Quadriceps Hematoma Aspiration

Other Names

Illustration of quadriceps femoris

Ultrasound convex view of mid-quadriceps anatomy. RF, rectus femoris; VI, vastus intermedius; VL, vastus lateralis; VM, vastus medialis.

Septated hematoma of the distal medial thigh

Anterolateral hematoma shown in both short axis and long axis

Thigh aspiration with needle in plane

(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.

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.

• Quadriceps Hematoma Aspiration
• Quad Hematoma Aspiration

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Background

Key Points

• Transducer: High frequency linear
• Needle: Length depends on location, gauge is 18 to 20

Anatomy of Quadriceps Femoris

• Confluence of Rectus Femoris, Vastus Lateralis, Vastus Intermedius, Vastus medialis
• Coalesces into Quadriceps Tendon
• Responsible for knee extension (rectus femoris is weak hip flexor)

Palpation Guidance vs Ultrasound Guidance

• This procedure can not be safely performed without ultrasound guidance
• Many hematomas are deep and require ultrasound guidance to successfully aspirate

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Indications

• Quadriceps Hematoma
  • Recommend aspiration within first 72 hours following injury
  • Beyond that, hematoma has started to solidify/ coagulate

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Greater than 72 hours out from injury

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Procedure

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 18 to 20 gauge, 1.5 to 3.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Transducer
  • Superficial injuries use linear array probe
  • Deeper injuries may require curvilinear probe
• Common ultrasound findings include:
  • Hypoechoic fluid collection
  • Scan in short/long axis to clearly delineate size

Technique

• Patient position
  • Supine with knee slightly flexed
  • May require internal/ external rotation to optimize approach
• Transducer
  • Long axis or short axis over the hematoma
• Needle Approach/ Orientation
  • In plane
  • Approach varies based on location
• Target
  • Center of hematoma
• Pearls and Pitfalls
  • If having trouble aspirating, using a larger gauge needle
  • You can lavage the area to help break up some of the clot
  • Hematoma can loculate requiring repositioning of the needle
  • Contraction of the quad muscle may help hematoma mobilization
  • Assistant can milk the hematoma and help move aspirate towards the needle

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Aftercare

• No significant restrictions
• Can augment with ice, NSAIDS
• Recommend compression with ace wrap or sleeve to reduce re-accumulation

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Complications

• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

• Procedures Main
• Ultrasound Main
• Thigh Pain Main

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