Intramuscular Hematoma Research Articles

Spontaneous Intramuscular Haematomas: A Single-Centre Retrospective Study and Proposed Management Algorithm.

Spontaneous intramuscular haematomas by definition are haematomas without known etiology and exclude those caused by trauma, surgery, and muscular disease. This is a rare condition which has been increasing in incidence lately largely due to anticoagulant therapy use and currently, there is no level 1 evidence with regards to the best management of these patients, with different institutions using different approaches to treatment. We retrospectively analyzed 31 patients who were treated with the diagnosis of spontaneous intramuscular haematoma in our center, in the years between 2013 and 2017. Patient information was recorded including patient characteristics, vital parameters, biochemical data, imaging data, risk stratification scores, and patient outcomes. We observed that on average males had longer hospitalizations and a higher baseline platelet count was a protective factor against haemorrhage. On temporal evaluation of haemoglobin levels, we saw an important drop of haemoglobin at T6 for the transfused patients. The majority of patients (61.29%) were treated with arterial embolization, with great technical and clinical success (94% and 81% respectively). There was also a very strong association between patients treated with non-operative therapy (NOT) and shorter hospitalization. Conclusion: NOT and embolization therapy are very effective treatments for spontaneous haematomas in the appropriate patient and should be included in the protocol. The small sample size was a very large limitation for the study, and a multicentric study is needed to further strengthen any associations we saw between risk factors and outcomes. We propose the need to perform a prospective study to ascertain the appropriate follow-up times for such investigations.

Out-of-hospital onset versus in-hospital onset for clinical outcomes in spontaneous intramuscular hematoma diagnosed by computed tomography: a retrospective cohort study.

The aging global population and the increasing use of antithrombotic agents have made spontaneous intramuscular hematomas (SIH) a growing concern. The association between the settings of SIH onset and clinical outcomes remains unclear. The aim of this study was to determine these associations. A retrospective cohort study was conducted in a tertiary hospital in Hiroshima, Japan between January 2008 and January 2022. We included consecutive patients aged ≥ 15years with SIH at any site diagnosed by computed tomography. The subjects were divided into two groups according to onset settings: out-of-hospital onset and in-hospital onset. The main outcome was treatment failure (composite of change in initial treatment and in-hospital death), and in-hospital mortality was also assessed. We used inverse probability of treatment weighting (IPTW) to estimate the causal effects of onset settings on outcomes. Of 84 included subjects with SIH, 63 had out-of-hospital onset and 21 had in-hospital onset. One subject (1.6%) with out-of-hospital onset and four subjects (19%) with in-hospital onset experienced treatment failure. In the IPTW cohort, in-hospital onset was associated with treatment failure [odds ratio (OR) 29, 95% confidence interval (CI) 7.2-270]. In addition, one subject (1.6%) with out-of-hospital onset and three subjects (14%) with in-hospital onset died during hospitalization. In-hospital onset was associated with a high rate of in-hospital mortality (OR 25, 95% CI 6.3-240) in the IPTW cohort. SIH with in-hospital onset had a poorer prognosis than that of SIH with out-of-hospital onset, suggesting that onset setting might be a novel predictor of clinical outcomes for SIH.

Life-Threatening Spontaneous Hematoma in Unusual Sites in Patients with COVID-19 on Anticoagulant Therapy: A Case Series

Thromboembolic manifestations are a common phenomenon in patients affected by corona virus (SARS CoV-2). Recent studies have shown that patients with acute renal failure are also at a greater risk of venous and arterial thromboembolism, 15-30% in ICU, and 7% inpatient care. However, frequently unjudicial use of anticoagulants may develop severe life-threatening hematoma. In our hospital settings we had a dedicated COVID Unit with a Hemodialysis facility. Our Nephrology department had managed 381 patients being COVID positive along with renal impairment from March 2020 to January 2022. Among these patients, four patients developed spontaneous non traumatic hematoma in unusual sites. On admission all the patients received treatment according to our national guidelines for COVID-19. Cases: It is a retrospective analysis in a single-centered hospital. Four cases with confirmed COVID-19 with acute kidney injury and on anticoagulant therapy had developed sudden concealed bleeding. These patients had no previous history of anticoagulant therapy before admission. Case 1 developed hemorrhage in Right lower anterior paramedian deep parietal wall of abdomen, Case 2 had hematoma in retroperitoneal space and in lower third of Iliopsoas, Case 3 developed hemorrhage in left cerebral hemisphere, Case 4 had Intramuscular Hematoma in left rectus abdominis. Out of these four patients two of them required Hemodialysis and one of them went into shock. All patients included were male. The mean age was 57±19.64years. All the four patients were initially managed conservatively with keen monitoring and with proper volume resuscitation, blood transfusion and discontinuation of the anticoagulants. Three of the patients survived with conservative management and one patient died due to sudden massive cardiac arrest. The use of therapeutic anticoagulant can increase the risk of bleeding in atypical sites and may exhibit higher patient death with COVID-19 if not identified at early stage. So a risk-benefit ratio of usage of anticoagulants should be kept in mind and further clinical trials needed to justify its random use in COVID-19. J Bangladesh Coll Phys Surg 2024; 42: 393-400

Delayed Compartment syndrome after total knee replacement: A case report with short review

Purpose: We would like to report a case which developed delay anterior thigh compartment syndrome after total knee replacement surgery and review the underlying risk factors. Method: A 67years old lady was suffered from delay thigh anterior compartment syndrome 4 days after total knee replacement surgery. Urgent fasciotomy was performed. Later work up showed a large intramuscular haematoma within the anterior compartment which required drainage. Discussion: Short review was performed to identify the risk factors for developing compartment syndrome after total knee replacement surgery. Management strategy and prognosis was also discussed. Conclusion: Compartment syndrome should be diagnosed and treated promptly. Patient with underlying risk factors must be identified and with close monitoring of this rare complication in post-operative period.

Severe muscle injury and extensive intramuscular haematoma of the vastus intermedius in a rugby player.

Severe muscle injury and extensive intramuscular haematoma of the vastus intermedius in a rugby player.

Ossified intramuscular hematoma of the paraspinal muscles: a case report

BackgroundOssified intramuscular hematomas (OIH) are an exceptionally rare condition that may be mistaken for alternative calcified intramuscular pathologies, such as myositis ossificans. Exceedingly few cases of OIHs have been reported to date, with no cases yet to be reported in the paraspinal muscles.Case presentationHere, we report on a patient who presented with a chronic back pain and swelling in the setting of trauma 15 years prior. Radiographic workup revealed a calcified mass in the erector spinae muscles. The lesion was surgically excised, and histologic examination confirmed the presence of an OIH. The patient did well postoperatively.ConclusionAn OIH is a poorly understood pathology. Although benign, these lesions can cause significant morbidity, and surgical excision is a reasonable and safe treatment option. OIHs may be distinguished from related calcified intramuscular pathologies based on key clinical features and distinct histopathology. Clinically, they are characterized by a history of remote trauma and, on histopathology, by compact, mature bone in the setting of an old, organizing hematoma. Despite this, similarities with other calcified intramuscular pathologies persist, and further study is warranted to better understand and classify these lesions.

Point-of-Care Ultrasound (POCUS) for Sideline Youth Sports Coverage.

The purpose of this review is to discuss the use of point-of-care ultrasound for sideline youth sports coverage. Participation in youth sports has been increasing, with trends that athletes are specializing earlier and competing at higher levels at younger ages (NSCH 2019, Fabricant 2013). Point-of-care ultrasound (POCUS) utilizes non-invasive imaging to diagnose and manage various musculoskeletal conditions ranging from traumatic injuries, such as fractures and intramuscular hematomas, to early screening for conditions such as asymptomatic knee lesions. Since it is well-tolerated by children and adolescents and allows for easy accessibility for sideline care, POCUS could provide a strong alternative to other imaging modalities such as x-ray and magnetic resonance imaging (MRI) as both have their limitations. Youth sideline sports coverage could be enhanced with immediate medical attention from ultrasound-trained medical professionals. On the sidelines of a traumatic injury, POCUS expedites patient care with immediate examination of acute injuries. In low resource and hard-to-reach locations such as a rural youth sporting event, it can be key in the triaging of injuries. As a supplement to a physical exam, the risk of a misdiagnosis is reduced, and a long, expensive trip to the hospital for unnecessary imaging studies may be avoided. Ultrasound is a versatile, non-invasive, radiation-free imaging modality that serves as an accessible option for sideline coverage at youth sporting events. Ultrasound is well-tolerated by children and adolescents. It can be used to evaluate, diagnose, and manage a range of musculoskeletal conditions at the sidelines of youth sports.

Severe Spontaneous Hematomas in Patients Hospitalized with COVID-19.

To describe the epidemiological, clinical, laboratory, and radiological characteristics, medical treatment, and outcomes of a case series of severe spontaneous hematoma in COVID-19. Material and Methods. This retrospective study included patients hospitalized for COVID-19 who were diagnosed with severe spontaneous bleeding complications by following a standardized treatment protocol that included computed tomography angiography (CTA) from 1 March 2020 to 28 February 2022. The main outcomes were embolization and all-cause mortality. Baseline variables were analyzed for their association with mortality using bivariable logistic regression, and results were expressed as odds ratios (OR) and 95% confidence intervals (CI). In total, 2450 adults were hospitalized for COVID-19 in our center during the study period. 20 patients presented severe and spontaneous intramuscular bleeding (8.1 per 1000 COVID-19 admission vs. 0.47 per 1000 non-COVID-19 admissions, p < 0.001); their median age was 68.5 years (interquartile range (IQR) 63, 80), they had high comorbidity (median Charlson comorbidity index 4.5), and 95% were receiving high doses of heparin. The median interval from COVID-19 symptoms to bleeding was 17 days (IQR 13, 24), and 70% reported cough as a previous symptom. Hypovolemic shock, hypotension, and abdominal pain were the most frequent symptoms of the hematoma. All presented decreased hemoglobin, and 95% required transfusion. Intramuscular hematoma occurred most frequently in the rectus sheath, iliopsoas compartment, and femoral-iliac compartment. All patients underwent embolization; mortality was 45%. We did not identify risk factors associated with an increased risk of death. Although severe bleeding is an uncommon complication of COVID-19, its prevalence is higher than in inpatients without COVID-19, it usually needs embolization, and it is associated with high mortality.

Spontaneous intramuscular hemorrhage in cancer-associated dermatomyositis: a case and literature review

BackgroundSpontaneous intramuscular hemorrhage (SIH) is a rare but life-threatening complication of dermatomyositis (DM). The pathogenetic mechanism and management of intramuscular hematoma in these patients remains unclear. Here we discuss a case of recurrent hemorrhage in a patient with cancer-associated DM, and review the relevant literature for timely diagnosis and treatment.Case presentationA 53-year-old male patient presented with rashes, muscle weakness, and dysphagia and was diagnosed with DM. During treatment, he developed SIH of the arm and right psoas major muscle successively. MRI showed extensive edema of the right shoulder girdle muscle and muscle groups of the upper arm. During the second SIH, a CT scan showed new-onset hematoma formation in the right psoas major muscle. The detection of D-dimer, thrombin-antithrombin III complex (TAT), plasmin-α2-plasmininhibitor complex (PIC) and tissue plasminogen activator-inhibitor complex (t-PAIC) indicated predominant hyperfibrinolysis over thrombosis. Blood transfusion and supportive treatment were immediately performed, and the hematoma did not expand. However, his abdominal distension was not relieved after active treatment. Further electronic gastroscopy discovered gastric sinus ulcers, and histopathology of the biopsy confirmed signet-ring cell carcinoma.ConclusionsAlthough patients with cancer-associated DM have an increased risk of thrombosis, prophylactic anticoagulation therapy needs deliberate consideration. It is important to monitor the coagulation parameters dynamically during anticoagulation therapy. Especially when the level of D-dimer is high, and it is uncertain whether the patient is in a state of thrombosis or hyperfibrinolysis, the detection of TAT, PIC, t-PAIC can help to determine whether to initiate anticoagulation therapy.

A Case of Spontaneous Calf Hematoma Complicating Dengue Hemorrhagic Fever: A Case Report

Dengue is the most common arboviral infection in the world. Dengue hemorrhagic fever (DHF) presents withmanifestations like gum bleeding, melaena, menorrhagia, epistaxis, hemoptysis and sometimes bleeding into the thirdspace all of which are well documented. Spontaneous intra-muscular hematoma is a rare manifestation of DHF; veryfew such cases have been reported so far. We report a 25-year-old woman who was admitted with DHF and later ondeveloped spontaneous calf muscle hematoma in the soleus muscle.&#x0D; Bangladesh Crit Care J March 2023; 11 (1): 36-38

Radial nerve palsy caused by a rapidly growing intramuscular hematoma in an infant with biliary atresia: a case report

BackgroundBiliary atresia (BA) is a rare cause of persistent jaundice in infants that can result in vitamin K malabsorption and vitamin K deficiency bleeding (VKDB). We present an infant with BA who developed a rapidly growing intramuscular hematoma in her upper arm after a vaccination which caused a radial nerve palsy.Case presentationAn 82-day-old girl was referred to our hospital because of a rapidly growing left upper arm mass. She had received three doses of oral vitamin K before age 1 month. At age 66 days, she received a pneumococcal vaccination in her left upper arm. On presentation, she showed no left wrist or finger extension. Blood examination revealed direct hyperbilirubinemia, liver dysfunction, and coagulation abnormalities, indicating obstructive jaundice. Magnetic resonance imaging showed a hematoma in the left triceps brachii. Abdominal ultrasonography revealed an atrophic gallbladder and the triangular cord sign anterior to the portal vein bifurcation. BA was confirmed on cholangiography. VKDB resulting from BA in conjunction with vaccination in the left upper arm were considered the cause of the hematoma. The hematoma was considered the cause of her radial nerve palsy. Although she underwent Kasai hepatic portoenterostomy at age 82 days, the obstructive jaundice did not sufficiently improve. She then underwent living-related liver transplantation at age 8 months. The wrist drop was still present at age 1 year despite hematoma resolution.ConclusionsDelayed detection of BA and inadequate prevention of VKDB can result in permanent peripheral neuropathy.

Management of autoimmune factor XIII deficiency in a frail, elderly patient.

Autoimmune factor XIII/13 deficiency (aFXIII deficiency) is a rare hemorrhagic disorder, for which typical guideline-directed treatment is aggressive immunosuppressive therapy. Approximately 20% of patients are over 80 years old; however, and optimum management of such patients has not reached consensus. Our elderly patient had massive intramuscular hematoma, and aFXIII deficiency was diagnosed. The patient opted against aggressive immunosuppressive therapy, so he was managed with conservative treatment only. Thorough survey of other correctable causes of bleeding and anemia is also required in similar cases. Our patient's serotonin-norepinephrine reuptake inhibitor use and multivitamin deficiency (vitamin C, B12 and folic acid) were revealed to be aggravating factors. Fall prevention and muscular stress prevention are also important in elderly patients. Our patient had two relapses of bleeding within 6 months, which were improved spontaneously by bed rest without factor XIII replacement therapy or blood transfusion. Conservative management may be preferred for frail and elderly patients with aFXIII deficiency when they opt against standard therapy.

Effectiveness of Ultrasound Guided Erector Spinae Plane Block Compared to Ultrasound Guided Modified Pectoral Nerves Block in Modified Radical Mastectomy: A Randomized Single Blinded Study

ABSTRACT Background Approximately, 40–60% of breast surgeries are associated with severe acute pain. The goal of this work was to compare the analgesic effectiveness and safety between erector spinae plane block (ESPB) and modified pectoral nerve block (MPECB) in patients having modified radical mastectomy (MRM). Methods This randomized single blinded study included 60 adult female aged 18–65, American Society of Anesthesiologists (ASA) I, II, III patients with body mass index between 20 and 35 kg/m2 who underwent MRM under general anesthesia (GA). Patients were divided into two equal groups. ESPB group received ESPB 30 mL levobupivacaine 0.25%, MPECB group received MPECB 10 ml levobupivacaine 0.25%. Blocks were done before induction of GA. Mean arterial blood pressure (MAP) and heart rate (HR) and numeric rating scale (NRS) were measured at PACU, 2, 4, 8, 12, 16, 20 and 24 h postoperatively, postoperative nausea and vomiting (PONV), assessed on a four-point verbal scale. Results Postoperative morphine consumption was significantly lower in MPECB group than in ESPB group. Numeric pain scale scores were significantly lower in MPECB patients both at rest and during movement than ESPB groups. Ramsey score in MPECB patients had better sedation scores in the first 4 h post-operative than ESPB group. Patients who received MPECB showed less PONV, but it was statistically insignificant and intramuscular hematoma was insignificantly higher in MPECB group. Conclusions MPECB provides safe and more effective analgesia in MRM compared to ESPB in the form of lower postoperative morphine consumption and low NRS scores.

Coexistence of Intramuscular Hematoma in Patients with a Diagnosis of COVID-19

Coexistence of Intramuscular Hematoma in Patients with a Diagnosis of COVID-19

Changes in the anatomical position of the superficial and deep femoral arteries during internal fixation of intertrochanteric fractures

Fixation for intertrochanteric proximal femoral fractures are increasing globally, one of the risks with surgical treatment is injury to the deep and superficial femoral arteries (DFA and SFA, respectively). The anatomic path of these vessels has been previously described, though the effect of reduction techniques, such as traction over a perineal post has not been well defined. This study addresses the question of: do closed reduction maneuvers on an orthopaedic trauma traction table affect the anatomical relationship of superficial and deep femoral arteries to the proximal femur in intertrochanteric proximal femoral fractures? Prospective observational single centre study of seventeen patients with pertrochanteric femoral fractures examined before and after applying traction for closed reduction. Doppler ultrasound was used to determine the proximity of these arteries to the proximal medial femoral cortex at three different levels. Our data demonstrates that internal rotation of the injured limb during reduction draws the arteries statistically closer to the medial cortex of the proximal femoral shaft at 3.5cm and 10.5cm distal to the lesser trochanter (SFA: 3.5cm - 38.0mm vs 34.7mm p 0.004, 10.5cm – 30.4mm vs 21.0mm p 0.02; DFA: 3.5cm – 26.4mm vs 22.3mm p 0.003, 10.5cm - 21.5mm vs 14.1mm p 0.007). No significant change in the artery position was noted in patients who did not require internal rotation to achieve fracture reduction. Surgeons performing these internal fixation procedures need to be aware of the anatomical changes to ensure patient safety and avoid complications including intramuscular haematomas and pseudoaneurysms. • Internal rotation laterally displaces the femoral artery during fixation on an orthopaedic traction table. • Care should be taken to avoid drill plunge beyond the medial femoral cortex. • Deep femoral artery is most ‘at risk’ of injury when using plate or distal locked nail constructs.

Acquired hemophilia A with intramuscular hematoma at an unusual age: a case report

Background. Acquired factor VIII (FVIII) deficiency or acquired hemophilia A (AHA) is very uncommon in children. Patients with AHA usually present with abnormal or unexpected bleeding which may be life-threatening. These patients usually have unexplained, prolonged, and isolated activated partial thromboplastin time (aPTT). Consequently, FVIII activity should be immediately evaluated. Bleeding prevention is important in patients with AHA.Case report. We present a case of a previously healthy 13-year-old female who presented with intramuscular hematoma, soft tissue hemorrhage, and epistaxis who was eventually diagnosed with AHA.Conclusion. To our knowledge, the present report is one of the few reported cases of an Asian patient that was diagnosed with acquired hemophilia A at a young age.

Multisystem inflammatory syndrome in a neonate with severe hemophilia - a diagnostic challenge in COVID times: a case report

BackgroundMultisystem Inflammatory Syndrome in Neonates (MIS-N) can occur following antenatal COVID- 19 infection in the mother. Here we report a rare case of a neonate with Hemophilia A and MIS-N.Case presentationA 2-day-old baby presented with an intramuscular hematoma, neonatal seizures, and isolated activated partial thromboplastin time (APTT) prolongation. The neurosonogram showed a subdural hematoma. A diagnosis of Hemophilia A was made and was confirmed by factor 8 assay and genetic analysis. Supportive measures and Factor 8 replacement was initiated. A rising trend of inflammatory markers and an ongoing need for mechanical ventilation were noted. As there was a history of COVID-19 in the mother in the third trimester, MIS-N was diagnosed. The baby was treated with intravenous immunoglobulin (IVIG) and steroids, and there was an improvement in the clinical and laboratory markers. However, the baby developed seizures on day 16. There was an increase in the subdural hemorrhage and a further rise in inflammatory markers. A craniostomy and hematoma evacuation was done and the baby improved.ConclusionThe concurrent occurrence of hemophilia A with intracranial bleed, and MIS-N in a neonate is a diagnostic challenge. It is important to have a high index of suspicion to ensure timely diagnosis and treatment of MIS-N in this pandemic era.

Spontaneous Intramuscular Hematomas in Patients with Severe COVID-19 (Case Report)

Aim of the study. To evaluate the risk factors for the occurrence of intramuscular hematomas in patients with severe coronavirus infection receiving anticoagulant therapy.Materials and methods. Intramuscular hematomas in five patients with severe COVID-19 disease are reported in the paper. The criteria for selecting patients for the study included respiratory distress requiring oxygen, radiographic signs of severe pneumonia, anticoagulant therapy using low molecular weight heparin (LMWH), and spontaneous intramuscular hematoma. Clinical manifestations, blood coagulation results, conservative and surgical management were analyzed.Results. Standard regimen anticoagulation therapy in patients with coronavirus infection requires vigilance because of a risk of development of hemorrhagic complications.Сonclusion. When assessing a patient with hematomas, an emphasis should be given to examination of patients and changes in hemoglobin and hematocrit levels. Best strategy of anticoagulant therapy for patients with coronavirus infection and high risk of VTE, as well as optimal laboratory monitoring during LMWH administration are yet to be explored.

Sarcoma presenting as upper limb intramuscular haematoma

Background/Introduction: Soft tissue sarcomas are usually found on the extremities but uncommonly present as intramuscular haematomas. We present one such Case and review the literature on the diagnosis and management of these lesions.

Guidelines for the management of acquired hemophilia A in elderly patients

Acquired hemophilia A is an autoimmune disease caused by antibodies against coagulation factor VIII (FVIII). These antibodies, called circulating FVIII anticoagulant or FVIII inhibitor, reduce plasma FVIII activity, which results in excessive bleeding. Acquired hemophilia A is classified as severe hemorrhagic disorder. Typical for this disease are extensive subcutaneous spontaneous blood extravasations, intramuscular and retroperitoneal hematomas, and post- -traumatic bleeds, including post-surgery bleeding. In approximately 30% of cases, acquired hemophilia A is initially manifested merely by minor bleeding, which may be often overlooked by physician, but as long as FVIII inhibitor is detected, patient is at risk of severe, sometimes fatal, hemorrhage. Acquired hemophilia A is most common in people aged 60–90 years. Patients in this age group often take anticoagulants, antiplatelet and non-steroidal anti-inflammatory drugs, and bruising and purpura are relatively common among them, so acquired hemophilia A can easily be overlooked. On the other hand, the delay in the diagnosis of the disorder may result in delayed initiation of hemostatic treatment and elimination of the FVIII inhibitor, which puts the patient at risk of premature death. The aim of this publication is to present the principles of diagnosis of acquired hemophilia A, the use of hemostatic drugs to inhibit and prevent bleeding, and immunosuppressive drugs to eliminate the FVIII inhibitor in elderly patients.