Chronic expanding hematoma of the thigh

Chronic Expanding Hematoma With Progressive Osteolysis After Total Hip Arthroplasty: A Case Report

A 31-year-old man without any other medical history developed severe hip pain seven years after right primary total hip arthroplasty (THA). Radiography revealed extensive progressive osteolysis around the cup and stem. Periprosthetic infections and adverse reactions to the metal debris were absent. Right revision THA was performed, and chronic expanding hematoma (CEH) was diagnosed based on a comprehensive assessment. CEH should be diagnosed early because progressive osteolysis may generate an extensive hematoma. Thus, it should be considered when progressive osteolysis of an unknown cause is encountered after THA.

Minimal intervention for neurofibromatosis type I manifestations: A case report

INTRODUCTION AND IMPORTANCE

Neurofibromatosis type I (NF1, OMIM: 162200) is a benign, autosomal dominant, tumorigenic predisposing syndrome with variable manifestations. Both neurofibromatosis and soft tissue sarcomas are associated with the formation of hematomas. Moreover, skeletal manifestations of NF1 include focal or generalized forms and expansive or infiltrative growth types.

CASE PRESENTATION

A 19-year-old NF1 female patient presented with an expanding post-traumatic facial hematoma that resembled a soft-tissue tumor at initial presentation. A congenital neck mass was noted ipsilateral to her craniofacial skeletal deformities. Multiple imaging modalities were used to aid diagnosis, and urgent surgical intervention of the expanding facial lesion was performed. Her neck lesion and skeletal deformities were monitored, and her recovery was uneventful at 1-year follow-up, with no progression.

CLINICAL DISCUSSION

A palpable, non-pulsatile soft tissue mass is a common clinical presentation with a diverse differential diagnosis. Despite the low incidence of post-traumatic vascular injuries and lesions in the maxillofacial region, neurofibromatosis-associated vasculopathy remains an underestimated and serious manifestation of NF1. The reported zygomatic arch deformity is believed to be unique. However, the NF1 tumor-associated skeletal malformations are not linearly related.

CONCLUSION

NF1 is a multisystem disorder necessitating an early multidisciplinary team approach. Minimal intervention can help convert an emergent operation into an urgent one and preclude the need for major surgery. The case illustrated a rare example of simultaneous affection of soft tissue and jaw bones in NF1 patients.

Onset of Chronic Expanding Hematoma 25 Years After Total Hip Arthroplasty

Chronic expanding hematoma (CEH) is a rare anatomical condition that gradually expands due to trauma or surgery. We report the case of a 56-year-old woman who developed CEH 25 years after metal-on-polyethylene total hip arthroplasty. She presented with swelling and radiating pain in the right inguinal region. Tocilizumab was administered for treating rheumatoid arthritis and renal amyloid A amyloidosis. Diagnostic imaging and partial resection revealed a soft tissue mass and a CEH, respectively. The symptoms recurred 6 months later; dialysis was initiated, and the CEH was resected under general anesthesia, leading to improvement. This case report emphasizes the importance of prompt diagnosis and intervention in CEH management for preventing further complications and improving the patient's quality of life.

Characteristic imaging findings in a patient with chronic expanding hematoma on the floor of the mouth

Chronic expanding hematoma (CEH) is defined as chronic hematoma enlargement for more than 1 month. Although CEH rarely occurs on the floor of the mouth, the need to distinguish these cases from malignant disease is critical, given the need for potentially extensive resection in patients with malignancy. We report a case of CEH on the floor of the mouth, which required differentiation from malignant tumor. A 42-year-old woman was referred to our hospital for a submucosal mass on the right floor of the mouth, with a diagnosis of class 3 on aspiration cytology. Computed tomography revealed a submucosal mass with peripheral calcification on the floor of the mouth, which exhibited a hypointense rim on T2-weighted imaging and gradual nodular-like enhancement in the periphery on contrast-enhanced magnetic resonance imaging. Enucleation was performed to reach a definitive diagnosis, and CEH was confirmed pathologically. Well-defined morphology, presence of calcification, a hypointense rim on T2-weighted imaging, and weak peripheral nodular-like enhancement may be characteristic findings of CEH on the floor of the mouth. Accordingly, these imaging features may aid in differentiating CEH from low-grade malignancies and in determining the optimal management strategy.

Problematic Imaging Diagnostics of Musculoskeletal Gossypiboma with Chronic Expanding Hematoma Mimicking Malignant Lesion

Both musculoskeletal gossypibomas and chronic expanding hematomas have been rarely reported; the reports that do exist are usually case reports. Our objective is to demonstrate problematic imaging diagnostics of an unusual presentation mimicking a malignant lesion. We report the case of a 47-year-old man who underwent bone graft harvesting from the iliac crest for spinal fusion due to scoliosis at 18 years of age, and 29 years later, he developed a growing, painful tumor at the original donor site (a bone defect in the iliac crest). It was challenging to differentiate a hematoma from a malignant tumor based solely on clinical and radiological workup, including an ultrasound-guided needle biopsy focused on viable tissue. The definitive diagnosis of a gossypiboma with a chronic expanding hematoma was based on histopathological assessment after wide surgical resection-a chronic expanding hematoma with multiple foamy macrophages and giant cells engulfing foreign material (original surgical hemostatic sponge).

Large intraosseous chronic expanding hematoma after total hip arthroplasty presenting with chronic disseminated intravascular coagulation: a case report and literature review

Background

A chronic expanding hematoma (CEH) is a rare complication caused by surgery or trauma; it mostly affects the soft tissues, such as those in the trunk or extremities. We present the first case of a large intraosseous CEH presenting with chronic disseminated intravascular coagulation (DIC), 22 years after total hip arthroplasty (THA); the CEH was treated with a single-stage excision and revision THA.

Case presentation

A 67-year-old man presented to our hospital with left thigh pain and an enlarging mass. He had no history of trauma, anticoagulant use, or a collagen vascular disorder. The patient initially declined surgery. Two years later, radiographs and computed tomography images revealed progressive osteolysis, marginal sclerosis, and calcification in the left femur, in addition to loosening of the femoral component. Laboratory data revealed anemia and chronic DIC of unknown causes. Magnetic resonance imaging revealed a “mosaic sign” on the mass, indicating a mix of low- and high-signal intensities on T2-weighted images. Needle biopsy prior to surgery revealed no infection or malignant findings. An intraosseous CEH was suspected due to extensive osteolysis and loosening of the femoral component. No other factors that could induce chronic DIC were identified, such as sepsis, leukemia, cancer, trauma, liver disease, aneurysms, or hemangiomas. Therefore, we speculated that the anemia and chronic DIC were caused by the large intraosseous CEH. A single-stage revision THA with surgical excision was performed to preserve the hip function and improve the chronic DIC. The postoperative histopathological findings were consistent with an intraosseous CEH. The anemia and chronic DIC improved after 7 days. There was no recurrence of intraosseous CEH or chronic DIC at the 6-month follow-up. The left thigh pain improved, and the patient could ambulate with the assistance of a walking frame.

Conclusions

The loosening of the femoral component caused persistent movement, which may have caused intraosseous CEH growth, anemia, and chronic DIC. It is important to differentiate CEHs from malignant tumors with hematomas. Furthermore, the “mosaic sign” noted in this case has also been observed on magnetic resonance images in other cases of CEH.

Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report

BACKGROUND

Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor.

CASE PRESENTATION

A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved.

CONCLUSIONS

The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping.

Telangiectatic soft tissue sarcoma and chronic expanding haematoma: a comparative review of MRI features

Soft tissue sarcomas containing a dominant component of haemorrhage are known to be aggressive tumours associated with a poor prognosis. Importantly, the clinical behaviour and imaging characteristics of extensively haemorrhagic soft tissue sarcomas (also termed telangiectatic soft tissue sarcomas) can resemble those of benign haematomas, particularly those that continue to expand over a prolonged period, so-called chronic expanding haematomas (CEH). The following review evaluates the current literature to identify the clinical, imaging and pathological characteristics of telangiectatic soft tissue sarcomas and to determine features that may help distinguish them from CEH. Ultimately, we suggest that lesions with sizeable regions of internal haemorrhage should be regarded with a high degree of suspicion for underlying malignancy and require referral to a tertiary sarcoma centre, where a carefully planned approach to biopsy and follow-up is needed to avoid errors in diagnosis.

Revision Total Hip Arthroplasty due to Catastrophic Osteolysis Caused by Massive Chronic Expanding Hematoma

An 84-year-old woman who underwent bilateral cementless total hip arthroplasty (THA) for dysplastic osteoarthritis 22 years ago was subjected to analysis. A huge soft-tissue mass was revealed in her left medial thigh. Plain radiographs of the left hip joint revealed severe osteolysis around the stem, cup, and ischium. Magnetic resonance imaging showed a 25 × 14-cm multilobulated mass with a thick-walled pseudocapsule. Two-stage surgery was performed with resection of the mass followed by a subsequent revision THA. The mass was diagnosed as a chronic expanding hematoma through gross and histologic findings. Two years after the revision THA, there was no recurrence of a hematoma. Two-stage revision THA was useful for definitive diagnosis, and good functional recovery was obtained after surgery.

Ewing Sarcoma Misdiagnosed as a Traumatic Hematoma: A Case from Family Practice

Patient: Female, 13-year-old

Final Diagnosis: Ewing sarcoma

Symptoms: Swelling

Medication:—

Clinical Procedure: —

Specialty: Family Medicine

Chronic Expanding Hematomas That Occurred 20 Years or More After Primary Total Hip Arthroplasty: A Report of 2 Cases

CASE

We report 2 patients who developed chronic expanding hematomas (CEHs) more than 20 years after ceramic-on-polyethylene total hip arthroplasty (THA). One CEH occurred after a minor fall, and the other appeared with no obvious injury. Neither of the 2 was on anticoagulation. Each caused extensive osteolysis.

CONCLUSION

The only 2 previously reported post-THA cases of CEH involved metal-on-metal THAs and occurred several years after the index THA. Our patients show that CEH also can occur after ceramic-on-polyethylene THA, even after an uneventful clinical course of more than 20 years. Complete removal of both hematoma stopped osteolytic progression, with no recurrence to date.

Extracorporeal shock wave therapy treatment of painful hematoma in the calf: A case report

BACKGROUND

Extracorporeal shock wave therapy (ESWT) can be applied to various musculoskeletal conditions including calcific tendinitis. Muscle injuries can lead to hematomas, and unabsorbed hematomas sometimes cause pain. We report a case of painful hematoma successfully treated with ESWT. To our knowledge, this is the first reported case of painful intramuscular hematoma treated with ESWT.

CASE SUMMARY

A 65-year-old man visited the outpatient department for left calf pain with swelling that had persisted since he slipped two weeks prior. The calf pain had persisted and was rated visual analog scale 7. On physical examination, there was a localized, stiff, ovoid mass on his left upper posterior calf. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle; its texture was firm with low heterogeneity. We applied ESWT to the hematoma. His pain decreased immediately to a visual analog scale 3, and the mass was softened. The texture of the hematoma became more heterogeneous on ultrasonography. Due to planned overseas travel, he returned three months after the initial visit to report that the pain and swelling were dramatically relieved after ESWT.

CONCLUSION

We propose that painful hematomas could be a new indication for ESWT. Further investigation on the effects of ESWT for hematomas is needed.

Chronic Expanding Hematoma in the Thigh: A Late Complication 32 Years After Treatment of Synovial Sarcoma: A Case Report

Patient: Female, 49

Final Diagnosis: Chronic expanding hematoma

Symptoms: Thigh swelling

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Huge chronic expanding hematoma of the iliac bone following multiple hip surgeries: a case report

Background

Chronic expanding hematoma is a rare entity resulting from trauma or surgery. This condition usually occurs in soft tissue, such as the trunk or extremities, while chronic expanding hematoma arising from bone has not been reported previously. We describe an unusual case of a huge intraosseous chronic expanding hematoma arising from the ilium, which had grown over a 40-year period following hip surgeries.

Case presentation

A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral arthroplasties in childhood. A physical examination revealed a large, firm, immobile mass at her right ilium. Based on radiographic findings, a type of slow-growing bone tumor was suspected, and an incisional biopsy was performed. A histopathologic examination revealed large amounts of old clotted blood within the lesion, and the capsule of the lesion was composed of dense, fibrous, connective tissue. There was no evidence of neoplasia, and chronic expanding hematoma was suspected. The lesion was resistant to conservative treatment, and so we performed an internal hemipelvectomy (including the capsule of the mass) and a reconstruction by hip transposition 2.5 years after the incisional biopsy. There was no recurrence of chronic expanding hematoma at the most recent follow-up of 1 year and 8 months postoperatively.

Conclusions

A chronic expanding hematoma is characterized by its persistence and increasing size more than 1 month after the trauma or surgical event suspected of causing hemorrhage. To the best of our knowledge, this is the first report of chronic expanding hematoma arising from bone. We performed internal hemipelvectomy and hip transposition, and there has so far been no recurrence. This disease may be considered a differential diagnosis for bone tumor when the patient has a history of surgery or trauma, regardless of how many years have passed since the index event.

Spontaneous hematoma of the thigh associated with antiproteinase-3 antibody in a patient with metastatic squamous cell carcinoma treated with nivolumab

We report an unusual case of spontaneous intramuscular hematoma associated with antiproteinase 3 antibody in a patient with metastatic squamous cell carcinoma receiving nivolumab and the medical literature is reviewed.

Organized hematoma of temporomandibular joint

Organized hematoma is a pseudo-tumorous lesion mostly occurs at sinonasal cavity and often confused with malignant neoplasm. The initiation of this lesion is blood accumulation, probably due to trauma, and this hematoma develops into organized hematoma as it encapsulated with fibrous band and neo-vascularized. Since it is uninformed at temporomandibular joint (TMJ) region, imaging diagnosis might be challenging. Also, delayed detection of mass involving TMJ is not uncommon due to confusion with joint disorder. Thus, this report introduced the rare pathology, organized hematoma on TMJ with advanced imaging features. Also, diagnostic point for early detection was described for the TMJ tumors and pseudo-tumors considering complexity of surgical intervention in this region.

Chronic Hematoma of the Neck

Chronic hematomas are defined as hematomas with slow, progressive growth over many weeks. They are an extremely rare cause of acute neck swelling in the pediatric population. They consist of an organized central mass of blood with granulation tissue and fibrotic changes peripherally. The presence of a capsule prevents resorption but allows for intracapsular bleeding with subsequent expansion. We describe a case of a 6-year-old girl who presented to the emergency department with a spontaneously occurring left neck mass in the supraclavicular region. A possible neoplasm was suggested on imaging. The patient was referred to a head and neck surgeon, she underwent a thorough workup, and the mass was ultimately surgically excised. Histologically, the mass was confirmed to be a chronic hematoma. The patient recovered uneventfully, and there has been no recurrence.

Pitfalls in soft tissue sarcoma imaging: chronic expanding hematomas

Solid or nodular enhancement is typical of soft tissue sarcomas although high grade soft tissue sarcomas and those with internal hemorrhage often appear heterogeneous with areas of nonenhancement and solid or nodular enhancement. These MRI findings often prompt an orthopedic oncology referral, a biopsy or surgery. However, not all masses with these imaging findings are malignant. We report the multimodality imaging findings of two surgically proven chronic expanding hematomas (CEH) with imaging features that mimicked sarcomas. A third case of nonenhancing CEH of the lower extremity is also presented as a comparison. It is important that in the correct clinical scenario with typical imaging findings, the differential diagnosis of a chronic expanding hematoma be included in the workup of these patients. An image-guided biopsy of nodular tissue within such masses that proves to be negative for malignancy should not necessarily be considered discordant. A correct diagnosis may prevent a morbid unnecessary surgery and may indicate the need for a conservative noninvasive follow-up with imaging.

Chronic Expanding Hematoma in the Extremities: A Clinical Problem of Adhesion to the Surrounding Tissues

Chronic expanding hematoma is characterized by continuous growth of a blood collection. We analyzed the clinical features of 7 patients with chronic expanding hematomas in the extremities, with an average age of 65.6 years. All lesions occurred in the lower extremities, with 4 seen in the thigh and 3 in the knee region. Six patients had subcutaneous hematomas, while 1 was deep-seated in the thigh. The magnetic resonance features of the lesion were compatible with those of a standard hematoma. A low signal intensity on T1- and T2-weighted imaging at the pseudocapsule was also characteristic. Cystic features were seen in 5 of 7 patients. All lesions were resected together with their pseudocapsule. In the subcutaneous lesions, it was necessary to resect adherent fascia, with or without involved skin. In the deep-seated thigh lesion, the common peroneal nerve was completely adherent to the pseudocapsule, a phenomenon from absence of the common peroneal nerve which appeared after resection. Chronic expanding hematomas of the extremities are predominantly located in the subcutaneous tissue of the lower extremity. The surrounding pseudocapsule is adherent to the adjacent tissues, and clinicians must be aware of this, especially when resecting a deep-seated lesion.

Chronic expanding hematoma: a late complication 45 years after thoracoplasty

A chronic expanding hematoma is a hematoma with long term, continuous growth. A 69-year-old male presented with an extra-thoracic chronic expanding hematoma 45 years after thoracoplasty. Six months prior to his visit with us, he had noticed a slight swelling on his back. Three months before his visit with us, the size of the swollen area gradually increased after bowling. Magnetic resonance imaging (MRI) showed an extra-thoracic lesion measuring 120 mm in diameter. Heterogeneous signal intensity on T1- and T2-weighted images inside the lesion was reflected as hematoma of various ages. The hematoma was successfully resected after preoperative embolization. Chronic expanding hematoma can be a delayed complication after thoracoplasty.

Angiosarcoma Arising in Chronic Expanding Hematoma: Five Cases of an Underrecognized Association

Little is known about the etiology or pathogenesis of angiosarcoma (AS). We describe a series of 5 cases of AS arising in chronic expanding hematomas. Inclusion criteria were the presence of a hematoma of at least 1-year duration and a thick fibrous wall surrounding the hematoma. Patients were 4 men and 1 woman; ages ranged from 43 to 71 years. Locations were the thigh (3), chest wall (1), and pelvic soft tissue involving the ischial bone (1). Hematoma duration ranged from 2 to 25 years. All cases had large cystic hematomas >10 cm; 2 had prior radiation. Thick fibrous walls surrounded the hematomas, with foci of hemosiderin and foamy histiocytes. Wall thickness ranged from 0.2 to 1.0 cm and varied within lesions. All AS were epithelioid, and in 3 cases the tumor invaded through the cyst wall. Immunoreactive nuclear c-myc was noted in 3/3 cases available for testing. Follow-up disclosed 4 patients developed metastatic disease, 3 of whom died of disease, 4, 8, and 15 months after diagnosis; the fourth patient is alive without disease after chemotherapy at 59 months. One patient without metastases is alive without disease 18 months after diagnosis; this tumor was confined to the cyst without penetration through the wall. We identified 4 similar cases in the literature, 3 as individual case reports (all epithelioid AS), and 1 as part of a series of AS. To our knowledge, this is the first series of AS arising in chronic expanding hematomas. Recognition of this unusual complication should alert clinicians to provide periodic clinical follow-up to these patients and to biopsy any case with sudden or uncontrolled enlargement. We recommend that excised chronic hematomas be well sampled histologically to search for AS and, if identified, to determine its extent and invasiveness.

Ultrasound-guided procedures to treat sport-related muscle injuries

Ultrasound is well known as a low-cost, radiation-free and effective imaging technique to guide percutaneous procedures. The lower limb muscles represent a good target to perform such procedures under ultrasound guidance, thus allowing for clear and precise visualization of the needle during the whole procedure. The knowledge of guidelines and technical aspects is mandatory to act in the most safe and accurate way on target tissues that can be as small as a few millimetres. This review will focus above the local treatments of traumatic lower limb muscle injuries described in literature, focusing on new and promising approaches, such as platelet-rich plasma treatment of muscle tears in athletes. For each procedure, a brief how-to-do practical guide will be provided, emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the lower limb muscles.

Chronic expanding hematoma, ruptured through the skin 53 years after buttock contusion

INTRODUCTION

Chronic expanding hematoma is a relatively rare complication of soft tissue trauma and often clinically mistaken for a malignant neoplasm.

PRESENTATION OF CASE

A 71-year-old female presented with a chronic expanding hematoma that ruptured through the buttock skin 53 years after the original contusion. The diagnosis of CEH was made based on the results of the biopsy, physical examination, and CT. The tumor was completely excised, and the defect was covered with a rhomboid flap.

DISCUSSION

There are no reports of lesions rupturing through the skin. Almost all instances of chronic expanding hematoma previously reported in the English literature have a history ranging from 1 month to 20 years. There is a report of a thorax CEH that ruptured into the lung parenchyma after 24 years, so it is conceivable that other subcutaneous CEHs could break through the skin several decades after their inception.

CONCLUSION

Once this lesion has ruptured, its differentiation from other entities becomes more complicated.

Chronic expanding hematoma in the retroperitoneal space: a case report

BACKGROUND

Chronic expanding hematoma is a rare condition that develops after surgery, trauma, or injury. It can also develop at any location in the body in the absence of trauma. Clinical findings and various diagnostic imaging modalities can aid in the differential diagnosis of this condition. In general, hematomas are naturally reabsorbed and rarely cause serious problems. However, hematomas that develop slowly without a history of trauma, surgery, or bleeding disorders could be difficult to differentiate from soft tissue neoplasms. In the present case, we describe a patient, without any history or physical evidence of trauma, who exhibited a large chronic expanding hematoma in the retroperitoneal space that resulted in hydronephrosis because of the pressure exerted on the left ureter.

CASE PRESENTATION

A 69-year-old man presented to our hospital with a swollen lesion in the left flank. A mass, 19 cm in diameter, was detected in the retroperitoneal space by computed tomography. We suspected the presence of a chronic expanding hematoma, soft tissue tumor, or left renal artery aneurysm. Surgical treatment was performed. However, postoperative histopathological examination indicated that the mass was a nonmalignant chronic expanding hematoma. No recurrence was observed during a 2-year follow-up period.

CONCLUSION

In patients without a history of trauma who present slowly growing masses, the differential diagnosis should include chronic expanding hematoma in addition to cysts and soft tissue tumors. Moreover, the use of magnetic resonance imaging and computed tomography is essential to differentiate between chronic expanding hematoma and soft tissue tumors.