IATROGENIC RETRACTION OF THE QUADRICEPS
Iatrogenic retraction of the quadriceps muscles with disabling static and funcţional changes, occurs after the administration of in-tramuscular injections administered to immature children, with a high degree of dystrophy or eutrophic infants.This occurs because of respiratory intercurrences, or of severe infections of the digestive or musculoskeletal systems treated with injections in the thigh area. (1) Following this aggressive treatment causes a fibrosclerosis, with retraction of the quadriceps muscles and knee extension blocking. (2) The stiffness can be full or parţial, unilateral or bilateral, with severe impairment of walking, with knees in extension, the disability will have to be corrected surgically. This paper aims to draw attention on these risks to all those involved in child care. We counted a total of 8 cases, found at The Pediatrics Orthopedics Surgery Clinic Timişoara, between 1995 and 2010. We consid-ered the treatments applied, way of administration, and social and family environment of these children. The results of this study allowed us to emphasize the seriousness of these iatrogenesis, with major therapeutic difiiculties, and the very gratifying fact that after changing the route in administrating medical treatments to children, such cases were no longer reported in recent years.
The clinical issue on retraction of the quadriceps muscles after repeated intramuscular injections, appears in medical literature from 30 – 40 years ago, belonging to the first papers written by : BIGAN (1964), GAMMIE(1963), GUN (1964), MALEK (1966), pediatric surgery realized the importance of the problem, while developing appropriate methods and techniques to recover the serious motor deficien-cies. Authors such as Petit (1967), RIGAULT (1967) and later POULIQUEN (1972), published a series of papers, with convincing results from the operated cases. (1)
Researching the literature data we conclude that these iatrogenesis are not as uncommon as one would think. Failure or late detection of cases appears because sometimes the medical practitioner is not suf-ficiently aware of such pathology. (4) (5) (6).
The pathogenesis of the disease must take account of local anatomy, knowing that in the thigh, the superficial fascia along with the lateral intermuscular septum and the femur, make a real division of the muscles in closed spaces, thus circulation and tis-sue function can be compromised by increasing local pressure.
We must take into account the mechanical role of repeated injections, the local irritating action of the drug administered, the appearance of intramuscular hematoma, all of them acting on a newborns and infants premature muscle, that has a greater capillary fragility and sometimes a deficit of clotting factors.
All of these overlap on an increasing local pressure caused by the drug solutions, along with repeated injections in a short period of time. In these conditions the fibroblasts proliferate and the muscle tissue is gradually invaded by a process of irreversible fibrosclerosis. (2)
Actual onset of the disease is always unnoticed, as it occurs during a serious disease, potentially life-threatening, condition for which the child receives numerous shots of antibiotics, symptomatic, vitamins, and others, an entire therapeutic arsenal, all in the thigh.
Clinical onset of iatrogenic retraction along with limitation of knee flexion occurs after 1-6 months after treatment in infants and 6-24 months after treatment in children.
Retraction of the quadriceps muscles is first observed when the child shows difficulty walking and frequent falls. The affected thigh is thinner, with an irregular surface, the consistency of the quadriceps muscles is uneven, sometimes presenting tough fibrous nodules.
In severe cases the retraction can cause a recurved knee.The child can walk better in unilateral forms as opposed to bilateral forms, in which case the child has trouble walking presenting a waddle as well as frequent stumbles and falls.
Figure 1. Very severe case of iatrogenic retraction of the quadriceps muscles.
The examination revealed limitation of knee flexion in varying degrees, from 60 ° to 4 ° – 5 °.
In terms of severity a classification of cases according to grade and shape distinguishes (7):
- A. VERY SERIOUS FORMS: bilateral retraction with flexion up to 10°.
- B. SEVERE FORMS: bilateral, with flexion up to 30
- C. AVERAGE FORMS: unilateral, with flexion up to 60°.
- D. MILD FORMS: higher form of flexion up to 90
Preventive treatment is of major importance, because curative treatment can never restore the affected quadriceps to 100% normal function.
Knowing the disease etiopathogenesis, prevention means avoiding the administration of injectable drugs in the thigh.
In severe forms with blocking flexion, the only treatment that can give good results is surgical.The technique used in our clinic consists of a complete extraperiosteal disinsertion to lower the quadriceps muscles, part of the tensor of the fascia lata and if needed the Sartorius muscle.
The approach path consists of a longitudinal incision from the upper anterior iliac spine, slightly arched towards the great trochanter, and goes on to the externai thigh up to the externai rotuliene fin.
We strictly perform the extraperiosteal disinsertion on the retracted quadriceps muscle, going from top to bottom and from the inside to the outside: vastus externus on the linea aspera of the femur, vas-tus intermedius, vastus internus, as well as the rectus femoris, by disinserting the tendon directly from the anterior inferior iliac spine and the reflected tendon from the joint capsule.
Figure 2. Surgical approach. The incision starts from the U.A.I.S. and goes to the external edge of the patella
The tensor of the fascia lata is elongated through multilevel scalariform incisions in its fibrous portion. In severe forms we disinsert the Sartorius muscle from the anterior superior iliac spine.
Following the complete muscle disinsertion we obtain a physiological flexion of the leg on the thigh by lowering about 10 cm of the retracted quadriceps muscle if needed.
Throughout this extremely laborious procedure a good haemostasis is required and a rigorous control of the bleeding in the surgical field.
The operation will be completed by closing the wound and suturing the skin.The muscles will be fixed in a down position, with the physiological flexion of the calf.
Figure 3. Extraperiosteal disinsertion of the quadriceps muscle
Figure 4. After completely disinserting the quadriceps muscle we get a leg on the thigh fl exion of over 110 °
Figure 5 Postoperative appearance. Immobilization with plaster splint, fl exion of leg on the thigh at 90 ° for 21 days
Figure 5 Postoperative appearance. Immobilization with plaster splint, flexion of leg on the thigh at 90 ° for 21 daysPostoperative immobilization consisted of a plaster splint or cast that keeps the knee flexed at 90 which will be kept on for 30 days.Postoperatively after removing the splint or cast, the patient will resume active progressive movements with the operated limb, under the guidance of a physiotherapist.
The study group included a total of 8 patients ages between 10 and 14 , admitted to the Pediatric Clinic of Surgery and Orthopaedics Timişoara between 1995 and 2010, all of them diagnosed with iatrogenic retraction of the quadriceps muscle. Depending on the severity of the disease in the studied group were found:
Among them were six boys and two girls. In the case of bilateral lesions a six month interval is advised between surgeries.
Postoperative patients were reviewed over a period of 2-4 years results being good and very good as follows:
- GOOD RESULTS: 3-Flexion of 90° toi 10°.
- VERY GOOD RESULTS: 5 – Flexion of over 110°.
We want to emphasize the importance of man-datory kinetotherapy immediately after removing the splint or cast.
Failing that, good and very good therapeutic results obtained with surgery are lost in time.
From our study group a total of 3 patients have not been to postoperative follow-ups after the second year, due to poor collaboration with the tutors.
While stressing the quite remarkable fact that from the study group two girls have had regular postoperative follow-ups, immediate and remote to the surgery, results being very good. Today they are young adults, they have jobs and a good social and family integration.
The reduced anatomical and funcţional potential of children’s muscle tissue, especially children who are endangered, immature, born underweight or suffering from advanced dystrophies, forces us to change our vision on injectable treatments, in order to avoid future serious iatrogenesis.
Taking into account the seriousness of such cases, with major disabilities and varying degrees of locomotor handicaps, prophylaxis is imperative at all lev-els of child care.
Prevention of iatrogenic retraction of the quadriceps muscles can be achieved by following these goals:
- careful consideration in prescribing injectable treatments.
- avoiding intramuscular administration of medicinal substances with a sclerosing effect.
- administrating intravenous treatments to children.
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Stefan Lazea, Divizia 9 Cavalerie str., no. 23, Timisoara