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. 2018 Jun 21;2018:bcr2017220446. doi: 10.1136/bcr-2017-220446

Femoral nerve paralysis complicating a post-traumatic iliopsoas haematoma

Mouadh Nefiss 1, Anis Tebourbi 1, Aymen Ben Maatoug 1, Ramzi Bouzidi 1
PMCID: PMC6020870  PMID: 29930178

Abstract

Paralysis of the femoral nerve secondary to iliopsoas haematoma is a rare post-traumatic complication. Because of the large differential diagnosis, a high level of suspicion is required for its early recognition. Treatment modalities are controversial due to the rarity of this entity. An 18-year-old student presented with complete paralysis of the knee extensors and a sensory deficit on the anterior side of the thigh 5 weeks after a sport accident. MRI of the lesser pelvis showed an iliopsoas haematoma. Surgical decompression was performed and recovery was complete at 6 months of follow-up.

Keywords: trauma, trauma cns /pns, orthopaedic and trauma surgery

Background

Paralysis of the femoral nerve secondary to an iliopsoas haematoma is widely reported in patients with blood coagulation disorders1 2 and those on anticoagulant treatment.3 4 However, post-traumatic aetiology is rare, with only 38 cases reported in the literature (table 1).

Table 1.

Reported cases of femoral nerve paralysis secondary to traumatic iliopsoas haematoma

Author Year Age/Sex Interval from injury to diagnosis (days) Quadriceps paralysis Surgery Neurological recovery
Tallroth15 1940 16/M 10 Complete Yes Complete
Strandell16 1942 18/M 9 Incomplete Yes Incomplete
19/M 18 Complete Yes Complete
Negishi17 1966 16/M 19 Incomplete No Incomplete
Green18 1972 16/F 6 Complete Yes Complete
Kunimatsu et al19 1976 16/F 1 Incomplete No Complete
Kataoka20 1976 17/F 25 Complete Yes Incomplete
Ramirez et al21 1983 18/M 30 Complete Yes Complete
Tanabe et al22 1984 13/M 24 Incomplete Yes Complete
14/M 25 Incomplete Yes Complete
Endo et al23 1988 14/M 0 Incomplete No Complete
32/M 2 Incomplete No Incomplete
Takemasa et al24 1988 18/M 0 Complete Yes Complete
Suzuki et al25 1988 18/F 2 Incomplete Yes Complete
Ogawa et al26 1990 42/M 60 Complete Yes Incomplete
Berlusconi and Capitani27 1991 M Not known Incomplete No Complete
Kohno et al28 1992 16/M 4 Incomplete Yes Complete
14/M 7 Incomplete Yes Complete
Rochman et al14 2005 20/M 7 Incomplete Yes Complete
Na et al29 2012 17/M 15 Incomplete Yes Complete
Sallahi et al30 2015 14/M 90 Complete Yes Incomplete
Lefevre et al5 systematic review: 16 patients 2015 Mean age: 16.6
11 M, 5 F		 2 days to 6 weeks Complete: 8/16
Incomplete: 8/16		 Yes: 9/16
No: 7/16		 Complete: 13/14
Incomplete: 1/14
Not reported: 2
Total 75 years Mean age: 17.6
Sex ratio: 29 M:9 F		 Mean: 16.7 days Complete: 14/38
Incomplete: 24/38		 Yes: 25/38
No: 13/38		 Complete: 28/36
Incomplete: 8/36
Not reported: 2
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F, female; M, male.

Management of these cases is still controversial, and there is no large series of patients from which to base treatment decisions.5–7 We present a case of femoral nerve palsy secondary to post-traumatic iliopsoas haematoma that resolved by operative management in an adolescent. We review the current literature available on this subject.

Case presentation

A healthy 18-year-old man in the terminal class of a secondary school fell down while preparing for a gymnastic exam. He described a fall on the lower left limb, causing pain in the groin area. He was unable to walk, which made him consult the emergency, where he received symptomatic drug, including non-steroidal anti-inflammatory drug. The pain became worse the following days and was associated with numbness and weakness of the left thigh. This paralysis was incomplete after injury, and progressed to complete paralysis later. He was admitted to our hospital 5 weeks after the injury.

On examination, he was not able to walk without support. A soft, tender mass was palpable on the left iliac fossa and the groin (figures 1 and 2). The thigh girth was 2 cm smaller on the left side than on the healthy side. The results of manual muscle testing of the left lower limb were 1 for the hip flexor and 0 for the knee extensors. Patellar tendon reflex was absent. Skin sensation was absent in the anterior aspect of the left thigh.

Figure 1.

Figure 1

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Amyotrophy of the left quadriceps.

Figure 2.

Figure 2

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Mass on the left iliac fossa.

Investigations

Plain radiographs of the pelvis were normal. Blood tests (coagulation time, prothrombin time and platelet count) did not show any abnormalities. An MRI revealed a haematoma of the iliacus muscle measuring 93×63×60 mm. The signal intensity in the mass varies from low to high on both T1-weighted and T2-weighted images (figure 3).

Figure 3.

Figure 3

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MRI of the pelvis before surgery. The signal intensity in the mass varies greatly, ranging from low to high. (A) Coronal and (B) axial images showing haematoma enveloping the femoral neurovascular bundle.

Complete paralysis of the femoral nerve resulting from the post-traumatic iliacus muscle haematoma was confirmed.

Treatment

Surgical evacuation of the haematoma was carried out under general anaesthesia (figure 4).

Figure 4.

Figure 4

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Evacuation of the haematoma.

Outcome and follow-up

The postoperative course was uneventful. The quadriceps muscle power returned to fair at 3 months and to normal at 6 months (figure 5, video 1).

Figure 5.

Figure 5

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Examination at 3 months.

Video1.

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DOI: 10.1136/bcr-2017-220446.video01
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Examination at 3 months.

Discussion

Paralysis of the femoral nerve due to compression by a haematoma of the iliopsoas in the lesser pelvis is a well-known complication in patients receiving anticoagulants (the incidence ranges from 1.3% to 6.6%) and haemophiliacs (the incidence ranges from 5.5% to 10.4%).7–9 This entity has also been described after hip surgery and surgery of the lesser pelvis.10 However, traumatic aetiology has not been reported widely in the literature. All published reports occurred in young patients (12–24 years old), and the common mechanism of injury is a sport accident (table 1).

Aetiopathogenesis hypothesis reported that the femoral nerve follows a pathway between the tendon of the psoas and the iliacus muscle, then passes under the iliac fascia, which is thick and not easily deformed. As a result, the femoral nerve is compressed along the iliopsoas groove and is then paralysed. This has been investigated experimentally by infusion of fluid or latex injection into the iliacus sheath.7 11 12

Haematomas in this region present insidiously and are not heralded by an obvious lesion or ecchymosis.6 On top of that, it is not spontaneously evacuated and causes chronic compression of the femoral nerve.

The diagnosis is suggested by questioning and clinical examination. In the most common cases, patients suffered from pain in the groin or the pelvis secondary to lumbar or pelvic trauma while participating in sports. They report numbness of the anterior thigh with weakness of the knee extensors.

Neurological symptoms developed rapidly (mean of 5 days after injury) and femoral palsy can be complete or partial. The severity of the nerve injury can be determined by an electromyography exam, and a diagnosis of compressive iliopsoas haematoma is confirmed by CT scan or MRI.5

The differential diagnosis for this syndrome is large, and early recognition requires a high level of suspicion.6 It can mimic a simple muscular strain, and if treated with non-steroidal anti-inflammatory drugs can lead to progression of the haematoma. The delay between the injury and the diagnosis varies from 2 days to 6 weeks.5

There is no large series of patients from which to base treatment decisions and modalities. The progressive nature of the neuropathy and anatomical studies showing a gradual increase of internal pressure in the iliacus compartment raise a question as to the method of treatment and its timing.13 Traditionally, non-operative treatment has been recommended in patients with blood dyscrasia and surgical decompression for cases of iliacus haematoma resulting from trauma.6 An alternative to open surgical treatment is percutaneous decompression. This treatment can be used only for liquid haematomas, and it would not be useful for patients whose diagnosis is delayed until they already have organised haematomas.7 14

We recommend conservative treatment in case of early diagnosis and partial paralysis, with close monitoring and surgical treatments in case of later diagnosis, especially in the presence of complete paralysis. The prognosis after surgical decompression is not pessimistic even in patients with complete paralysis.

Learning points.

  • As the number of young adults participating in sport increases, it is important to include iliacus haematoma in the differential diagnosis of groin pain.

  • Conservative management can be proposed under strict supervision of the neurological examination.

  • In case of complete femoral nerve palsy, surgery is necessary regardless of the delay between injury and diagnosis.

Footnotes

Contributors: All authors have approved of the submission. MN: information-gathering for scientific research and writing. AT: the patient’s surgeon, correction of the article. ABM: scientific research. RB: correction of the article.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

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