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Ultrasound Diagnosis of Quadriceps Tendon Rupture
The Journal of Emergency Medicine, Vol. 35, No. 3, pp. 293–295, 2008 Copyright © 2008 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $–see front matter
doi:10.1016/j.jemermed.2007.05.015
Ultrasound in Emergency Medicine
ULTRASOUND DIAGNOSIS OF QUADRICEPS TENDON RUPTURE Brian G. LaRocco,
MD,
George Zlupko,
MD, FACEP,
and Paul Sierzenski,
MD, FACEP, RMDS
Department of Emergency Medicine, Christiana Care Health Services, Newark, Delaware Reprint Address: Brian G. LaRocco, MD, 24 Gina Marie Lane, Elkton, MD 21921
e Abstract—Quadriceps tendon ruptures are an uncommon knee injury. The diagnosis is often complicated by a limited examination secondary to edema and pain, the insensitivity of radiographs, and the unavailability of nonemergent magnetic resonance imaging. A delay in diagnosis and treatment has been shown to cause significant morbidity. A case report of bilateral quadriceps tendon rupture is presented demonstrating the utility and ease of bedside ultrasound to rapidly confirm the diagnosis. © 2008 Elsevier Inc.
emia, and hypertension presented to the ED complaining of being unable to walk. The patient stated that while he was walking up a flight of stairs, his right knee “gave out.” Interestingly, the same occurred to his left knee the day prior while walking down a flight of stairs. The night prior he was seen at another ED, diagnosed with a left knee sprain, and sent home on crutches with a brace. He described a “pop” sensation each time a knee gave out. He denied any pain at rest, but was unable to extend either leg. The patient’s past medical history is as described above, for which he was taking glyburide, hydrochlorothiazide, and lovastatin. Additionally, he was started on a cephalosporin 4 days prior for a localized skin abscess on the right scalp. He denied previous knee injury, trauma, or steroid injection. The surgical, social, and family histories were non-contributory. On physical examination, the patient was a moderately obese male in no major distress sitting on a stretcher with knees slightly flexed. The vital signs were all within normal limits. The musculoskeletal examination revealed the right knee to have a moderate effusion without ecchymosis, and a visible defect superior to the patella. The left knee was slightly edematous, obscuring any visible defect. Passive range of motion was within normal limits on the right knee, and slightly decreased on the left knee. There was no varus or valgus instability or joint line tenderness. Lachman test was negative bilaterally. There was a palpable defect superior to the right patella. This could not be appreciated on the left secondary to the edema. Strength was 0/5 for leg extension
e Keywords—bedside ultrasound; quadriceps tendon rupture
INTRODUCTION The value of bedside ultrasound in the Emergency Department (ED) is well established for numerous applications such as evaluating abdominal trauma, deep vein thrombosis, abdominal aortic aneurysm, and vascular access, to name a few. Novel applications of bedside ultrasound are continually gaining acceptance in the ED. We present a case report demonstrating the utility of bedside ultrasound in the evaluation of a musculoskeletal injury, specifically a quadriceps tendon rupture.
CASE REPORT A 52-year-old man with a past medical history of noninsulin-dependent diabetes mellitus, hypercholesterol-
RECEIVED: 27 October 2005; FINAL ACCEPTED: 9 November 2006
SUBMISSION RECEIVED:
1 September 2006; 293
294
B. G. LaRocco et al. Table 1. Conditions Associated with Quadriceps Tendon Rupture Obesity Diabetes mellitus Chronic renal failure Gout Rheumatoid arthritis Systemic lupus erythematosus Hyperparathyroidism Multiple steroid injections Infection
Figure 1. 2D ultrasound of patient’s right knee showing disrupted quadriceps tendon and an acute bleed.
bilaterally. Patellar reflexes could not be elicited. Distally, there was 5/5 strength of the ankles, palpable pulses, and normal reflexes. A/P and lateral radiographs were read as normal. Bedside ultrasound with a linear probe revealed anechoic areas superiorly to the patellae bilaterally with disrupted quadriceps tendons (Figures 1, 2). This was seen more clearly on the right due to the acuity of the two injuries. The left, being injured the night before, had developed more edema and a hematoma, making the image less distinct. The diagnosis of bilateral quadriceps tendon ruptures was made. Orthopedic surgery was consulted immediately, and the patient was taken to surgery the following day without any further imaging studies.
DISCUSSION When compared to all types of knee injuries, quadriceps tendon rupture is a relatively rare cause of knee pain. However, it is three times more common than patellar
Figure 2. 2D ultrasound of patient’s left knee showing disrupted quadriceps tendon and hematoma, indicating this injury is likely older than that in right knee.
tendon rupture, which is more common in patients under 40 years of age (1). Men and patients older than 40 years of age are most often afflicted. Most have an underlying medical condition affecting the vascular system predisposing them to rupture (Table 1). Unilateral rupture is 15–20 times more common than bilateral ruptures, which our patient had suffered (2). Steiner and Palmer published the first description of bilateral rupture of quadriceps tendons in 1949 (3). In one study of 55 bilateral quadriceps tendon ruptures, 76% had an underlying medical condition predisposing them to rupture (4). Ruptures may occur anywhere along the tendon, but are most common at the osseotendinous junction within 2 cm of the superior pole of the patella (5). The tendon usually ruptures as a result of a sudden forceful contraction in a partially flexed knee, frequently in a patient attempting to prevent a fall after a loss of balance. A patient will often present complaining of immediate onset of knee pain before, during, or after a fall. They may also complain of an audible “pop” sensation, or the knee “giving out.” In a partial tear, a patient may complain of difficulty climbing stairs, or the knee intermittently giving way while walking. A triad of knee pain, loss of active leg extension, and a palpable suprapatellar gap has been described for complete tears. Partial tears usually present with pain, inability to fully extend the leg against force, and may or may not have a palpable defect. However, presentation for any degree of tear is highly variable, and the physical examination is frequently limited by pain and swelling. As seen in our patient after his right knee injury on the previous day, misdiagnosis is common, ranging from 10% to 50% (6). Therefore, imaging is often necessary to accurately make the diagnosis, and can assist in differentiating partial and complete tears. Radiographs may show signs of quadriceps tendon rupture, but are rarely sufficient to make the definitive diagnosis. Signs of quadriceps tendon rupture on a lateral radiograph include an obliteration of the quadriceps tendon shadow, a patella baja (low-riding patella), a suprapatellar soft tissue mass representing retraction of torn tendons, and an avulsion of small bone fragments from the superior pole of the patella (7). On tangential view, a degenerative bony spur
US Dx Quad Rupture
on the superior pole of the patella (“tooth sign”) may be seen in quadriceps tendon degeneration or rupture. Our patient displayed none of these radiographic signs. Furthermore, radiography is notoriously poor at diagnosing a quadriceps tendon rupture. In one study, only 33% (6 of 18) of quadriceps tendon ruptures were diagnosed correctly with radiography alone (7). Historically, arthrography had been used for diagnosis. This has been almost universally supplanted by the less invasive ultrasound and magnetic resonance imaging (MRI) (8). MRI has become the imaging study of choice when there is any doubt about the diagnosis. MRI is the most sensitive and specific imaging modality, being able to differentiate complete from partial tears, and to localize the precise site of injury. Therefore, MRI is routinely used for presurgical planning (9). However, MRI is time-consuming due to unavailability, it is expensive, and it has contraindications such as implanted metal. Ultrasound is rapid, inexpensive, and has no contraindications. It is a highly sensitive and specific means of assessment (10). In one study of 29 patients with injuries to the quadriceps tendon, ultrasound correctly diagnosed the four complete ruptures that were subsequently confirmed surgically, with no false positives (10). Ultrasound can delineate the location of rupture, and help differentiate complete from partial tears (6,10). The normal quadriceps tendon is 6 to 11 mm thick, and has homogenous groups of linearly oriented echoes extending the length of the tendon (Figure 3). In complete tears, the free ends of tendon fibers are separated by a hematoma represented by a hypoechoic to anechoic area (Figure 1). In partial tears, a focal hypoechoic defect is seen. Distraction of the patella may increase the gap and aid in visualization of complete tears. The principle drawback of ultrasound is that it is operator dependent. However, the superficial position of the quadriceps tendons makes obtaining images relatively simple. This was confirmed by a study in which 12
Figure 3. 2D ultrasound of normal quadriceps tendon demonstrating intact linear striations.
295
quadriceps tendon ruptures (partial and complete) were correctly diagnosed by ultrasound (10). Whereas no laboratory study is required to diagnose quadriceps tendon rupture, studies may be sent to rule out endocrine, renal, and rheumatologic disease, particularly in bilateral ruptures. Management from the ED includes knee immobilization with prompt orthopedic referral. The patient may be weight bearing as tolerated in the immobilizer. Ice, compression, and analgesics are useful adjuncts, as in all knee injuries. Partial tears may be managed conservatively, with 4 to 6 weeks of knee immobilization in full extension, followed by range-of-motion and quadricepsstrengthening exercises. Complete ruptures require surgical repair. Early intervention is generally recommended, as the tendon begins to retract within 72 h (6). Optimal outcomes occur when surgery is performed within 2 days to 2 weeks of the injury (5). Our patient was diagnosed rapidly by bedside ultrasound, and was seen by Orthopedics within 2 h of our initial examination. The quadriceps tendons were repaired the following day. After admission, a more detailed history was taken in which the patient denied steroid knee injections or recent fluoroquinolone use. The laboratory workup was all within normal limits, including an erythrocyte sedimentation rate, anti-nuclear antibody, Hemoglobin A1C, kidney, thyroid, and parathyroid function tests. The immediate post-operative course was unremarkable, and the patient was discharged to a rehabilitation facility 3 days after surgery.
REFERENCES 1. Scuderi GR, Scott WN, Install JN. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Fractures in adults, 4th edn. Philadelphia: Lippincott-Raven; 1996:2017–23. 2. Caborn DN, Boyd DW. Tendon ruptures. In: Fu FH, Harner CD, Vince KG, eds. Knee surgery. Baltimore: Williams & Wilkins; 1994:911–25. 3. Steiner C, Palmer L. Simultaneous bilateral rupture of quadriceps tendon. Am J Surg 1949;78:752–5. 4. Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. Orthopedics 2003;26:797– 8. 5. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 1981;63:932–7. 6. Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11:192–200. 7. Kaneko K, DeMouy EH, Brunet ME, Benzian J. Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure. J Emerg Med 1994;12:225–9. 8. Spector ED, DiMarcangelo MT, Jacoby JH. The radiographic diagnosis of quadriceps tendon rupture. N J Med 1995;92:590 –2. 9. Calvo E, Ferrer A, Robledo AG, Alvarez L, Castillo F, Vallejo C. Bilateral simultaneous spontaneous quadriceps tendons rupture: a case report studied by magnetic resonance imaging. Clin Imaging 1997;21:73– 6. 10. Bianchi S, Zwass A, Abdelwahab IF, Banderali A. Diagnosis of tears of the quadriceps tendon of the knee: value of sonography. AJR Am J Roentgenol 1994;162:1137– 40.
doi:10.1016/j.jemermed.2007.05.015
Ultrasound in Emergency Medicine
ULTRASOUND DIAGNOSIS OF QUADRICEPS TENDON RUPTURE Brian G. LaRocco,
MD,
George Zlupko,
MD, FACEP,
and Paul Sierzenski,
MD, FACEP, RMDS
Department of Emergency Medicine, Christiana Care Health Services, Newark, Delaware Reprint Address: Brian G. LaRocco, MD, 24 Gina Marie Lane, Elkton, MD 21921
e Abstract—Quadriceps tendon ruptures are an uncommon knee injury. The diagnosis is often complicated by a limited examination secondary to edema and pain, the insensitivity of radiographs, and the unavailability of nonemergent magnetic resonance imaging. A delay in diagnosis and treatment has been shown to cause significant morbidity. A case report of bilateral quadriceps tendon rupture is presented demonstrating the utility and ease of bedside ultrasound to rapidly confirm the diagnosis. © 2008 Elsevier Inc.
emia, and hypertension presented to the ED complaining of being unable to walk. The patient stated that while he was walking up a flight of stairs, his right knee “gave out.” Interestingly, the same occurred to his left knee the day prior while walking down a flight of stairs. The night prior he was seen at another ED, diagnosed with a left knee sprain, and sent home on crutches with a brace. He described a “pop” sensation each time a knee gave out. He denied any pain at rest, but was unable to extend either leg. The patient’s past medical history is as described above, for which he was taking glyburide, hydrochlorothiazide, and lovastatin. Additionally, he was started on a cephalosporin 4 days prior for a localized skin abscess on the right scalp. He denied previous knee injury, trauma, or steroid injection. The surgical, social, and family histories were non-contributory. On physical examination, the patient was a moderately obese male in no major distress sitting on a stretcher with knees slightly flexed. The vital signs were all within normal limits. The musculoskeletal examination revealed the right knee to have a moderate effusion without ecchymosis, and a visible defect superior to the patella. The left knee was slightly edematous, obscuring any visible defect. Passive range of motion was within normal limits on the right knee, and slightly decreased on the left knee. There was no varus or valgus instability or joint line tenderness. Lachman test was negative bilaterally. There was a palpable defect superior to the right patella. This could not be appreciated on the left secondary to the edema. Strength was 0/5 for leg extension
e Keywords—bedside ultrasound; quadriceps tendon rupture
INTRODUCTION The value of bedside ultrasound in the Emergency Department (ED) is well established for numerous applications such as evaluating abdominal trauma, deep vein thrombosis, abdominal aortic aneurysm, and vascular access, to name a few. Novel applications of bedside ultrasound are continually gaining acceptance in the ED. We present a case report demonstrating the utility of bedside ultrasound in the evaluation of a musculoskeletal injury, specifically a quadriceps tendon rupture.
CASE REPORT A 52-year-old man with a past medical history of noninsulin-dependent diabetes mellitus, hypercholesterol-
RECEIVED: 27 October 2005; FINAL ACCEPTED: 9 November 2006
SUBMISSION RECEIVED:
1 September 2006; 293
294
B. G. LaRocco et al. Table 1. Conditions Associated with Quadriceps Tendon Rupture Obesity Diabetes mellitus Chronic renal failure Gout Rheumatoid arthritis Systemic lupus erythematosus Hyperparathyroidism Multiple steroid injections Infection
Figure 1. 2D ultrasound of patient’s right knee showing disrupted quadriceps tendon and an acute bleed.
bilaterally. Patellar reflexes could not be elicited. Distally, there was 5/5 strength of the ankles, palpable pulses, and normal reflexes. A/P and lateral radiographs were read as normal. Bedside ultrasound with a linear probe revealed anechoic areas superiorly to the patellae bilaterally with disrupted quadriceps tendons (Figures 1, 2). This was seen more clearly on the right due to the acuity of the two injuries. The left, being injured the night before, had developed more edema and a hematoma, making the image less distinct. The diagnosis of bilateral quadriceps tendon ruptures was made. Orthopedic surgery was consulted immediately, and the patient was taken to surgery the following day without any further imaging studies.
DISCUSSION When compared to all types of knee injuries, quadriceps tendon rupture is a relatively rare cause of knee pain. However, it is three times more common than patellar
Figure 2. 2D ultrasound of patient’s left knee showing disrupted quadriceps tendon and hematoma, indicating this injury is likely older than that in right knee.
tendon rupture, which is more common in patients under 40 years of age (1). Men and patients older than 40 years of age are most often afflicted. Most have an underlying medical condition affecting the vascular system predisposing them to rupture (Table 1). Unilateral rupture is 15–20 times more common than bilateral ruptures, which our patient had suffered (2). Steiner and Palmer published the first description of bilateral rupture of quadriceps tendons in 1949 (3). In one study of 55 bilateral quadriceps tendon ruptures, 76% had an underlying medical condition predisposing them to rupture (4). Ruptures may occur anywhere along the tendon, but are most common at the osseotendinous junction within 2 cm of the superior pole of the patella (5). The tendon usually ruptures as a result of a sudden forceful contraction in a partially flexed knee, frequently in a patient attempting to prevent a fall after a loss of balance. A patient will often present complaining of immediate onset of knee pain before, during, or after a fall. They may also complain of an audible “pop” sensation, or the knee “giving out.” In a partial tear, a patient may complain of difficulty climbing stairs, or the knee intermittently giving way while walking. A triad of knee pain, loss of active leg extension, and a palpable suprapatellar gap has been described for complete tears. Partial tears usually present with pain, inability to fully extend the leg against force, and may or may not have a palpable defect. However, presentation for any degree of tear is highly variable, and the physical examination is frequently limited by pain and swelling. As seen in our patient after his right knee injury on the previous day, misdiagnosis is common, ranging from 10% to 50% (6). Therefore, imaging is often necessary to accurately make the diagnosis, and can assist in differentiating partial and complete tears. Radiographs may show signs of quadriceps tendon rupture, but are rarely sufficient to make the definitive diagnosis. Signs of quadriceps tendon rupture on a lateral radiograph include an obliteration of the quadriceps tendon shadow, a patella baja (low-riding patella), a suprapatellar soft tissue mass representing retraction of torn tendons, and an avulsion of small bone fragments from the superior pole of the patella (7). On tangential view, a degenerative bony spur
US Dx Quad Rupture
on the superior pole of the patella (“tooth sign”) may be seen in quadriceps tendon degeneration or rupture. Our patient displayed none of these radiographic signs. Furthermore, radiography is notoriously poor at diagnosing a quadriceps tendon rupture. In one study, only 33% (6 of 18) of quadriceps tendon ruptures were diagnosed correctly with radiography alone (7). Historically, arthrography had been used for diagnosis. This has been almost universally supplanted by the less invasive ultrasound and magnetic resonance imaging (MRI) (8). MRI has become the imaging study of choice when there is any doubt about the diagnosis. MRI is the most sensitive and specific imaging modality, being able to differentiate complete from partial tears, and to localize the precise site of injury. Therefore, MRI is routinely used for presurgical planning (9). However, MRI is time-consuming due to unavailability, it is expensive, and it has contraindications such as implanted metal. Ultrasound is rapid, inexpensive, and has no contraindications. It is a highly sensitive and specific means of assessment (10). In one study of 29 patients with injuries to the quadriceps tendon, ultrasound correctly diagnosed the four complete ruptures that were subsequently confirmed surgically, with no false positives (10). Ultrasound can delineate the location of rupture, and help differentiate complete from partial tears (6,10). The normal quadriceps tendon is 6 to 11 mm thick, and has homogenous groups of linearly oriented echoes extending the length of the tendon (Figure 3). In complete tears, the free ends of tendon fibers are separated by a hematoma represented by a hypoechoic to anechoic area (Figure 1). In partial tears, a focal hypoechoic defect is seen. Distraction of the patella may increase the gap and aid in visualization of complete tears. The principle drawback of ultrasound is that it is operator dependent. However, the superficial position of the quadriceps tendons makes obtaining images relatively simple. This was confirmed by a study in which 12
Figure 3. 2D ultrasound of normal quadriceps tendon demonstrating intact linear striations.
295
quadriceps tendon ruptures (partial and complete) were correctly diagnosed by ultrasound (10). Whereas no laboratory study is required to diagnose quadriceps tendon rupture, studies may be sent to rule out endocrine, renal, and rheumatologic disease, particularly in bilateral ruptures. Management from the ED includes knee immobilization with prompt orthopedic referral. The patient may be weight bearing as tolerated in the immobilizer. Ice, compression, and analgesics are useful adjuncts, as in all knee injuries. Partial tears may be managed conservatively, with 4 to 6 weeks of knee immobilization in full extension, followed by range-of-motion and quadricepsstrengthening exercises. Complete ruptures require surgical repair. Early intervention is generally recommended, as the tendon begins to retract within 72 h (6). Optimal outcomes occur when surgery is performed within 2 days to 2 weeks of the injury (5). Our patient was diagnosed rapidly by bedside ultrasound, and was seen by Orthopedics within 2 h of our initial examination. The quadriceps tendons were repaired the following day. After admission, a more detailed history was taken in which the patient denied steroid knee injections or recent fluoroquinolone use. The laboratory workup was all within normal limits, including an erythrocyte sedimentation rate, anti-nuclear antibody, Hemoglobin A1C, kidney, thyroid, and parathyroid function tests. The immediate post-operative course was unremarkable, and the patient was discharged to a rehabilitation facility 3 days after surgery.
REFERENCES 1. Scuderi GR, Scott WN, Install JN. In: Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Fractures in adults, 4th edn. Philadelphia: Lippincott-Raven; 1996:2017–23. 2. Caborn DN, Boyd DW. Tendon ruptures. In: Fu FH, Harner CD, Vince KG, eds. Knee surgery. Baltimore: Williams & Wilkins; 1994:911–25. 3. Steiner C, Palmer L. Simultaneous bilateral rupture of quadriceps tendon. Am J Surg 1949;78:752–5. 4. Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. Orthopedics 2003;26:797– 8. 5. Siwek CW, Rao JP. Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg Am 1981;63:932–7. 6. Ilan DI, Tejwani N, Keschner M, Leibman M. Quadriceps tendon rupture. J Am Acad Orthop Surg 2003;11:192–200. 7. Kaneko K, DeMouy EH, Brunet ME, Benzian J. Radiographic diagnosis of quadriceps tendon rupture: analysis of diagnostic failure. J Emerg Med 1994;12:225–9. 8. Spector ED, DiMarcangelo MT, Jacoby JH. The radiographic diagnosis of quadriceps tendon rupture. N J Med 1995;92:590 –2. 9. Calvo E, Ferrer A, Robledo AG, Alvarez L, Castillo F, Vallejo C. Bilateral simultaneous spontaneous quadriceps tendons rupture: a case report studied by magnetic resonance imaging. Clin Imaging 1997;21:73– 6. 10. Bianchi S, Zwass A, Abdelwahab IF, Banderali A. Diagnosis of tears of the quadriceps tendon of the knee: value of sonography. AJR Am J Roentgenol 1994;162:1137– 40.