‘A Snap, a Dent, and then Sono: The Role of POCUS in Diagnosing Quadriceps Tendon Rupture in the
Emergency Department – A Case Report’
Dr Himanshu Gul Mirani, Dr Ravi Maharaj
Case Presentation:
A 63-year-old male presented to the emergency department (ED) following a fall at a golf course. He lost his footing and landed on his left knee, which bent completely backwards. He experienced a sudden "give" in the thigh muscles and noted the formation of a "dent"; in the suprapatellar region, which quickly became swollen. The patient was unable to bear weight post-injury. His past medical history was significant for ischemic heart disease and bilateral hip replacements.
A Snap, a Dent, and then Sono: The Role of POCUS in Diagnosing Quadriceps Tendon Rupture in the Emergency Department – A Case Report
Management and Outcome:
On examination, localized swelling was observed in the suprapatellar region of the left lower thigh. The patient had an inability to perform a straight leg raise. There was localized tenderness over the inferolateral region of the left anterior thigh. A ‘gap’ was palpable in the lower thigh. Sensation remained intact, and systemic examination was unremarkable.
Investigation:
Point-of-care ultrasound (POCUS) was performed at the initial assessment. Normal striated tendon fibers were observed on the right side. However, on the left side, fibers appeared discontinuous with hypoechoic or anechoic areas, suggestive of fiber disruption, bleeding, or hematoma formation, indicative of a quadriceps tendon injury.
A left knee X-ray did not show any bony injury but demonstrated local swelling and possible loss of quadriceps tendon integrity.
The patient was admitted under orthopedic services for further management.
Key Learnings and Points:
Although MRI remains the gold standard for diagnosing quadriceps tendon rupture, this case underscores the utility of POCUS in expediting referrals and streamlining management in a resource-limited setting. Given the increasing demands on the NHS, early POCUS assessment can facilitate timely specialist review and intervention.
Traumatic quadriceps tendon rupture is an uncommon but significant injury, with an incidence of approximately 1.37 per 100,000 per year, most commonly affecting males over 40 years of age (Pope et al., 2023). Traditionally, MRI is considered the definitive imaging modality; however, POCUS performed by ED physicians offers a rapid, non-invasive alternative for initial diagnosis.
Studies have demonstrated the high sensitivity of POCUS in detecting quadriceps tendon ruptures. Arnold et al. (2022) report that POCUS has a sensitivity of 90-100% in identifying tendon disruptions when performed by trained emergency physicians. Another study by Pope et al. (2023) emphasizes how POCUS enables rapid identification of soft tissue injuries, reducing delays in orthopedic referral and intervention. Early imaging with POCUS, particularly in a time-sensitive healthcare system, aligns with the leveraging bedside ultrasound to expedite decision-making and improve patient flow.