thigh injury

7/21/2019 Thigh Injury

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Introduction

Several types of quadriceps injuries can occur, the most common being the quadriceps

contusion, which is painful and disabling. The usual cause of the quadriceps contusion

is a direct blow to the anterior thigh from an object or another person (eg, helmet, knee).

ery rarely, this injury can be severe enough to progress to an acute compartment

syndrome. !ecause the quadriceps is in contact with the femur throughout its length, it

is susceptible to compression forces. The rectus femoris is the most commonly injured

portion of the muscle because of its anterior location. "inimally, impact causes cellular

edema of the muscle, but complete capillary disruption with locali#ed hemorrhageleading to a tense anterior compartment can occur. The muscle is more resistant to

injury if it is struck while in a contracted nonfatigued state. $ther quadriceps injuries

range from simple strains to more comple% and disabling muscle ruptures.

$ther types of quadriceps injuries include strains of the quadriceps tendon, complete

and partial tears of the quadriceps tendon, and fascial rupture of the quadriceps muscle.

Specific areas of the quadriceps are affected for each of these diagnoses. The classic

quadriceps strain occurs at the conjoined muscle tendon junction (jumper&s knee). The

partial tear of the quadriceps most commonly affects the indirect (distal) head of the

rectus femoris. 'ascial rupture usually occurs anteriorly at the mid thigh and causes a

muscle hernia.

Frequency:

In the US: hile quadriceps strains are common, minimal information about the

frequency with respect to specific sports is available. s for quadriceps

contusions, the most detailed frequency data come from the *S "ilitary


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cademy at est +oint, and the distribution per year is as follows rugby -. /,

karate and judo 0.1/, football 2.3/, and all other sports fewer than 2/.

4uadriceps muscle hernias are believed to be more common in soccer,

basketball, and rugby.

The incidence of jumper&s knee at the quadriceps insertion onto the patella is less

common than patellar tendinitis. $ne study reported that of all tendinopathies

affecting the e%tensor mechanism, the frequency of patellar tendinitis at its

insertion was 35/, quadriceps tendinitis was 05/, and patellar tendinitis at its

insertion into the tibial tuberosity was 26/.

7upture of the quadriceps tendon is more common in both older patients and

younger athletes. Several studies show that the mean age of patients with

quadriceps rupture is about 35 years. 8owever, in athletes, the mean age cited

ranges from 25916 years. Sports associated with quadriceps rupture are high

jump, basketball, and weight lifting. 7upture is also not uncommon in patients

with renal failure.

Functional Anatomy: The quadriceps femoris acts as a hip fle%or and knee e%tender.

The quadriceps femoris is composed of the following

7ectus femoris

astus lateralis

astus medialis

astus interomedialis


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$rigins:insertions of quadriceps components include the following

7ectus femoris 9 ;lium:tibial tuberosity

astus lateralis 9 'emur:tibial tuberosity

astus medialis 9 'emur:tibial tuberosity

astus interomedialis 9 'emur:tibial tuberosity

The 1 thigh compartments are as follows

nterior 9 4uadriceps muscles, femoral nerve and artery

+osterior 9 8amstring muscles, sciatic nerve

"edial 9 dductor muscles, cutaneous branch of obturator nerve


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Sport Specific Biomechanics: The function of the quadriceps is primarily that of tibial

(knee) e%tension. $ne electromyography (m? this corresponds to a calculated tensile force in the patellar tendon

of times body weight.

The mechanical properties of the quadriceps have been studied. The central aspect of 269mm wide sections of the quadriceps was subjected to tensile loading and compared

to a similar patellar tendon section. The ultimate load to failure of the unconditioned

patellar tendon was higher (51.- >:mm 0) than the unconditioned quadriceps tendon

(11.3 >:mm 0). Strain at failure was also higher for the preconditioned patellar tendon

(2-.-/) than for the quadriceps tendon (22.0/).

"icroscopic sections of human quadriceps tendon as it inserts into the patella show no

crimping and no cement line. This is unlike other tendon insertion sites. The

interdigitation between collagen fibers and the distinction between tendon and bone was

least distinct along the anterior third of the patella.

discussion of the biomechanics of specific injuries is as follows

Strains, overuse, and rupture The most common sites of injury correlate to the muscle

tendon junctions both pro%imally and distally and to the muscle belly itself. "uscle

strains are usually due to repetitive functional overload. >ot surprisingly, quadriceps

strains most commonly affect athletes who subject their knees to high levels of repeated


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loading of the e%tensor mechanism. The overuse trauma may range from microscopic

failure of soft tissue with its associated inflammation or gross rupture. =ross rupture

may be partial or complete. large sudden load may cause the entire insertion to be

compromised, leading to complete rupture. 7epetitive loading, particularly eccentricloads, causes microfailure, usually at the muscle tendon junction. This microfailure can

result in partial tears.

Contusion @irect trauma to the quadriceps may cause muscle fiber and connective

tissue rupture and formation of a hematoma. Trauma to the quadriceps causes muscle

fiber rupture, disruption of connective tissue, and hematoma formation. ;nflammatorycells and macrophages enter the site of injury and begin clearing necrotic muscle cells.

This process occurs over 091 days. Then, muscle cells attempt to regenerate at the

same time scar tissue is being formed. severe thigh contusion can lead to a

compartment syndrome.

Muscle hernia The cause of this is not clear. ;t is usually associated with a sudden

forceful kick, but it may be associated with a weakened or previously injured quadriceps

fascia.

'racture of any bone in the skeleton is a painful injury sure to interfere with the function

of the part. "ost fractures heal with no long term consequence and others either fail to

heal or continue to cause pain and decreased function. Some simple information about

fractures will make it easier to understand the often frustrating ordeal of recovery.

fracture is any structural failure in bone. There is no difference between a AbreakA and

a AfractureA. There are several kinds of fracture patterns and many locations. Still there


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are patterns, so that most fractures follow a few simple ones. The following discusses

some of the ways that we describe fractures, in terms of what is important to the patient.

fracture is said to be AcompoundA when it punctures the skin and A closed A if it does

not. bone can be compounded from the outside by a bullet or other object. "ore

commonly the sharp bone end punctures the skin from inside the limb. The significance

is that an open fracture invites the complication of infection. Bompound or open

fractures are cleansed in the operating room as soon as possible. ;f the wound is visibly

dirty internal fi%ation is usually limited to pins or other simple methods that do not raise

the risk of infection.

fracture is described by its degree of displacement. This is usually non9displaced,

mildly displaced or completely displaced. The amount of displacement is very important

because displaced fractures are usually unstable and may not remain in position in a

cast. "any displaced fractures need surgical fi%ation.

Cocation of a fracture is important. ;n the long bones fractures are either near the end

and close to the joint, in the joint, or in the shaft portion. Shaft fractures are slow to

heal. tibia or femur fracture in the leg may take - or 5 months to heal. This

encourages us to do internal fi%ation to avoid complications from long term cast.

Stiffness in joints is one of those. fracture in a joint surface is likely to cause late

arthritis problems and these fractures are usually treated surgically unless completely

non9displaced. 'ractures near the joint heal more rapidly than the shaft and may be

treated with cast or with surgery.


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History:

4uadriceps contusion

o The mechanism is usually a blow to the anterior thigh with an object (eg,

bat) or contact with another athlete (eg, knee, head) or gear (eg, helmet).

o severe trauma and large contusion can lead to a compartment

syndrome. This diagnosis should be considered in patients with crush

injuries, in patients with fractures resulting from high9energy trauma, in

patients on anticoagulants, in patients with bleeding disorders, and in

patients with multiple traumas.

o compartment syndrome of the thigh is very rare compared to

compartment syndromes of the lower leg. The thigh compartments are

much larger, allowing for tissue e%pansion, and the forces are distributed

over a greater area. *nless rapid bleeding has occurred, these patients

generally present with a gradual increase in their symptoms. The blood

vessels injured usually are the deep perforating branches of the vastus

intermedius (because of the direct attachment of that muscle to the

femur).

o *ntreated, a compartment syndrome may lead to muscle necrosis,

fibrosis, scarring, and limb contractures. >erve injury may result either from the direct blow or from compression within the compartment.

o Symptoms include painful anterior thigh, painful weightbearing, and

unwillingness to fle% the knee because of thigh pain.


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4uadriceps tendon sprain

o !la#ina first described peripatellar tendinitis affecting the quadriceps

tendon or the patellar tendon and termed this jumper&s knee in 2D 1. 8e

noted that it commonly occurred in jumping athletes.o The mechanism is sudden stretching or repeated eccentric contraction of

the muscle causing pain and dysfunction immediately or 291 days later.

o Symptoms include pain with ambulation and knee fle%ion and inability to

e%tend the knee if the quadriceps is ruptured.

4uadriceps muscle partial tear

o The mechanism is kicking or sprinting.

o ;ncomplete intrasubstance tears of the rectus femoris tendon occur at the

deep portion of the indirect head and the muscle there. The location, while

along the distal part of the rectus femoris, is more pro%imal than the

quadriceps strain at the patellar insertion.

4uadriceps tendon rupture "any authors have concluded that the tendon

usually ruptures in an area of tendinosis. ;n patients with bilateral injuries or

injuries associated with trivial trauma and no history of previous strain,

consideration should be given to the associated use of anabolic steroids or the

diagnoses of renal disease and metabolic bone disease (hyperparathyroidism).

Special cases This category includes ruptures after surgery. The surgeries that

may be associated with this complication include lateral release, total knee

replacement, or anterior cruciate ligament or posterior cruciate ligament

reconstruction. 7upture of the quadriceps tendon after surgery may be


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associated with the procedure to harvest the graft used to reconstruct the

cruciate ligaments or aggressive release of soft tissues in the case of lateral

release and total knee replacement.

Physical:

4uadriceps contusion

o >ormal medial and posterior thigh

o Tensely edematous and tender anterior thigh

o Cimited knee fle%ion

"ild 9 =reater than D6E

"oderate 9 'rom -59D6E

Severe 9 Cess than -5E

o 'or ruptures (complete and partial)


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o Straight9leg raise +atients are able to perform this unless the e%tensor

mechanism is disrupted.

o >ormal sensation in distal e%tremity ;f sensation is compromised,

consider compartment syndrome. The anterior compartment contains the

femoral nerve, and testing of the lateral, intermediate, and medial

cutaneous nerves should be performed if compartment syndrome is

suspected.

o +ain @isproportionately high level of pain for e%amination triggers

suspicion of compartment syndrome.

Muscle strain Tenderness is elicited by direct palpation of the quadriceps at the

patellar insertion, or the patient reports pain when testing for resisted e%tension.

4uadriceps muscle hernia soft mobile mass, which may be tender, is palpated

anteriorly with contraction of the quadriceps. fascial defect may be appreciated.

Muscle partial tear: Thigh asymmetry with a nontender or mildly tender muscle

mass at the distal aspect of the rectus femoris is a common finding.

Quadriceps tendon rupture

o ;nability to straight9leg raise (e%tensor mechanism disrupted)

o "uscular defect in distal anterior thigh with mass in pro%imal thigh


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Causes:

4uadriceps contusion or compartment syndrome 9 @irect blow to anterior aspect

of thigh

4uadriceps strain or rupture 9 cute stretch or repeated eccentric muscle

contractions with immediate or delayed (291 d) presentation of pain, stiffness,

and decreased function

4uadriceps tendinitis

The kneecap (patella) is a small bone in the front of the knee. ;t glides up and down a

groove in the thigh bone (femur) as the knee bends and straightens. Tendons connect

muscles to bone. The strong quadriceps muscles on the front of the thigh attach to the

top of the patella via the quadriceps tendon. This tendon covers the patella and

continues down to form the Arope9likeA patellar tendon. The patellar tendon in turn,

attaches to the shin bone (tibia). The quadriceps muscles, straighten the knee by pulling

at the patella via the quadriceps tendon. 4uadriceps tendinitis is the term used to

describe inflammation of the quadriceps tendon.

4uadriceps tendinitis usually occurs as a result of overdoing an activity and placing too

much stress on the quadriceps tendon before it is strong enough to handle the stress.

This overuse results in &micro tears& in the quadriceps tendon which leads to

inflammation and pain. $ver time damage to the quadriceps tendon can occur. ;n

e%treme cases, the quadriceps tendon may become damaged to the point of complete

rupture.


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4uadriceps tendinitis is common in people involved in activities that include a lot of

running, jumping, stopping and starting. +ain from quadriceps tendinitis is felt in the

area just above the patella. There may be swelling in and around the quadriceps tendon

and it may be sensitive to touch. The pain can be mild or in some cases the pain can beso bad that it prevents athletes from playing their sport.


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Femoral Shaft Fracture

"uch force is required to produce fractures of the shaft of the femur. They tend to be

displaced due to muscle action upon the fracture fragments. The superficial femoral

artery may be injured with comple% fractures of the distal femur.

+ radiograph of the distal femur. This demonstrates a comminuted, overriding fracture

of the distal femur. There is profound osteopenia.

Cateral radiograph of the distal femur.
http://www.gentili.net/image1.asp?ID=296325183&imgid=FemurfxCT1.jpg&Fx=Femoral+Shaft+Fracturehttp://www.gentili.net/image1.asp?ID=296325183&imgid=Lateraldistalfemurfx600.jpg&Fx=Femoral+Shaft+Fracturehttp://www.gentili.net/image1.asp?ID=296325183&imgid=APdistalfemurfx600.jpg&Fx=Femoral+Shaft+Fracture


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%ial BT. The distal femur demonstrates the severely thinned corte% along with thefracture.

%ial BT. This image shows the comminution of this distal femur fracture

8ow is it treatedH

"ost femur fractures need to be fi%ed in surgery. Iour leg may be placed in traction in

the hospital before surgery is done.

"ethods used to fi% a femur fracture include surgery to insert

steel screws

steel plates and steel screws

steel rods, which can be placed down the center of the shaft of the femur.
http://www.gentili.net/image1.asp?ID=296325183&imgid=FemurfxCT2.jpg&Fx=Femoral+Shaft+Fracture


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;n healthy adults, casts are rarely used for femur fractures. body cast that includes the

entire injured leg and part of the uninjured leg are commonly used for femur fractures in

young children.

!reaks at or near the knee joint usually require plates and screws or just the screws.

Shaft fractures, as in the midthigh, are usually fi%ed with a rod.

Iou will need to use crutches for J to 20 weeks after surgery. Iour health care provider

and physical therapist will tell you whether or not you should put weight on your injured

leg, which will depend on how bad the fracture is and how it has been treated.

hile you are still healing after surgery, you will begin physical therapy to regain

strength in your muscles and to loosen up your joints. ("uscles are usually injured in a

femur fracture, and your hip and knee commonly become stiff due to the injury and

surgery.)

Bomplete recovery may take many months, depending on how bad the fracture wasand the e%tent of any other injuries. The break itself should heal in about - months. Iour

health care provider will take %9rays regularly to see how the bone is healing. 'ull

recovery, however, requires the muscles and joints to heal as well. Iour provider and

physical therapist will assess the recovery of your muscles and joints by measuring joint

mobility and the return of muscle strength, fle%ibility, and coordination. Iour health care

provider may decide to remove the plates, screws, or rods sometime after your leg has

fully healed.


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hen can ; return to my sport or activityH

7eturning to your sport or activity after a femur fracture can be a long process. ;t may

take a year before you can return to some sports. hen your bone is healed and you

have done some basic rehabilitation, you will begin rehab activities and e%ercises

specific to your sport. ;t may take a few months to complete this recovery phase, after

which you can return to your sport. ;t usually takes months after you return to your sport

to reach your preinjury level of performance.

The following list gives some general requirements that you might be e%pected to meet

in order to return safely to your sport

Iou have full range of motion in the injured leg compared to the uninjured leg.

Iou have full strength of the injured leg compared to the uninjured leg.

Iou can sprint straight ahead without pain or limping.

Iou can do -59degree cuts, first at half9speed, then at full9speed.

Iou can do 069yard figures9of9eight, first at half9speed, then at full9speed.

Iou can do 269yard figures9of9eight, first at half9speed then at full9speed.

Iou can jump on both legs without pain, and you can jump on the injured leg

without pain.

8ow can ; prevent a femur fractureH

'emur fractures are usually caused by accidents that cannot be prevented. This type of

fracture rarely occurs in common team sports. 8owever, it is important to use good

judgment in sports such as skiing, rock climbing, snowmobiling, and horseback riding. ;t

is also important to have a good diet with enough calories and calcium.


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thigh injury

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