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Quadriceps Contusion

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Other Names

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

Background

History

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]

Pathophysiology

Midthigh short axis illustration of anterior compartment illustration[4]
  • General
    • Occur as the result of a direct blunt force trauma to the muscle
    • Most commonly occurs at the Rectus Femoris muscle belly[5]
    • Diagnosis is primarily clinical
  • 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
  • Etiology
    • Usually a direct blow from opponents knee, foot or head[6]
    • Can also occur due to blow from a piece of equipment (racquet, ball, puck, etc)

Risk Factors

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

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Knee Pain


Clinical Features

  • 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[7]

Radiographs

Ultrasound

  • Can be used to
    • Evaluate hematoma
    • Exclude other injuries
  • Hematoma
    • Can quantify size
    • Coagulated blood vs liquified blood
Axial cuts of thigh MRI showing large mass on T1 (A) and T2 (B)[4]

MRI

  • Can be used to
    • Evaluate hematoma, extend of injury
    • Exclude other injuries
    • Preoperative planning
  • Hematoma
    • More sensitive than CT in showing active hemorrhage[8]

Classification

Jackson and Feagin Classification for Contusions

  • Mild[9]
    • ROM: >90°
    • Gait: Normal
  • Moderate
    • ROM<: 45–90°
    • Gait: Antalgic
  • Severe
    • ROM: <45°
    • Gait: Severely antalgic

Management

Nonoperative

  • Indications
    • Virtually all cases
  • Immobilization for first 24 hours post injury
    • Aronen et al: keep knee flexed to 120°[10]
    • 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[11]
  • Physical Therapy
    • Initiate early, emphasis on range of motion, passive and active stretching
  • Hematoma Aspiration
    • Performed under ultrasound guidance
  • 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)[12]
  • 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[13]

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[14]
    • 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[13]

See Also


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. Ryan, Jack B., et al. "Quadriceps contusions: West point update." The American Journal of Sports Medicine 19.3 (1991): 299-304.
  6. Rothwell AG. Quadriceps hematoma. A prospective clinical study. Clin Orthop Relat Res 1982;171:97–103.
  7. https://radiopaedia.org/cases/24042
  8. Swensen SJ, Keller PL, Berquist TH, et al. Magnetic resonance imaging of hemorrhage. AJR Am J Roentgenol 1985;145:921–7.
  9. Jackson DW, Feagin JA. Quadriceps contusions in young athletes. J Bone Joint Surg. 1973;55A:95–105.
  10. 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.
  11. Fijn R, Koorevaar RT, Brouwers RBJ. Prevention of heterotopic ossification after total hip replacement with NSAIDs. Pharm World Sci. 2003;25:138–145.
  12. Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusion: West Point update. Am J Sports Med. 1991;19:299–304
  13. 13.0 13.1 Mithöfer K, Lhowe DW, Altman GT. Delayed presentation of acute compartment syndrome after contusion of the thigh. J Orthop Trauma 2002;16:436–8.
  14. 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:
10 August 2021 17:23:23
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