Quadriceps Contusion

Introduction

An injury commonly seen in athletes
- occurs as a result of direct trauma
- common in contact sports

Presentation

Symptoms
- pain at anterior thigh
Physical exam
- tenderness at anterior thigh
- limited active knee flexion due to pain
- possible knee effusion
- peform straight leg raise to ensure extensor mechanism is intact
- test sensory branches of femoral nerve (lateral, intermediate, and medial cutaneous nerves) during evaluation for compartment syndrome

Imaging

Radiographs
- imaging not necessary if mild contusion and extensor mechanism intact
- plain radiograph to evaluate for myositis ossificans in chronic injuries
MRI
- has the highest sensitivity and specificity for disorders of the quadriceps
- MRI helpful in moderate to severe contusions or if quadriceps tendon competency in doubt

Treatment

Nonoperative
- immobilize in 120 degrees of knee flexion for 24 hours followed by therapy
  - indications
    - acute injuries
  - technique
    - acute phase
      - cold therapy
      - ACE bandage or hinged knee brace
    - subacute phase
      - begin active pain-free quadriceps stretching several times a day thereafter
      - weight bearing as tolerated with use of crutches often needed initially
      - close monitoring for compartment syndrome
Operative
- thigh fasciotomies
  - indications
    - compartment syndrome present

Complications

Compartment syndrome
- usually rupture of deep perforating branches of the vastus intermedius
Myositits ossificans
- incidence of 5-9% rate with quadriceps contusion

TAG

(OBQ09.247) A 20 year-old Division 1 football player is injured in practice. His treatment regimen includes immobilization of the knee in 120 degrees of flexion. What injury has this patient most likely sustained? Topic

Review Topic

1. Iliac crest contusion
2. Avulsion fracture of the lesser trochanter
3. Quadriceps contusion
4. Hamstring rupture
5. Sports Hernia

PREFERRED RESPONSE ▶

DISCUSSION: This patient has a quadriceps contusion. Acute management includes cold compression and immobilization in flexion. Surveillance for compartment syndrome is needed acutely and chronic manifestations include myositis ossificans. Iliac crest contusions or “hip pointers” occur after direct trauma and benefit from placing the affected leg in extension. Athletic pubalgia or “sports hernia” is an injury to the muscles of the abdominal wall or adductor longus that produces anterior pelvis and groin pain in the absence of a true inguinal hernia. The references by Ryan et al and Aronen et al are Level 4 studies of soldiers sustaining quadriceps contusions treated with hyperflexion of the knee and cold compresses. The average time of disability was 3-13 days between the 2 studies. There was a 5% and 9% rate of myositis ossificans, respectively. Illustration A depicts the position of immobilization for quadriceps contusion treatment.

Illustrations: A

REFERENCES:

1. Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991 May-Jun;19(3):299-304. PMID:1867338 (Link to Abstract)

2. Aronen JG, Garrick JG, Chronister RD, McDevitt ER. Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion. Clin J Sport Med. 2006 Sep;16(5):383-7. PMID:17016112 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 16 Ratings

Level of Evidence 4 (Case Series)

Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991 May-Jun;19(3):299-304. PMID:1867338 (Link to Abstract)
Aronen JG, Garrick JG, Chronister RD, McDevitt ER. Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion. Clin J Sport Med. 2006 Sep;16(5):383-7. PMID:17016112 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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