Arch Orthop Trauma Surg (1992) 112:45-46
mrhi'e°fOrthopaedic a.dTl'allmaSurgery © Springer-Verlag 1992
Traumatic rupture of the quadriceps tendon in a 16-year-old girl A case report P. Adolphson Department of Orthopedics, Danderyd Hospital, S-182 88 Danderyd, Sweden
Summary. T r a u m a t i c r u p t u r e of the quadriceps t e n d o n is well k n o w n to occur in middle-aged m e n [3, 5], in patients on hemodialysis for renal failure [2, 9, 12], and in patients with diabetes [1], but only very rarely in y o u n g and healthy w o m e n . W e r e p o r t a case of traumatic rupture of the quadriceps t e n d o n of a girl without any of the predisposing factors listed.
Case report A 16-year-old girl was admitted to our hospital after receiving a kick from a horse against her left thigh, which resulted in a large intramuscular hematoma located in the middle of the vastus lateralis region. She was kept under observation for a compartment syndrome during the following 2 days, but none developed. Standard radiographs of the left femur including the knee were normal and there was no clinical swelling of the knee. The pain subsided, she returned home and was referred to a physiotherapist. She was
Fig. 1. Anteroposterior radiograph of the injured knee. The ruptured tendon edge is seen proximally with the avulsed bone fragment Correspondence to: Dr. P. Adolphson, Department of Orthopedics, Danderyd Hospital, S-182 88 Danderyd, Sweden
able to lift her leg with the knee joint extended but had marked reduction of knee flexion to 90° due to the intramuscular hematoma and pain. Five weeks later the girl was readmitted because of new trauma to the same leg. This time she had fallen in the street, with the front of her left knee directly hitting the ground. On admission there was gross hemarthrosis and a marked subcutaneous swelling of the suprapatellar region. She was unable to lift her leg with the knee joint extended, but no defect in the quadriceps tendon could be palpated because of the swelling. This time radiographs of the left knee demonstrated an avulsion of a small semilunar bone fragment from the patella that was displaced approximately 2 cm proximally (Fig. 1). At surgery the next day the distal end of the tendon was found to be completely separated from the proximal part of the patella, carrying a brim of cancellous bone. The tendon was reinserted and a circular cast applied for 6 weeks. The postoperative course was uneventful, and after 3 months she had regained full active mobility of the knee joint.
Discussion R u p t u r e of the quadriceps t e n d o n occurs most c o m m o n l y in m e n after the age of 40 and after a m i n o r trauma. Scuderi [10] p r e s e n t e d a series of 20 cases. T h e r e are also several papers reporting this condition in patients with a chronic illness, e.g. diabetes, gout, uremia, or hyperparathyroidism. Thus, Spencer [12] and R y u z a k i et al. [9] rep o r t e d this injury without appropriate t r a u m a in patients receiving hemodialysis t h e r a p y for end-stage renal failure, and they discussed w h e t h e r it was the disease itself or an osteoclastic effect of the a c c o m p a n y i n g h y p e r p a r a thyroidism that caused the w e a k e n i n g of the t e n d o n insertion. Bilateral, s p o n t a n e o u s , simultaneous quadriceps t e n d o n ruptures have also b e e n described in patients suffering f r o m these disorders [4, 13], and this is a strong indicator that the condition is a sign of skeletal or collagenous weakening. Siwek and R a o [11] reviewed the literature f r o m 1880 to 1978 and f o u n d that of 69 patients whose age was given, only two were less than 20 years old. Naver and A a l b e r g [6] have r e p o r t e d a case with great similarities to ours: the patient was a healthy 16-year-old girl who sustained c o m p l e t e lateral dislocation of the patella during a handball game. She was treated with a cylinder cast for 3 weeks and had g o o d function of the quadriceps muscle w h e n this cast was r e m o v e d . T w o weeks
46 l a t e r she fell o n ice a n d s u s t a i n e d c o m p l e t e r u p t u r e o f t h e q u a d r i c e p s t e n d o n . T h e a u t h o r s s t a t e t h a t in t h e i r case t h e r u p t u r e , as in all cases of d e g e n e r a t i v e q u a d r i ceps t e n d o n r u p t u r e , o c c u r r e d in an a r e a o f a b n o r m a l t e n d o n , a n d t h a t t h e a t t a c h m e n t o f t h e vastus m e d i a l i s to t h e p a t e l l a was t o r n at t h e first t r a u m a . H o w e v e r , this was n o t t h e case in o u r p a t i e n t , w h o h a d a d i r e c t b l o w a g a i n s t h e r l a t e r a l distal f e m u r at t h e t i m e of t h e first accident. T r a u m a a n d i m m o b i l i z a t i o n a r e b o t h c o m m o n causes o f r e g i o n a l o s t e o p e n i a in t h e a p p e n d i c u l a r skeleton: N i l s s o n a n d W e s t l i n [8] f o u n d t h a t m i n o r t r a u m a such as a n o p e r a t i o n for an i n j u r y to t h e s e m i l u n a r cartil a g e was a s s o c i a t e d w i t h a p e r m a n e n t b o n e loss of 9 % , a n d N i l s s o n [7] f o u n d p e r s i s t e n t d e m i n e r a l i z a t i o n o f a b o u t 25% in t h e f e m o r a l c o n d y l e s o f p a t i e n t s w h o w e r e t r e a t e d with a cast for tibial shaft f r a c t u r e s . T h e m i n e r a l loss was m o s t l y c o n f i n e d to w o m e n . T h e r e f o r e , it is a fair a s s u m p t i o n t h a t o u r p a t i e n t , d e s p i t e h e r age, d e v e l o p e d significant o s t e o p e n i a as a result o f t h e t r a u m a a n d t h e r e l a t i v e i m m o b i l i z a t i o n d u r i n g t h e 5 w e e k s a f t e r t h e first trauma, which weakened the bone attachment of the t e n d o n to t h e p a t e l l a a n d c o n t r i b u t e d to t h e t e n d o n r u p t u r e at t h e s e c o n d t r a u m a .
References 1. Bhole R, Johnson JC (1985) Bilateral simultaneous spontaneous rupture of quadriceps tendons in a diabetic patient. South Med J 78 : 486 2. Bhole R, Flynn JC, Marbury TC (1985) Quadriceps tendon ruptures in uremia. Clin Orthop 195 : 200-206
3. Keogh P, Jai Shanker S, Burke T, O'Connell RJ (1988) Bilateral simultaneous rupture of the quadriceps tendons. A report of four cases and review of the literature. Clin Orthop 234: 139-141 4. Lavalle C, Aparicio LA, Moreno J, Chavez de los Rios J, Robles-Paramo A, Fraga A (1985) Bilateral avulsion of quadriceps tendons in primary hyperparathyroidism. J Rheumatol 12: 596-598 5. MacEachern AG, Plewes JL (1984) Bilateral simultaneous rupture of the quadriceps tendons. Five case reports and a review of the literature. J Bone J Surg [Br] 66 : 81-83 6. Naver L, Aalberg JR (1985) Rupture of the quadriceps tendon following dislocation of the patella. J Bone J Surg [Am] 67: 324-325 7. Nilsson B (1966) Post-traumatic osteopenia; a quantitative study of the bone mineral in the femur following fracture of the tibia in man using 241 americium as a photon source. Acta Orthop Scand [Suppl] 37 : 91 8. Nilsson B, Westlin N (1969) Osteoporosis following injury to the semilunar cartilage. Calc Tiss Res 4 : 185-187 9. Ryuzaki M, Konishi K, Kasuga A, Kumagai H, Suzuki H, Abe S, Saruta T, Takami H, Tashiro M (1989) Spontaneous rupture of the quadriceps tendon in patients on maintenance hemodialysis - report of three cases with clinicopathological observations. Clin Nephrol 32 : 144-148 10. Scuderi C (1958) Rupture of the quadriceps tendon: study of twenty tendon ruptures. Am J Surg 95 : 626 11. Siwek CW, Rao JP (1981) Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg [Am] 63 : 932-937 12. Spencer JD (1988) Spontaneous rupture of tendons in dialysis and renal transplant patients. Injury 19 : 86-88 13. Wilkinson S, Houpt JB, Pritzker KPH, Goldhar JNH, Gross AE (1981) Avulsion of the quadriceps tendons in a patient with an unusual deforming arthritis and varied skin lesions. J Rheumatol 8 : 983-988 Received March 15, 1991
mrhi'e°fOrthopaedic a.dTl'allmaSurgery © Springer-Verlag 1992
Traumatic rupture of the quadriceps tendon in a 16-year-old girl A case report P. Adolphson Department of Orthopedics, Danderyd Hospital, S-182 88 Danderyd, Sweden
Summary. T r a u m a t i c r u p t u r e of the quadriceps t e n d o n is well k n o w n to occur in middle-aged m e n [3, 5], in patients on hemodialysis for renal failure [2, 9, 12], and in patients with diabetes [1], but only very rarely in y o u n g and healthy w o m e n . W e r e p o r t a case of traumatic rupture of the quadriceps t e n d o n of a girl without any of the predisposing factors listed.
Case report A 16-year-old girl was admitted to our hospital after receiving a kick from a horse against her left thigh, which resulted in a large intramuscular hematoma located in the middle of the vastus lateralis region. She was kept under observation for a compartment syndrome during the following 2 days, but none developed. Standard radiographs of the left femur including the knee were normal and there was no clinical swelling of the knee. The pain subsided, she returned home and was referred to a physiotherapist. She was
Fig. 1. Anteroposterior radiograph of the injured knee. The ruptured tendon edge is seen proximally with the avulsed bone fragment Correspondence to: Dr. P. Adolphson, Department of Orthopedics, Danderyd Hospital, S-182 88 Danderyd, Sweden
able to lift her leg with the knee joint extended but had marked reduction of knee flexion to 90° due to the intramuscular hematoma and pain. Five weeks later the girl was readmitted because of new trauma to the same leg. This time she had fallen in the street, with the front of her left knee directly hitting the ground. On admission there was gross hemarthrosis and a marked subcutaneous swelling of the suprapatellar region. She was unable to lift her leg with the knee joint extended, but no defect in the quadriceps tendon could be palpated because of the swelling. This time radiographs of the left knee demonstrated an avulsion of a small semilunar bone fragment from the patella that was displaced approximately 2 cm proximally (Fig. 1). At surgery the next day the distal end of the tendon was found to be completely separated from the proximal part of the patella, carrying a brim of cancellous bone. The tendon was reinserted and a circular cast applied for 6 weeks. The postoperative course was uneventful, and after 3 months she had regained full active mobility of the knee joint.
Discussion R u p t u r e of the quadriceps t e n d o n occurs most c o m m o n l y in m e n after the age of 40 and after a m i n o r trauma. Scuderi [10] p r e s e n t e d a series of 20 cases. T h e r e are also several papers reporting this condition in patients with a chronic illness, e.g. diabetes, gout, uremia, or hyperparathyroidism. Thus, Spencer [12] and R y u z a k i et al. [9] rep o r t e d this injury without appropriate t r a u m a in patients receiving hemodialysis t h e r a p y for end-stage renal failure, and they discussed w h e t h e r it was the disease itself or an osteoclastic effect of the a c c o m p a n y i n g h y p e r p a r a thyroidism that caused the w e a k e n i n g of the t e n d o n insertion. Bilateral, s p o n t a n e o u s , simultaneous quadriceps t e n d o n ruptures have also b e e n described in patients suffering f r o m these disorders [4, 13], and this is a strong indicator that the condition is a sign of skeletal or collagenous weakening. Siwek and R a o [11] reviewed the literature f r o m 1880 to 1978 and f o u n d that of 69 patients whose age was given, only two were less than 20 years old. Naver and A a l b e r g [6] have r e p o r t e d a case with great similarities to ours: the patient was a healthy 16-year-old girl who sustained c o m p l e t e lateral dislocation of the patella during a handball game. She was treated with a cylinder cast for 3 weeks and had g o o d function of the quadriceps muscle w h e n this cast was r e m o v e d . T w o weeks
46 l a t e r she fell o n ice a n d s u s t a i n e d c o m p l e t e r u p t u r e o f t h e q u a d r i c e p s t e n d o n . T h e a u t h o r s s t a t e t h a t in t h e i r case t h e r u p t u r e , as in all cases of d e g e n e r a t i v e q u a d r i ceps t e n d o n r u p t u r e , o c c u r r e d in an a r e a o f a b n o r m a l t e n d o n , a n d t h a t t h e a t t a c h m e n t o f t h e vastus m e d i a l i s to t h e p a t e l l a was t o r n at t h e first t r a u m a . H o w e v e r , this was n o t t h e case in o u r p a t i e n t , w h o h a d a d i r e c t b l o w a g a i n s t h e r l a t e r a l distal f e m u r at t h e t i m e of t h e first accident. T r a u m a a n d i m m o b i l i z a t i o n a r e b o t h c o m m o n causes o f r e g i o n a l o s t e o p e n i a in t h e a p p e n d i c u l a r skeleton: N i l s s o n a n d W e s t l i n [8] f o u n d t h a t m i n o r t r a u m a such as a n o p e r a t i o n for an i n j u r y to t h e s e m i l u n a r cartil a g e was a s s o c i a t e d w i t h a p e r m a n e n t b o n e loss of 9 % , a n d N i l s s o n [7] f o u n d p e r s i s t e n t d e m i n e r a l i z a t i o n o f a b o u t 25% in t h e f e m o r a l c o n d y l e s o f p a t i e n t s w h o w e r e t r e a t e d with a cast for tibial shaft f r a c t u r e s . T h e m i n e r a l loss was m o s t l y c o n f i n e d to w o m e n . T h e r e f o r e , it is a fair a s s u m p t i o n t h a t o u r p a t i e n t , d e s p i t e h e r age, d e v e l o p e d significant o s t e o p e n i a as a result o f t h e t r a u m a a n d t h e r e l a t i v e i m m o b i l i z a t i o n d u r i n g t h e 5 w e e k s a f t e r t h e first trauma, which weakened the bone attachment of the t e n d o n to t h e p a t e l l a a n d c o n t r i b u t e d to t h e t e n d o n r u p t u r e at t h e s e c o n d t r a u m a .
References 1. Bhole R, Johnson JC (1985) Bilateral simultaneous spontaneous rupture of quadriceps tendons in a diabetic patient. South Med J 78 : 486 2. Bhole R, Flynn JC, Marbury TC (1985) Quadriceps tendon ruptures in uremia. Clin Orthop 195 : 200-206
3. Keogh P, Jai Shanker S, Burke T, O'Connell RJ (1988) Bilateral simultaneous rupture of the quadriceps tendons. A report of four cases and review of the literature. Clin Orthop 234: 139-141 4. Lavalle C, Aparicio LA, Moreno J, Chavez de los Rios J, Robles-Paramo A, Fraga A (1985) Bilateral avulsion of quadriceps tendons in primary hyperparathyroidism. J Rheumatol 12: 596-598 5. MacEachern AG, Plewes JL (1984) Bilateral simultaneous rupture of the quadriceps tendons. Five case reports and a review of the literature. J Bone J Surg [Br] 66 : 81-83 6. Naver L, Aalberg JR (1985) Rupture of the quadriceps tendon following dislocation of the patella. J Bone J Surg [Am] 67: 324-325 7. Nilsson B (1966) Post-traumatic osteopenia; a quantitative study of the bone mineral in the femur following fracture of the tibia in man using 241 americium as a photon source. Acta Orthop Scand [Suppl] 37 : 91 8. Nilsson B, Westlin N (1969) Osteoporosis following injury to the semilunar cartilage. Calc Tiss Res 4 : 185-187 9. Ryuzaki M, Konishi K, Kasuga A, Kumagai H, Suzuki H, Abe S, Saruta T, Takami H, Tashiro M (1989) Spontaneous rupture of the quadriceps tendon in patients on maintenance hemodialysis - report of three cases with clinicopathological observations. Clin Nephrol 32 : 144-148 10. Scuderi C (1958) Rupture of the quadriceps tendon: study of twenty tendon ruptures. Am J Surg 95 : 626 11. Siwek CW, Rao JP (1981) Ruptures of the extensor mechanism of the knee joint. J Bone Joint Surg [Am] 63 : 932-937 12. Spencer JD (1988) Spontaneous rupture of tendons in dialysis and renal transplant patients. Injury 19 : 86-88 13. Wilkinson S, Houpt JB, Pritzker KPH, Goldhar JNH, Gross AE (1981) Avulsion of the quadriceps tendons in a patient with an unusual deforming arthritis and varied skin lesions. J Rheumatol 8 : 983-988 Received March 15, 1991
