Traumatic rupture of the quadriceps tendon by itself is not an uncommon clinical condition. However, its association with concurrent ipsilateral closed distal tibia oblique fracture is exceedingly rare with only one previously reported case in English literature. The dual diagnosis of this atypical combination of injury may be masked by pain and immobilization of the more obvious fracture and may be missed, unless the treating physician maintains a high index of suspicion. Suprapatellar knee pain with or without a palpable gap in the quadriceps tendon and inability to straight leg raise in the setting of a distal tibia fracture should raise concern, but if initial treatment employs a long-leg splint the knee symptoms may be muted. In this report, we describe this unusual combination of injury in a 67-year-old male patient who sustained a trivial twisting injury to the leg. The aim of this report is to raise awareness and emphasize the importance of thorough and repeated clinical examinations in the presence of distracting injuries. Despite the complexity of the problem, standard techniques for quadriceps tendon repair using transpatellar bone tunnels following locked intramedullary rodding of the tibia fracture may lead to optimal outcomes.
Lower extremity tendon lacerations in conjunction with tibia fractures are often seen with high velocity open injuries. However, isolated tendon injures are relatively uncommon with low energy closed tibial fractures. Most studies in literature report associations between tibialis anterior, Achilles tendon, and tibialis posterior tendon lacerations with tibia fractures [
Although complete quadriceps tendon ruptures can be frequently diagnosed on clinical examination from the triad of acute knee pain, inability to extend the knee, and presence of suprapatellar gap, the diagnosis may be missed due to pain from other distracting injuries such as distal tibia fractures. Only a limited clinical exam is often possible in these situations, and injuries to the quadriceps tendon may be overlooked. Therefore, quadriceps tendon ruptures may potentially be diagnosed intraoperatively, when patients are taken to the operating room after induction of anesthesia for treatment of other injuries, when a more detailed examination is possible. Failure to address a complete laceration of the quadriceps tendon may preclude direct repair and lead to substantial loss of quadriceps strength, patella baja, and considerable disability long-term. Early diagnosis is even more essential when a tibial fracture is considered for nonoperative treatment in a cast, as the diagnosis may be delayed for many weeks. In this report, we describe a patient who sustained an ipsilateral acute complete rupture of the quadriceps tendon with a distal tibia oblique fracture and a supination external rotation ankle injury. The goal of this report is to emphasize the possibility of ipsilateral quadriceps tendon ruptures with oblique distal tibia fractures and to caution orthopaedic surgeons to maintain a high index of suspicion and perform thorough clinical examination to diagnose this injury preoperatively. To the best of our knowledge this association has not been extensively described with one previous report of a similar injury [
A 67-year-old male with past medical history of diabetes mellitus, opioid dependence, and prostate cancer fell down an embankment while attempting to urinate off the side of a road suffering a twisting injury to his left lower extremity. He was seen at an outside emergency department and found to have a closed, comminuted, oblique fracture of left distal tibia-fibula (see Figures
Preoperative AP and lateral radiographic images of the left leg.
During the surgical procedure, the nondisplaced posterior malleolus fracture was stabilized initially with a percutaneous screw directed anteromedial to posterolateral. The knee was then examined which revealed a substantial gap in the suprapatellar region suggestive of a quadriceps tendon rupture. A midline incision was then made 6 centimeters proximal to the superior pole of the patella to the tibial tubercle. A complete rupture of the quadriceps tendon was found on exploration. The tibia fracture was then stabilized with an intramedullary rod inserted after splitting the patellar tendon in standard fashion (see Figures
Intraoperative fluoroscopy images following tibial rodding and percutaneous fixation of the posterior malleolus.
Postoperative radiographs at 4-week follow-up.
Radiographs at 2-month follow-up showing interval healing with callus formation.
Combinations of tendon ruptures with closed isolated tibial shaft fractures are rare injuries that present a diagnostic challenge since physical examination is often limited due patient discomfort, immobilization, and swelling. In addition, suboptimal radiographs in trauma situations are not uncommon and identifying patella baja as a surrogate radiographic indicator of quadriceps tendon injury in lateral knee projections may be exceedingly difficult. Thus, a high index of clinical suspicion is necessary to diagnose quadriceps tendon injuries in patients with tibia fractures. Even with complaints of knee pain and inability to extend the leg, the cause may be mistakenly attributed to musculoskeletal pain from the trauma or an intraarticular ligamentous injury. Primary repair is required once the diagnosis has been made. An advantage of making the quadriceps rupture diagnosed preoperatively is that it may facilitate intramedullary rodding of the tibia fracture using a suprapatellar approach. Access is often easier through the tendon rupture with primary repair performed after the rod has been inserted and locked.
Tibialis anterior, tibialis posterior, and Achilles tendon ruptures are the most commonly reported tendon lacerations seen in conjunction with ipsilateral tibia fractures (see Table
Studies on tendon ruptures after tibial shaft fractures.
Author (year) | Number of |
Age |
Mechanism |
Diagnosis | Time of |
Treatment | Duration of |
Outcomes |
---|---|---|---|---|---|---|---|---|
Grenier and Guimont [ |
1 | 39 | Weightlifting | Bilateral quadriceps tendon rupture w/left distal tibia oblique fx | Preoperative | Bilateral repair of quadriceps tendons with limited ORIF with screws for distal tibia fx | 5 years | Excellent with FROM in the knee |
Mirza and Korber [ |
1 | 19 F | MCC | Distal tibial oblique shaft fx w/ipsilateral ATT rupture | 1 year following injury | LLC for distal tibia fx; repair of ATT rupture; delayed direct repair after tenolysis | 8 months | 10-degree active dorsiflexion and normal plantar flexion |
Korovessis et al. [ |
1 | 26 M | Midshaft tibia w/ipsilateral PTT and FDL rupture | Intraoperative | ORIF tibia and direct repair of PTT and FDL | 6 months | 10-degree ankle dorsiflexion deficit | |
Din and Therkilsden [ |
1 | 41 M | MCC | Midshaft tibia fx w/ipsilateral ATT rupture | Postoperative | IMR tibia; repair of ATT | NR | NR |
Givissis et al. [ |
1 | 17 | MCC | Distal tibia fx w/ipsilateral ATT rupture | Preoperative | ORIF distal tibia fx w/plates and screws and direct repair of ATT | 3 years | Full active dorsiflexion |
Mechrefe et al. [ |
1 | 32 M | MVC | Distal tibia fx with avulsion fx of tibialis anterior tendon insertion | Intraoperative | ORIF of tibia fx w/plates and screws and repair of ATT avulsion with suture anchors | 6 months | Excellent; no bracing needed |
Ebrahimi et al. [ |
1 | 26 M | MCC | Distal tibia comminuted fx w/ATT rupture | Intraoperative | ORIF distal tibia fx w/plates and screws and direct repair of ATT | 12 months | Return to work and recreational activities |
Hill et al. [ |
1 | 27 M | MCC | Open distal tibia fx w/achilles tendon rupture | Intraoperative | IMR tibia; direct repair of Achilles tendon | 5 months | Return to full activity |
Jarvis and Cannada [ |
1 | 48 M | MCC | Distal tibia-fibula fx (OTA type 43A) w/PTT rupture | Intraoperative | Bridging Ex-fix followed by ORIF tibia and fibula; PTT direct tenodesis to FDL | 1 year | AOFAS score 85/100; return to work |
Our patient | 1 | 67 M | Fall with twisting injury | Distal tibia oblique fx w/quadriceps tendon rupture w/ | Intraoperative | Quadriceps tendon repair and IMR tibia and ORIF posterior malleolus fx | 6 months | Return to work and recreational activities |
PTT: posterior tibial tendon; ATT: anterior tibial tendon; ORIF: open reduction internal fixation; MVA: motor vehicle accident; MCC: motor cycle crash: IMR: intramedullary rodding; OTA: orthopaedic trauma association; Fx; fracture; NR: not reported; Ex-Fix: external fixator; FDL: flexor digitorum longus; w/: with; Fx: fracture; FROM: full range-of-motion.
Concurrent occurrence of a tibia fracture and quadriceps tendon rupture is exceedingly uncommon with only one case reported in literature. Grenier and Guimont described the occurrence of bilateral quadriceps tendon ruptures with isolated left distal tibia fractures in a 39-year-old weightlifter [
In conclusion, concomitant ipsilateral rupture of quadriceps tendon, closed oblique fracture of the distal tibia, and supination external rotation ankle injuries are rare and to the best of our knowledge have not been extensively reported. Obtaining detailed history of the mechanism of injury and careful clinical evaluation of suprapatellar gap and straight leg raise in patients with oblique fractures of the distal tibia may raise suspicion of this uncommon combination of injuries. Prompt diagnosis may avoid long-term complications and allow early optimal management of this rare combination of injuries. Additionally, when computed tomographic (CT) scans are performed for distal tibia fractures, it may not be unreasonable to obtain sections of the distal femur including knee to supplement a difficult clinical exam for suspected diagnoses of periarticular tendon injuries. Moreover, magnetic resonance imaging of the knee may be obtained preoperatively in the presence of strong suspicion for ligamentous and tendon injuries. Although we did not employ a suprapatellar technique for insertion of tibial intramedullary rod, in the presence of a quadriceps tendon rupture, it may be practical to use this method as it avoids further injury to the extensor mechanism.
The authors declare that they have no conflicts of interest.