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Updated: Jun 1 2021

Quadriceps Contusion

Images contusion mri.jpg contusion_moved.jpg contusion mri.jpg
  • summary
    • A quadriceps contusion is a muscle injury to the quadriceps caused by a direct blow to the anterior thigh.
    • Diagnosis is made clinically with tenderness and ecchymosis over the anterior thigh.
    • Treatment is conservative with NSAIDs, rest and immobilization in 120 degrees of flexion using an ace wrap or hinged knee brace immediately after injury for 24-48 hours.
  • Epidemiology
    • Demographics
      • 2:1 male: female ratio
      • athletes
        • football, soccer, rugby most common sports
        • more common during competition than practice
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • a direct blow to thigh compressing the anterior thigh musculature into the femur
      • pathophysiology
        • small muscle fiber tears lead to hemorrhage and swelling into the anterior compartment
        • myonecrosis and hematoma forms followed by scar formation then muscle regeneration
  • Anatomy
    • Muscles
      • anterior compartment
        • sartorius
        • rectus femoris
        • vastus laterals
        • vastus medialis
        • vastus intermedius
      • medial compartment
        • gracillis
        • adductor magnus
        • adductor longus
        • adductor brevis
      • posterior compartment
        • biceps femoris
        • semitendinosus
        • semimembranosus
  • Classification
      • Jackson and Feagin Classification
      • Mild
      • > 90 degrees ROM
      • Moderate
      • 45-90 degrees ROM
      • Severe
      • < 45 degrees ROM
  • Presentation
    • History
      • collision or direct blow to the thigh during competition
    • Symptoms
      • pain
        • worsening severity over the first 24-48 hours
        • worse with dynamic movements and with knee flexion
    • Physical exam
      • inspection
        • swelling, ecchymosis, point tenderness
        • compare thigh firmness and circumference to contralateral side
        • possible palpable defect indicating partial or complete muscle tear
        • possible knee effusion
      • motion
        • variable loss of knee flexion
      • antalgic gait
      • provocative tests
        • straight leg raise to test integrity of extensor mechanism
      • neurovascular
        • distal neurovascular exam to evaluate for thigh compartment syndrome
  • Imaging
    • Radiographs
      • indications
        • only necessary acutely in severe injuries with high suspicion for underlying fracture
      • findings
        • myositis ossificans
          • occasionally seen in chronic cases
    • MRI
      • indications
        • concern for extensor mechanism disruption
        • best to demonstrate the degree of soft tissue involvement and extensor mechanism integrity
      • finding
        • will find edema with muscles
  • Differential
    • Maintain suspicion for compartment syndrome in severe injuries
  • Treatment
    • Nonoperative
      • immobilization, cryotherapy, NSAIDs, physical therapy
        • indications
          • first line of treatment for acute injuries
        • begin immediately to minimize hematoma formation
    • Operative
      • thigh fasciotomy
        • indications
          • compartment syndrome
  • Techniques
    • Immobilization, cryotherapy, NSAIDs, physical therapy
      • immobilization
        • in 120 degrees of flexion using an ace wrap or hinged knee brace immediately after injury for 24-48 hours, frequent use of cold therapy
      • physical therapy
        • transition to stretching and active ROM exercises after initial flexion period, protected weight-bearing with crutches often required
        • begin functional rehabilitation and sport-specific activities once full and pain-free ROM achieved
    • Thigh fasciotomies
      • approach
        • single anterolateral incision over length of thigh allows access to anterior and posterior compartments
      • decompression
        • incise fascia lata to expose and decompress anterior compartment
        • retract vastus lateralis medially to expose lateral intermuscular septum
        • incise lateral intermuscular septum to decompress posterior compartment
        • may add medial incision to decompress adductor compartment if involved
  • Complications
    • Myositis Ossificans
      • incidence ranges from 9-18%
      • more common with severe contusions
      • develops 2-4 weeks following injury
      • lesions followed with serial imaging, characteristic “egg-shell” calcifications on radiographs
      • treatment
        • observation often successful
        • resection if continued pain with loss of strength and knee motion
          • only operate on mature lesions showing no signs of continued growth
          • maturation occurs around 6-12mos
    • Compartment syndrome
      • usually due to rupture of deep perforating branches of the deep femoral vessels
      • treatment
        • thigh fasciotomy
  • Prognosis
    • Self-limited course with a prolonged disability without appropriate treatment
    • Initiation of treatment greatly expedites recovery and return to sport (13 days for mild contusions)
    • Time to return directly correlated with initial severity of injury
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