Bilateral Quadriceps Tendon Ruptures in a Healthy, Active DutySoldier: Case Report and Review of the Literature - PDF Document

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  1. MILITARY MEDICINE, 171, 12:1251, 2006 Bilateral Quadriceps Tendon Ruptures in a Healthy, Active Duty Soldier: Case Report and Review of the Literature Guarantor: MAJ Anthony E. Johnson, MC USA Contributors: MAJ Anthony E. Johnson, MC USA*†; MAJ Stephen D. Rose, MC USA*‡ Unilateral quadriceps tendon ruptures are not uncommon. These injuries have been reported to occur spontaneously and after seemingly trivial trauma in elderly individuals, patients undergoing renal dialysis, and patients with metabolic de- rangements such as hyperparathyroidism. In young patients, unilateral quadriceps tendon ruptures have been reported as complications of burns, anabolic steroid abuse, and elective orthopedic surgery. Bilateral quadriceps tendon ruptures in young healthy patients are rare injuries. We present the case of a young, healthy, active duty soldier who sustained bilateral quadriceps tendon ruptures after a relatively minor trauma. admitted to the internal medicine service for evaluation for a presumed syncopal episode. His reported history and a review of his medical records did not reveal any past or actively managed medical problems. Complete blood count results were normal. A comprehensive metabolic panel revealed no abnormalities, in- cluding blood urea nitrogen and creatinine levels. Serum elec- trolyte (including calcium) levels, as well as uric acid levels, were within normal limits. Electrocardiography showed sinus brady- cardia without any other abnormalities, which was unchanged from the patient’s previous commissioning or 5-year periodic military physical examinations. The orthopedics service was consulted after a through neurological evaluation, including computed tomography and magnetic resonance imaging (MRI) of the head and cervical and thorocolumbosacral spine, revealed no abnormalities. On physical examination, the patient had bilateral, grossly edematous knees, but with readily palpable defects in the quad- riceps tendon. Plain radiographs of his knees revealed no frac- tures but did demonstrate gross edema and enthesopathy of the proximal pole of the patella. MRI demonstrated that the patient had a complete rupture of the left quadriceps tendon (Fig. 1) and an incomplete rupture of the right quadriceps tendon (Fig. 2). He underwent surgical repair of the left quadriceps tendon 7 days after injury. The right quadriceps tendon was treated nonsurgi- cally. The patient was placed in range-of-motion braces with strict non-weight-bearing, because of his bilateral injuries. Three weeks after surgery, he was slowly advanced to weight- bearing as tolerated. Passive range-of-motion exercises were initiated under the close supervision of a physical therapist. By 12 weeks after surgery, the patient was walking without assis- tance. He was back to full, unlimited, active duty by 24 weeks. Downloaded from https://academic.oup.com/milmed/article-abstract/171/12/1251/4578206 by guest on 12 May 2020 Introduction U and after seemingly trivial trauma in elderly individuals, pa- tients undergoing renal dialysis, and patients with metabolic derangements such as hyperparathyroidism. tients, unilateral quadriceps tendon ruptures have been re- ported as complications of burns, anabolic steroid abuse, and elective orthopedic surgery.7,10–16 Bilateral quadriceps tendon ruptures, however, are unusual injuries. The first case of bilateral quadriceps tendon rupture was reported by Steiner and Palmer in 1949.15Since that time, ?45 cases of bilateral quadriceps tendon ruptures have been reported in the English-language literature.7Cases of bilateral quadriceps tendon ruptures generally involve elderly patients and/or patients with chronic metabolic disorders. In the few cases involving young patients, there is usually a high-energy mechanism of injury or an association with anabolic steroid use.10Active duty patients are generally without chronic meta- bolic diseases, are physically fit, and are prohibited by regula- tion from anabolic steroid use. The purpose of this article is to present a case of simultaneous, bilateral, quadriceps tendon rupture in a healthy, active duty individual and to present a review of the literature. nilateral quadriceps tendon ruptures are not uncommon. These injuries have been reported to occur spontaneously 1–9In young pa- Clinical Presentation The diagnosis of quadriceps tendon rupture is largely based on a careful history and physical examination. The examining physician should maintain a high index of suspicion for any patient presenting with acute onset of pain about the knee and an inability or unwillingness to actively extend the knee in the presence of preserved active knee flexion.10The triad of knee pain, an inability to actively extend the knee, and the presence of a suprapatellar gap is usually diagnostic.17A palpable depres- sion superior to the patella is considered pathognomonic for quadriceps tendon rupture.10However, despite these seemingly apparent clinical findings, the diagnosis is often missed initially. A large hematoma may mask the suprapatellar gap. Further- more, a preserved patellar retinaculum may impart some ability for active leg extension, albeit with weakness and extensor lag. Therefore, diagnostic failure rates of 10 to 50%, with delays in diagnosis ranging from days to months, have been reported.10In cases in which a large hematoma obscures the suprapatellar Case Report A 46-year-old, active duty, male commissioned officer was brought into our emergency department after falling down a single flight of stairs while observing a local rodeo. During his evaluation, it was noted that the patient was unable to actively extend his knees, although he was awake, oriented, and coop- erative. However, he was able to actively flex his knees. He was *Hand Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234-3600. †Staff orthopedist, Fort Eustis, VA 23604-5548. ‡Orthopedic Hand Surgery Staff, Brooke Army Medical Center, Fort Sam Houston, TX 78234-3600. This manuscript was received for review in July 2005. The revised manuscript was accepted for publication in May 2006. 1251 Military Medicine, Vol. 171, December 2006

  2. 1252 Bilateral Quadriceps Tendon Ruptures Downloaded from https://academic.oup.com/milmed/article-abstract/171/12/1251/4578206 by guest on 12 May 2020 Fig. 1. T1-weighted (left) and T2-weighted (right) MRI scans, demonstrating a complete tear of the left quadriceps tendon (arrows). Fig. 2. T1-weighted (left) and T2-weighted (right) MRI scans, demonstrating a partial tear of the right quadriceps tendon (arrows). gap, active flexion of the hip while the patient is supine causes the rectus femoris to contract, pulling the remaining quadriceps proximally. The quadriceps tendon is a coalescence of the tendinous por- tions of the quadriceps (rectus femoris, vastus intermedius, vastus lateralis, and vastus medialis).18The genu articularis, an anatomic variant, may contribute fibers to the quadriceps tendon.10The tendinous portions of these muscles form distinct planes, which facilitates MRI.18–20The transmission of force from the quadriceps tendon to the patellar tendon is complex. 17Thus, the defect may widen at the site of rupture. Military Medicine, Vol. 171, December 2006

  3. Bilateral Quadriceps Tendon Ruptures 1253 Rehabilitation Markedly higher forces can be generated during eccentric con- traction of the quadriceps, which is when most quadriceps ten- don injuries occur. Rehabilitation of partial tendon ruptures treated nonsurgi- cally is described above. Postoperative rehabilitation involves immobilization for 48 to 72 hours, followed by full weight-bear- ing in full extension while supported by a locked, hinged, range- of-motion brace.10Although some controversy exists concerning the timing of range of motion, Rougraff et al.6found no differ- ence between early and delayed range of motion in a study of 53 ruptures. However, early controlled motion and tensile stress applied to a repaired tendon were shown to promote earlier organization and remodeling of collagen fibers, to decrease the amount of scar tissue, and to increase tendon strength, com- pared with immobilized tendons.36Range-of-motion exercises should be started within 4 to 6 weeks of immobilization. The brace may be removed once the patient has demonstrated good quadriceps muscle control and can perform a straight leg raise. The ultimate goal is to achieve good functional range of motion by 12 to 16 weeks after repair. 10,21 Radiological Studies Plain radiographs are not usually diagnostic for quadriceps ten- don injuries. However, they are used to rule out other causes of extensor mechanism disruption, such as tibial tubercle fractures/ avulsionsandpatellarfractures.Apatellaraltaorbajamayormay not be present.18,22Ultrasonography has been advocated by some authors for diagnosis of neglected quadriceps tendon ruptures, but its value in the diagnosis of acute ruptures is questionable, because a large hematoma may obscure the rupture.23,24Ultra- sonography is especially helpful, however, for assessment of the repaired tendon after surgery or in the presence total knee arthro- plasty, where the metallic implant would limit the usefulness of MRI.Computedtomographywouldaddnoinformationnotalready gained by adequate plain radiographs.10MRI is the most accurate method for assessing tendons. It is especially useful in determin- ing partial versus complete ruptures.19,20 Downloaded from https://academic.oup.com/milmed/article-abstract/171/12/1251/4578206 by guest on 12 May 2020 Complications Loss of knee motion, especially knee flexion, is the most com- mon complication after quadriceps tendon repair. Another com- mon complication is weakness and atrophy of the quadriceps muscles. However, outcome studies showed that surgical repair within 2 to 3 weeks after injury resulted in 85 to 92% patient satisfaction, with 84% return to previous occupations.37How- ever, ?50% were unable to return to preinjury levels of recre- ational athletic activity.38Proper preoperative patient counsel- ing is mandatory. The usual surgical complications of surgical wound infection and delayed wound healing are also expected, especially in the presence of chronic disease. If augmentation (especially wire) is used, then failure of the augmentation may cause skin irritation, necessitating removal.10Patella alta, baja, or incongruity may occur.22Therefore, proper attention should be paid to patellar alignment during repair. Treatment Partial or incomplete tears of the quadriceps tendon are usually treated nonsurgically, once a complete rupture has been ruled out via a thorough history, physical examination, and targeted radio- logical studies as indicated.10,25The knee is immobilized in exten- sion for a period not to exceed 6 weeks. At that point, protected range-of-motion exercises and quadriceps strengthening may be started. The presence of even a small amount of effusion can decrease quadriceps strength and delay rehabilitation.10There- fore, aggressive treatment of knee effusion with ice, compression, and judicious use of anti-inflammatory medications is warranted. Aspiration of the traumatic hemarthrosis may be necessary to decrease the effusion. If aspiration is desired, however, then it should be performed early, to avoid the difficulty of trying to evac- uate a consolidated hematoma. Surgical treatment is warranted for complete tendon rup- tures. Numerous techniques have been described for the surgi- cal treatment of quadriceps tendon ruptures.26–33Common to all techniques is the development of full-thickness skin flaps, de- bridement and freshening of the tendon ends, and repair of the retinaculum. Midsubstance tears may be repaired primarily end to end, provided adequate tissue exists proximally and distally. The most common site of injury is at or near the osteotendinous junction.21The most common technique is via drill holes in the patella. Augmentation, if necessary or preferred, may be per- formed with wire, Leeds-Keio ligament, Dacron tape, or Mer- silene tape.10The quadriceps turn-down, as described by Scu- deri,34is another method for acute repair or for augmentation of tendons that appear tenuous after repair. Chronic neglected tendon ruptures are a difficult problem. If the tendon ends are able to be approximated, then primary repair with any of the described techniques may be performed. If the tendon has retracted, then the quadriceps must be elevated from the femur and all adhesions released to gain length.35If apposition is still not possible, then the tendon-lengthening technique described by Codivilla is the recommend treatment.10 Conclusions Simultaneous, bilateral, quadriceps tendon ruptures are un- usual injuries. A high initial index of suspicion, care history, and thorough physical examination, coupled with appropriate radiological studies (MRI in most cases, with ultrasonography in cases where MRI is contraindicated, such cases with indwelling metallic hardware), are necessary for timely accurate diagnosis. Partial or incomplete ruptures may be treated successfully with careful monitored rehabilitation. Complete ruptures require surgical repair within 2 to 3 weeks after injury. 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