population, as a greater number of persons are participating in recreational activities. The quadriceps tendon rupture is not a common condition among acute causes of knee pain. However, it can be quite debilitating. The usual clinical presentation includes a middle-aged person presenting with a history of fall accompanied by swelling and inability to extend the knee. Providers who are faced with this clinical situation should be able to recognize this condition sooner than later. It is very important that precise clinical decisions be made, so as to achieve best outcomes. This article reviews the etiology, epidemiology, clinical presentation, differential diagnosis, and management of quadriceps tendon rupture.

Keywords: Patellar tendon, quadriceps tendon, rupture


How to cite this article:
Nori S. Quadriceps tendon rupture. J Family Med Prim Care 2018;7:257-60

How to cite this URL:
Nori S. Quadriceps tendon rupture. J Family Med Prim Care [serial online] 2018 [cited 2019 Jul 22];7:257-60. Available from: http://www.jfmpc.com/text.asp?2018/7/1/257/231574




  Introduction Top


The etiology of acute knee pain is quite variable and encompasses many structures including bones, ligaments, soft tissues, and mensci, while the differential diagnosis of chronic knee pain includes infection, arthritis, tumors and other space occupying lesions, acute knee pain particularly trauma is related to menisci ligaments, fractures and tendon rupture. We present a case of traumatic quadriceps tendon rupture and discuss the etiology, diagnostic testing and management.


  Case Report Top


A middle aged male with a history of hypertension presented to our institution with a history of fall on the street. He was unable to straighten his leg and bear weight on the right lower extremity

Physical examination revealed a heavy set male in moderate distress. He reported pain level of an 8 on visual analogue scale. There was anterior knee swelling. The range of motion (ROM) of the knee was limited in both flexion and extension. Manual muscle testing was limited due to pain. The popliteal pulse and dorsalis pedis pulses were intact. There was a visible gap in the quadriceps tendon about 2–3 cm above the patella. The patient was unable to stand or extend his knee due to pain.

Clinical course

A tentative diagnosis of quadriceps tendon rupture was made. The patient had a magnetic resonance imaging (MRI) which confirmed the diagnosis. He had repair of the quadriceps tendon and was placed in a long leg cast. After undergoing acute rehabilitation for 8 days, he was discharged. At 3-month follow-up, the patient was walking with a cane.


  Discussion Top


Quadriceps tendon rupture is not commonly seen in clinical practice. Complete ruptures can be very disabling and occur during a fall while the person is trying to prevent the fall. This occurs because during flexion the knee is under maximum tensile stress and when an attempt is made to extend the knee to stand, the tendon strength can not with stand the stress. This causes it to break. Clinical findings include acute pain, inability to actively extend the knee, and a suprapatellar gap. Ambulation is not possible due to inability to extend the knee and excruciating pain.

Anatomy

The quadriceps muscle is composed of 4 muscle bellies: the rectus femoris, vastus medialis, lateralis, and intermedius. This tendon inserts into the patella. The quadriceps muscle is the main extensor of the knee. Three major vascular arcades, i.e., medial, lateral, and peripatellar arcades provide blood supply to the quadriceps tendon. A relatively hypovascular zone exists about 1–2 cm superior to the patella, thus making it more susceptible to injury.[1]

Epidemiology

The incidence of complete quadriceps tendon ruptures is reported as rare. One study from the UK reported it as 1.37/100,000/year, with a mean age of 50.5 in men and 51.7 in women.[2] Patellar tendon ruptures occur in younger than 40 and quadriceps ruptures in older than 40 group. The extensor mechanism injuries are more likely to occur as a sequela to preexisting pathology, which is usually of the overuse type as tendonitis, microtears, and poor structural mechanism.

Ninety-one percent of the quadriceps and 95.5% of the patellar tendon ruptures occurred in males between 61 years for quadriceps tendon rupture and 39.5 years for patellar tendon rupture. Body mass index varied between 30.0 ± 6.05 kg/m 2 for quadriceps tendon rupture.

Frequently associated medical comorbidities are rheumatoid arthritis, SLE, gout, chronic renal Failure, secondary hyperparathyroidism, diabetes mellitus, and peripheral vascular disease [Table 1].[3]
Table 1: Predisposing factors

Click here to view


Fluoroquinolones have also been associated with tendon ruptures. Although the exact mechanism is not clear. Corticosteroid injections in and around tendons and joints have been known to alter the collagen composition and ability to heal.

Spontaneous ruptures were reported in 3.2% of cases. The most common sites of tear were noted between 1 cm and 2 cm of the superior pole of the patella and in older people, at the osseotendinous junction.

Tears of quadriceps occur through the rectus tendon at its insertion into the proximal pole of patella. Tears usually occur a few centimeters proximal to the superior pole of the patella. A small piece of rectus tendon may avulse.

In 65% of people, it is seen at the insertion of the patellar tendon over the patella and in 25% at the quadriceps tendon insertion on the patella and in 10% patellar insertion over the tibial tuberosity.[4]

Ruptures of the patellar tendon usually occur in the inferior pole of the patella and can also cause avulsion of bone.

The deferential diagnosis of acute knee pain is outlined in [Table 2].
Table 2: Differential diagnosis of acute knee pain

Click here to view


Imaging

Radiographs may show inferior displacement of the patella along with bony avulsion in quadriceps tendon rupture and superior displacement in patella tendon rupture [Figure 1]. MRI examination may be helpful in detecting other intraarticular pathology [Figure 2]. Parfitt and Petrie propose that all suspected patients should either proceed directly to MRI or be initially assessed by ultrasound (US), followed by an MRI to eliminate false positive diagnoses.[5]
Figure 1: X-ray showing migration of patella due to quadriceps tendon rupture, case courtesy of http://radiopedia.org/”. From the casehttp://radiopedia.org/cases/11858

Click here to view
Figure 2: Magnetic resonance imaging of quadriceps tendon rupture. Yellow arrow pointing to the gap between the tendon and its insertion on the patella. http://radiopaedia.org/cases/quadriceps-tendon-rupture-3. Case courtesy of Dr. Ahmed Abd Rabou, Radiopaedia.org, rID: 22644

Click here to view


Bedside utility of US has become easier and less expensive than MRI. Quad tendon is 6–11 mm thick with linearly oriented homogeneous echoes extending through the length of the tendon [Figure 3]a. With complete tears a hypo echoic area separating the tendon from the bone is seen. This is due to the hematoma. A focal hypoechoic area represents a partial tear. In complete tears, fiber continuity is lost and is replaced by intratendinous fluid [Figure 3]b.[6]
Figure 3: (a) Ultrasound of normal homogeneous fibrillary pattern of the quadriceps tendon (yellow arrow) (http://www.ultrasoundcases.info) (b) Ultrasound of rupture of quad tendon yellow arrow pointing to hematoma. Quadriceps tendon rupture longitudinal. ID:/34262-Afbeelding2.jpg (http://www.ultrasoundcases.info) The Netherlands

Click here to view


Management

Partial ruptures are managed by evacuation of the hemarthrosis to reduce pain and tenderness followed by rest, ice, compression, and anti-inflammatory medication. Knee is immobilized in full extension for about 6 weeks, followed by progressive knee ROM and strengthening in therapy. For complete ruptures, open repair and reconstruction is required. Early repair is recommended to avoid retraction and atrophy of quad muscle.[7]

Gradual progression to weight-bearing is advocated.[8],[9]

Chronic ruptures

Repeated chronic ruptures can be challenging due to scar formation and tendon retraction. Primary approximation and reconstruction with hamstring grafts have been recommended.[10]

Outcomes of surgical repair for complete tears

Patients generally report satisfactory results following their surgical repair.

Worst results were noted in delayed repairs. Reported complications included heterotopic ossifications in 6.9% of patients, deep venous thrombosis or pulmonary embolism in 2.5%, superficial infection in 1.2%, and deep infection in 1.1%. It appears that the type of surgical repair does not influence the clinical results. The overall rate of rerupture was 2%.


  Conclusions Top


Knee injuries can account for 19.4 million visits/year. Complete quadriceps tendon ruptures are uncommon injuries, usually resulting from indirect trauma, in middle-aged men more than women. Early diagnosis and prompt repair is crucial, to obtain optimal results. Good to excellent functional results are usually achieved. Patients with associated comorbidities such as DM and CRF may be particularly susceptible to complications, which include deep vein thrombosis, pulmonary embolism, and rerupture.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yepes H. Tang M, Morris SF, Stanish WD. Relationship between hypovascular zones and patterns of rupture of the quadriceps tendon. J Bone Joint Surg Am. 2008;90:2135-41  Back to cited text no. 1
    
2.
Clayton RAE, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008;39:1338-44.  Back to cited text no. 2
    
3.
Karistinos A, Paulos LE. “Ciprofloxacin-induced” bilateral rectus femoris tendon rupture. Clin J Sport Med 2007;17:406-7.  Back to cited text no. 3
[PUBMED]    
4.
Ferreti A. Epidemiology of jumper's knee. Sports Med 1986;3:289-95.  Back to cited text no. 4
    
5.
Perfitt JS, Petrie MJ, Blundell CM, Davies MB. Acute quadriceps tendon rupture: A pragmatic approach to diagnostic imaging. Eur J Orthop Surg Traumatol 2014;24:1237-41.  Back to cited text no. 5
[PUBMED]    
6.
Orlandi D, Corazza A, Arcidiacono A, Messina C, Serafini G, Sconfienza LM, et al. Ultrasound-guided procedures to treat sport-related muscle injuries. Br J Radiol 2016;89:20150484.  Back to cited text no. 6
    
7.
Ramseier LE, Werner CM, Heinzelmann M. Quadriceps and patellar tendon rupture. Injury 2006;37:516-9.  Back to cited text no. 7
[PUBMED]    
8.
O'Shea K. Kenny P. Donovan J. Condon F. McElwain JP. Outcomes following quadriceps tendon ruptures. lnjury.2002;33:257-260.  Back to cited text no. 8
    
9.
Konrath GA, Chen D, Lock T, et al. Outcomes following repair of quadriceps tendon ruptures. J Orthop Trauma. 1998;12:273-9.  Back to cited text no. 9
    
10.
Hak DJ, Sanchez A, Trobisch P. Quadriceps tendon injuries. Orthopedics 2010;33:40-6.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
   
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusions
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed752    
    Printed16    
    Emailed0    
    PDF Downloaded117    
    Comments [Add]    

Recommend this journal