QUADRICEPS
CONTRACTURE
Dr. Alok Umre , Indira
Gandhi Medical College, Dept. Of Orthopaedics, Nagpur.
INTRODUCTION
Contracture
suggests fibrosis or scarring in a muscle. It is commonly use
wherever there is shortness of the muscle relative to the bones
and joints with which it is associated, resulting in fixed
deformity or limited movement in the affected joints.
AETIOLOGY
1)
Hnevkovsky was the first one in 1961 to describe quadriceps
contracture. He reported in 12 children in whom gradual
limitation of knee flexion developed without previous injury or
inflammation. He regarded the condition as a localized form of
modysplasia.
2)
Fairbank and Barrett reported indentical twins with quadriceps
contractures; they believed these contractures were congenital.
3)
Gunn in 1964 showed a relationship between progressive
quadriceps contracture arising in childhood and intramuscular
injections, and his findings were confirmed by Lloyd-Roberts and
Thomas.
The
injection most common given was for tetanus. Second most
common cause for injection was antibiotics , vit. K, and ascorbic
acid etc.
4)
The condition may occur bilaterally. Contracture can even start
to develop more than 10 years after the injections, but the
average time is less than 3 years.
MECHANISM
OF CONTRACTURE
The
exact mechanism causing these contractures is unclear but
suggested causes include compression of the muscle bundles and
capillaries by the volume of medication injected and the toxicity
of the drug.
SITE
OF CONTRACTURE
·
Most common site is Vastus intermedius
·
Natrajan demonstrated that vastus intermedius was having poorest
blood supply among the other quadriceps muscle.
·
Second most common site is Vastus lateralis
·
Mukherjee and Das, described a tendinous band which normally runs
along the antero-medial border of the vastus lateralis which
becomes fibrosed and fails to lengthen with growth of the femur.
·
Rectus femoris involvement is seen in countries like Japan where
injection are given in front of Thigh.
CLINICAL
FEATURES
It
is more common in children may be because of lack of muscle
bulk and increase incidence of injections. Patient
may present in variety of ways but the most common is progressive
painless loss of active & passive flexion at the knee joint.
Mostly in Asian countries children present with difficult in
squating. In leter childhood, the patient may present wit
habitual dislocation of the patella.
On
examination power is good. Quadriceps are wasted firm and
fibrotic.
Patella
is found to be small and high particularly in genu recurvatum.
Injection
scar is visible with dimpling of skin in mid thigh most prominent
on knee flexion.
An
important sign is that if the patella is held in the midline t is
impossible to flex the knee by more than about 300;
further flexion is possible only if the patella is allowed to
dislocate laterally. Patches of whiteness and dimpling of the
skin are due to subcutancous fat atrophy. Hyperextension and
subluxation of the knee may occur with continued growth. Habital
dislocation of the patella is common.
X-RAY
FINDINGS
Not
seen early but if untreated the muscle contracture can cause
changes in the soft tissues and in the articular cartilage of the
femur and tibia. Progressive displacement and hypoplasia of the
patella can occur. Flattening of the femoral condyles, genu
recurvatum anterior dislocation of the tibia and degenerative
changes in the joint are seen.
PATHOGENESIS
Nicoll
suggests that the following may be involved in quadriceps
contracture : 1) fibrosis of the vastus intermedius muscle tying
down the rectus femoris to the femur in the suprapatellar pouch
and proximally, 2) adhesions between the patella and the femoral
condyles, 3) fibrosis and shortening of the lateral expansions of
the vasti and their adherence to the femoral condyles, and 4)
actual shortening of the rectus femoris muscle.
TREATMENT
1)
During the early stage of contracture, when no significant joint
changes have occurred, Sengupta recommends proximal release to
eliminate extensor lag and hemarthrosis of the knee.
2)
When more extensive changes are apparent, a thompson type of
quadricepsplasty is indicated.
3)
When genu recurvatum has developed, a supracondylar femoral
osteotomy can be done.
4)
Arthrodesis may be indicated if symptoms are severe.
5)
Occasionally, only the rectus femoris tendon may be involved,
there being limitation of knee flexion with the hip extended but
full movement with the hip flexed. In this Sasaki et al. Reported
that excellent result were obtained using a longitudinal skin
incision over the rectus muscle through which the fibrotic muscle
was released with a transverse incision. After surgery the leg
was positioned with the knee in 90 degrees of flexion and the hip
in full extension, but a cast was not used. Active exercises were
begun at 2 days. Surgery is performed after 6 years of
age.
6)
In patients with recurrent dislocation of the patella, reefing of
the medial capsule of the knee may be necessary in addition and ,
occasionally, transfer of the gracilis tendon to the
supero-medial aspect of the patella if dislocation continues to
recur.
| Result
|
Active
+ passive extension of knee |
| Good |
90-1350 |
| Fair |
45-900
+ extension lag present |
| Poor
|
More
extension lag + decrease power in quadriceps |
POOR
PROGNOSIS FACTORS
Genu
recurvatum
Old
patient
Post
polio sequele of quadriceps
