A 54-Year-Old Man

and Iain McNamara¹

(1)

Trauma & Orthopaedics, Norfolk & Norwich University Hospital, Norwich, United Kingdom

A 54-year-old man was sent for a second opinion having presented 5 weeks previously complaining of right thigh pain for 2 weeks and then heard a pop from his knee which became acutely painful when he was walking. From then he had found it difficult to weight-bear and to straight leg raise. He had pain and tenderness superolateral to his patella. He had not sustained any injury. The pain was so severe that he was unable to move his knee. He had been placed in an extension knee orthosis and was using crutches. At presentation he was investigated and found to have a vastus intermedius tear on ultrasound, which was the working diagnosis. The pain had persisted. He was really incapacitated, barely able to move his knee, and reluctant to remove his orthosis. He was on a plethora of drugs, including opiates, which were not controlling his pain.

Question 1

Does the history fit with a vastus intermedius tear?

Past Medical History

Some 6 years previously, he had undergone a medial unicompartmental knee replacement, followed subsequently by a patellofemoral compartment replacement; both performed elsewhere.

Four months prior to his current problem, he had presented as an Emergency to the General Surgeons with severe right testicular pain. No cause was found; renal and ureteric calculi were excluded.

Apart from this he was fit and well.

Examination

He was reluctant to have his distal thigh touched and would only move the knee from 0–30°. There was no obvious effusion. He could not straight leg raise, but there was no defect in the quadriceps tendon. The patella felt stable. He had a number of points that were exquisitely painful with hyperalgesia around the distal quadriceps, principally to the lateral side.

Images

Ultrasound Report

The distal insertional tendon of vastus intermedius has ruptured and retracted proximally.

The midline rectus femoris-quadriceps tendon-patella unit is intact. Vastus medialis is intact. Vastus lateralis is also probably intact, although it is less easy to identify. There is a moderate effusion in the superolateral pouch.

Question 2

What do the plain radiographs show?

Question 3

What is the diagnosis and how are you going to manage him?

Progress

He remained on the ward for 14 days including 10 days with an epidural for pain and a CPM machine to mobilise his knee, with regular input from the Pain Team. He went home with his pain reasonably controlled with oral analgesics mobilising without an orthosis on crutches. Outpatient physiotherapy was arranged.

Only gold members can continue reading. Log In or Register to continue