ramon balius - quadriceps muscle injuries diagnosis

Diapositiva 1

Quadriceps Muscle Injuries DiagnosisConsell Catal de lEsportClnica DiagonalClnica Creu Blanca

Level of Evidence IVRamon BaliusXavier Alomar

To thank

For trust in me

1

Check list

Direct Mechanism ..Clinical findingsIndirect Mechanism MR and/or US - RF origin injuries - RF MTJ injuries

Check list

Direct Mechanism ..Clinical findingsIndirect Mechanism MR and/or US - RF origin injuries - RF MTJ injuries

We use different kinds of diagnosis depending on the of the injury type.

I have divided my talk into 2 parts.

First, we are going to look atSecondly, we are going to look at

SO, LETS BEGIN WITH DIRECT MECHANISM INJURY

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Direct Mechanism. Quadriceps Muscle

Clinical diagnosisVastus lateralis & vastus intermediusDifferent degrees of injury Aponeurosis & subcutaneous tissue involved

Contusion Grade IContusion Grade IIContusion Grade III

The Diagnosis has always clinical.Depending on differents findings , we can ctalog/see.We said before and normally involves the aponeurosis.3

Contusion grade I Full Flexion Capillary rupture: Blood into connective tissueClassical bruise (ecchymosis)



We can find a CONTUSION OF FIRST DEGREE:THE PATIENT CAN DO FULL FLEXIONBECAUSEREALLY IS A BRUISE

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This is an example of I Grade of contusin

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Contusion grade IIKnee Flexion over 90 but not completeCrushing of muscle fibers with vasomotor reactionCan exist extravasated blood produces a hematoma

24 hours

6d

15d (asymptomatic)



WE CAN FLEX THE KNEE MORE THAN 90 BUT DON'T ARRIVE TO THE FULL FLEXION.

IN THIS CASE A CRUSHING OF MUSCLE FIBERS EXIST

AND CAN EXIST .

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THIS IS AN EXAMPLE 5

Contusion grade IIIFlexion IT. (Hsu, 2005; Bordalo-Rodrigues, 2005)There is a lesional cadence (Ouellette et al, 2006)

INDIRECT

DIRECT

CONJOINED12

Carlo Martinoli1 to 3 ... increasing severityRectus Femoris Origin Injuries

Dr. Pedret

What do we know about ?Historical trend is

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In elite athletes, depending on outcome, very different treamentsMistakes are not allowedUS only for experts (IT described by Martinoli, published by Pesquer et Al. (2016)MR mandatory

FHShort-axis

AIIS1122**Long-axiseccentric comet tailImages by Carlo Martinoli

See the tendons origin by US is not easy.Recently11

Direct Tendon RuptureINDIRECTDIRECT

DIRECTINDIRECT

INDIRECTIndirect Tendon RuptureCONJOINTED TENDONConjointed Tendon RuptureNO DIRECT TENDON

A Rodas and Balius case (1999)29 y.o. Hockey goalkeeper.Non surgical treatment.Conjoint tendon rupture

2014 follow-up. Spontaneous reconstruction of both tendonsMuscular body fallenThin Indirect TendonMuscularBodyfallenDirect tendonreconstructed

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muscle-within-muscle

Rectus femoris mTJ injury

THE RECTUS FEMORIS HAS A BIPENNATUS STRUCTURE, BUT IS MORE THAN THOSE.

- THE RECTUS FEMORIS HAS A CT WHICH IS AN EXPANSION FROM THE INDIRECT TENDON

- AND IT HAS A ANTERIOR APONEUROSIS THAT COMES FROM A DIRECT TENDON

IF WE COULD BECOMING UNANCHORED THE INDIRECT TENDON FROM THE ACETABULAR RIDGEAND MOVE THIS TROUGH TO 15

Rectus femoris musculotendinous injuryDepending on Musculotendinous JunctionMuscular Injuries settle over musculo-tendinous junctions

Central Aponeurosis. Central Tendon Injury (CTI) Direct Tendon Expansion. Superficial Injury Distal Posterior Fascia. Distal Peripheral Injury Proximal Posterior Fascia. Proximal Peripheral Injury

16WE KNOW THAT A MUSCLE STRAIN IS LOCATED IN...

SO, THERES 3 mtj THAT PRODUCES DIFFERENT LEVELS OF INJURY

- ONE, THE TEAR ABOUT CT- SECOND, THE TEAR FOCUS ON- THIRD, THE TEAR IS LOCATED- LASTLY, THE RUPTURE APPEARS

Central Aponeurosis. Central Tendon Injury

Little stumpPalpable pastingPalpable depression

17LETS BEGIN BY THE RUPTURE THAT AFFECTS CT

POCO APARATOSOS: SYMPTOMS LITTLE BULKY

HOW DO WE SEE BY THIS INJURY?1. BULLS EYE PATTERN (PA-TORN) ... MEANS2. BIRD FEATHER PATTERN (PA-TORN) ... MEANS

BY US/RMI WE CAN KNOW IF THE INJURY HAS BAD PROGNOSIS OR NOT.WHIP = LTIGO

Central Aponeurosis. Central Tendon InjuryAcute InjuryLittle HematomaTendinous BandPalpation like a canaloniBad Prognosis Image

18WE CAN FIND A PATIENT WITH AN ACUTE RUPTURE

1. BY MR2. BY US WE SEE THE INJURY...

WE CAN FIND A PATIENT WITH A PAIN/COMPLAINT IN ANT. ASPECT. OF THE THIGHT FOR A LONG TIME

WE HAVE TWO DIFFERENTS EVOLUTION WITH DIFFERENTS MANAGEMENT.

Central Aponeurosis. Central Tendon InjuryAcute InjuryLittle HematomaTendinous BandBad Prognosis ImageFibrous/Calcified ScarSoft scar

19FIRST:

WE CAN SEE A LARGE FIBROSIS LIKE IN THIS CASE.

FOR US THIS IS A GOOD EVOLUTION CAUSE THERES A SCAR AND

WHEN A SOCCER PLAYER EXPLAIN-US PAIN AND WE SEE THIS


20SOMETIMES WE CAN SEE UNTIL DIPOSITS OF CALCIUM, BUT THE MANAGMENT IS THE SAME..

BUT SOMETIMES WE CAN FIND (SEGENT)

Soft ScarContralateral


21ANOTHER EVOLUTION THAT IS WORST THAN BEFORE.

IN THIS IMAGE: atrophy and fatty infiltration around the tendon

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THIS IMAGE MINDS THAN PROBABLY THE TRACTION HAS BEEN DONE WHEN THE RUPTURE WAS RECENT

AND PRODUCE A WEAK SCAR, CALLED "SOFT SCAR

BY US WE SEE THE ECHOSTRUCTURE

2. Direct Tendon Expansion. Superficial InjuryRarePoor symptomsNo stumpMinimal myofascial hematomaMR/US careful: not be confused with avulsion

22NEXT TYPE OF INJURY THAT WE CAN SEE IS FOCUSED ON...

- RARE- POOR SYMPTOMS- THERES not STUMP BECAUSE THE CONNECTIVE HIDES THE INJURY

THE US MANAGEMENT HAVE TO DO A LOT CAREFULLY

3. Posterior Fascia. Distal Peripheral Injury

Large and sometimes high stump Frequent myofascial hematomaCystic hematomaLaminar fibrous scar

Better prognosis than CTI

OTHER TYPE OF INJURY QUITE FREQUENT IS

THE POSTERIOR FASCIA HUGS THE RF POSTERIORLY

THE IMAGE IS SPECTACULAR

SEEMS A VERY BAD INJURYBUTIT HAS A GOOD PROGNOSIS

ONLY EVOLVE INTO A BIG SCAR

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Evolution: Cystic Hematoma

CLEAVAGE PLANE BETWEEN

COULD PRODUCE A TYPICAL PSEUDOCIST.

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09.01.2013

20.11.2012

13.11.2012

23.02.2013

09.01.2013

30.02.2013Evolution: Laminar Fibrous Scar

FINALLY

- LAMINAR FIBROUS SCAR- THE ONLY PROBLEM IS

THE ATHLETE FEELS TENSION IN THE ANTERIOR THIGH WHEN HE STARTS THE SEASON.

THIS A CASE FROM A DEFENDER OF ANDORRA'S TEAM

HE WAS PLAYING SOCCER WITHOUT ANY PROBLEM AND SUDDENLY HE FELT A PUNTUAL PAIN.

HE CAME TO VISIT US

NEVER AGAIN HE HAS PROBLEMS

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Cross i cols, 2004

26NOT MANY PAPERS ABOUT ANTOMICAL AND CLINICAL IMAGE

BUT EVEN LESS ABOUT THE PROGNOSIS & RTP

OUR CONTRIBUTION IS IT

WEVE EVALUATEDWEVE COMPARED

WERE VERY PROUD

4. Posterior Fascia. Proximal Peripherical Injury No stumpOften asymptomaticFluid Collection "in eyeCharacteristic fibrous scars

European Journal of Radiology, 2012

27THE LAST TYPE OF INJURY

ITS THAT WHICH IS LOCATED IN...

WE COME ACROSS IT BY CHANCE

WELL, THATS ALL FROM ME TODAY. ITS BEEN A GREAT PLEASURE TO SHARE THIS WITH YOU TODAY.

THANK YOU VERY MUCH.

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ramon balius - quadriceps muscle injuries diagnosis

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