Quadriceps contracture

1. QUADRICEPS CONTRACTURE

2. Acquired extension contracture of infancy or childhood.
Less common than flexion contracture.
F > M
Initially thought to be congenital, or secondary to progressive
idiopathic fibrosis of the vastus intermedius muscle
Nearly all children, H/O serious illness in early infancy.

3. ETIOLOGY
Repeated IM inj in thigh during infancy.
Antibiotic, analgesics, antiepileptic.
Abscess
Muscle trauma
United fracture.

4. PATHOPHYSIOLOGY
Volume of drug inj in to young babies compresses the capillaries
& muscle fibres  M. ischaemia  fibrotic changes.
Local M. necrosis at the site of inj.
Irritative nature of the drug.
Combined with severe underlying disease, poor nutrition &
prolonged recumbency.

5. Muscle fibrosis  adherent to bone & deep fascia 
dimple.
Muscle fails to develop with the bone  flexion becomes
more & more restricted.
Delay between the inj & contracture always present.
# femur – Q adherent to callus – limit flexion.

6. CLINICAL FEATURES
Painless, progressive limitation of both active & passive knee
flexion with an extension contracture.
Affected knee is normal at birth.
Parents note the child’s difficulty in squatting, kneeling,
sitting cross-legged, running, or climbing stairs.
Walks with limp due to straight knee or unstable quadriceps
gait.

7. Dimple , which deepens with forced flexion of knee.
ROM; Painless in the available arc.
Atrophy of thigh, absence of creases.
Subcutaneous hardness.
Genu- recurvatum in severe cases
High riding patella.
Habitual dislocation P in chronic case.

8. DIMPLE

10. X ray
Contracture – progressive displacement & hypoplasia of
patella, fragmentation of inf. Pole of patella.
Skeletal changes in distal femur articular surface points
anteriorly.
Femoral condyles gets flattened.
Tibial dislocated anteriorly.
Gross degenerative changes.

13. Differential diagnosis
C. genu recurvatum, Arthogryposis
 cong. Short Q, present at birth @ with other
deformities.
Cong. & habitual dislocation patella  Q mech is relatively
short, ROM not affected.
Polio, myelomeningocele & NM disorders – unbalanced Q
action – extension deformities.

14. TREATMENT
Early recognisation & prevention through passive ex. in
children receiving intramuscular inj.
Physio / passive stretching ex [doubtful use]
Always surgical release is necessary.
Indicated to prevent late changes in the condyles & patella.

15. Structures in contracture [Nicoll]
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

16. Sengupta – proximal release
During early stages
When no significant jt changes occurred
Principle –fibrosed muscles is in the upper lateral part of thigh
[inj]
Upper attachment of V.L is detached from its origin after
transversely cutting the fibrosed IT band.
Fibrosed V. intermedius is erased from the femur.

17. Rectus femoris if fibrosed also to be released from its origin.
Advantages:
1.Eliminate extensor lag
2.Hemarthrosis
3.Performed at the site of the pathology
4.Postoperative mobilisation is quicker
5.High scar produces a more acceptable cosmetic result.

18. Thompson - Quadricepsplasty
When there is more extensive changes
success depends on
1)whether the rectus femoris muscle has escaped injury,
2) how well this muscle can be isolated from the scarred parts of
the quadriceps mechanism,
3)how well the muscle can be developed by active use.

19. Rectus muscle released from vasti on both sides
Fibrotic V. intermedius partially excised.
Intra-articular adhesions removed.
Vasti are sutured with rectus keeping knee flexed.
Rectus if contracted is elongated by V-Y plasty.

20. Postop
knee was immobilised in plaster at 50* for 2-3 days.
The knee then placed in a CPM.
This was followed by intensive physiotherapy.
Stretching ex are continued throughout the growing period.

21. Supracondylar femoral osteotomy – when genu recurvatum
with degenerative changes developed in order to gain
flexion.
Arthrodesis – if arthritis symptoms are severe.