9.5. Retroperitoneal Hemorrhage
- Lumbar plexus may be compressed within the psoas muscle:
- Weakness in territories of both obturator and femoral nerves
- Femoral nerve may be compressed in isolation by hematoma within the iliacus muscle:
- Iliacus fascia is tighter than psoas fascia: smaller hematomas produce femoral compression more frequently than diffuse lumbar plexus damage
- Iliacus and psoas hemorrhage:
- During anticoagulation
- Heparin > warfarin
- Often no preceding trauma; occasionally trivial trauma precedes the hemorrhage
- Differential diagnosis of hemorrhagic plexus lesions:
- Athletic injury; hyper extension and avulsion of the iliacus muscle from the ilium
- Localized blunt trauma; pelvic fracture
- Disseminated intravascular coagulation
- Hemophilia or other clotting disorders
- Leukemia
- Aneurysmal rupture
- Injection site in the buttocks (patients with bleeding diathesis)
- Anticoagulation
Clinical Presentation of Femoral Nerve Compression by Iliacus Hematoma
- Pain in the groin radiating to anterior thigh and medial lower leg (L3, L4)
- Position of comfort; flexed hip
- Positive reverse straight leg raising test
- Minimally painful Patrick's maneuver (internal/external rotation of the hip)
- Weakness of quadriceps; loss of sensation in femoral nerve territory
- Hematoma may be palpable in the iliac fossa or the groin
Psoas Muscle Hematoma
- Causes Plexopathy
- Negative reverse straight leg raising test (forced hip extension)
- Hip is not usually flexed; initially severe groin and lower abdominal pain
- No palpable hematoma; rarely a groin mass is palpable
- Thigh adductor muscle weakness (obturator nerve)
- Rarely hip flexion with external rotation of the leg is painful
- Abrupt drop of hemoglobin
- Hemorrhagic plexus lesions:
- Rarely bilateral
- Differential diagnosis includes:
- Appendicitis
- Post-surgical procedures
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