Working Diagnosis:
Spontaneous intramuscular hematoma

Prior to the patient's CT, though after his INR level was obtained, a reviewed differential included: intramuscular hematoma, occult acetabular fracture, avulsion fracture or subluxation.

Treatment:
Patient was given fresh frozen plasma (FFP) and IV vitamin K for his elevated INR. Repeat level was 2.96.

Orthopedics recommended conservative management and monitoring for signs of compartment syndrome, expanding hematoma or femoral nerve irritation. The patient was advised to apply heat to the thigh areas to promote resorption and was weight bearing as tolerated.

Outcome:
The patient was ambulating well with the assistance of a rolling walker within 2 days. Prior to his total hip arthroplasty he was ambulating with a rolling walker at home though he was able to ambulate without assistive device following his surgery. Therefore he was ultimately discharged to a short term rehab unit where he worked with physical therapy 3 times a week to regain his baseline mobility.

Author's Comments:
A spontaneous muscular hematoma is a rare complication of anticoagulation. The true incidence is unknown as the condition is often misdiagnosed. A drop in hemoglobin or abnormalities in coagulation should prompt consideration for further work up. Treatment is centered around supportive care with blood transfusions and reversal of anticoagulation agents. Incision and drainage is indicated when hematomas compromise neurovascular structures or fail conservative management. The femoral nerve traverses through the iliacus muscle. Due to the anatomy, iliacus muscle hematomas can cause femoral nerve compression and it is important to perform a thorough motor and sensory exam of the affected extremity.

Editor's Comments:
Dislocations following a total hip arthroplasty will often present with an internally rotated and shortened leg due to entrapment of the femoral head behind the acetabulum. Dislocations will often occur due to patient noncompliance with post operative restrictions, implant malpositioning, or soft tissue injuries/deficiencies. The majority of dislocations will occur within the first month with higher risk in female patients, over 70 years old, prior spinal fusion, and posterior approach. Dislocations that present over 5 years from original surgery are often related to polyethylene liner degradation.

References:
1. Palatucci V, Lombardi G, Lombardi L, Giglio F, Giordano F, Lombardi D. Spontaneous muscle haematomas: management of 10 cases. Transl Med UniSa. 2014;10:13-17. Published 2014 Apr 8.
2. Kong WK, Cho KT, Lee HJ, Choi JS. Femoral Neuropathy due to Iliacus Muscle Hematoma in a Patient on Warfarin Therapy. J Korean Neurosurg Soc. 2012;51(1):51-53.
3. Shimodaira M, Kitano T, Kibata M, Shirahata K. An oblique muscle hematoma as a rare cause of severe abdominal pain: a case report. BMC Res Notes. 2013;18:6-18.
4. Titone C, Lipsius M, Krakauer JS. Spontaneous hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery. 1972;72(4):568-72.
5. Zahar, A; Rastogi, A; Kendoff, D. Dislocation after total hip arthroplasty. Current reviews in musculoskeletal medicine. 2013. 6(4) 350-356

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