ELSFVl ER

BILATERAL SIMULTANEOUS SPONTANEOUS QUADRICEPS TENDONS RUPTURE A CASE REPORT STUDIED BY MAGNETIC RESONANCE IMAGING

EMIL10 CALVO, MD, ANTONIO FERRER, MD,

ANGEL G. ROBLEDO, MD, L. ALVAREZ, MD,

F. CASTILLO, MD, AND C. VALLEJO, MD

A rare case of bilateral, simultaneous, and spontane- ous rupture of the quadriceps tendon in Q previous healthy young mQn is presented. Magnetic resonance imaging [MH] defined accurately the features of the tear showing different levels of rupture on each side. This finding was especially helpful in preoperative planning. 0 Elsevier Science Inc., 1997

KEY WORDS:

Quadriceps; Rupture; Magnetic resonance imaging

INTRODUCTION

Unilateral rupture of the quadriceps tendon is well known. However, bilateral, simultaneous, and spon- taneous rupture of the quadriceps tendon is very rare. It usually occurs in the elderly or in patients suffering from chronic diseases. Ruptures tend to lo- calize at the tendosseous junction in older patients and at the midtendinous area in younger patients. Diagnosis of quadriceps tendon rupture is clinical, but this entity seems to be so rare that quite often the diagnosis is missed (l-3). We report a case of bilat- eral simultaneous and spontaneous rupture of the quadriceps tendons in a young, previously healthy patient. The different magnetic resonance features of

From the Departments of Orthopedic Surgery and Traumatol- ogy (E.C., A.F., L.A., F.C., C.V.) and Radiology (A.G.R.), Funda- cion Jimenez Diaz, Universidad Autonoma, Madrid, Spain.

Address reprint requests to: Emilio Calvo, MD, Virgen de Aran- zazu, 1, 28034, Madrid, Spain.

Received August 20, 1995; accepted October 11, 1995.

both quadriceps are studied and the role of magnetic resonance imaging in diagnosis and surgical treat- ment of this entity is emphasized. As far as we know, this is the first reported case of bilateral quadriceps tendon rupture studied by magnetic resonance im- aging (MRI) .

CASE REPORT

A 3%year-old man who was not fat was referred to our clinic because he could not extend his knees ac- tively. Three weeks before, while running after his 3-year-old daughter, he felt a sudden pain in both knees and fell forward. He was unable to walk and was taken to the emergency department of a hospital. Mild effusions in both knee joints and pain in the in- sertion of vastus medialis of the right knee were noted. Radiographs showed no bony injuries, arthro- centesis yielded blood, and a CT scan demonstrated only bilateral joint effusion. He was discharged with- out a definitive diagnosis. When he was first seen in our clinic mild effusions and suprapatellar defects were noted, and the patient was unable to extend his knees actively.

According to the clinical picture, the patient was diagnosed of bilateral rupture of the quadriceps ten- don. Magnetic resonance imaging (MRI) of both knees was performed in the sagital plane. MRI con- firmed the diagnosis showing different levels of rup- ture (Figure 1 and 2). The left tendon was disrupted at the oseotendinous junction and although the right tendon was also ruptured distally, the tendon re- mained attached to the patella.

CLINICAL IMAGING 1997;21:73-76 0 Elsevier Science Inc., 1997 655 Avenue of the Americas, New York, NY 10010

0899-7071/97/$17.00 PII SO899-7071(96)00053-S

74 CALVO ET AL. CLINICAL IMAGING VOL. 21, NO. 1

FIGURE 1. Sagittal images (A) TR 740TE 20 and (B) gradient echo, TR 800/TE 30, of the right knee showing the site of the rupture at the distal part of the quadriceps tendon. Some tendon remains attached to the superior pole of the patella. Proximal retraction of the tendon is well demonstrated and a low-signal intensity in A and hyperintense and heterogeneous tissue band in B suggest fibrous tissue and hemorrhage. There is deformity of skin and subcutaneous tissue in the inferior part of the thigh.

The patient had no history of trauma, chronic dis- eases, or drug intake. Routine laboratory studies, the glucose tolerance test, rheumatoid factor, ANA, PPD, TSH, TRH, and VDRL were within normal limits.

Surgical repair was undertaken and MRI findings were confirmed. The left quadriceps tendon was completely disrupted just proximal to the superior pole of the patella, whereas the right tendon was rup-

FIGURE 2. Sagittal images of the left knee (A) (TR 740/TE 25) and (B) (gradient echo, TR 740/TE 30) demonstrate detach- ment of the quadriceps tendon from the superior pole of the patella.

JANUARY/FEBRUARY 1997 QUADRICEPS TENDONS RUPTURE 75

TABLE 1. Predisposing Conditions to Tendon Rupture

Age Obesity Chronic renal failure Diabetes mellitus Gout Rheumatoid arthritis Hyperparathyroidism Systemic lupus erythematosus Steroid therapy Tuberculosis Syphilis Chronic anaemia Tumour infiltration Arteriosclerosis Tendinous calcification Roughening or deformity of bone Burn injury

tured at the midtendinous area, and scarred fibrous tissue was found in continuity between the proximal and distal edges. No biopsy was taken, but the quad- riceps mechanism and surrounding soft tissues ap- peared normal. The left tendon was repaired with wire sutures passed through drill holes in the pa- tella. A freshening of the edges and end-to-end repair was carried out in the right tendon with multiple su- tures reinforced with a flap from vastus medialis. Bi- lateral plaster cylinders in full extension were ap- plied for 6 weeks, after which an intense physical therapy program was instituted with good outcome.

DISCUSSION

Bilateral, simultaneous, and spontaneous rupture of the quadriceps tendon is a rare injury that is usually associated with several predisposing factors (Table 1).

Ruptures of the knee joint’s extensor mechanism tend to affect the patellar tendon or the patella itself in younger patients, whereas most of the ruptures of the quadriceps tendon occur after the age of 40 (4). Patients under 50 should be carefully examined for predisposing causes of the rupture.

Whereas quadriceps tendon tears are more fre- quently localized at the osteotendinous junction, this tendon can also rupture at the midtendinous area (5). Predisposition of the site of the tear ac- cording to age has also been noted. Patients older than 40 years are prone to ruptures at the tendon- bone junction, while younger patients have more ruptures at the midtendinous area. The case pre- sented here, a middle-aged man, is a good example of both levels of tear.

Diagnosis of quadriceps tendon rupture is clini- cal. History usually includes an injury in the form of

a fall coupled with a violent contraction of the quad- riceps. Sudden pain and a tearing sensation in the in- jured area is generally described by the patient. A palpable sulcus above the patella, swelling of the knee, and inability to extend the knee actively with unhampered flexion are present on physical exami- nation (2). However, spontaneous quadriceps rup- ture is often missed. Several factors can be responsi- ble for this: It is rare. it can occur in healthy young adults, injury at the time of rupture may not have oc- curred, the defect in the tendon may not be detected due to hematoma formation, and when bilateral, a comparative physical examination cannot be per- formed. On the other hand, ruptured quadriceps in patients with chronic disease states are frequently first seen by nonorthopedic surgeons and physicians, and it is not rare to mistake the condition for a neuro- logical paralysis (2). Because the clinical diagnosis of traumatic rupture of the quadriceps tendon is often initially overlooked a number of complementary di- agnostic techniques have been proposed. Roentgeno- graphy can be helpful but is often nonspecific or reveals only indirect signs of the disruption, like for- ward tilting of the patella, calcifications in the sub- stance of the tendon, suprapatellar effusion, or a poorly defined soft tissue shadow of the tendon (6).

Ultrasonography is inexpensive and may show the break in the tendon, but the echo can be obscured by abnormal overlying soft tissue (7). It is now generally accepted that MRI is the most satisfactory way to in- vestigate tendon ruptures. MRI reveals the swelling secondary to hematoma and proximal retraction of the quadriceps and defines accurately the site and extent of the rupture, which can be very helpful in preoperative planning. Not all cases of ruptured quadriceps require surgery. All the cases that have lost the voluntary extension power of the knee be- cause of complete tear of the tendon need surgical correction but some cases have only a partial tear and can be treated conservatively. MRI provides an ex- cellent means of evaluating the extent of these injur- ies. Multiple surgical techniques for repairing the ruptured tendon have been described. The level of injury is one of the most important factors in tech- nique selection. In this case, different surgical tech- niques were planned on both sides according to MRI findings. CT scan has a very limited value in tendon ruptures as this case shows.

In summary, bilateral, simultaneous, and sponta- neous rupture of the quadriceps tendon is a rare en- tity that can be easily overlooked. Although the diag- nosis is clinical, MRI was shown to be most useful in diagnosis confirmation and preoperative planning.

76 CALVO ET AL. CLINICAL IMAGING VOL. 21, NO. 1

REFERENCES 4. Siwek KW, Rao JP. Bilateral simultaneous rupture of the quad- riceps tendons. Clin Orthop 1978;131:252-254.

Rasul AT, Fischer DA. Primary repair of quadriceps tendon ruptures: results of treatment. Clin Orthop 1993;289:205-207.

Nance EP, Kaye JJ. Injuries of the quadriceps mechanism. Radi- ology 1982;142:301-307.

Bohle R, Johnson JC. Bilateral simultaneous spontaneous rup- ture of the quadriceps tendons in a diabetic patient. South Med J 1985;78(4):486.

Dhar S. Bilateral, simultaneous, spontaneous rupture of the quadriceps tendon: a report of 3 cases and a review of the litera- ture. Injury 1988;19:7-8.

MacEachern AG, Plewes JL. Bilateral simultaneous spontane- ous rupture of the quadriceps tendons. J Bone Joint Surg (Br) 1984;66B:81-83.

Ramsey RH, Muller GE. Quadriceps tendon rupture: a diagnos- tic trap. Clin Orthop 1970;70:161-164.

5.

6.

7.