Thigh Hematoma Research Articles

Invited commentary

The authors report on a 13-year-old, 4-foot-5-inch, 99-pound boy who experienced a distal superficial femoral artery occlusion as a result of blunt trauma. Intimal injury is one plausible etiology for blunt trauma occlusion, which could, if a wire passed easily, be stented open with some risk for showering acute thrombus. The patient was nearing 6 hours of acute limb ischemia. A rapid attempt at stent placement with the possible need for distal thrombolysis could provide a solution to a difficult problem. The trade-off for rapid restoration of blood flow is the placement of a metal stent in a small and yet to fully mature superficial femoral artery. Most current data would suggest that stent placement in this location has a significant risk of restenosis or occlusion within a relatively short time, and the stent cannot be expected to grow with the child. There is no track record for such a device in children. These concerns can, of course, be ignored in favor of salvage if that is the most logical choice. Theoretically, drug-eluting stents, absorbable stents, and covered stents may improve this outlook but are not directly pertinent to this case. I do not feel that the vascular surgeon/interventionalist reading this article should go away with the impression that autogenous vein is likely to fail in the scenario presented or that a great saphenous vein in a 13-year-old is too small to use as an arterial conduit. It has been my experience and many others that patients much younger with an even smaller great saphenous vein can expect that this conduit will provide for initial limb salvage, will grow with the patient, and will not become aneurysmal over time.1Dalsing M.C. Cikrit D.F. Sawchuk A.P. Open surgical care of children less than 13 years old with lower extremity vascular injury.J Vasc Surg. 2005; 41: 983-987Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The presence of a large thigh hematoma is concerning because it suggests the possibility of vascular disruption with extravasation prior to protective thrombosis of the bleeding vessel. Stenting in this case might have converted a protective clot to an active rebleed, and certainly thrombolysis would have been contraindicated. In my opinion, this should have been considered by the authors, and some explanation should have been provided as to why this was not a concern. One successful case in a teenager does not allow the authors to answer the question they pose in the title: “is stenting a good option?” It is one innovative option, with the proof of “goodness” yet to come.

Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy for Acute Pulmonary Embolism After Total Hip Arthroplasty

Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.

Epidemiology of injuries in English professional rugby union: part 1 match injuries

Objectives: To undertake a detailed, large scale epidemiological study of match injuries sustained by professional rugby union players in order to define their incidence, nature, severity, and causes. Methods: A...

Thigh Compartment Syndrome: Diagnosis and Surgical Treatment

Thigh compartment syndrome is uncommon and may go unrecognized. Signs and symptoms include a history of thigh swelling and/or hematoma and pain after minor injury in a patient who is anticoagulated. Surgical approaches to the deep thigh compartments are described.

INCREASED RISK OF HAEMORRHAGIC COMPLICATIONS IN RENAL ALLOGRAFT RECIPIENTS RECEIVING SYSTEMIC HEPARIN EARLY POST TRANSPLANTATION.

P173 Aims: To document the risk of haemorrhagic complications in renal allograft (RA) recipients requiring systemic heparinisation within the first 2 weeks post transplantation, compared to RA recipients not requiring heparin. Methods: A retrospective review of the records of the 326 RA recipients from 1/1998-7/2003 was performed. Data obtained included recipient demographics, requirement for and dosing of systemic heparin, nature and management of haemorrhagic complications. Statistics were performed by SPIDA. A p value < 0.05 was considered significant. Results: 16/326(4.9%) of RA recipients were initiated on intravenous (iv) unfractionated heparin within the study period. Enoxaparin was subsequently used in 10/16(62.5%) of these recipients. There was no difference in age, sex or type of renal transplant between the RA recipients receiving IV Heparin versus non-heparinised RA recipients. Indications for heparin included- 9 pre-existing thrombotic disorder (6 clinical thrombotic episodes & documented thrombotic disorder, 3 clinical thrombotic episodes only), 4 mechanical heart valve, 2 intrarenal arterial branch thrombosis, 1 early pulmonary embolus. Intravenous heparin was instituted at a median 8(1-14) days post transplantation. Heparin was instituted at a dose of 500-1,000 IU per hour to maintain an APTT level within twice the normal range. Haemorrhagic complications occurred in 10/16(62.5%) of RA recipients on IV heparin versus 11/310(3.5%) of non-anticoagulated RA recipients [p=0.0001]. Haemorrhagic complications in the IV heparin group were 5-periallograft haemorrhage (2 episodes prior to initiation of iv heparin), 8 perigraft/retroperitoneal haematomas, and 1 gastrointestinal bleed. Haemorrhagic episodes in the non-heparinised RA recipients included 7-periallograft haemorrhage, 4 perigraft haematomas. Haemorrhage occurred at a mean 9.75(2-43) days into the course of IV Heparin. The median peak APTT 24 hours prior to haemorrhage in RA recipients on Heparin was 68.5(58-180) versus a median peak APTT of 70(50-140) in RA recipients on Heparin who did not sustain a haemorrhagic complication [p=0.30]. Major intervention (predominantly surgery) was required in 6/16(37%) of RA recipients on IV Heparin versus 7/310(2.2%) of non-heparinised RA recipients [p<0.0001]. Enoxaparin was instituted at a mean 22.5(4-55) days post transplantation. Delayed haemorrhage subsequently occurred in 4/10(40%) of RA recipients on Enoxaparin at a median 18.75(3-44) days into the course of Enoxaparin. Haemorrhagic complications on Enoxaparin included 2-periallograft haemorraghe (both requiring surgery), 1 retroperitoneal haematoma, and 1 deep thigh haematoma. Conclusions: Haemorrhagic complications of both a major and of a minor nature occur more commonly in RA recipients requiring early post transplantation IV Heparin. Haemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with/without complications. Delayed haemorrhage was also seen with the subsequent use of Enoxaparin.

Giant Femoropopliteal Artery Aneurysm and Vein Rupture

Atherosclerotic popliteal aneurysms are the most common peripheral artery aneurysms. Thrombosis, embolization, rupture, and compression of adjacent structures are well-known complications. We report a patient with a giant thigh hematoma and a pulsatile mass thought to be a ruptured popliteal artery aneurysm. It proved to be an unruptured 8.5 cm femoropopliteal aneurysm with avulsed and bleeding adjacent veins, the source of the hematoma. This constitutes the first known report of this unusual complication.

Outcome after autogenous brachial-axillary translocated superficial femoropopliteal vein hemodialysis access

Objective The optimal configuration for patients with “complex” or “tertiary” hemodialysis access needs remains undefined. This study was designed to examine the utility of the autogenous brachial-axillary translocated superficial femoropopliteal vein access (SFV ACCESS) in this subset of patients. Methods Patients presenting for permanent hemodialysis access without a suitable upper extremity vein for autogenous access identified by duplex ultrasound mapping and those with repeated prosthetic access failures were considered candidates for SFV ACCESS. Ankle-brachial indices were obtained, and duplex scanning of the superficial femoropopliteal and saphenous veins was performed. Patients deemed candidates for SFV ACCESS also underwent preoperative upper extremity arteriography and venography. A retrospective review of the complete medical record was performed, and a follow-up telephone or personal interview was conducted. Results Thirty patients (mean age ± SD, 54 ± 15 years; male, 33%; white, 37%; with diabetes, 50%; obese, 21%) underwent SFV ACCESS among approximately 650 access-related open surgical procedures during the study period. The patients had been receiving dialysis for 4 ± 5 years (range, 0-24 years), and had 3 ± 3 (range, 0-17) prior permanent accesses, whereas 90% were actively dialyzed through tunneled catheters. In-hospital 30-day mortality was 3%, and the hospital length of stay was 7 ± 7 days. Fifty-seven percent of the patients experienced some type of perioperative complication, and 38% required a remedial surgical procedure. Hand ischemia developed in 43% of the patients (severity grade: 1, 10%; 2, 7%; 3, 27%), and a distal revascularization, interval ligation was performed in all those with grade 3 ischemia. Thigh wound complications or hematomas developed in 23% of the patients, and arm wound complications or hematomas developed in 17%. The incidence of thigh wound complications was significantly greater (57% vs 9%; P = .03) in obese patients, but the other perioperative complications analyzed could not be predicted on the basis of age, gender, or comorbid conditions. The SFV ACCESS was cannulated 7 ± 1 weeks postoperatively. The primary, primary assisted, and secondary patency rates were 96% ± 4%, 100% ± 0%, and 100% ± 0%, respectively, at 6 months; 79% ± 8%, 91% ± 6%, and 100% ± 0%, respectively, at 12 months; and 67% ± 13%, 86% ± 9%, and 100% ± 0%, respectively, at 18 months (life table analysis; % ± SE). Conclusions The intermediate term functional patency rate after SFV ACCESS is excellent, although the magnitude of the procedure and the complication rate are significant. SFV ACCESS should only be considered in patients with limited access options.

Balloon angioplasty as a treatment of failing infrainguinal autologous vein bypass grafts.

The purpose of this study was to evaluate the role of balloon angioplasty in the treatment of failing infrainguinal vein bypass (IVB) grafts. A retrospective chart review of patients undergoing revision of a failing IVB graft by vascular surgeons at a tertiary care center from 1990 to 2001 was performed. Failing bypass grafts were identified by routine duplex scan surveillance and physical examination. The criteria for endovascular intervention varied on the basis of surgeon preferences and time period; factors considered when choosing balloon angioplasty included significant comorbidities that precluded operative intervention, the lack of adequate conduit for surgical revision, or poor accessibility of the stenotic lesion. Data recorded included demographic patient data, type of IVB graft, patency status, further procedures performed, and all complications and mortalities. Cumulative primary and assisted patency rates were calculated by using Kaplan-Meier life-table analysis. A total of 45 balloon angioplasties were performed in 36 patients. There were 36 angioplasties of vein bypass grafts, and additional balloon angioplasties were performed on nine of these patients. Locations of IVB grafts included femoropopliteal (13 patients), femorodistal (13), and popliteal to distal (10). Initial success was achieved in 33 of 36 vein bypass grafts (91.7%). In these bypass grafts, the stenotic lesions were identified and treated at the proximal anastomosis (3 patients), mid-bypass graft (6 patients), and distal anastomosis (27 patients). Autogenous vein was used for all bypass grafts. Cumulative vein bypass graft (life-table analysis) primary patency rates (those free of occlusion or bypass graft threatening stenosis) were 74.2% at 6 months, 62.7% at 12 months, and 58.2% at 24 months. Repeat interventions included surgical thrombectomy with vein patch angioplasty or bypass graft revision, as well as repeat balloon angioplasty with or without thrombolysis. Cumulative assisted vein bypass graft patency rates (those free of occlusion or bypass graft threatening stenosis) were 87.0%, 83.2%, and 78.9% at 6, 12, and 24 months, respectively. Two patients (4%) developed thigh hematomas; no other procedure-related complications were noted, and there were no deaths in the perioperative period. Balloon angioplasty of failing infrainguinal vein bypass grafts can be successfully performed with a low rate of complications. Acceptable short-term patency can be achieved. This procedure should be considered as an initial option in failing IVB grafts.

Traitement d’une hémophilie acquise chez un patient septique

Introduction. – Acquired haemophilia is a rare bleeding diathesis caused by auto-immune depletion of factor VIII. It is characterised by spontaneous haemorrhagic syndrome, which can be fatal sometimes. Exegesis. – A 71 year-old man presents in a dysimmunitary context (rheumatoid arthritis complicates by an acquired haemophilia) a septicemia with a methicillin resistant staphylococcus aureus. At the time of the hospitalization, the patient is febrile (39 °C). The activated partial thromboplastin time is very much increased, the level of factor VIII is lowered by 7% and the title of the inhibitor to factor VIII amounts to 140 Bethesda unities. An haematoma of the right root thigh is also noted. In that case, the concomitant presence of septicemia makes difficult the use of immunosuppressive therapy usually recommended to decrease auto-antibody’s level. For the management of the septicemia, an adapted antibiotherapy (vancomycin then teicoplanin) is organized to J1. To control haemorrhagic risk, immunoglobulins are prescribed from d12 to d16, without immediate results. Then prednisone is introduced. We observe a very fast decrease of the anticoagulant circulating title with a neat improvement of the clinical state, allowing so to realize a draining puncture of the psoas. This invasive investigation required the use of prothrombinic complex concentrates ((Feiba ®) in the dose of 80 UI/kg two to three times a day). Biopsy does not show infection source. Conclusion. – The infection delayed the prescription of immunosuppressive therapy and the surgery. Use of corticoids, following 5 days of intravenous polyvalent immunoglobulin, was the good choice. After 7 weeks of hospitalization the patient has recovered a normal haemostasis results, and a good general state.

Poster 66: Osteochondroma associated with ruptured bursa presenting as hamstring injury and hematoma: a case report

Setting: Academic outpatient physiatric private practice. Patient: A 53-year-old man. Case Description: The patient presented with complaints of left posterior thigh and knee pain and hematoma 4 days after twisting his left leg. He developed buttock pain, followed by a “baseball-sized” gluteal mass, both of which resolved over the next 2 days. Physical findings included tenderness to palpation over the ischial tuberosity, large ecchymosis, and swelling suggestive of hematoma extending from the left gluteal area to the calf. Neurologic exam was normal except for mild left hamstring weakness. Assessment/Results: Clinical presentation was consistent with hamstring injury with hematoma formation. Radiographs of the pelvis were negative for hamstring avulsion, however, they demonstrated the incidental findings of calcifications over the neck of the femur, suggestive of cartilaginous lesions. Subsequent magnetic resonance imaging demonstrated a large osteochondroma and a large, partially ruptured bursa formation with intact hamstrings, fluid collection causing partial encasement of the sciatic nerve, and effacement of the proximal hamstrings, gluteus maximus, and adductus magnus. Discussion: This is the first reported case, to our knowledge, of osteochondroma of the femur associated with large bursa formation presenting as hamstring injury in an older patient. Osteochondroma is a common tumor, which usually presents in adolescence. Large bursa formation in association with osteochondroma of the femur is a rare complication that may represent malignant transformation and must be ruled out. Conclusion: Osteochondroma with large bursa formation can have unusual presentations, including the appearance of hamstring injury and hematoma. Presumed hamstring injuries are commonly managed conservatively and, in most cases, imaging studies do not play a significant role in the work-up. However, diagnostic imaging can play a central role in the diagnosis of bone tumors.

DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

Australian football: Injury profile at the community level

Successful injury prevention relies on injury surveillance to establish the extent of the problem, to monitor injury patterns and to evaluate prevention strategies. Despite the popularity of participation in Australian football at the community level, few injury surveillance studies have been published describing the pattern of injuries at this level of participation. In contrast, ongoing injury surveillance at the elite-level is well established. Reliance on injury data from the elite-level of Australian football to guide injury prevention at the community level may not be appropriate due to differences across the levels with respect to exposure, fitness and skill level. Therefore, specific injury surveillance at the community level of Australian football is warranted. This study describes the epidemiology of community level Australian football injuries. Injury surveillance was undertaken in five amateur Australian football clubs over the 1999 season. The 320 participating players sustained 421 injuries over the season. The overall rate of injury was 27 injuries per 1000 player hours. Injuries were most commonly sustained at the start of the season and during the second quarter of match participation. Hamstring muscle strains were the most common injury sustained, followed by thigh haematomas and lateral ligament sprains of the ankle. The injury surveillance system used in this study was well accepted by the clubs and provides detailed data for the prioritisation of future injury prevention research at the community level of Australian football.

Efficacy of thing protectors in preventing thigh haematomas

Thigh haematomas are extremely common in Australian Rules Football (ARF). This is in contrast to contact sports overseas, the likely reason is the increased use of thigh protectors as part of team uniforms in contact sports such as American football. Thigh haematomas can have a significant impact on an athlete's performance, ranging from short term performance impairment, muscle deconditioning and compartment syndromes, to long term problems, such as career threatening myositis ossificans and possibly muscle tears. To assess the efficacy of thigh protectors made for Australian Football, a prospective study was undertaken involving two teams in the elite junior (U 18) VSFL competition in SE Australia. One team wore thigh protectors over the course of the season while the other team acted as controls and did not wear thigh protectors. The control group suffered nine thigh haematomas, while the protected group had none (p<0.01). The possible de-conditioning effect of the haematomas was evidenced by two of the control group suffering torn quadriceps within four weeks of the haematoma. The protectors were generally well tolerated by all but one player, except in hot conditions, when they were uncomfortable.

Perforation-Invagination (PIN) Stripping of the Long Saphenous Vein Reduces Thigh Haematoma Formation in Varicose Vein Surgery

Objective: To compare the extent of thigh haematoma formation after perforation-invagination (PIN) stripping with that occurring after standard plication stripping of the long saphenous vein. Design: Prospective, within-case, randomised study with analysis on an intention-to-treat basis. Setting: The radioisotope department of a university teaching hospital. Patients: Fourteen patients undergoing bilateral varicose vein surgery. Interventions: Red blood cell labelling in vivo with 99Tcm. Preoperative imaging of the long saphenous vein using a gamma camera. Randomisation of one leg to PIN stripping and the other to standard stripping of the long saphenous vein to the knee. Patients were reimaged 6 h postoperatively. Main outcome measures: The extent of thigh haematoma formation. Results: There was no significant difference with respect to the severity of varicosities in the long saphenous vein in the thigh between the limbs assigned to each group ( n = 11) on the preoperative images ( T = 25, 0.5&gt; p&gt;0.1, Wilcoxon signed rank test). Thigh haematoma in the limbs that had undergone PIN stripping of the long saphenous vein was significantly less than that in the limbs that had undergone standard stripping (T = 10, 0.05&gt; p&gt;0.01, Wilcoxon signed rank test). Conclusion: PIN stripping of the long saphenous vein results in significantly decreased haematoma formation compared with standard stripping.

Vascular injuries complicating osteosynthesis in proximal femur fractures

While there are quite a number of reports on vascular injuries complicating hip arthropasty by acetabular component screw fixation, retractor tip pressure or extruding bone cement, the incidence of deep femoral vessel injuries in operative fixation of proximal femoral fractures is comparatively seldom described. We report on two patients with per- and subtrochanteric femoral fractures who sustained injuries of deep femoral artery branches during the implantation of a dynamic hip screw (DHS) and a dynamic condylar screw (DCS), which resulted in a massive thigh hematoma and a fist-size pseudoaneurysm respectively and necessitated surgical intervention in either case. We blame these vascular injuries on the pressure of Hohmann retractors exposing the femoral bone or on the drilling of boreholes for plate attachment. After discussing various operative procedures, we conclude that intramedullar implants are safer than plates with regard to potential vascular complications.

Efficacy of thigh protectors in preventing thigh haematomas

Efficacy of thigh protectors in preventing thigh haematomas

Invaginating versus Classic Stripping of the Long Saphenous Vein A Randomized Prospective Study

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

Perforation-Invagination (PIN) Stripping of the Long Saphenous Vein Reduces Thigh Haematoma Formation in Varicose Vein Surgery

Perforation-Invagination (PIN) Stripping of the Long Saphenous Vein Reduces Thigh Haematoma Formation in Varicose Vein Surgery

Comparison of injuries in elite senior and junior Australian football

Three thousand and thirty one AFL and 1034 injuries in the VSFL U/18 competition were recorded by club doctors over the 1992, 1993 and 1994 seasons. Hamstring strains had the highest incidence (86.4 per 10,000 player hours) and prevalence (30.2 hours missed per 1000 hours) of any injury in the AFL, but were significantly less common in the U/18 competition. Other injuries which were common in both competitions were ankle sprains, thigh haematomas, concussion, groin strains and head lacerations. Injury prevalence was higher overall in the AFL, with lower limb muscle strains (hamstring, calf, quadriceps) being significantly more prevalent than in the U/18 competition. Injuries which were significantly more prevalent in the U/18 competition included stress fractures and concussion. Subsequent to this study, coaches and medical staff in the U/18 competition were made aware of the high risk of stress fractures in young footballers with heavy training loads. The AFL injury survey is ongoing and in the process of being computerised; risk factors for specific injuries with high rates are being studied further.

Thigh Hematoma in the Active and Aging Person with Spinal Cord Injury

An active lifestyle in the aging person with spinal cord injury (SCI) increases the potential for injuries to the musculoskeletal system. We report three unusual cases of thigh hematoma with no apparent history of trauma in aging patients with long-standing SCI. These patients were all employed and had active lifestyles. They ranged in age from 43 to 60 years, with lesions from T8 to T11 and had been paraplegic for 12-30 years. They presented with thigh swelling without any obvious cause. Diagnostic work-up did not reveal etiology. However, a functional history, re-creation of their activities and seating assessment identified the most likely causes of the thigh hematomas. Treatment of thigh hematoma is discussed. Physicians treating patients with long-standing SCI should pay special attention to changes in function and lifestyle and their potential effects on the musculoskeletal system. (J Spinal Cord Med 1997; 20:70-73)