Early evacuation of haematoma causing sciatic nerve compression: Yes or no? A comparative case report

Abstract

A 68-year-old gentleman, Mr. GS, with a past medical history of Atrial Fibrillation (AF) and chronic renal disease (due to chronic glomerulonephritis) presented to a fracture clinic with a history of progressing foot drop and complete anaesthesia of the L4 to S1 dermatomes and dysthaesia to the surrounding dermatomes. He was on anti-hypertensive therapy in addition to warfarin for AF. A week previously the patient had been on holiday in Spain and had fallen. He complained of pain and swelling around the right iliac crest and was able to weight-bear almost immediately. Over the next 2 days the pain worsened and he noticed a weakness in dorsi-flexion of the foot and some numbness. A pelvic radiograph at the Emergency Dept. was taken which demonstrated a longitudinal fracture of the right iliac blade (Fig. 1). On arrival in orthopaedic clinic he mobilised with a frame and had an obvious foot drop. Examination revealed plantar flexion, dorsi-flexion and EHL function of just 1/5 (MMC scale). In addition the patient also had anaesthesia and pain in an L4 to S2 dermatomal distribution with brisk reflexes. After discussion with our radiology colleagues, an MRI of the hip, pelvis and lumbar spine was performed specifically to exclude nerve root avulsion injuries. The spine images were unremarkable, but the pelvic films showed amass suggestive of a haematoma (see Figs. 2 and 3). The imageswere sent to a specialist regional orthopaedic centre to rule out a sarcoma. Over the next 8 months, the patient’s neurological symptoms slowly improved, but there was some residual neurological deficit.