· includes
· quadriceps muscle
· quadriceps tendon
· medial and lateral retinaculum
· patellar tendon
· tibial tubercle
· active extension prevented by obstacle
· depends on age
· 10-15 - avulsion of tibial tuberosity
· 20-40 - rupture of patellar tendon
· 40-60 - fracture of patella
· 60-80 - rupture of quadriceps tendon
· usually occurs in elderly patient or patient on prolonged corticosteroids
· due to decreased vasculature and collagen weakness
· occasionally occurs in young athlete
· due to excessive contracture
· occurs as
· rupture of belly of rectus femoris
· avulsion of quadriceps tendon from superior patella
· rupture at musclulotendinous junction (athlete)
· presents with
· palpable gap in tendon
· haemarthrosis
· extensor lag or deficit
· often difficult to diagnose once acute features settle
· function usually good if tear incomplete
· incomplete
· immobilise for 4 weeks in extension
· then rehabilitate
· complete
· surgical repair
· athlete
· surgical repair
Technique
· midline incision
· Bunnell type repair
· can reinforce with
· piece of proximal quadriceps aponeurosis
· wire around patella
· postoperative
· brace for 4 weeks
· crutches for 8 weeks
· start static quadriceps exercises at 10 days
· start flexion at 3 weeks
· start active extension at 6 weeks
· less common
· usually occurs in young people
· often previous history of tendonitis +/- steroid injections
· most common at level of inferior pole of patella
· less common at tibial tubercle
· midsubstance ruptures rare
· severe pain
· palpable defect
· extensor deficit
· patella alta
· requires operative repair
· midsubstance tears sutured directly
· avulsions reattached through drillholes
· may be reinforced with wire loop
· immobilised for 6 weeks
· then gradual ROM
· condition of apophysis into which part of patellar tendon inserts
· occurs in teenagers
· males more common
· corresponds with growth spurt
· age 12-14 in boys
· age 11-13 in girls
· may be bilateral
· 20-30%
· traction injury
· due to recurrent microtrauma
· usually no history of injury
Symptoms
· pain after activity
· esp. kicking and jumping
· tender lump
· pain on direct blow
· difficulty kneeling
Signs
· tender lump over tibial tuberosity
· pain on active extension
· important to exclude other causes
· shows enlarged fragmented tibial tuberosity
· CT scan may define ossicle in patellar tendon
· usually resolves spontaneously
· restriction of provocating activities
· removal of ossicle if unresponsive
· similar condition
· traction injury of lower pole of patella where patellar tendon inserts
· common in high jumpers
· differential diagnosis
· patellar tendinitis
· patellar stress fracture
· bipartite patella
· usually recovers with rest
· most common in athletes
· esp. if involved in running, jumping and kicking
· insidious onset of pain at inferior pole of patella
· pain may
· occur after activity only
· be present also during activity
· interfere with participation
· localised tenderness at inferior pole
· no effusion or joint abnormality
· may progress to rupture
· usually normal
· may show
· traction spurs
· calcification of patellar tendon
Nonoperative
· activity modification
· warmup and stretching
· ice and NSAIDs
· HCLA should be avoided as weakens tendon
Operative
· if fails to resolve and interferes with activity
· involves resection of degenerative part of tendon
· patella may develop from one or multiple ossification centres
· failure of centres to fuse may produce bipartite or tripartite patella
· usually bilateral and painless
· accessory fragments are usually
· superolateral (75%)
· lateral (20%)
· inferior (5%)
· pain may result from repetitive microtrauma with injury to synchondrosis
· treated with immobilisation for 4 weeks
· excision or internal fixation may be indicated for lesions that fail to settle