641 - Delayed Diagnosis of Traumatic Quadriceps Tendon Rupture

Case Diagnosis: Delayed Diagnosis of Traumatic Quadriceps Tendon Rupture

Case Description: A 68-year-old-male patient presented after a fall from a stepladder with a left leg laceration requiring debridement. Initial evaluation did not reveal weakness or limited range of motion. A right knee x-ray for pain showed no bony abnormality. Upon admission to inpatient rehabilitation right knee extension strength testing was limited by pain. He required acute care transfer for septic shock twice. During the first acute care readmission, physical therapy noted right knee buckling, pain and knee extension weakness. During the second acute care readmission, PM&R was consulted for the first time at the prior inpatient rehabilitation facility’s request. The physiatrist noted right knee extension pain, weakness (1/5 strength), inability to fully extend, and a palpable defect at the distal right quadriceps tendon. MRI was recommended and demonstrated a complete tear of the right distal quadriceps tendon attachment with retraction. The patient underwent repair of the right quadriceps tendon.

Discussions: Quadriceps tendon injury classically presents with pain, knee extension weakness, and a suprapatellar defect. Unilateral eccentric contraction and hyperflexion after ground level fall are the most common mechanisms of injury.  Physicians should maintain a high suspicion for tendinous and ligamentous injury after trauma. Delayed quadriceps tendon repair may require additional operative procedures and is associated with poorer post-operative functional outcomes, persistent knee extensor weakness, and decreased range of motion. This patient remained maximum assist during his acute stay before and after the procedure, and discharged to a skilled nursing facility.

Conclusions:

Delay in recognition of quadriceps tendon rupture may alter surgical technique, and impair functional recovery. This case emphasizes the importance of an interdisciplinary approach, thorough physical examination, and education of referral sources on the role and added value of Physical Medicine and Rehabilitation physicians throughout the care continuum.