Updated: 3/28/2019

Quadriceps Contusion

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Introduction
  • Description                          
    • a contusion of the thigh due to direct trauma
  • Epidemiology 
    • demographics
      • 2:1 male: female ratio
      • athletes
        • football, soccer, rugby most common sports
        • more common during competition than practice
  • 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
  • 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
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
 
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
 

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Questions (4)
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(SAE13BS.11) After sustaining a muscle contusion injury, prolonged immobilization leads to Review Topic | Tested Concept

QID: 8244
1

increased tensile stiffness.

43%

(448/1035)

2

increased granulation tissue production.

51%

(530/1035)

3

improved recovery of tensile strength.

2%

(19/1035)

4

reduced incidence of myositis ossificans.

3%

(36/1035)

L 4 D

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(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? Review Topic | Tested Concept

QID: 3060
1

Iliac crest contusion

1%

(9/1738)

2

Avulsion fracture of the lesser trochanter

1%

(20/1738)

3

Quadriceps contusion

67%

(1171/1738)

4

Hamstring rupture

30%

(530/1738)

5

Sports Hernia

0%

(3/1738)

L 3 D

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CASES (2)
Topic COMMENTS (3)
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