Abstract
Quadriceps muscle contusions are most commonly encountered in contact sports such as football, soccer, basketball, and wrestling. Injury is usually caused by a direct impact that leads to hemorrhage and inflammation. Pain, swelling, and decreased range of motion are typically seen in the first 24 hours, which can lead to short-term functional limitation. There can be a variable amount of swelling and ecchymosis over the anterior thigh due to hematoma formation with a palpable mass noted in the anterior thigh. Range of motion evaluation is needed to assess the severity of the contusion. Utilizing a variety of imaging techniques may assist in the identification of a contusion as well as ruling out other pathology. Compartment syndrome is an early possible complication of quadriceps contusion while myositis ossificans is considered if the patient continues to have painful range of motion after 3 to 4 weeks. Appropriate treatment will include cryotherapy and compression to reduce hematoma formation in the early period of injury while avoiding nonsteroidal anti-inflammatory drugs in the first 24 hours after injury. Rehabilitation consists of three phases to limit bleeding, restore function, and return to sport within 5 to 8 weeks.
Keywords
Contusion, Hematoma, Muscle, Quadriceps, Strain, Thigh
| Synonym | |
| |
| ICD-10 Codes | |
| S70.00 | Contusion of unspecified hip |
| S70.01 | Contusion of right hip |
| S70.02 | Contusion of left hip |
| S70.10 | Contusion of unspecified thigh |
| S70.11 | Contusion of right thigh |
| S70.12 | Contusion of left thigh |
| S80.10 | Contusion of unspecified lower leg |
| S80.11 | Contusion of right lower leg |
| S80.12 | Contusion of left lower leg |
| Add seventh character for episode of care (A—initial encounter, D—subsequent encounter, S—sequelae) | |
Definition
Muscle contusions and strains account for 90% of contact sport-related injuries. Quadriceps muscle contusions result from blunt trauma to the anterior thigh and are encountered most commonly in contact sports such as football, soccer, basketball, and wrestling. Injury is caused by a direct hit from a helmet, shoulder pad, elbow, or knee, or being struck by a puck while playing hockey. The acute trauma damages muscle tissue, causing hemorrhage and subsequent inflammation. A contracted muscle will absorb more force and this will result in a less severe injury. At 12 to 24 hours after the injury, quadriceps contusions are graded mild, moderate, or severe. A mild contusion has more than 90 degrees of knee flexion with normal gait; moderate, between 45 and 90 degrees of knee flexion with antalgic gait; and severe, less than 45 degrees of knee flexion with severely antalgic gait.
Symptoms
Quadriceps contusions may not be immediately evident after the contact injury. Pain, swelling, and decreased range of motion of the knee, particularly flexion, are seen within 24 hours. Symptoms may worsen with active muscle contraction and with passive stretch. Loss of knee range of motion can be the result of muscle and articular edema as well as of physiologic inhibition of the quadriceps muscle group and “splinting” due to pain. After injury, the quadriceps muscle group often becomes stiff, and the patient may have difficulty bearing weight on the affected extremity, resulting in an antalgic gait. Hemorrhage and resultant hematoma are described as either intermuscular (between the muscles) or intramuscular (within a muscle).
Physical Examination
Visual inspection of quadriceps contusion shows a variable amount of swelling and discoloration over the anterior thigh due to hematoma formation and intramuscular bleeding. Pain of varying intensity is present on palpation of the quadriceps muscle group. A firm palpable mass may be noted in the anterior thigh and is usually due to hematoma formation; if the hematoma formation is large, a knee effusion may also be present. Bone incongruity and tenderness may indicate fracture of the femur, patella, or tibial plateau. Check for the presence of distal pulses and capillary refill and assess range of motion of adjacent joints to be sure that the injury is localized to the anterior thigh.
Evaluation of range of motion reveals decreased knee flexion, especially past 90 degrees; knee extension will be less painful than flexion. Extension lag or complete lack of extension is noted in partial or complete quadriceps rupture. With quadriceps tendon rupture, a palpable defect may be present. However, quadriceps rupture is a relatively rare injury, more common in patients older than 50 years, and it is typically associated with underlying metabolic or inflammatory disease. Muscle stretch reflexes of the patellar tendon may be inhibited, and serial measurements of thigh circumferences should be made during the initial 24- to 72-hour postinjury period to assess for possible compartment syndrome. Paresthesias, loss of pulses, distal pallor, intense pain, and decreased temperature should alert the clinician to consider this diagnosis (see Chapter 67 ). Sensory testing should include the femoral and saphenous nerve distribution of the distal leg.
An intermuscular hematoma with septal or fascial sheath hemorrhage may be more likely to disperse and to result in distal ecchymosis. If the contusion is in the distal third of the quadriceps, discoloration and swelling will often track into the knee region because of gravity. An intramuscular hematoma may resolve more slowly and may be associated with myositis ossificans and scar contracture.
Functional Limitations
Initially, gait will be antalgic and weight bearing difficult on the involved extremity. Rehabilitation typically occurs in three phases. In the first phase (first 24 hours), pain usually limits activity, and the patient may require crutches. During a period of days to weeks, climbing stairs, running, and “kicking” activities will be limited secondary to knee stiffness and pain associated with terminal knee flexion and extension. Most patients recover uneventfully.
Diagnostic Studies
Plain radiographs are initially obtained in moderate to severe quadriceps contusions to rule out a coexisting fracture. Magnetic resonance imaging is the diagnostic imaging study of choice and allows visualization of the involved quadriceps muscles. Resolution of the injury, as detected by magnetic resonance imaging, lags behind functional recovery. Ultrasound (US) may be helpful to differentiate between multiple soft tissue pathologies of the quadriceps, including tendon injury, muscle strain, and separation of the skin and adipose from the fascia which can be filled with blood (Morel-Lavallée lesion). Advantages to using US versus other imaging modalities include increased portability, decreased cost, the ability to use a dynamic evaluation, and the ability to perform interventional procedures under US guidance, if needed. Sonographic evaluation of the quadriceps will start over the mid-anterior thigh in the transverse (short-axis) view. Visualization of the rectus femoris and vastus intermedius with the underlying femur will be a starting point. Identification of the vastus medialis and vastus lateralis can be observed as well. The examiner can then evaluate the quadriceps in the longitudinal (long axis) view. Sonographic evidence of an acute muscle contusion may be seen as an area of hyperechogenicity and swelling of the quadriceps muscle with focal hematomas having a variable appearance over time. Calcifications noted on US exam may differentiate changes related to myositis ossificans within 4 to 8 weeks. US may also be utilized to differentiate a quadriceps contusion from a Morel-Lavallée lesion, demonstrated by a compressible anechoic or hypoechoic fluid collection located in between the deep subcutaneous fat and the fascia. Nuclear bone scan may be ordered in the days to weeks after injury to assess for the development of myositis ossificans traumatica, heterotopic bone formation that may develop in up to 20% of injuries. Bone scans are more sensitive than plain films for detection of heterotopic bone formation and can be useful in monitoring its resolution. Suspicion of compartment syndrome warrants consideration of intracompartmental pressure monitoring, although conservative management in cases without concomitant fracture has been reported. Compartment syndrome may be more likely in a patient with associated fracture or suspected large-vessel injury. For severe contusions or in a patient who appears ill, laboratory work is indicated, including creatine kinase activity, hematocrit determination, and possibly coagulation studies.
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