Palpable Defect Research Articles

Operative management of chronic isolated rectus femoris rupture with semitendinosus graft and biofiber: A case report

Rectus femoris tear is rare and often overlooked in emergencies. The majority of quadriceps muscle belly injuries can be successfully treated conservatively and for less active, older populations Non-operative management is reasonable. A case report of a 19-year-old male Kabbaddi player who sustained an injury to his rectus femoris muscle belly while playing 5 months back. This young patient did not recover the functional outcome required to get back to running and participating in kabaddi despite 5 months of physiotherapy and non-operative management and had complaints of Pain over midthigh and weakness in quadriceps during hip flexion and knee extension. This leads to Hindrances in Jumping, running, and kicking movements. Tenderness over the midthigh and palpable defect with Pain upon resisted hip flexion or extension was seen.3/5 quadriceps power was noted. Ultrasound and MRI were done to confirm the clinical diagnosis. Operative treatment using the semitendinosus allograft with bio fiber reconstruction system to augment rectus femoris repair allowed immediate full passive flexion of the knee and an early graduated physiotherapy program leading to a return to running and his previous level of sport without any restrictions. Surgical treatment of rectus femoris tear seems to be a good option for Chronic tears.

PFANNENSTIEL HERNIA – AN UNDER DIAGNOSED PATHOLOGY OFTEN OVERLOOKED AND POTENTIALLY PREVENTABLE

Abstract Objective Pfannenstiel incision was described in 1900 and is widely used for C-section. Obstetricians tear the rectus muscles and posterior sheath apart and don’t reapproximate this layer. As consequence, it leaves a gap between both recti which allows herniation of abdominal contents between the anterior rectus sheath and muscle. The aim was describing this defect and its characteristics as well as propose an awareness strategy to avoid symptomatic patients being dismissed after “normal” scan or physical examination. Method A prospective observational study was conducted on 32 patients, between January 2019–2024. Data collected (history, examination, and relevant investigations) was entered in a proforma, tabulated, and analysed. Most of patients presented with discomfort, swelling, intermittent nausea and all reported a bulge. Distension was noted in 42%. On physical examination all had some degree of asymmetry. However no cough impulse or palpable defect was detected. They were mainly diagnosed on CT scans (77%) although some radiology reports denied the presence of a hernia because the anterior sheath was intact. The rest were found incidentally at laparoscopy for unrelated conditions. Most defects were repaired with sutures while larger defects were repaired with mesh. Two patients presented with small bowel obstruction. Conclusion Pfannenstiel hernia is atypical with unique anatomic features and the radiological signs may be subtle. Increased awareness by surgeons and radiologists should avoid this condition being missed. It may be preventable by attention to closing the posterior layer at the index operation.

Acute Patellar Tendon Ruptures: An Update on Management.

Patellar tendon ruptures can be debilitating injuries. When incomplete, partial tears can be managed nonsurgically with immobilization and progressive rehabilitation. Although complete ruptures remain a relatively uncommon injury, they portend a high level of morbidity. Ruptures typically result from an acute mechanical overload to the extensor mechanism, such as with forced quadriceps contraction and knee flexion. However, chronically degenerated tendons are also predisposed to failure from low-energy injuries. Diagnosis can often be made clinically with recognition of a palpable defect to the tendon, localized patellar tendon tenderness, and inability to actively extend the knee. Diagnosis and surgical planning can be established with radiograph, ultrasonography, or magnetic resonance imaging. Surgical repair is the mainstay of treatment, and there have been many recent advances in repair technique, optimal reconstruction strategies, and supplemental fixation. Time to surgery for complete tears remains the most important prognosticator for success. Direct primary repair can be completed with transosseous tunnels, suture anchor repair, or end-to-end repair. Tendon reconstruction can be achieved with or without mechanical or biologic augments. Rehabilitation programs vary in specifics, but return to sport can be expected by 6 months postoperatively.

A Case Report of an Isolated Calvarial Defect in the Region of the Lambdoid Suture: A Rare Bone Manifestation of Neurofibromatosis Type 1

The Calvarial bone defects in the lambdoid suture region are a rare bone manifestation of neurofibromatosis type 1. They may be isolated or associated with an adjacent structural lesion, such as a dural ectasia or plexiform neurofibroma. The underlying pathophysiology for the development of these types of skull defects is still unclear. We present the case of a Calvarial defect in the region of the lambdoid suture in a 7-year-old boy with a medical history of neurofibromatosis type 1 who was referred for a brain scan to explore a palpable skull defect in right parieto-occipital region , noticed by his doctor.

“Luggage Tag” Suture Modification for Closing the Quadriceps Tendon Autograft Harvest Site

The quadriceps tendon (QT) is increasingly used as an autograft for anterior cruciate ligament reconstruction. Closure of the harvest site helps with fluid extravasation from the joint for the duration of the procedure. In addition, closure of the QT removes the palpable defect noticed by many patients and prevents superficial infections from spreading deep to the joint. This Technical Note describes how to perform the “luggage tag” suture modification to efficiently and reproducibly close the QT harvest site with an arthroscopic self-retrieving suture passer.

Arthrotomy Dehiscence After Total Knee Arthroplasty With a Barbed Suture.

Meticulous arthrotomy closure during total knee arthroplasty (TKA) is essential to preserve quadriceps strength and maintain proper patellar tracking. We recently encountered a subset of patients referred with anterior knee pain, a palpable retinaculum defect, and quadriceps weakness. Each patient was found to have an arthrotomy dehiscence. This study highlights arthrotomy dehiscence as a failure mechanism after TKA. A retrospective case series of patients who underwent primary TKA followed by subsequent capsular dehiscence was reviewed. We investigated whether the dehiscence was related to trauma, the presence of a palpable arthrotomy defect, patellar tracking, quadriceps strength, and the type of closure technique. All patients had an atraumatic disruption and presented with anterior knee pain and quadriceps weakness. Fourteen of 18 patients (78%) had a palpable defect along the medial retinaculum. Nine of 18 patients (50%) had patellar subluxation or tilting. Barbed sutures were used in 13 of 18 (72%) patients. A simple arthrotomy repair (44%) or a vastus medialis obliquus advancement (56%) was used successfully in all patients. Atraumatic arthrotomy dehiscence as a cause of TKA failure historically has been a rare event. Recently, we have noticed a disturbing number of patients presenting with this failure mechanism. With this study, we call attention to this unique atraumatic failure mechanism in patients presenting with anterior knee pain after TKA. Surgeons should be aware of this risk when using barbed sutures alone and should consider routinely reinforcing the arthrotomy with interrupted sutures. Level IV, Retrospective Case Series.

A Woman With Painful Shoulder

A 24-year-old woman with a previous right shoulder dislocation presented to the emergency department with sudden onset of right shoulder pain after being struck by an open car door 3 days ago. On examination, there was a loss of the deltoid contour with a palpable defect (Figure 1). She had positive Dugas test findings and could perform flexion and abduction of the right arm up to 60 degrees as well as almost full external rotation without pain restraint. Standard projection (Figure 2) radiography and point-of-care ultrasound of the right shoulder were performed (Figure 3).

Revision Quadriceps Tendon Repair With Bone-Achilles Allograft Augmentation

Background: Surgical repair of chronic quadriceps tendon ruptures can be daunting, especially after failure of a prior repair. In this setting, tissue quality is usually poor, necessitating graft augmentation. In this video, we describe our technique for Achilles tendon allograft augmentation for revision quadriceps tendon repair. Indications: Failed quadriceps tendon repair defined as ongoing extensor mechanism deficit including patella baja, functional deficit, or palpable quadriceps defect with confirmed retear on advanced imaging. Technique Description: Patient is placed in the supine position, and a midline incision is extended to the tibial tubercle. Full thickness medial and lateral flaps are raised, nonviable scar tissue is excised, and suprapatellar adhesions are released to ensure full mobilization of the viable remnant quadriceps. A plane is then developed deep to the patellar tendon paratenon from proximal to distal. A reamer is used to prepare a socket just medial to the tibial tubercle. The calcaneal bone block of the Achilles allograft is fashioned to match the recipient site on the tibia with a sagittal saw. The graft is shuttled deep to the paratenon, and the bone plug is fixed to the tibia with an interference screw. Suture from the patellar anchors is then used to place 2 running Krackow stitches spanning the remnant quadriceps tendon proximally. The remnant tissue is subsequently reduced and tied with an anchor pull-through technique. The soft tissue component of the Achilles graft is laid over the repair and oversewn with free nonabsorbable suture. Patient is placed in a brace locked in extension for 6 weeks and allowed to be weight bearing as tolerated. Results: Long-term patient-reported outcomes of Achilles allograft reconstruction for revision extensor mechanism repairs are limited. Two studies of 17 reconstructions each reported this to be a reliable and durable option at a mean follow-up of 65 and 52 months, respectively. Discussion/Conclusion: Revision surgery for extensor mechanism deficits can be a challenging procedure. Our preference is to perform augmentation with Achilles allograft with bone plug fixation on the tibial side. This allows for augmentation of the entire extensor mechanism, as well as bone-to-bone healing on the tibial side.

1630 Laparoscopic Repair of Linea Arcuata Hernia Presenting as Generalised Abdominal Pain - a Case Report

Abstract Background Arcuate line hernia (LAH) is an abnormal ascending herniation of intraperitoneal structures over the linea arcuate, between the rectus abdominus muscle and the posterior layer of its sheath. It is a rare clinical entity often associated with non-specific abdominal pain, posing a significant diagnostic challenge. The true prevalence is unknown, and diagnosis is almost always radiological. Case Report We report the case of a 57-year-old lady investigated extensively for frequent episodes of generalised abdominal pain. No palpable hernial defect or other pathology was identified on clinical examination. Subsequent computed tomography(CT) of the abdomen and pelvis revealed a 95 x 74 mm arcuate line hernia(LAH) anterior to the transversalis fascia, containing small bowel loops. She underwent an elective laparoscopic repair involving closure of the hernial defect with 2-0 knotless barbed sutures and reinforcement with a 20 x 15 cm underlay mesh. Postoperative recovery was uneventful, with complete resolution of her symptoms. One year after the repair there were no signs of recurrence. Discussion To our knowledge, only eleven prior cases of symptomatic LAH have been reported in the literature. There is no conclusive evidence regarding most appropriate diagnostic imaging, treatment approach and follow up regimen. Clinical diagnosis is difficult. Existing literature suggests use of CT scan as the primary imaging modality for diagnosis. The laparoscopic approach is safe, feasible and has certain advantages. This includes confirmation of diagnosis, excludes the presence of concomitant hernias and enables inspection of herniated viscera. Prosthetic mesh reinforcement is considered to minimise recurrence. Long term follow-up of these patients is required

A Man With Painful Knee

A healthy 49-year-old man presented to the emergency department with sudden onset of right knee pain after a fall at his farm. On examination, he was unable to walk or to extend his knee. There was a palpable defect 2 cm superior to the right patella. Plain film (Figure 1) and point-of-care ultrasound of the right knee were performed (Figure 2 and Video).

A clinicoradiological classification and a treatment algorithm for traumatic triceps tendon avulsion in adults

PurposeTriceps tendon avulsion (TTA) is an uncommon injury, and there are no classifications or treatment guidelines available. This study aims to describe a clinicoradiological classification and treatment algorithm for traumatic TTA in adults. The functional outcome of surgical repair has been evaluated too. MethodsA retrospective analysis of adult patients with traumatic TTA treated in our institution between January 2012 and December 2017 was done. We only included complete TTA injuries. Children below 15 years, with open injuries, associated fractures, or partial TTA were excluded. The data were obtained from hospital records. The intraoperative findings were correlated with the clinicoradiological presentation for classifying TTA. The functional outcome was analyzed using the Mayo Elbow Performance index and Hospital for Special Surgery elbow score. ANOVA test was used to assess the statistical significance. ResultsThere were 15 patients included, 11 males and 4 females. The mean age was (31.5 ± 9.15) years, and the mean follow-up was (22.4 ± 8.4) months. Fall on outstretched hand was the mode of injury. In 6 patients, diagnosis was missed on the initial visit. TTA were classified as Type I: palpable soft-tissue defect without bony mass; Type II: palpable soft-tissue defect with a wafer-thin/comminuted bony fragment on X-ray; Type III: palpable soft-tissue defect with a bony mass and a large bony fragment on X-ray without extension to the articular surface; and Type IV: an olecranon fracture with less than 25% of the articular surface. An algorithm for treatment was recommended, i.e. transosseous suture repair/suture anchor for Type I, transosseous suture repair for Type II, and tension band wiring or steel wire sutures for Types III and IV. All the patients achieved good to excellent outcome: the mean Mayo Elbow Performance index was 100 and Hospital for Special Surgery score was 98.26 ± 2.60 on final follow-up. ConclusionOur clinicoradiological classification and treatment algorithm for TTAs is simple. Surgical treatment results in excellent functions of the elbow. Since it is a single-center study involving a very small number of cases, a multicenter study with a larger number of patients is required for external validation of our classification and treatment recommendations.

Repair of a Chronic Triceps Tendon Rupture in a Dog Using an Autogenous Thoracolumbar Fascia Onlay Graft

AbstractA 5-year-old 38 kg entire male German Shepherd dog was referred for persistent non-weight bearing left thoracic limb lameness 5 weeks following failed triceps tendon repair. Physical exam revealed complete incompetence of the triceps mechanism with a large palpable defect proximal to the olecranon and when the shoulder was fixed in extension, the elbow could be fully flexed. A purulent draining tract was present on the caudolateral aspect of the distal brachium. Staged tendon repair was delayed until resolution of infection to allow for improved healing. Culture following surgical exploration of the traumatized area with resection of sinus tract and interposed fibro-granulomatous tissue yielded no growth. Definitive triceps brachii tendon repair was augmented with an autogenous thoracolumbar fascia onlay graft. Postoperatively, the repair was protected with a spica splint and the left thoracic limb immobilized with the elbow maintained in an extended position for 6 weeks. Re-evaluation 7 months later revealed the patient to be free of lameness. Disruption of the triceps brachii tendon is a rarely reported tendon injury with chronic disruption of triceps tendon associated with a guarded prognosis. To the authors knowledge, successful surgical repair of tendinous injury incorporating the use of an autogenous thoracolumbar fascia onlay graft has not previously been described.

Associations between clinical findings and MRI injury extent in male athletes with acute adductor injuries — A cross-sectional study

ObjectivesTo investigate the association between clinical assessment and MRI measures of oedema and MRI grading in male athletes with acute adductor injuries. DesignCross-sectional study. MethodsWe included 81 consecutive athletes with acute adductor injuries. All athletes received a standardized clinical assessment and magnetic resonance imaging (MRI), blinded to clinical information. We analysed correlations between extent of palpation pain and extent of MRI oedema for the adductor longus. We compared the clinical assessment to MRI adductor injury grading (0−3) using ordinal regression. We analysed positive and negative predictive values (PPV/NPV) of a complete adductor longus avulsion. ResultsProximal-distal length of adductor longus palpation pain had fair correlation with MRI proximal-distal oedema length oedema (r=0.309, p=0.022). Cross-sectional surface area of palpation pain had poor correlation with corresponding cross-sectional MRI oedema area (r=0.173, p=0.208). The symptoms subscale of the Copenhagen Hip And Groin Outcome Score (HAGOS) for the period since injury (log odds ratio=0.97, p=0.021) and passive adductor stretch pain (log odds ratio=0.35, p=0.046) were associated with MRI injury grading. If there was a palpable defect, MRI always showed a complete avulsion (PPV=100%). Several tests had high negative predictive values: passive adductor stretch (100%), palpation pain at the adductor longus insertion (98%), and the FABER test (98%). ConclusionsThe extent of palpation pain does not indicate the extent of MRI oedema in acute adductor longus injuries. A worse modified HAGOS symptoms subscale score and passive adductor stretch pain indicate a higher MRI adductor injury grade. Clinical examination tests have high ability to detect or rule out a complete adductor longus avulsion on MRI.

Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study

Background: Time to return-to-sport (RTS) after acute adductor injuries varies among athletes, yet we know little about which factors determine this variance. Purpose: To investigate the association between initial clinical and imaging examination findings and time to RTS in male athletes with acute adductor injuries. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: Male adult athletes with an acute adductor injury were included within 7 days of injury. Standardized patient history and clinical and magnetic resonance imaging (MRI) examinations were conducted for all athletes. Athletes performed a supervised standardized criteria-based exercise treatment program. Three RTS milestones were defined: (1) clinically pain-free, (2) completed controlled sports training, and (3) first full team training. Univariate and multiple regression analyses were performed to determine the association between the specific candidate variables of the initial examinations and the RTS milestones. Results: We included 81 male adult athletes. The median duration for the 3 RTS milestones were 15 days (interquartile range, 12-28 days), 24 days (16-32 days), and 22 days (15-31 days), respectively. Clinical examination including patient history was able to explain 63%, 74%, and 68% of the variance in time to RTS. The strongest predictors for longer time to RTS were pain on palpation of the proximal adductor longus insertion or a palpable defect. The addition of MRI increased the explained variance with 7%, 0%, and 7%. The strongest MRI predictor was injury at the bone-tendon junction. Post hoc multiple regression analyses of players without the 2 most important clinical findings were able to explain 24% to 31% of the variance, with no added value of the MRI findings. Conclusion: The strongest predictors of a longer time to RTS after acute adductor injury were palpation pain at the proximal adductor longus insertion, a palpable defect, and/or an injury at the bone-tendon junction on MRI. For athletes without any of these findings, even extensive clinical and MRI examination does not assist considerably in providing a more precise estimate of time to RTS.

Treatment of Direct Head of the Rectus Femoris Injury with PRP Therapy in a Division I Basketball Player

A 20-year-old Division I collegiate basketball player with a previous medical history significant for recurrent left patellar tendinopathy presented to us after sustaining an injury to his left thigh that occurred while jumping during a basketball game. Physical examination was performed two days later and revealed a diffusely swollen and engorged left thigh. There was a noticeable defect of the mid to proximal quadriceps along the RF at the musculotendinous junction anteriorly. He experienced tenderness along the musculotendinous junction of the rectus, the mi substance of the quadriceps, and the quadriceps tendon. No palpable defect of the quadriceps tendon was appreciated. Patient was able to obtain and maintain a straight leg raise.

Tumbling Triceps in Gymnastics

HISTORY: 21 year old female, D-1 gymnast, with 2 weeks of tight and achy right triceps pain. Athlete noted pain after practice, denies specific injury. Her pain is worse with resisted elbow extension. She is treating conservatively, rehabbing with ATC with strengthening both shoulder and arm, and is now tolerating forward tumbling, but soreness remains with backward tumbling. She feels she has plateaued in progress. PE: Grossly unremarkable, no ecchymosis or swelling. She has tenderness to triceps muscle belly without palpable muscle defect. ROM and strength are intact at her shoulder and elbow. She is neurologically intact distally. DDX:Triceps tear, triceps tendinopathy, shoulder pathology TEST & RESULTS: MSK US-proximal, mid belly of long head of triceps muscle fiber disruption with 2 cm fiber gap and hematoma. Extensive hyperemia in zone of injury and 8 cm of fascial thickening. Active contraction demonstrates fiber gap without contraction at zone of injury and abnormal contraction of surrounding fibers. FINAL/WORKING DX: Acute tear of right triceps, long head, grade 2b TREATMENT & OUTCOMES: Platelet-rich plasma injection into triceps tear followed by compression and 2 days rest. Progressive, sport-specific, pain-free strengthening with ATC guidance. Athlete avoided weight bearing on hands and stretching of triceps. She tolerated dance and trampoline work without issue. Upon reaching 80% speed/power without pain or functional limitation, 2 weeks after diagnosis, we performed serial US exams to evaluate tissue healing and guide progressive muscle loading. 2 week US demonstrated decreased fascial thickening, 2 cm fiber gap w/hyperemia persisted. Absent contraction at site of injury remained, abnormal contraction of surrounding fibers was improved. Continued rehab, did not progress beyond 80% at this time regardless of pain-free status. 4 week US revealed resolution of hematoma and fascial edema. Mild hyperemia remained at zone of injury. Some abnormal contraction at site of injury present, and normalized contraction of surrounding fibers. Athlete was released to gradually RTP under ATC guidance. Athlete progressed overhead loading, reached 100% power/speed and was advanced to forward and eventually backward tumbling. She tolerated full RTP 8 weeks after initial US. Athlete remains without re-injury.

Acute Proximal Posterior Thigh Pain in a Division 1 Women’s Soccer Player

HISTORY: A 22-year-old female soccer player for a Division 1 College team with a previous history of contralateral hamstring injury a year ago presents to the training room with acute onset left posterior thigh pain. She was seen in the training room 5 days prior with an ache in the posterior thigh. Sideline ultrasound was unremarkable for any abnormality at that time. Pain worsened while performing a drill during practice so she presents for re-evaluation. PHYSICAL EXAMINATION: No obvious gait abnormalities. No ecchymosis over posterior thigh. Tender to palpation at left proximal semitendinosus muscle belly but no palpable defect noted. Resisted knee flexion/hamstring activation and reverse plank reproduced pain. Strength was full and symmetric and sensation intact in bilateral lower extremities. DIFFERENTIAL DIAGNOSIS: 1. Acute medial hamstring strain/tear 2. Proximal medial hamstring tendinitis 3. Ischial bursitis 4. Adductor strain TEST AND RESULTS: Limited training room ultrasound reveals separation in the layers of investing fascia of semitendinosus/biceps femoris interval with sonopalpation tenderness reproducing her concordant symptom at the proximal hamstring region. There were no signs of muscular injuries on ultrasound. FINAL WORKING DIAGNOSIS: Acute left proximal semitendinosus/biceps femoris fascia tear without sonographic evidence of muscle strain in a senior soccer player with 3 games left of her career. TREATMENT AND OUTCOMES: Using sonographic guidance, 4 cc of autologous conditioned plasma (ACP/PRP) was injected at the site of fascial abnormality. Patient remained prone for 5 minutes following the injection followed by application of ACE wrap for the next 2 hours and use of thigh compression until she was pain free. She was instructed to rest completely for 24 hours with a progressive rehabilitation program to return to play. At 6 days post procedure, she progressed to jogging and warm up exercises with minimal residual pain but was advised to continue to refrain from soccer. At 1-week post procedure she was completely pain free and was cleared to return to play in the game the following day. She then returned as a starter in the last game of the season, 11 days post injection, and even assisted a goal that led to her team’s win. She is now 22 days post injury and remains pain free.

Penile Fracture : Experience from a Tertiary Care Hospital

Introduction: Penile fracture is a misnomer, penile fracture is defined as rupture of the tunica albuginea of one or both corpus cavernosum. The usual cause is abrupt bending of the erect penis by blunt trauma, which may occur during sexual intercourse, masturbation, rolling over on the bed, or falling onto the erect penis. Diagnosis of penile fracture is made on the basis of history and physical examination. the standard model of management is surgical.Methods: This retrospective study was conducted in the department of surgery SMHS hospital Srinagar,(Jammu and Kashmir), extending over a period of about three and a half years from June 2013 to January 2017. All patients with diagnosed penile fracture were included in this study. All except one patient were operated on the same day of admission.Results: out of a total of 50 patients studied, the mean age of presentation was 26.7 years. The majority (56%)were below 30 years of age.21 (42%) of the patients were married.majority42% of the patients reported masturbation as a cause of trauma, followed by vaginal intercourse in38% and rolling on the erect penis in 20%. About 80% of patients gave a history of audible click/crackling sound. All patients had swelling and discoloration on examination,90% of patients had a penile deformity, only 36 % had a palpable defect. Doppler USG was correct in 93% of patients. The majority (44%) of patients had defects less than 1cm. the defect was mostly seen on the right side (68%).most patients had proximal penile defect (56%). Mean hospital stay was 2.9 days. One patient (2%) had urethral trauma.Surgery had a recurrence of 2%.and a total postoperative complication rate of 10%.Conclusions: Penile fracture though reported rarely, is a common entity. Penile fracture is a urological emergency.Diagnosis is mainly on clinical grounds.Immediate surgical repair is the standard treatment of a penile fracture.

Nontraumatic rupture of the costal margin: a single-center experience.

Rupture of the costal margin is uncommon. Whilst most often seen after major trauma, we describe its occurrence in patients with no direct chest trauma. A search was performed in our thoracic surgery database for all patients with rupture of the costal margin. Patients were excluded if the injury was a result of trauma. Data were collected on sex, age, body mass index, profession, past medical history, smoking status, presenting complaint, mechanism of injury, and management. There were 9 patients with rupture of the costal margin that was caused in all cases by a severe coughing fit. All patients were male and the mean age was 62.5 years (range 47-76 years). Chronic obstructive pulmonary disease was present in 6 cases. Presentations included a palpable defect (5 cases), cough (9 cases), and chest pain (6 cases). On radiological examination, all patients had widening of the rib space, 4 had associated rib fractures, and 5 had lung herniation. Time from injury to presentation was 12 months (range 1-24 months). All patients underwent surgery and were followed-up for 59 months (range 8-129 months). Two patients suffered major complications in the immediate postoperative period. Rupture of the costal margin, in the absence of direct trauma, is characterized by pain, a palpable defect, and lung herniation. It is associated with widening of the rib space and rib fractures, and can be treated surgically with success but not without significant risks.

Bilateral Simultaneous Rupture of the Quadriceps Tendon in a Healthy Elderly Woman: A Case Report

Background: Quadriceps tendon ruptures are uncommon injury that affects middle-aged women, predominantly it affects middle aged men. However, the bilateral quadriceps tendon rupture is extremely rare in the absence of systemic disease. Subjects and Method: We reported a case of bilateral quadriceps tendon rupture in a healthy 65 year old female. She felt pain in both knees since 4 months before entering the hospital. Local physical examination on both knees reveal the loss of normal contour of rectus femoris, tenderness at superior pole patella the ruptur site, and palpable defect within 2 cm of superior pole patella. Patient unable to extend knee against resistance, and unable to perform straight leg raise. The patient was carried out a surgical repair with consent. Results: After the surgery both knees were immobilized with knee extension splint for 6 weeks. Patient evaluation revealed no pain and progressive recovery of muscular strength after four months and could be able to walk and returned to normal activity. Conclusion: Surgery is needed to repair quadriceps rupture. Keywords : Quadriceps tendon, quadriceps rupture, repair tendon. Correspondence: Pamudji Utomo. Faculty of Medicine, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta, Central Java, Indonesia. Email: utomodr@yahoo.com. Indonesian Journal of Medicine (2019), 4(1): 54-58 https://doi.org/10.26911/theijmed.2019.04.01.09