Contusion Injury

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Clinical Features and Evaluation

Muscle contusions represent the second most common form of muscle injury after strain injuries.35,36 This injury typically involves the anterior, posterior, and lateral thigh, as well as the anterior arm.35 In animal models of contusion, crush mechanisms result in muscle fiber rupture leading to an intramuscular hematoma, edema, and inflammation.37 Due to the hematoma formation, contusion injury is often complicated by the development of myositis ossificans. Myositis ossificans is discussed in more detail later. Muscle healing after contusion is similar to that seen after strain injuries but is associated with less scar formation.

Contusion injuries have been reported to occur in virtually all contact sports. They are clinically diagnosed almost universally by localized pain, swelling, limited range of motion of the joints involving the affected muscle, and, often, a palpable mass.38 There should be a high degree of suspicion for a contusion in contact athletes sustaining any injury, even if that athlete does not relate a specific injury. In a series of 117 quadriceps contusions in military academy cadets, the most common mechanism of injury was a knee to the thigh (48 of 117) followed by helmet (31 of 117), shoulder (12 of 117), direct blow (8 of 117), object (6 of 117), ground contact (5 of 117), kicking (2 of 117), and other (5 of 117).38 The highest injury rate was among rugby players (4.7%), but the greatest number of injuries in this patient population occurred during contact football.38

While clinical diagnosis of contusion injury is straightforward, assessing the extent of injury is not as easily established and imaging studies may be of utility in this regard.35 Ultrasonogra-phy can distinguish a focal hematoma from diffuse swelling and edema, and MRI can assist in resolving a diagnosis given limited medical history, determining the extent of initial injury, and in following resolution of injury over time periods.35,39 It should be stressed that findings on MRI persist beyond the period of clinical symptoms and that there are reports of athletes performing at the professional level without limitations despite persistent MRI findings.39 This study also demonstrated that contusions may involve only one muscle group, despite diffuse swelling in an entire compartment.

Treatment Options

The goal of treatment of muscle contusions is to limit swelling and hemorrhage, minimize the amount of scar formation, and preserve bioelasticity, contractility, and strength of the injured and uninjured muscle tissue. The balanced use of early, short-term immobilization followed by accelerated motion is critical (Fig. 13-9). An early report in cadets described short periods of quadriceps immobilization with the knee in extension38; however, this protocol was changed to 24 to 48 hours of immobilization with the hip and knee flexed as far as comfortable to maintain the quadriceps under tension.38 This change was driven by the clinical observation after immobilization in extension that flexion was the slowest motion to return. Flexion is thought to minimize the bleeding into the muscle.

Management of muscle contusions is driven by the classification of the initial injury. Common to all treatment algorithms is the liberal use of cryotherapy to reduce microvascular perfusion and subsequent edema formation,35 compression, elevation, and relative rest. The classification scheme of Ryan et al38 for quadriceps contusions is most widely used and applied to other areas of the body as well. Mild contusions are defined as active knee motion greater than 90 degrees, moderate contusions 45 to 90 degrees, and severe contusions less than 45 degrees. Table 13-3 contains the management protocol for quadriceps contusions. This is a progressive protocol consisting of three phases: phase

I, limitation of hemorrhage; phase II, restoration of pain-free motion; and phase III, functional rehabilitation of strength and endurance. Severe contusions require bed rest with hip and knee flexion to tolerance. In military cadets, this is accomplished with admission to the hospital; outside the military, this may be achieved with bed rest at home with excuse from classes or work. Mild and moderate contusions are managed similarly; however, the strict call for bed rest is not indicated. This initial period of treatment progresses to the second phase when thigh girth is stable and the patient is pain free at rest. Phase I typically is 24 to 48 hours in length. Phase II initiates motion and for severe contusions begins with continuous passive motion until painless passive range of motion is achieved from 0 to 90 degrees, and then continues phase II exercises for the outpatient condition using supine and prone active flexion and well-leg gravity-assisted motion with a stationary bike. All injuries progress to phase III when 120 degrees of pain-free active knee flexion and equal thigh girths are obtained. Phase III involves graded return to activities with the underlying requirement that they are always performed pain free. These activities include increasing resistance on the stationary bike, isokinetic exercise, swimming, walking, jogging (pool then surface), and running. During any phase, should the patient experience pain or loss of motion, they are moved back to the previous level.

Rights were not granted to include this figure in electronic media. Please refer to the printed publication.

Figure 13-9 Algorithm for the evaluation and management of muscle contusion injuries. (From Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.)

Table 13-3 Treatment Protocols for Management of Quadriceps Contusions

Phase I

Phase II

Inpatient Quadriceps Contusion Therapy

Purpose Limit hemorrhage

Restoration of pain-free motion

Modalities Rest; bed rest; ice: ice pack applied to injured area; compression: thigh-length support hose and Ace wrap entire thigh; elevation: hip and knee flexed to tolerance

Continuous passive motion; well-leg gravity-assisted motion; supine and prone active knee flexion; isometric quadriceps contraction; ice, crutch ambulation; Ace wrap

Advance to next phase when Comfortable; pain free at rest; stabilized thigh girth

Pain-free passive range of motion 0 to 90 degrees; good quadriceps control; crutch ambulation with patient weight bearing to tolerance and negotiating steps Continue Phase II as outpatient

Phase I Phase II

Phase III

Outpatient Quadriceps Contusion Therapy

Purpose Limit hemorrhage Restoration of pain-free motion Functional rehabilitation: strength and endurance

Modalities

Rest; weight bearing to tolerance, crutch ambulation if limp present; ice: ice massage for 10min; cold pack/cool whirlpool for 20min; compression: Ace wrap entire thigh (occasional use: long-leg support hose, confirm taping); elevation: in class and in barracks, hip and knee flexed to tolerance; isometric quadriceps contracture <10 reps

Ice or cool whirlpool, 15-20min; isometric quadriceps exercises, 15-20min; supine and prone active flexion; well-leg gravity-assisted motion; static cycle: minimum resistance; discard:

(1) crutches when range of motion >90 degrees, no limp, good quadriceps control, and pain free, with flexed weight-bearing gait;

(2) Ace, when thigh girth reduced to equivalent of uninjured thigh

Always pain free: static cycle with increasing resistance; Cybex; swim; walk; jog (pool and surface); run

Modalities

Rest; weight bearing to tolerance, crutch ambulation if limp present; ice: ice massage for 10min; cold pack/cool whirlpool for 20min; compression: Ace wrap entire thigh (occasional use: long-leg support hose, confirm taping); elevation: in class and in barracks, hip and knee flexed to tolerance; isometric quadriceps contracture <10 reps

Ice or cool whirlpool, 15-20min; isometric quadriceps exercises, 15-20min; supine and prone active flexion; well-leg gravity-assisted motion; static cycle: minimum resistance; discard:

(1) crutches when range of motion >90 degrees, no limp, good quadriceps control, and pain free, with flexed weight-bearing gait;

(2) Ace, when thigh girth reduced to equivalent of uninjured thigh

Always pain free: static cycle with increasing resistance; Cybex; swim; walk; jog (pool and surface); run

Advance to next phase when

Comfortable; pain free at rest; stabilized thigh girth

>120 degrees pain-free active knee motion; equal thigh girth bilaterally

Full active range of motion; full squat; pain free in all activities; wear thigh girdle with thick pad 3-6mo for all contact sports

Mild and moderate, treat daily; severe, treat twice daily.

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

As in the treatment of muscle strain injury, the use of NSAIDs is controversial. The West Point series used no medications in the treatment of quadriceps contusions and experienced no loss to activity return.38 There are no other large clinical series from which to draw inferences about NSAID use, although there is some animal research in this area. NSAIDs have been found to decrease the catabolic loss of protein in the early postinjury period as well as the degree of inflammatory response, but this has also led to a decrease in tensile muscle strength in the long term.35 Thus, the beneficial effect in the short term may be overshadowed by the longer term inhibition of the normal muscle regeneration cascade.36 While no firm evidence supports this application, at our institution, we currently begin a course of NSAIDs 2 days after injury to limit formation of myositis ossificans.

Surgery The operative treatment of contusions is controversial. Anecdotal descriptions exist of large hematomas being evacuated after contusions,35 and in the face of large spatial defect within a contused muscle, direct suturing of muscle may be indicated, but more work is needed to make a generalization about surgery for this problem. The incidence of compartment syndrome in the thigh after contusion is not well described, but in rare instances may occur and must then be treated with fas-ciotomy. Most authors advocate a high clinical suspicion for compartment syndrome in limbs where thigh girth fails to stabilize after contusion and recommend compartment pressure monitoring; however, no report of anterior thigh compartment release for contusion related compartment syndrome has demonstrated muscle injury at the time of surgery.39 None of the major series describing treatment of quadriceps contusions report any cases of compartment syndrome or the completion of thigh fasciotomies.38-40 In cases in which arterial injury is suspected, fasciotomy should still be considered as a treatment option. Arteriography is a useful study in this unlikely scenario.

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