Diagnostic Radiology
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Rupture of the Quadriceps Tendon: Diagnosis by Arthrography 1
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David V. Jelaso, M.D., and George A. Morris, M.D. Arthrography revealed an abnormal tract of contrast agent dissecting from the suprapatellar bursa into the soft tissue anterior to the patella and downward to a level 9 cm beneath the tibial plateau in a patient with complete rupture of the quadriceps tendon. The bursal anatomy of the anterior portion of the knee is reviewed in relation to the capsule-forming structures of the quadriceps expansion. The use of knee arthrography for the assessment of quadriceps tendon injury is advocated. INDEX
TERMS:
Knee, arthrography. Tendons
RadIology 116:621-622, September 1975
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• HE value of arthrography in identifying injury to func-
Ttionally important capsule-forming structures is well established in the shoulder where inappropriate opacification of the subacromial bursa enables diagnosis of rotator cuff tear. In an analogous fashion, abnormal opacification of accessory bursae at knee arthrography may provide clinically useful information about the integrity of the quadriceps expansion which forms the anterior fibrous capsule of the knee joint. The arthrographic findings associated with rupture of the quadriceps tendon have been described in a patient with a partial tear (5). In the case presented here, arthrography confirmed the clinically suspected diagnosis of complete rupture of the quadriceps tendon.
Fig. 1. Diagrammatic representation of the mid-sagittal plane of the knee, emphasizing the anterior relationships. The ventral bursae are shown here in solid black, in a distended state. The hatched area represents the subcutaneous areolar layer in which the subcutaneous prepatellar and infrapatellar bursae reside. This layer provides a potential cleavage plane between the skin and the anterior fibrous capsule of the knee. The quadriceps mechanism is represented in this section as the patellar tendon (Q), the patella (Pl, and the patellar ligament (L). On either side of the plane shown here, expansions of the vastus medialis and vastus latera lis extend backward to the level of their respective collateral ligaments, forming the medial and lateral patellar retinacula. The patellar tendon, ligament, and retinacula constitute the anterior fibrous capsule of the knee joint.
ANATOMY The standard anatomic description of the ventral bursae of the knee is shown diagrammatically in Figure 1 (3). The suprapatellar bursa is the only one which normally fills with contrast substance on routine arthrographic examination. It is apparent from Figure 1 that a tear of the quadriceps tendon exposes the subcutaneous areolar layer, a cleavage plane between the skin and the quadriceps expansion. Extravasated contrast material from the suprapatellar bursa dissects along this plane. The resulting opacification may include subcutaneous prepatellar and infrapatellar bursae as illustrated in the following case.
At surgery, a complete transverse tear of the quadriceps tendon from the superior pole of the patella was confirmed. It appeared that the abnormal tract of contrast substance seen radiographically defined a traumatic space which incorporated the subcutaneous prepatellar and infrapatellar bursae. The tendon was freshened and reanastomosed through drill holes to the superior pole of the patella. The postoperative course was uneventful.
CASE REPORT The patient, a 79-year-old man, was admitted through the emergency room one week after having slipped on a wet surface in a laundromat. Several times after his initial injury he was seen in the hospital emergency room, complaining of pain and inability to extend the knee, but was discharged on each occasion when knee radiographs revealed only diffuse anterior soft-tissue swelling. Finally, he was seen by an orthopedic surgeon who admitted him to the hospital. The history was not revealing. Pertinent findings on physical examination were confined to the right knee where diffuse anterior swelling was noted. There was tenderness above the patella which was ballotable, and a palpable defect was noted just superior to the patella. The patient was unable to extend his knee. The clinical impression was rupture of the quadriceps tendon. At arthrography, an abnormal tract of contrast material was identified dissecting from the suprapatellar bursa into the soft tissue anterior to the patella and downward in this superficial plane to a level 9 cm beneath the tibial plateau (Fig. 2). This finding confirmed the clinical impression of quadriceps tendon rupture.
DISCUSSION There is general agreement that the deep infrapatellar bursa, the suprapatellar bursa, and the subcutaneous prepatellar bursae are ubiquitous (3, 7). The universality of the subcutaneous infrapatellar bursa is, however, in dispute. According to one description (2), the subcutaneous prepatellar and infrapatellar bursae form a single structure. Sharrard (4) states that the subcutaneous infrapatellar bursa was not found in a series of autopsy dissections despite its presence clinically in kneeling miners, leading him to conclude that this bursa was acquired. In Smason's case, a space conforming to the expected di-
1 From the Departments of Radiology (D. V. J., Director) and Orthopedic Surgery (G.A.M.), Clearwater Community Hospital, Clearwater, Fla. Accepted for publication in April 1975. shan
621
622
DAVID
V.
JELASO AND GEORGE
Fig. 2. A. This arthrographic view in lateral projection shows an abnormal tract of contrast material extending from the suprapatellar bursa. In its downward dissection it incorporates the subcutaneous prepatellar bursa at the level of the straight arrow (--+) and the subcutaneous infrapatellar bursa at the level of the hatched arrow (++). B. The anterior relationship to the patella of the abnormal tract of contrast substance is best shown in this view from the arthrogram with the knee slightly oblique from the true lateral projection.
A.
MORRIS
September 1975
appear to be of inestimable value in the prediction of tears of the quadriceps expansion. These caudad dissections of contrast material associated with quadriceps tendon tear should be readily distinguishable from the pseudocyst formation near the apex of the suprapatellar bursa described by Duncan (1) in patients with rupture of the suprapatellar bursa. As is the case with many tendon injuries unaccompanied by fracture, the diagnosis of quadriceps tendon rupture is often missed (6). The presence of local pain, tenderness and swelling in a patient who is unable to extend the knee and in whom a defect replacing the normal quadriceps tendon is palpated, points to the correct diagnosis. Many injured patients will, however, have a loss of extensor function due to the pain of a contusion, thus impeding the clinical assessment. In doubtful cases, there would appear to be a useful place for arthrography in defining the extent of injury to the quadriceps mechanism. Arthrography may also prove useful in identifying partial quadriceps tears in patients who present with recurrent prepatellar effusions following trauma, as in Smason's case (5). Department of Radiology Clearwater Community Hospital Clearwater, Fla. 33516
REFERENCES mension of the subcutaneous prepatellar bursa was opacified (5). In our case, the contrast agent anterior to the patella outlines a space comprising two compartments which communicate across a septated channel. We believe that this is a tract created by the trauma which incorporates the subcutaneous prepatellar and infrapatellar bursae. Caudad dissection in a plane superficial to the patella through the subcutaneous prepatellar bursa and into the subcutaneous infrapatellar bursa as the consequence of an enlarging effusion under tension could produce this result. Regardless of the ultimate determination of the true dimensions of the anterior subcutaneous bursae of the knee, and the location of contrast substance in relation to these bursae in any given case, the identification of contrast agent in a prepatellar plane would
1. Duncan AM: Arthrography in rupture of the suprapatellar bursa with pseudocyst formation. Am J RoentgenoI121:89-93, May 1974 2. Gardener E, Gray OJ, O'Rahilly R: Anatomy. Philadelphia, Saunders, 2d ed, 1963, P 285 3. Warwick R, Williams PL, ed: Gray's Anatomy. Philadelphia, Saunders, 35th Brit ed, 1973, P 455 4. Sharrard WJW: Haemobursa in kneeling miners. Proc Roy Soc Med 54:1103-1104, Dec 1961 5. Smason JB: Post-traumatic fistula connecting prepatellar bursa with knee joint. Report of a case. J Bone Joint Surg 54A: 1553-1554, Oct 1972 6. Smillie IS: Injuries of the Knee Joint. Edinburgh, Livingstone, 4th ed, 1971, P 184 7. Sobotta J, Figge F: Atlas of Human Anatomy. New York, Hafner, 8th English ed, 1968, Figs. 270-275
•
Rupture of the Quadriceps Tendon: Diagnosis by Arthrography 1
•
David V. Jelaso, M.D., and George A. Morris, M.D. Arthrography revealed an abnormal tract of contrast agent dissecting from the suprapatellar bursa into the soft tissue anterior to the patella and downward to a level 9 cm beneath the tibial plateau in a patient with complete rupture of the quadriceps tendon. The bursal anatomy of the anterior portion of the knee is reviewed in relation to the capsule-forming structures of the quadriceps expansion. The use of knee arthrography for the assessment of quadriceps tendon injury is advocated. INDEX
TERMS:
Knee, arthrography. Tendons
RadIology 116:621-622, September 1975
•
• HE value of arthrography in identifying injury to func-
Ttionally important capsule-forming structures is well established in the shoulder where inappropriate opacification of the subacromial bursa enables diagnosis of rotator cuff tear. In an analogous fashion, abnormal opacification of accessory bursae at knee arthrography may provide clinically useful information about the integrity of the quadriceps expansion which forms the anterior fibrous capsule of the knee joint. The arthrographic findings associated with rupture of the quadriceps tendon have been described in a patient with a partial tear (5). In the case presented here, arthrography confirmed the clinically suspected diagnosis of complete rupture of the quadriceps tendon.
Fig. 1. Diagrammatic representation of the mid-sagittal plane of the knee, emphasizing the anterior relationships. The ventral bursae are shown here in solid black, in a distended state. The hatched area represents the subcutaneous areolar layer in which the subcutaneous prepatellar and infrapatellar bursae reside. This layer provides a potential cleavage plane between the skin and the anterior fibrous capsule of the knee. The quadriceps mechanism is represented in this section as the patellar tendon (Q), the patella (Pl, and the patellar ligament (L). On either side of the plane shown here, expansions of the vastus medialis and vastus latera lis extend backward to the level of their respective collateral ligaments, forming the medial and lateral patellar retinacula. The patellar tendon, ligament, and retinacula constitute the anterior fibrous capsule of the knee joint.
ANATOMY The standard anatomic description of the ventral bursae of the knee is shown diagrammatically in Figure 1 (3). The suprapatellar bursa is the only one which normally fills with contrast substance on routine arthrographic examination. It is apparent from Figure 1 that a tear of the quadriceps tendon exposes the subcutaneous areolar layer, a cleavage plane between the skin and the quadriceps expansion. Extravasated contrast material from the suprapatellar bursa dissects along this plane. The resulting opacification may include subcutaneous prepatellar and infrapatellar bursae as illustrated in the following case.
At surgery, a complete transverse tear of the quadriceps tendon from the superior pole of the patella was confirmed. It appeared that the abnormal tract of contrast substance seen radiographically defined a traumatic space which incorporated the subcutaneous prepatellar and infrapatellar bursae. The tendon was freshened and reanastomosed through drill holes to the superior pole of the patella. The postoperative course was uneventful.
CASE REPORT The patient, a 79-year-old man, was admitted through the emergency room one week after having slipped on a wet surface in a laundromat. Several times after his initial injury he was seen in the hospital emergency room, complaining of pain and inability to extend the knee, but was discharged on each occasion when knee radiographs revealed only diffuse anterior soft-tissue swelling. Finally, he was seen by an orthopedic surgeon who admitted him to the hospital. The history was not revealing. Pertinent findings on physical examination were confined to the right knee where diffuse anterior swelling was noted. There was tenderness above the patella which was ballotable, and a palpable defect was noted just superior to the patella. The patient was unable to extend his knee. The clinical impression was rupture of the quadriceps tendon. At arthrography, an abnormal tract of contrast material was identified dissecting from the suprapatellar bursa into the soft tissue anterior to the patella and downward in this superficial plane to a level 9 cm beneath the tibial plateau (Fig. 2). This finding confirmed the clinical impression of quadriceps tendon rupture.
DISCUSSION There is general agreement that the deep infrapatellar bursa, the suprapatellar bursa, and the subcutaneous prepatellar bursae are ubiquitous (3, 7). The universality of the subcutaneous infrapatellar bursa is, however, in dispute. According to one description (2), the subcutaneous prepatellar and infrapatellar bursae form a single structure. Sharrard (4) states that the subcutaneous infrapatellar bursa was not found in a series of autopsy dissections despite its presence clinically in kneeling miners, leading him to conclude that this bursa was acquired. In Smason's case, a space conforming to the expected di-
1 From the Departments of Radiology (D. V. J., Director) and Orthopedic Surgery (G.A.M.), Clearwater Community Hospital, Clearwater, Fla. Accepted for publication in April 1975. shan
621
622
DAVID
V.
JELASO AND GEORGE
Fig. 2. A. This arthrographic view in lateral projection shows an abnormal tract of contrast material extending from the suprapatellar bursa. In its downward dissection it incorporates the subcutaneous prepatellar bursa at the level of the straight arrow (--+) and the subcutaneous infrapatellar bursa at the level of the hatched arrow (++). B. The anterior relationship to the patella of the abnormal tract of contrast substance is best shown in this view from the arthrogram with the knee slightly oblique from the true lateral projection.
A.
MORRIS
September 1975
appear to be of inestimable value in the prediction of tears of the quadriceps expansion. These caudad dissections of contrast material associated with quadriceps tendon tear should be readily distinguishable from the pseudocyst formation near the apex of the suprapatellar bursa described by Duncan (1) in patients with rupture of the suprapatellar bursa. As is the case with many tendon injuries unaccompanied by fracture, the diagnosis of quadriceps tendon rupture is often missed (6). The presence of local pain, tenderness and swelling in a patient who is unable to extend the knee and in whom a defect replacing the normal quadriceps tendon is palpated, points to the correct diagnosis. Many injured patients will, however, have a loss of extensor function due to the pain of a contusion, thus impeding the clinical assessment. In doubtful cases, there would appear to be a useful place for arthrography in defining the extent of injury to the quadriceps mechanism. Arthrography may also prove useful in identifying partial quadriceps tears in patients who present with recurrent prepatellar effusions following trauma, as in Smason's case (5). Department of Radiology Clearwater Community Hospital Clearwater, Fla. 33516
REFERENCES mension of the subcutaneous prepatellar bursa was opacified (5). In our case, the contrast agent anterior to the patella outlines a space comprising two compartments which communicate across a septated channel. We believe that this is a tract created by the trauma which incorporates the subcutaneous prepatellar and infrapatellar bursae. Caudad dissection in a plane superficial to the patella through the subcutaneous prepatellar bursa and into the subcutaneous infrapatellar bursa as the consequence of an enlarging effusion under tension could produce this result. Regardless of the ultimate determination of the true dimensions of the anterior subcutaneous bursae of the knee, and the location of contrast substance in relation to these bursae in any given case, the identification of contrast agent in a prepatellar plane would
1. Duncan AM: Arthrography in rupture of the suprapatellar bursa with pseudocyst formation. Am J RoentgenoI121:89-93, May 1974 2. Gardener E, Gray OJ, O'Rahilly R: Anatomy. Philadelphia, Saunders, 2d ed, 1963, P 285 3. Warwick R, Williams PL, ed: Gray's Anatomy. Philadelphia, Saunders, 35th Brit ed, 1973, P 455 4. Sharrard WJW: Haemobursa in kneeling miners. Proc Roy Soc Med 54:1103-1104, Dec 1961 5. Smason JB: Post-traumatic fistula connecting prepatellar bursa with knee joint. Report of a case. J Bone Joint Surg 54A: 1553-1554, Oct 1972 6. Smillie IS: Injuries of the Knee Joint. Edinburgh, Livingstone, 4th ed, 1971, P 184 7. Sobotta J, Figge F: Atlas of Human Anatomy. New York, Hafner, 8th English ed, 1968, Figs. 270-275
