Acute major haematoma in a patient on long-term anticoagulation: Case report

Title : Acute major haematoma in a patient on long-term anticoagulation: Case report

Abstract:

Background: Intramuscular haematomas account for approximately 5.8% of emergency department admissions and occur predominantly in anticoagulated patients, particularly older women with renal impairment. Reduced creatinine clearance may lead to accumulation of anti-factor Xa activity, predisposing to significant bleeding even in the absence of active haemorrhage on imaging.

Case Presentation: A 58 year-old woman with chronic kidney disease, short gut syndrome with ileostomy, chronic obstructive pulmonary disease, and portal vein thrombosis on lifelong LMWH presented following a fall three weeks earlier. During admission for electrolyte imbalance and acute kidney injury, she developed an acute haemoglobin drop from 117 g/L to 55 g/L. CT imaging demonstrated extensive intramuscular haematomas involving the right gluteal and anterior, posterior, and adductor compartments of the thigh. Despite transfusion and absence of active haemorrhage on CT angiography, haemoglobin continued to fall with increasing pain and tense swelling, raising concern for delayed compartment syndrome. She underwent fasciotomy with evacuation of haematoma and was transferred to the intensive care unit for postoperative observation. Twenty days postoperatively, she developed a spontaneous anterior thigh swelling with a further haemoglobin drop from 120 g/L to 45 g/L and worsening renal function (eGFR). Repeat CT and CT angiography demonstrated multifocal, organised intramuscular haematomas without active haemorrhage and preserved vascular flow. Anticoagulation was withheld and she was managed conservatively with gradual clinical and radiological resolution.

Conclusion: This case highlights the diagnostic and management challenges of recurrent intramuscular haematomas in anticoagulated patients with renal impairment, emphasising the importance of multidisciplinary assessment, careful anticoagulation management and close clinical surveillance when imaging is inconclusive.

Biography:

Dr. Zena Alwaily is a UK-trained junior doctor who completed her medical degree at the University of Dundee and is currently in foundation training within NHS Scotland. She has developed broad clinical experience across surgery, trauma and orthopaedics, and acute medicine. Zena has a particular interest in trauma and orthopaedics, education, and quality improvement, leading and presenting departmental audits in surgery. She is actively involved in teaching medical students and developing accessible e-learning resources. Her academic interests include trauma, peri-operative decision-making, and improving diagnostic pathways. She aspires to pursue specialty training while continuing clinical research and innovation.