Complex Quadriceps Injury

[Johannah Pham]

Hi birdies,

I’m an Ultrasound trainee and a super novice when it comes to scanning of the quadriceps muscle. They are few and far between in our practice. I wanted to share a case from today to hopefully gain some insight!
Patient is a 75 year old male, who fell heavily onto bitumen, onto his right anterolateral thigh.
On physical exam, there was no obvious bruising at all.

The ultrasound images are attached.

Proximal vastus lateralis (VL) – ?Myofascial tear measuring 30 x 57mm.
Deep to VL laterally: 72 x 69 x 19mm hematoma/collection.
Between VL and vastus intermedius: 30 x 31 x 15mm hematoma/collection.
Distal vastus lateralis – 43 x 59 x 8mm ?myofascial tear
Prox-mid Rectus Femoris – Normal origin at AIIS. Normal intramuscular appearances.
Distal Rectus Femoris – ?Tear at MTJ
11 x 49 x 9mm hematoma/fluid. Overlying subcutaneous oedema.
Quad Tendon still attached at patella.
VMO – NAD

Are these appearances consistent with the described myofascial tears, hematomas, and RF MTJ tear?

Thanks!
Jo

• This topic was modified 2 years, 6 months ago by Johannah Pham.

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[Stephen Bird]

Hi Jo,

Lovely images,

The quadriceps can be tricky to navigate, especially rectuf femurs as it has three intramuscular tendons to consider and is in essence a muscle inside another muscle.
I think it is unique in many ways.

I am currently recording a webinar on this muscle for the upcoming ASA meeting and as soon as they have shown it I will put it on the website for you to enjoy. I am also doing one on the calf injuries.

You will enjoy them when I load them up soon,

Your case is interesting.

Musacles can be damaged by overloading (over-stretching) the muscle leading to tendon tears and MTJ tears. There is also the concept of myofascial tears which I am less of a believer as I feel most of these can be allocated MTJ status from the intramuscular tendon collagen.

The other mechanism is a crush injury where the muscle is compressed by external force and it bleeds leading to a haematoma. In these cases the haematoma does not need to be associated with any of the usual MTJ areas.

In your case I feel that external compression ands hematoma’s are the more likely answer.

The haematoma in vests intermedius is a classic and the other areas you have documented are also consistent with intramuscular hematoma’s following compression.
Was the patient taking any blood thinning medication (it would be common a that age) and may have contributed.
You do not get much external bruising as the blood is trapped inside the muscles fascia and can not reach the subcutaneous space.

I feel like you have multiple compression induced haematomas in the locations you perfectly describe rather than multiple MTJ or myofascial tear injuries.

Keep an eye out for the new presentations as they will provide a lot of additional information on this topic.

Happy scanning,

Steve

[Johannah Pham]

Hi Stephen,

Thanks for taking the time to respond to me. Your explanation of this as a ‘crush injury’ with resulting hematoma makes sense. There wasn’t the right mechanism for a muscle tear. Unfortunately I didn’t find out if the patient was on blood thinners. I’ll remember these pointers in future scans!

I’m looking forward to seeing your new presentations. 🙂

Kind regards,
Jo

[Stephen Bird]

The history is always a great clue to what you will find,

Really nice work Jo,

Have a great week,

Steve

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