A Multidisciplinary Approach to Optimizing Long-Term Functional Prognosis of A Girl With Quadriceps Fibrosis

Abstract

The consequences and optimal treatment of quadriceps fibrosis following intramuscular quinine injection during childhood remain unclear. We report here a case of a 17-year-old girl who experienced unilateral quadriceps fibrosis following intramuscular injection of quinine as a baby. This case report describes the evolution of the condition during the child's growth, the long-term impact of early fibrosis on range of motion, muscle volumes, strength, gait, and activities of daily living. Rehabilitation involved orthoses and physiotherapy from the age of 6 years, when her knee flexion was reduced to 90°. A Judet quadricepsplasty was performed at 12 years because of continued loss of knee range with consequences for gait. At 16 years, knee range was satisfactory and gait variables were normalized. Functional evaluations and quality of life scales showed excellent recovery. Isometric strength of the involved quadriceps remained lower than the expected age-matched strength. Magnetic resonance imaging identified amyotrophy of the quadriceps, specifically the vastus intermedius. Despite being a focal impairment, quadriceps fibrosis had wider consequences within the involved limb, the uninvolved limb and functioning. This case report illustrates how children with quadriceps fibrosis can have a good prognosis, with excellent functional results at the end of the growth period, following early and appropriate management.

Keywords: activities of daily living; gait analysis; magnetic resonance imaging; paediatric intramuscular injection; quadriceps fibrosis; strength rehabilitation.

Fig. 1

Timeline: rehabilitation support and surgical management throughout the growth.

Fig. 2

Knee kinematics (gait analysis). Knee kinematics of the involved limb at 10, 12 and 14 years of age. Gait deterioration at 12 years indicated the need for surgery to improve knee flexion during swing phase (peeak reduced to 40˚). Gait normalized at 2 years post-surgery (peak 60˚)

Fig. 3

Graph showing the fatty infiltration of leg muscle, expressed as a percentage of the total volume, for the vastus intermedius at 12 years of age, before the Judet quadricepsplasty. The data were assessed by a DIXON sequence using MRI images taken different levels.

Fig. 4

A 3-dimensional illustration of the thighs of the child aged 14, 2 years post Judet quadricepsplasty. Each thigt muscle volume was assessed with MRI using an E-THRIVE sequence by manual segmentation of cross sectional area of each slice 9, 10 and showed atrophy of the whole anterior compartment, and more specifically of the Vastus intermedius. a) 3 dimensional reconstructions of thigh muscles based on manual segmentation completed with voxel remesh technique. b) MRI Axial section of the distal third of both thighs. c) 3 dimensional reconstructions: axial section. Vastus intermedius is colored in red on each figure and surrounded with a dotted line.