Full Thickness Tear of Quadriceps Tendon Associated with Clo
Quadriceps tendon integrity should be evaluated while performing ORIF for distal femoral comminuted intra-articular fracture.

Choice of approach for surgical fixation to be chosen appropriately to evaluate tendon integrity.

End-to-end suturing gives good results when intrasubstance tears are encountered, but the technique depends on surgeon preference.

Immobilization in extension for 6 weeks is sufficient after which gradual knee-bending exercises started with 10° gain of movement in each week.

Patient counseling regarding the role of supervised rehabilitation is of paramount importance for a successful outcome.

A 34-year-old female patient presented to the emergency department following an accidental fall from the height of the second floor. The patient was evaluated and stabilized with standard advanced trauma life support protocols, and subsequently, a secondary survey was done. After obtaining radiographs, she was diagnosed with a closed right-sided distal femur intra-articular fracture (AO type 33C2) with an undisplaced patella fracture and left-sided fracture of the shaft of the femur with an ipsilateral patella fracture.

A computed tomography scan of the right knee was done to better understand the fracture morphology and for surgical planning. The patient was initially managed with skeletal traction on both sides, and on day 2, once the patient was stable, definite fixation was planned. Closed reduction and femur interlock nailing were done for the left femur shaft fracture, and tension band wiring with encircling wiring was done for the ipsilateral patella fracture simultaneously. After an interval of 3 days, a definite fixation of the right intra-articular distal femur fracture was done using a lateral parapatellar approach. On deep dissection, incidentally, a complete tear of quadriceps tendon was noted. The tear was horizontally oriented, about 2.5 cm proximal to the superior pole of the patella. There was just the sleeve of the medial retinaculum found intact. The distal femoral comminuted fracture was fixed with an anatomical pre-contoured distal femoral locking plate (AO, Synthes), and the ipsilateral undisplaced patella fracture with intact retinaculum was managed conservatively.

The left knee was mobilized in the immediate postoperative period with partial weight-bearing as tolerated. For the right side, the patient was given a hinged knee brace locked in extension for initial 6 weeks. After that, gradual and controlled knee flexion was started with a rate of 10° of flexion increment every week. At 16 weeks, 100° of knee flexion was achieved, and the brace was discontinued. Strengthening exercises were started after 20 weeks. The patient was allowed to perform straight leg raising and active knee bending against resistance. At 24 weeks, the knee range of motion achieved was 0–110°, and there was no extension lag. This protocol for rehabilitation was meticulously supervised by experienced physiotherapists. Radiographic ongoing healing was evident at 20 weeks. The left-sided femur shaft and patellar fracture achieved radiologic union at 16-week follow-up. Left knee range of motion was 0–130°.

The patient started full-weight bearing mobilization at 6 months and was pain-free with a normal gait. Quadriceps muscle strength testing was done using a handheld dynamometer at 6, 8, and 12 months, which revealed nearly equal strength in bilateral quadriceps at 8 months. We used a handheld dynamometer because of the convenience of use in the outpatient department. The Tegner Lysholm Knee Score was good (88) at the right knee and excellent at the left knee (97) at the final follow-up of one year. The patient was able to actively squat, though had difficulty sitting crossed leg on the floor due to restriction of terminal knee flexion.