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).
Very rarely, this injury can be severe enough to progress to an acute compartment
syndrome. Because 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. Minimally, impact causes cellular
edema of the muscle, but complete capillary disruption with localized hemorrhage
leading to a tense anterior compartment can occur. The muscle is more resistant to
injury if it is struck while in a contracted nonfatigued state. Other quadriceps injuries
range from simple strains to more complex and disabling muscle ruptures.
Other 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. Fascial rupture usually occurs anteriorly at the mid thigh and causes a
muscle hernia.
Frequency:

In the US: While quadriceps strains are common, minimal information about the
frequency with respect to specific sports is available. As for quadriceps
contusions, the most detailed frequency data come from the US Military

Academy at West Point, and the distribution per year is as follows: rugby 4.7%,
karate and judo 2.3%, football 1.6%, and all other sports fewer than 1%.
Quadriceps 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. One study reported that of all tendinopathies
affecting the extensor mechanism, the frequency of patellar tendinitis at its
insertion was 65%, quadriceps tendinitis was 25%, and patellar tendinitis at its
insertion into the tibial tuberosity was 10%.
Rupture 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 65 years. However, in athletes, the mean age cited
ranges from 15-30 years. Sports associated with quadriceps rupture are high
jump, basketball, and weight lifting. Rupture is also not uncommon in patients
with renal failure.
Functional Anatomy: The quadriceps femoris acts as a hip flexor and knee extender.
The quadriceps femoris is composed of the following:

Rectus femoris

Vastus lateralis

Vastus medialis

Vastus interomedialis

Origins/insertions of quadriceps components include the following:

Rectus femoris - Ilium/tibial tuberosity

Vastus lateralis - Femur/tibial tuberosity

Vastus medialis - Femur/tibial tuberosity

Vastus interomedialis - Femur/tibial tuberosity

The 3 thigh compartments are as follows:

Anterior - Quadriceps muscles, femoral nerve and artery

Posterior - Hamstring muscles, sciatic nerve

Medial - Adductor muscles, cutaneous branch of obturator nerve

Sport Specific Biomechanics: The function of the quadriceps is primarily that of tibial
(knee) extension. One electromyography (EMG) study showed that the maximum
extension moment and maximum quadriceps EMG activity were early in the kicking
action, as the initial flexion changes to extension. This moment occurs before the foot
makes contact with the ball. The peak activity of the hamstring occurs after the
quadriceps peak, shortly before the ball is struck. The largest extension moment in this
study was 260 Nm; this corresponds to a calculated tensile force in the patellar tendon
of 7 times body weight.
The mechanical properties of the quadriceps have been studied. The central aspect of
10-mm 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 (53.4 N/mm2) than the unconditioned quadriceps tendon
(33.6 N/mm2). Strain at failure was also higher for the preconditioned patellar tendon
(14.4%) than for the quadriceps tendon (11.2%).
Microscopic 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.
A 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 proximally and distally and to the muscle belly itself. Muscle
strains are usually due to repetitive functional overload. Not surprisingly, quadriceps
strains most commonly affect athletes who subject their knees to high levels of repeated

loading of the extensor mechanism. The overuse trauma may range from microscopic
failure of soft tissue with its associated inflammation or gross rupture. Gross rupture
may be partial or complete. A large sudden load may cause the entire insertion to be
compromised, leading to complete rupture. Repetitive loading, particularly eccentric
loads, causes microfailure, usually at the muscle tendon junction. This microfailure can
result in partial tears.
Contusion: Direct 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. Inflammatory
cells and macrophages enter the site of injury and begin clearing necrotic muscle cells.
This process occurs over 2-3 days. Then, muscle cells attempt to regenerate at the
same time scar tissue is being formed. A severe thigh contusion can lead to a
compartment syndrome.
Muscle hernia: The cause of this is not clear. It is usually associated with a sudden
forceful kick, but it may be associated with a weakened or previously injured quadriceps
fascia.
Fracture of any bone in the skeleton is a painful injury sure to interfere with the function
of the part. Most 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.
A fracture is any structural failure in bone. There is no difference between a "break" and
a "fracture". There are several kinds of fracture patterns and many locations. Still there

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.
A fracture is said to be "compound" when it punctures the skin and "closed" if it does
not. A bone can be compounded from the outside by a bullet or other object. More
commonly the sharp bone end punctures the skin from inside the limb. The significance
is that an open fracture invites the complication of infection. Compound or open
fractures are cleansed in the operating room as soon as possible. If the wound is visibly
dirty internal fixation is usually limited to pins or other simple methods that do not raise
the risk of infection.
A fracture is described by its degree of displacement. This is usually non-displaced,
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. Many displaced fractures need surgical fixation.
Location of a fracture is important. In 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. A tibia or femur fracture in the leg may take 4 or 5 months to heal. This
encourages us to do internal fixation to avoid complications from long term cast.
Stiffness in joints is one of those. A fracture in a joint surface is likely to cause late
arthritis problems and these fractures are usually treated surgically unless completely
non-displaced. Fractures near the joint heal more rapidly than the shaft and may be
treated with cast or with surgery.

History:

Quadriceps contusion

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).

A 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 high-energy trauma, in
patients on anticoagulants, in patients with bleeding disorders, and in
patients with multiple traumas.

A 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 expansion, and the forces are distributed
over a greater area. Unless 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).

Untreated, a compartment syndrome may lead to muscle necrosis,

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

Symptoms include painful anterior thigh, painful weightbearing, and

unwillingness to flex the knee because of thigh pain.

Quadriceps tendon sprain

o

Blazina first described peripatellar tendinitis affecting the quadriceps

tendon or the patellar tendon and termed this jumper's knee in 1973. He
noted that it commonly occurred in jumping athletes.

The mechanism is sudden stretching or repeated eccentric contraction of

the muscle causing pain and dysfunction immediately or 1-3 days later.

Symptoms include pain with ambulation and knee flexion and inability to
extend the knee if the quadriceps is ruptured.

Quadriceps muscle partial tear

The mechanism is kicking or sprinting.

Incomplete 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 proximal than the
quadriceps strain at the patellar insertion.

Quadriceps tendon rupture: Many authors have concluded that the tendon
usually ruptures in an area of tendinosis. In 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. Rupture of the quadriceps tendon after surgery may be

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:

Quadriceps contusion

Normal medial and posterior thigh

Tensely edematous and tender anterior thigh

Limited knee flexion

Mild - Greater than 90

Moderate - From 45-90

Severe - Less than 45

For ruptures (complete and partial): Extensor lag indicates partial and
complete tears; no extension indicates complete tear.

Gait abnormalities

Mild - Normal

Moderate - Antalgic

Severe - Severe limp

Knee effusion: Effusion may or may not be present.

Exquisite anterior thigh tenderness with knee flexion

Increased circumference of affected thigh

Straight-leg raise: Patients are able to perform this unless the extensor
mechanism is disrupted.

Normal sensation in distal extremity: If 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.

Pain: Disproportionately high level of pain for examination 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 extension.

Quadriceps muscle hernia: A soft mobile mass, which may be tender, is palpated
anteriorly with contraction of the quadriceps. A 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

Inability to straight-leg raise (extensor mechanism disrupted)

Muscular defect in distal anterior thigh with mass in proximal thigh

Causes:

Quadriceps contusion or compartment syndrome - Direct blow to anterior aspect

of thigh

Quadriceps strain or rupture - Acute stretch or repeated eccentric muscle

contractions with immediate or delayed (1-3 d) presentation of pain, stiffness,
and decreased function

Quadriceps tendinitis

The kneecap (patella) is a small bone in the front of the knee. It 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 "rope-like" 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. Quadriceps tendinitis is the term used to
describe inflammation of the quadriceps tendon.
Quadriceps 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. Over time damage to the quadriceps tendon can occur. In
extreme cases, the quadriceps tendon may become damaged to the point of complete
rupture.

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

running, jumping, stopping and starting. Pain 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 be
so bad that it prevents athletes from playing their sport.
Examination techniques that detect tenderness and swelling in or around the
quadriceps tendon are helpful in determining if someone has quadriceps tendinitis. Xrays are occasionally done to make sure that the quadriceps tendon does not have any
calcium in it. Other tests such as diagnostic ultrasound or Magnetic Resonance Imaging
(MRI) are sometimes used to rule out more extensive damage to the quadriceps
tendon.
Treatment of quadriceps tendinitis may include relative rest, icing, medications to
reduce inflammation and pain, stretching and strengthening exercises. Quadriceps
tendinitis may be prevented by easing into jumping or running sports and by using good
training techniques. Off-season strength training of the legs, particularly the quadriceps
muscles, can also help. Doctors and physiotherapists trained in treating this type of
overuse injury can outline a treatment plan specific to each individual.

Femoral Shaft Fracture

Much 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 complex fractures of the distal femur.

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

of the distal femur. There is profound osteopenia.

Lateral radiograph of the

distal femur.

Axial CT. The distal femur demonstrates the severely thinned cortex along with the
fracture.

Axial CT. This image shows the comminution of this distal femur fracture

How is it treated?
Most femur fractures need to be fixed in surgery. Your leg may be placed in traction in
the hospital before surgery is done.
Methods used to fix 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.

In healthy adults, casts are rarely used for femur fractures. A body cast that includes the
entire injured leg and part of the uninjured leg are commonly used for femur fractures in
young children.
Breaks at or near the knee joint usually require plates and screws or just the screws.
Shaft fractures, as in the midthigh, are usually fixed with a rod.
You will need to use crutches for 8 to 12 weeks after surgery. Your 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.
While you are still healing after surgery, you will begin physical therapy to regain
strength in your muscles and to loosen up your joints. (Muscles are usually injured in a
femur fracture, and your hip and knee commonly become stiff due to the injury and
surgery.)
Complete recovery may take many months, depending on how bad the fracture was
and the extent of any other injuries. The break itself should heal in about 4 months. Your
health care provider will take x-rays regularly to see how the bone is healing. Full
recovery, however, requires the muscles and joints to heal as well. Your provider and
physical therapist will assess the recovery of your muscles and joints by measuring joint
mobility and the return of muscle strength, flexibility, and coordination. Your health care
provider may decide to remove the plates, screws, or rods sometime after your leg has
fully healed.

When can I return to my sport or activity?

Returning to your sport or activity after a femur fracture can be a long process. It may
take a year before you can return to some sports. When your bone is healed and you
have done some basic rehabilitation, you will begin rehab activities and exercises
specific to your sport. It may take a few months to complete this recovery phase, after
which you can return to your sport. It 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 expected to meet
in order to return safely to your sport:

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

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

You can sprint straight ahead without pain or limping.

You can do 45-degree cuts, first at half-speed, then at full-speed.

You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.

You can do 10-yard figures-of-eight, first at half-speed then at full-speed.

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

How can I prevent a femur fracture?

Femur fractures are usually caused by accidents that cannot be prevented. This type of
fracture rarely occurs in common team sports. However, it is important to use good
judgment in sports such as skiing, rock climbing, snowmobiling, and horseback riding. It
is also important to have a good diet with enough calories and calcium.