A 14-year-old girl is brought to the emergency department by her parents for the evaluation of left knee pain that started 2 hours ago. The girl landed on her left foot after jumping to spike the ball at a volleyball game and immediately felt an excruciating pain in her left knee. Her father says, "Her knee is very swollen, and I had to carry her here because she isn't able to put any weight on her left leg." The patient had no prior injury to the leg. Medical history is significant for systemic lupus erythematosus, which has been well controlled on daily hydroxychloroquine for the past year. The patient received a course of high-dose glucocorticoids last year, when she was initially diagnosed, but none since. She is also taking calcium and vitamin D supplements. Vital signs are normal. The patient is crying and in moderate distress due to pain. On physical examination, there is diffuse swelling and tenderness in the anterior left knee. Passive extension and flexion of the left knee does not elicit pain or a palpable click along the joint line; however, the patient is unable to extend the left knee against resistance or raise the leg off the examination table without assistance. With the knee flexed at 30 degrees, there is minimal anterior movement of the tibia in relation to the femur. Valgus stress to the left knee does not reveal an increased laxity. The patient has 2+ pedal pulses bilaterally and sensation is intact. Which of the following is the most appropriate next step in management of this patient?

Question

A 14-year-old girl is brought to the emergency department by her parents for the evaluation of left knee pain that started 2 hours ago.  The girl landed on her left foot after jumping to spike the ball at a volleyball game and immediately felt an excruciating pain in her left knee.  Her father says, "Her knee is very swollen, and I had to carry her here because she isn't able to put any weight on her left leg."  The patient had no prior injury to the leg.  Medical history is significant for systemic lupus erythematosus, which has been well controlled on daily hydroxychloroquine for the past year.  The patient received a course of high-dose glucocorticoids last year, when she was initially diagnosed, but none since.  She is also taking calcium and vitamin D supplements.  Vital signs are normal.  The patient is crying and in moderate distress due to pain.  On physical examination, there is diffuse swelling and tenderness in the anterior left knee.  Passive extension and flexion of the left knee does not elicit pain or a palpable click along the joint line; however, the patient is unable to extend the left knee against resistance or raise the leg off the examination table without assistance.  With the knee flexed at 30 degrees, there is minimal anterior movement of the tibia in relation to the femur.  Valgus stress to the left knee does not reveal an increased laxity.  The patient has 2+ pedal pulses bilaterally and sensation is intact. Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has a complete rupture of the patellar tendon due to her inability to extend the knee or maintain passive extension. Surgical repair is the treatment of choice and should be performed as soon as possible to optimize recovery of knee function and decrease the likelihood of long-term disability. Delayed treatment can lead to limited range of motion of the knee, quadriceps muscle atrophy, and contracture formation. (Choices A and C) Supportive care (eg, rest, elevation, pain control) is appropriate initial management of a complete patellar tendon tear prior to operative management. However, such patients should not bear weight on the affected extremity or return to baseline activity prior to surgery. Incomplete tears (eg, partial ability to extend the knee) can often be treated conservatively with physical therapy and a gradual return to baseline activity. (Choice B) Intraarticular corticosteroid injections may be indicated in the treatment of joint pain in juvenile idiopathic arthritis. Such injections may predispose a patient to a patellar tendon rupture and have no role in management once a tear has occurred. (Choice D) Lower extremity casting or immobilization is indicated for fractures or after reduction of a dislocation. Surgical repair is required for a complete patellar tendon rupture. Educational objective: Early surgical repair of a ruptured patellar tendon optimizes recovery of normal knee motion to prevent long-term disability. References: Reconstruction techniques and clinical results of patellar tendon ruptures: evidence today. (http://www.ncbi.nlm.nih.gov/pubmed/25819155)

A 14-Year-Old Girl Is Brought to the Emergency Department by Her