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Quadriceps Contusion

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(Redirected from Quad Contusion)

Other Names

  • Quadriceps bruise
  • Quad bruise
  • Quadriceps muscle contusion
  • Thigh contusion
  • Thigh Hematoma
  • Soft tissue hematoma of thigh
  • Thigh intramuscular hematoma
  • Quadriceps Hematoma

Background

History

  • Needs to be updated

Epidemiology

  • Likely the second most common quadriceps injury after strain[1]
  • Thigh contusions reportedly account for 10% of all injuries sustained from illegal contact among professional association football players.[2]
  • Thigh contusions are estimated to represent about 12% of thigh muscle injuries[3]

Demographics

  • More common in males by 2:1 ratio (need citation)

Introduction

Midthigh short axis illustration of anterior compartment illustration[4]
Cross-sectional anatomy of the thigh, demonstrating the anterior (quadriceps), posterior (hamstrings), and medial (adductor) compartments. Note the relatiosnship between the intermuscular septa and the neurovascular structures of each compartment.[5]
E. Anterior attachments of extensors of knee. F. Quadriceps femoris. G. Vastus intermedius. H. Posterior attachments of extensors of knee. I. Vastus medialis and lateralis.[6]

General

  • Occur as the result of a direct blunt force trauma to the muscle, typically the anterior compartment
  • Diagnosis is primarily clinical with tenderness and bruising over the site of injury
  • Treatment is conservative (rest, NSAIDS, Ice) with compression and the knee held in flexion

Injury pattern

  • Causes rupture of muscle fibers at or adjacent to point of contact
  • Subsequently, there is swelling, a hematoma may form causing pain, restriction in motion
  • Myonecrosis can occur and eventually scar formation, muscle regeneration

Etiology

  • Usually a direct blow from opponents knee, foot or head[7]
  • Can also occur due to blow from a piece of equipment (racquet, ball, puck, etc)
  • More likely to occur in game than in practice

Anatomy of the Anterior Compartment of the Thigh

Risk Factors

Sports

  • Football
  • Soccer
  • Karate
  • Judo
  • Rugby
  • MMA

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Knee Pain

Clinical Features

Clinical progression of a lateral thigh contusion[9]

History

  • History of direct trauma to quadriceps
  • Will describe localized pain at the site of injury
  • Athlete will complain of swelling, decreased range of motion

Physical Exam: Physical Exam Knee

  • Ecchymosis, swelling may be observed
  • Tenderness to palpation
  • Range of motion is restricted
  • Palpable hematoma is sometimes felt

Special Tests

Evaluation

Long axis thigh ultrasound showing a well defined hematoma[10]
Axial cuts of thigh MRI showing large mass on T1 (A) and T2 (B)[4]
(A) A shaver (white arrows) is introduced to the right thigh under ultrasound guidance to the center of the hematoma. (B) The shaver is kept parallel to the US probe. (C) After removal of the hematoma at its center, the tip of the shaver as well as the US probe are synchronously brought to the peripheral part of the hematoma, and removal of the remaining hematoma is performed. A milking maneuver (yellow arrows) of the hematoma by an assistant is added to aid in the complete evacuation of the hematoma.[11]
1: Wide haematoma on quadriceps due to partial muscular rupture. 2: Residual cavity after 300.000 UI urokinase injection and drainage. 3: 24h control. Increasing cavity size due to hematoma liquefaction. 4: Overall resolution after aspiration by needle 5: 1 week control. Complete resolution of the intramuscular hematoma. Persists partial fibers rupture in initial cicatrization phase.[12]

Radiographs

Ultrasound

  • Can be used to
    • Evaluate hematoma
    • Exclude other injuries
  • Hematoma
    • Can quantify size
    • Coagulated blood vs liquified blood

MRI

  • Can be used to
    • Evaluate hematoma, extend of injury
    • Exclude other injuries
    • Preoperative planning
  • Hematoma
    • More sensitive than CT in showing active hemorrhage[13]

Classification

Jackson and Feagin Classification for Contusions[14]

  • Mild
    • ROM: >90°
    • Gait: Normal
  • Moderate
    • ROM<: 45–90°
    • Gait: Antalgic
  • Severe
    • ROM: <45°
    • Gait: Severely antalgic

Management

Contused knee held in flexion with acewrap and an icepack over the thigh[15]

Nonoperative

  • Indications
    • Virtually all cases
  • Immobilization for first 24 hours post injury
    • Aronen et al: keep knee flexed to 120°[16]
    • Use elastic wrap or Ace Wrap to help maintain flexion
    • Can also be placed in Hinged Knee Brace at 120°
  • After 24 hours
    • Maintain compression
    • Begin gentle, passive, pain free range of motion
  • Ice Therapy
    • Particularly useful in first few days
  • NSAIDS
    • Consider delaying for 24-48 hours to avoid interference with coagulation
    • Useful early for pain
    • Long term effects on muscle healing are not well understood
    • Consider for at least 7 days to reduce risk of heterotopic bone formation[17]
  • Physical Therapy
    • Initiate early, emphasis on range of motion, passive and active stretching
  • Quadriceps Hematoma Aspiration
    • Performed under ultrasound guidance
    • Recommended in the first 72 hours
  • Protective Thigh Padding
    • Can be used for prevention
    • Recommended prior to return to sport
  • Additional considerations
    • Delay in recovery or failure to improve should raise alarms
    • Consider slowly expanding or non-resolving hematoma
  • Not recommended

Operative

  • Indications
    • Hematoma refractory to percutaneous drainage

Rehab and Return to Play

Rehabilitation

  • Early/ Passive
    • Emphasis on passive and active range of motion
    • Stretching
    • Isometric quad strengthening
  • Active
    • Can begin when the athlete is pain free, actively flex knee to at least 120°
    • Functional rehabilitation

Return to Play/ Work

  • Athlete should be
    • Pain free
    • Have 120° knee flexion with hip in extension
    • Strength at least 90% of contralateral limb
    • Perform all aspects of functional testing without limitatiom

Complications and Prognosis

Prognosis

  • Severity classification suggests longer disability time with increasing severity
    • Ryan et al: 13 days (mild), 19 days (moderate), 21 days (severe)[18]
  • Thigh hematoma
    • Time to return to play following conservative management is 29.3 days[4]
  • If compartment syndrome develops
    • Increased likelihood athlete doesnt return to previous performance, even with fasciotomy and compartment release[19]

Complications

  • Hematoma
  • Myositis Ossificans
    • Proliferation of bone and cartilage in a muscle previously exposed to trauma and haematoma
  • Acute Compartment Syndrome
    • Less common in thigh due to tolerating larger compartment volumes[20]
    • If acute compartment syndrome is identified or suspected, the patient should be admitted to the hospital with emergent surgical management
    • Can lead to delayed or subacute presentation as well[19]

See Also

Internal

External

References

  1. ↑ Holbrook TL, Grazier K, Kelsey JL, Stauffer RN (eds): The Frequency of Occurrence, Impact, and Cost of Selected Musculoskeletal Conditions in the United States. Chicago: American Academy of Orthopaedic Surgeons, 1984.
  2. ↑ Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011;45:553–8.
  3. ↑ Ueblacker P, Müller-Wohlfahrt HW, Ekstrand J. Epidemiological and clinical outcome comparison of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male elite football players: UEFA Elite League study of 2287 thigh injuries (2001–2013). Br J Sports Med 2015;49:1461–5.
  4. ↑ 4.0 4.1 4.2 Haws, Brittany E., et al. "Definitive management of thigh contusions in athletes: but how definitive? A systematic review." Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2.2 (2017): 67-74.
  5. ↑ Burghardt, Rolf D., et al. "Compartment syndrome of the thigh. A case report with delayed onset after stable pelvic ring fracture and chronic anticoagulation therapie." BMC geriatrics 10 (2010): 1-5.
  6. ↑ Moore, Keith L., and Arthur F. Dalley. Clinically oriented anatomy. Wolters kluwer india Pvt Ltd, 2018.
  7. ↑ Rothwell AG. Quadriceps hematoma. A prospective clinical study. Clin Orthop Relat Res 1982;171:97–103.
  8. ↑ Ryan, Jack B., et al. "Quadriceps contusions: West point update." The American Journal of Sports Medicine 19.3 (1991): 299-304.
  9. ↑ Image courtesy of https://www.physio-pedia.com/
  10. ↑ https://radiopaedia.org/cases/24042
  11. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Quiñones
  12. ↑ Almazán, E., C. Parra-Fariñas, and A. Rivas. "Ultrasound-guided drainage of soft tissue haematomas." European Congress of Radiology-ECR 2016, 2016.
  13. ↑ Swensen SJ, Keller PL, Berquist TH, et al. Magnetic resonance imaging of hemorrhage. AJR Am J Roentgenol 1985;145:921–7.
  14. ↑ Jackson DW, Feagin JA. Quadriceps contusions in young athletes. J Bone Joint Surg. 1973;55A:95–105.
  15. ↑ Image courtesy of orthobullets.com
  16. ↑ Aronen, John G., et al. "Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion." Clinical Journal of Sport Medicine 16.5 (2006): 383-387.
  17. ↑ Fijn R, Koorevaar RT, Brouwers RBJ. Prevention of heterotopic ossification after total hip replacement with NSAIDs. Pharm World Sci. 2003;25:138–145.
  18. ↑ Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusion: West Point update. Am J Sports Med. 1991;19:299–304
  19. ↑ 19.0 19.1 Mithöfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment syndrome after contusion of the thigh. J Orthop Trauma 2002;16:436–8.
  20. ↑ Ojike NI, Roberts CS, Giannoudis PV. Compartment syndrome of the thigh: a systematic review. Injury 2010;41:133–6.
Created by:
John Kiel on 9 August 2021 15:29:58
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Last edited:
25 September 2024 15:21:49
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