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    A Woman With Difficulty in Bending Her Kne 2017 Journal of Medical Ultrasoun

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    Ryana Fitriana II
    1) A 54-year-old woman presented with right knee pain when squatting and difficulty bending her knee after mild trauma to her distal thigh. 2) Ultrasound imaging revealed a hypoechoic mass in her right distal thigh, replacing the second layer of muscle, consistent with a hematoma. 3) Based on the absent vastus intermedialis muscle, the diagnosis was a complete tear of the vastus intermedialis muscle with formation of a hematoma.

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    A Woman With Difficulty in Bending Her Kne 2017 Journal of Medical Ultrasoun

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    Ryana Fitriana II
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    1) A 54-year-old woman presented with right knee pain when squatting and difficulty bending her knee after mild trauma to her distal thigh. 2) Ultrasound imaging revealed a hypoechoic mass in her right distal thigh, replacing the second layer of muscle, consistent with a hematoma. 3) Based on the absent vastus intermedialis muscle, the diagnosis was a complete tear of the vastus intermedialis muscle with formation of a hematoma.

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    1) A 54-year-old woman presented with right knee pain when squatting and difficulty bending her knee after mild trauma to her distal thigh. 2) Ultrasound imaging revealed a hypoechoic mass in her right distal thigh, replacing the second layer of muscle, consistent with a hematoma. 3) Based on the absent vastus intermedialis muscle, the diagnosis was a complete tear of the vastus intermedialis muscle with formation of a hematoma.

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    22 views3 pages

    A Woman With Difficulty in Bending Her Kne 2017 Journal of Medical Ultrasoun

    Uploaded by

    Ryana Fitriana II
    1) A 54-year-old woman presented with right knee pain when squatting and difficulty bending her knee after mild trauma to her distal thigh. 2) Ultrasound imaging revealed a hypoechoic mass in her right distal thigh, replacing the second layer of muscle, consistent with a hematoma. 3) Based on the absent vastus intermedialis muscle, the diagnosis was a complete tear of the vastus intermedialis muscle with formation of a hematoma.

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    © All Rights Reserved
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    of 3

    Journal of Medical Ultrasound (2017) 25, 184e186

    Available online at www.sciencedirect.com

    ScienceDirect
    Chinese Taipei Society of
    Ultrasound in Medicine
    journal homepage: www.jmu-online.com

    IMAGING FOR RESIDENTS

    A Woman with Difficulty in Bending her Knee


    Ke-Vin Chang*

    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital,


    Bei-Hu Branch, Taipei, Taiwan

    Section 2dAnswer Discussion

    A 54-year-old woman complained of severe right knee pain The patient complained of pain at the right anterior thigh,
    when she squatted to pick up a fallen object. There was prompting us to scrutinize any lesion inside the knee or at
    mild ecchymosis at her distal thigh. She then found diffi- the distal femur. First, the investigators need to screen for
    culty to bend her knee. Figure 1 was obtained from the pathology inside the suprapatellar pouch, such as effusion,
    anterior aspect of her distal thigh and Figure 2 reveals hypertrophic synovium, plicas, and calcific deposition in-
    elastography of the same region. Figure 3 shows the com- side the bursa. When performing the scan, the examiner
    parison between the painful and normal sides. What is your can require the patient to contract the quadriceps muscle
    diagnosis? by hyperextending the knee, which can drive the effusion
    to collect in the area proximal to the superior patellar pole.
    Second, the quadriceps tendon disorder can also result
    Interpretation
    in anterior knee pain. When examining the quadriceps
    tendon, the knee needs to be flexed to tighten the tendon.
    In Figure 1, the transducer was placed on the anterior The quadriceps tendon appears laminated, comprising
    distal thigh, revealing a hypoechoic mass locating above three layers: the rectus femoris most superficially, the
    the femur. In Figure 2, we found that the elasticity of the vastus medialis and vastus lateralis in the middle and the
    lesion was not different from the muscle above. In vastus intermedialis most deeply [1]. Awareness of the
    Figure 3, we saw that the second layer of the muscle was arrangement helps the examiner to track the quadriceps
    replaced by the hypoechoic heterogenic mass, looking like tendon backward to its muscle origin. Regarding the
    a hematoma. At the normal side, the rectus femoris quadriceps tendon, calcification, tendinopathy, and tear
    muscle was seen at the superficial layer while the vastus are common pathological findings identified using
    intermedialis could be visualized at the deep layer. ultrasound.
    Therefore, the ultrasound pictures were indicative of In the present case, the quadriceps tendon appeared
    vastus intermedialis muscle complete tear with a forma- relatively normal. However, while tracking the tendon
    tion of a hematoma.

    Conflicts of interest: The author declares no conflicts of interest.


    * Correspondence to: Dr Ke-Vin Chang, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu
    Branch, 87, Neijiang Street, Wanhua District, Taipei City 108, Taiwan.
    E-mail address: [email protected].

    http://dx.doi.org/10.1016/j.jmu.2017.03.006
    0929-6441
    Difficulty in Bending the Knee 185

    Figure 1 B-mode ultrasound imaging of right distal thigh. The arrowheads indicate the lesion.

    Figure 2 B-mode imaging (left) and elastography (right) of the lesion. The image was obtained by using an ultrasound machine
    equipped with a high frequency transducer and the function of elastography (Ecube 15; Alpinion, Seoul, Korea).
    186 K.-V. Chang

    more proximally, we found that a hypoechoic area sur-


    rounded the femur and was just located underneath the
    rectus femoris muscle. In the panoramic view, we noticed
    the lesion extending from the proximal one third of the
    thigh to the suprapatellar region. The echotexture of the
    lesion was compatible with an organized hematoma [2].
    Based on the finding of absent vastus intermedialis muscle,
    the diagnosis of complete tear of the vastus intermedialis
    was thus confirmed. The physician should also check the
    coagulation profile when a huge hematoma is detected in a
    case with mild trauma.

    References

    [1] Waligora AC, Johanson NA, Hirsch BE. Clinical anatomy of the
    quadriceps femoris and extensor apparatus of the knee. Clin
    Orthop Relat Res 2009;467:3297e306.
    [2] Lee JC, Mitchell AW, Healy JC. Imaging of muscle injury in the
    elite athlete. Br J Radiol 2012;85:1173e85.

    Figure 3 Panoramic view of the distal thigh at the normal


    and abnormal sides.

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