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Q1: What is the likely clinical diagnosis?
The triad of groin pain, hip flexion, and femoral neuropathy indicates iliopsoas sheath haemorrhage. This condition occurs in patients with inherited coagulation disorders, particularly haemophilia A, and in patients on oral anticoagulants.1,2 Spontaneous haemorrhage occurs deep to the iliacus fascia from the iliacus or psoas muscles, blood tracking from the retroperitoneal space into the pelvic extraperitoneal space. Occasionally massive bleeding can lead to signs of volume deficit.
The iliacus fascia invests the psoas major and iliacus muscles and continues inferiorly as the posterior wall of the femoral sheath. This explains the association with femoral neuropathy, the nerve lying in the groove between the iliacus and psoas muscles. The predilection for the iliacus muscle is unclear.
Q2: What lesion is shown on the computed tomograms (see p 627)?
The computed tomograms shows a collection behind the left iliacus muscle which displaces this anteriorly and separates it from the iliac blade. The left iliopsoas muscle appears enlarged with heterogeneous attenuation internally.
Q3: How should this condition be managed?
In our patient, warfarin was temporarily stopped. He was administered vitamin K, and thereafter started on heparin. The international normalised ratio came down from 7.2 to 2.0 within 24 hours. The pain resolved. There was some residual non-disabling thigh weakness at the time of discharge.
Haemorrhage into the iliacus and or psoas muscles is a well recognised complication of overanticoagulation, as well as of haemophiliac disorders. The precise incidence and initiating mechanism of this condition is unclear. Two anatomical syndromes have been described.
Spontaneous haemorrhage may commence either in the iliacus muscle, in which case bleeding occurs deep to the iliacus fascia and a femoral neuropathy may coexist. Alternatively bleeding may commence in the psoas major muscle initially or spread from the iliacus muscle to the psoas. In this case involvement of other components of the lumbosacral plexus, including the obturator nerve and the lateral femoral cutaneous nerve of the thigh, is likely. A similar clinical picture may be produced by neoplastic infiltration of the lumbosacral plexus.
Pain is the presenting feature, involving the groin, and radiating to the thigh and leg. This is followed by gradually increasing paraesthesiae and limb weakness. A flexion and lateral rotation deformity of the hip may ensue. Passive hip extension is restricted and painful. Delayed development of bruising in the groin may occur. The pain may resolve in a week, with slower and often incomplete recovery of neurological function. In 10%–15% of cases there may be no significant improvement.3
There is little definitive guidance on management, as the literature is largely anecdotal and based on case reports or small case series. Overanticoagulation needs to be recognised and corrected. Computed tomography or ultrasound guided aspiration may be helpful, especially if sepsis is suspected.4
The prognosis must remain guarded, as residual neurological sequelae are possible even where surgical treatment has been undertaken. With the increasing usage of therapeutic anticoagulation, doctors dealing with anticoagulated patients need to be aware of this clinical presentation.
Iliopsoas sheath haemorrhage.
We wish to thank Dr David Grant for selecting and commenting on the radiographs.