Ramon Balius - Quadriceps Muscle Injuries Diagnosis
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Transcript of 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)
Direct Mechanism. Quadriceps Muscle
Clinical diagnosisVastus lateralis & vastus intermediusDifferent degrees of injury Aponeurosis & subcutaneous tissue involved
We can find a CONTUSION OF FIRST DEGREE:THE PATIENT CAN DO FULL FLEXIONBECAUSEREALLY IS A BRUISE
----------------------------------------------
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)
Direct Mechanism. Quadriceps Muscle
Clinical diagnosisVastus lateralis & vastus intermediusDifferent degrees of injury Aponeurosis & subcutaneous tissue involved
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 .
----------------------------
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
Central Aponeurosis. Central Tendon InjuryAcute InjuryLittle HematomaTendinous BandBad Prognosis ImageFibrous/Calcified ScarSoft scar
20SOMETIMES WE CAN SEE UNTIL DIPOSITS OF CALCIUM, BUT THE MANAGMENT IS THE SAME..
BUT SOMETIMES WE CAN FIND (SEGENT)
Soft ScarContralateral
Central Aponeurosis. Central Tendon InjuryAcute InjuryLittle HematomaTendinous BandBad Prognosis ImageFibrous/Calcified ScarSoft scar
21ANOTHER EVOLUTION THAT IS WORST THAN BEFORE.
IN THIS IMAGE: atrophy and fatty infiltration around the tendon
--------------------------------------------------
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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