Femoral nerve palsy secondary to traumatic pseudoaneurysm and iliacus hematoma

Abstract

The authors report a case of traumatic femoral nerve palsy caused by a pseudoaneurysm of the iliolumbar artery and a iliacus muscle hematoma. This case report details not only the classic history and physical findings seen in patients such as this one, but also illustrates an unusual source of the hematoma and a discussion of its treatment. A 20-year-old man was assaulted and presented to the authors's institution with a 1-week history of severe pain in the left anterior thigh and groin, weakness in the left quadriceps muscle, and numbness in the anterior thigh and medial distal leg. Imaging studies demonstrated a large, 9.4 x 6.4 x 5.2-cm iliacus hematoma as well as a pseudoaneurysm originating from the left iliolumbar artery. The patient underwent angiographic embolization of the pseudoaneurysm followed by surgical evacuation of the hematoma. The embolization was performed before surgery to prevent any possible rebleeding from the pseudoaneurysm during evacuation of the hematoma. Femoral nerve palsy caused by traumatic iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. In this case, embolization of the iliolumbar artery pseudoaneurysm followed by surgical evacuation of the hematoma resulted in a nearly full recovery of the femoral nerve as of the last follow-up examination.

Subperiosteal hematoma of the iliac bone: imaging features of acute and chronic stages with emphasis on pathophysiology

“…Avulsion of the periosteum covering the internal surface of the iliac bone is prone to damage the nutrient vessels, mostly branches arising from the iliolumbar artery [12]. In a few cases in the literature, the authors observed a small pseudoaneurysm in the vicinity of these nutrient foramina [4,13,14]. For some authors, the presence of these aneurysms may explain brisk bleeding from the medial and inferior walls of the subperiosteal cavity during surgery [2,8].…”

“…This semiological aspect requires further discussion as this distinction was not always made in similar cases in the literature. Based on the published images, numerous cases reported as "intramuscular" iliac hematomas [13,14,[17][18][19][20][21][22] may actually have been subperiosteal hematomas (Table 3). Interestingly, all these patients were under 22 years old, further supporting the theory of periosteal avulsion.…”

“…On the other hand, patients with genuine intramuscular hematomas were older and receiving anticoagulant therapy [23][24][25][26][27][28]. Although surgical correlation was obtained in some of these misclassified cases [13,14,18,19,21], the procedure was perhaps aimed more at immediately treating femoral nerve compression than determining the precise location of the hematomas. Moreover, the exact location of the periosteum in a highly remodeled and bulging muscle may be hard to investigate from a superficial subperitoneal portal.…”

Femoral nerve palsy due to Iliopsoas hematoma

“…The treatment of the disease may differ depending on the severity of symptoms and underlying disease. If the hematoma is small or there is evidence of clinical improvement, conservative treatments such as bed rest, correction of blood coagulation disorder and transfusion are preferred (7). Treatment decision about this clinical entity depends on the speed of onset, the size of hematoma and the degree of neurological impairment.…”

Diagnostic Gait Pattern of a Patient with Longstanding Left Femoral Nerve Palsy: A Case Report

“…2,3 Iatrogenic injury may occur as a result of the lithotomy position, prolonged traction, thermal injury or laceration. 4 The reported incidence of iatrogenic injury ranges from 0.2% to 0.4%.…”