Disclosures: Elizabeth A. Fierro, DO: No financial relationships or conflicts of interest

Case Diagnosis: Right quadriceps muscle tear

Case Description or Program Description: A 90-year-old male with past medical history of atrial fibrillation (with pacemaker, on Coumadin), hypertension, hyperlipidemia, benign prostatic hyperplasia presented to acute inpatient rehabilitation after a right femoral neck fracture status post closed reduction and percutaneous pinning. After 10 days, the patient made significant gains, ambulating 900 feet with a rolling walker and supervision. Subsequently, he developed acute right thigh edema and pain rated 10 out of 10 in intensity with regression of ambulatory status.

Setting: Acute inpatient rehabilitation

Assessment/Results: On exam, right thigh with effusion, warmth, and tenderness to palpation. Dimpling was noted superior to the right patella. Strength testing revealed knee extension weakness, rated 0/5 in strength, compared to 4/5 previously, with associated functional decline. Given the non-MRI compatible pacemaker, a point-of-care bedside ultrasound was judiciously obtained, revealing a tear of the quadriceps musculature associated with large intramuscular hematoma. Subsequent CT imaging was obtained which confirmed the diagnosis.

Discussion (relevance): The diagnosis of quadriceps muscle tear after surgical fixation of a femoral neck fracture is quite rare. The diagnosis is complicated by limited examination due to pain, insensitivity of radiographs, and the unavailability and contraindications of MRI. Imaging is required to make the definitive diagnosis. Bedside ultrasound served as a rapid and safe imaging modality to diagnose his quadriceps tear. In this case, the diagnosis was imperative given the need to stop anticoagulation to prevent further bleeding into the hematoma.

Conclusions: Physiatrists should be cognizant that ultrasound is a safe, reliable tool that can be readily used at the bedside for musculoskeletal diagnosis. This case highlights the utility of ultrasound in the diagnosis of a quadriceps muscle tear after surgical fixation of a femoral neck fracture. The diagnostic capabilities of ultrasound are highly user-dependent, highlighting the importance of diagnostic training.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/utilizing-bedside-ultrasound-to-diagnose-quadriceps-muscle-tear-a-case-report/