Quadriceps Contusion

By admin On Oct 19, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Kinshasa Morton

Jason P. Womack

Basics

Description

Traumatic thigh injury resulting in muscle fiber damage along with capillary rupture and subsequent bleeding into the quadriceps muscle tissue. Usually the result of a blunt force blow to the anterior, medial, or lateral thigh, most commonly occurring in contact sports:

Recurrent quad contusions predispose to more severe injury and development of complications.
Delay in onset of therapy leads to a higher percentage of complications and delay in recovery.
Synonym(s): Charley horse; Thigh bruise; Dead leg; Quadriceps hematoma

Epidemiology

Percentage of participants that will sustain a quad contusion in 1 yr (per sport) (1):
- Rugby = 4.7%
- Karate/judo = 2.3%
- Football = 1.6%
- All other sports are <1%.
Muscle contusion injuries are 2nd only to strain injuries as a major cause of morbidity in the modern athlete (2).

Risk Factors

More prevalent in contact sports (rugby, mixed martial arts, football)
Inappropriately sized, thinly cushioned, or nonuse of thigh pads (football)
Bleeding disorders predispose to hematoma formation.

Commonly Associated Conditions

Myositis ossificans traumatica (MOT):
- Benign formation of heterotopic bone and cartilage in soft tissue that previously sustained trauma or contusion injury:
  - Development related to severity of injury
  - Incidence with muscle contusion injury reported as 9–17% (2)
  - Suspect when contusion injuries do not resolve within 2 wks (2)
  - Suspect when contusion injuries worsen rather than improve over time (2)
  - May be confused with osteosarcoma on imaging (2)
Acute compartment syndrome (ACS):
- Rare complication of quadriceps contusions in which increased pressure within the fascial compartments of the thigh results in circulatory failure. If severe and left untreated, it may lead to nerve damage and tissue necrosis:
  - Suspect when pain is out of proportion to injury
  - Suspect with finding of paresthesia, which may be progressive
  - Most commonly occurs with femur fracture, rarely with quadriceps contusion

Diagnosis

History

Patients give history of blunt force trauma to the thigh sustained during collision, usually while playing a sport. Complaint of pain and swelling in the area of trauma and also difficulty in ambulation are common:
- Collison may have been with another person or playing object (baseball, field hockey ball, hockey puck).
- Pain and/or swelling may be immediate or delayed.
History or rapid, progressive swelling accompanied by numbness and exquisite pain may signify the development of ACS. This may necessitate quick intervention (compartment pressures, neurochecks, fasciotomy).
Relevant past medical history/history of previous injury:
- Has there been a previous similar injury to the same area?
  - Recurrent injury may result in the development of MOT.
- What has been the duration of the injury?
  - Contusion injuries that linger and have not resolved within 2 wks may be progressing to MOT.
- Is there a history of bleeding/coagulation disorders or current use of anticoagulants?
  - If so, may lead to increased bleeding and large hematoma formation that again may lead to MOT or delayed recovery

Physical Exam

Observation:
- May ambulate with antalgic gait or has reluctance to bear weight
Appearance:
- May have area of ecchymosis
- Swelling in the anterior thigh, which may extend to proximal knee:
  - Patients with severe quad contusions may get knee effusion without intra-articular pathology
  - Serial thigh circumference measurements taken to assess expansion or resolution of swelling
Palpation:
- Tense and tender to palpation over anterolateral thigh
Range of motion (ROM):
- Reduced ability to actively flex the knee
- Quad contusions are graded by ROM deficit with active knee flexion (3)[C]:
  - Mild (>90 degrees of active flexion)
  - Moderate (45–90 degrees of active flexion)
  - Severe (<45 degrees of active flexion)
Strength:
- Reduced ability to perform straight leg raise
- Reduced ability to perform knee extension against resistance
Sensation:
- Sensation deficits along anterolateral thigh are rare. If present must consider ACS.

Diagnostic Tests & Interpretation

Imaging

Plain radiographs:
- Rarely needed acutely unless concern for femur fracture
- Useful in assessing for MOT if prolonged symptoms (>2 wks) or progressive symptoms:
  - Radiographic abnormalities can be seen within 18–21 days (2).
US:
- Rarely needed acutely unless trying to differentiate between quad contusion or quad tendon rupture
- May be used to differentiate between diffuse muscle edema and acute hematoma formation
- Can be used to assess for size of hematoma

P.499

MRI:
- Again, rarely needed unless contusion injury is moderate to severe, or slow to resolve
- Helpful when patient's symptoms do not match physician's clinical findings (4)
- Imaging modality of choice for the visualization of quad contusion injuries:
  - Reveals injuries that may be missed by US (4)
  - Allows for more accurate assessment of site and extent of injury (4)
  - Better assessment of size and extension of hematomas
  - Serial MRIs may be done to follow resolution
- Resolution of MRI abnormalities usually lag behind clinical resolution by up to 2 wks.
- Caution, as early MOT is difficult to differentiate from osteosarcoma

Differential Diagnosis

Quadriceps strain
Quadriceps tendon rupture
Quadriceps spasm/cramp
Acute compartment syndrome of the thigh
Femur fracture

Treatment

Acute treatment (1st 24 hr):
- R.I.C.E. (Rest, Ice, Compression, Elevation) (4)[C]:
  - Rest reduces retraction of ruptured myofibrils, preventing large gaps in the muscle.
  - Icing associated with smaller hematoma formation, less inflammation, and early muscle regeneration
  - Compression reduces IM bleeding.
  - Elevation reduces interstitial fluid accumulation (swelling).
- Collectively, these measures limit the severity of quad contusions.
Immobilization:
- Immobilize in 120 degrees of knee flexion with either brace or figure of 8 Ace bandaging for 1st 24 hr (3)[B]:
  - Shown to decrease time to return to play compared with traditional treatment
  - Also functionally compresses injury
- Use crutches to aid in ambulation and to rest injury.
- Discontinue immobilization after 24 hr.
NSAIDs treatment:
- Early use (24–48 hr after injury) is controversial because of theoretic increased risk of bleeding and worsen of hematoma formation
- Early short-term use has shown no adverse effects on healing process (5,6)[B].
- For moderate-to-severe quad contusions, a 7-day course of NSAID treatment recommended to help prevent MOT (5):
  - Consider waiting 48–72 hr to reduce theoretical risk of increased bleeding.
Subacute treatment (after 1st 24 hr):
- Ensure thigh circumference has stabilized (3)[C].
- Discontinue immobilization and begin stretching (3)[C]:
  - Passive flexion with goal of 120 degrees of pain-free flexion
  - Begin active quad stretching and strengthening exercises once pain decreases and motion improves.
- Strengthening should progress from isometric to isotonic to isokinetic training (6).
- Discontinue crutch use when pain-free ambulation achieved
Long-term treatment/rehabilitation:
- May return to sports-specific training when (3,6)[C]:
  - ROM on injured quad side and uninjured side are equal.
  - Use of injured quad is pain-free with basic movement.
- Prior to return to sport, player should be fitted for oversized quad pad (3)[C]:
  - Helps to protect from recurrent injury, which could lead to MOT
  - Wear for 3–6 mos or until end of season

Surgery/Other Procedures

Rarely do quad contusions and hematomas require surgery or percutaneous aspiration (7)[C].
Use of corticosteroids is generally contraindicated for treatment of muscle contusion injuries (8)[C].
Athletes with MOT who have persistent pain and limited motion may have the heterotopic bone removed when it has matured (2)[C]:
- Should not be performed until at least 12 mos after the initial injury
- Bone scan or plain films determine maturity of the tumor.
ACS of thigh almost always can be treated conservatively. When unresponsive to conservative measures, then requires fasciotomy (7)[C].

References

1. Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusions. West Point update. Am J Sports Med. 1991;19:299–304.

2. Beiner JM, Jokl P. Muscle contusion injury and myositis ossificans traumatica. Clin Orthop Relat Res. 2002;403(suppl):S110–S119.

3. Aronen JG, Garrick JG, Chronister RD, et al. Quadriceps contusions: clinical results of immediate immobilization in 120 degrees of knee flexion. Clin J Sport Med. 2006;16:383–387.

4. Järvinen TA, Järvinen TL, Kääriäinen M, et al. Muscle injuries: biology and treatment. Am J Sports Med. 2005;33:745–764.

5. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006;16:170–174.

6. Järvinen TA, Järvinen TL, Kääriäinen M, et al. Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol. 2007;21:317–331.

7. Diaz JA, Fischer DA, Rettig AC, et al. Severe quadriceps muscle contusions in athletes. A report of three cases. Am J Sports Med. 2003;31:289–293.

8. Beiner JM, Jokl P, Cholewicki J, et al. The effect of anabolic steroids and corticosteroids on healing of muscle contusion injury. Am J Sports Med. 1999;27:2–9.

Codes

ICD9

924.00 Contusion of thigh