Case Report

Traumatic subperiosteal pseudoaneurysm: rare cause of subperiosteal hematoma

Abstract

Subperiosteal hematoma arises usually after blunt trauma to the bone. It is due to disinsertion or rupture of a muscle tendon or injury of nutrient artery of bone [1]. Subperiosteal hematoma is a Rare condition and develops mainly in the orbit because the periosteum is more loosely attached to the bone. Thus, few cases of subperiosteal hematoma in iliac bone are reported. Traumatic pseudoa- neurysm develops mainly after Penetrating or blunt trauma. It can be easily diagnosed by intravenous contrast computed tomography or magnetic resonance imaging by seen extravasation of contrast dye. We present a case of subperiosteal hematoma with subperiosteal pseudoaneu- rysm after Blunt pelvic trauma in a 17-year-old Adolescent boy. The pseudoaneurysm arose from a branch of superior gluteal artery, but it was not seen in the initial contrast computed tomography scan.

This 17-year old adolescent boy was transferred to our emergency department (ED) with severe painful right hip and weakness in the right leg. He fell to the ground on his right side while horseback riding 2 days before, and the pain had worsened progressively. He had no significant past medical history. On physical examination, there was no evidence of external trauma, for example, swelling, ecchymosis, or external wound. He was tender from the right hip and groin to the thigh. We found grade 1/5 weakness in the right hip flexor and quadriceps muscle and hyperesthesia on femoral nerve distribution. All blood work results, including coagulation test and plain radiographs, were normal. A contrast enhanced pelvic computed tomography (CT) scan was performed for further evalua- tion. We found a large hematoma arising from the right iliac wing, and there was no extravasation of contrast media (Fig. 1). He was admitted to the hospital with the diagnosis of femoral nerve palsy due to subperiosteal hematoma of iliac bone. The patient was treated conservatively, and his femoral palsy nearly resolved at hospital day 7. He was

discharged to continue rest at home. He revisited our ED 1 day later with right hip pain and weakness on the right leg after squatting on his haunches. Follow-up contrast CT scan confirmed known subperitoneal hematoma in the right iliac wing, but with more hyperdense central area (Fig. 2A). We reconstructed the CT image for evaluation of pelvic vessels and found that a 1.2 x 1.8 cm pseudoaneurysm arose from a branch of the right superior gluteal artery (Fig. 2B). Then, the patient was referred to a radiologist, who performed angiography and embolization. Access was done via right femoral artery; the culprit artery was embolized by gelfoam particles (Fig. 3). Four weeks after embolization, follow-up CT scan was performed. It showed reduction in size and no extravasation. The patient was discharged with no neuro- logic abnormalities at hospital day 30.

Subperiosteal hematoma most often occurs after blunt or penetrating trauma. NonTraumatic causes are coagulopathy, neurofibromatosis, Gaucher disease, neurofibromatosis, osteogenesis imperfecta, meningomyocele, scurvy, and Valsalva maneuver in healthy individuals [2-5]. Subper- iosteal hematoma usually occurs in the orbit in children and young adults because the periosteum is loosely attached to

Fig. 1 A large hematoma arising from the right iliac wing. There was no extravasation of contrast media.

0735-6757/$ - see front matter (C) 2009

1172.e6 Case Report

the bone in this location, and this tendency is more salient in children [6,7].

Reported cases of subperiosteal pseudoaneurysm were few. Poplausky et al [8] hypothesized that the rare development of subperiosteal pseudoaneurysms is due to the fact of that most of them are self-limiting and thrombose spontaneously. It is presumed that the reason why the pseudoaneurysm was not found in initial CT scan is the pseudoaneurysm was thrombosed temporally.

Subperiosteal pseudohematoma can be diagnosed easily by enhanced CT/magnetic resonance imaging with central extravasation of contrast agent. But temporally thrombosed pseudoaneurysm can be missed, like in our case. Angio- graphy remains the gold standard for diagnosing pseudoa- neurysm, but it is invasive. Computed tomography angiography has a shorter acquisition time, so it may be

Fig. 3 Artery was embolized by gelfoam particles.

Fig. 2 Follow-up contrast CTscan confirmed known subperitoneal hematoma in the right iliac wing, but with more hyperdense central.

more valuable in the ED. Pseudoaneurysm can be treated with conservative measure in large (N3 cm), symptomatic, expanding hematomas or those associated with large hematomas that are generally thought to be the most prone to remain patent and eventually rupture [9]. However, the risk of Spontaneous rupture of extraorganic visceral pseu- doaneurysm is very high regardless of its size [10,11]. Several treatment methods have been reported for pseudoa- neurysm but should be tailored to the site, rupture risk, and clinical setting of the pseudoaneurysm as well as to patient comorbidities. Recently, minimal invasive techniques have been developed as alternatives to traditional surgery. Ultrasonography-guided compression has replaced surgery, but only fairly superficial pseudoaneurysm can be treated. Ultrasonography-guided percutaneous thrombin injection has replaced ultrasonography-guided compression at many institutions [12]. It can be used in deep visceral arteries, especially when the donor artery is endoluminally inacces- sible [13-15]. However, it failed to thrombose in another similar case, and we felt that it was not safe in deep pelvic artery [8]. Thus, we decided to approach by transcatheter method. Endoluminal management methods (embolization and stent placement) are selected according to the expend- ability of the donor artery, pseudoaneurysmal neck size, and collateral circulation [13,16]. In the case presented, we decided to embolize the feeding artery with gelfoam.

The salient feature in this case is that subperiosteal hematoma was not seen in the initial contrast CT scan. Most subperiosteal hematomas are self-limiting but can cause continuous bleeding, resulting in serious clinical problems such as femoral neuropathy in the presence of pseudoaneu- rysm. Symptomatic hematoma should be suspicious for the presence of a pseudoaneurysm.

Case Report 1172.e7

Hyuk Joong Choi MD Department of Emergency Medicine Hanyang University Hospital

Seoul 133-792, South Korea

Christopher C. Lee MD

Department of Emergency Medicine Center for International Emergency Medicine Stony Brook University Medical Center

Stony Brook, NY 11794, USA E-mail address: [email protected]

Tae Ho Lim MD Department of Emergency Medicine Hanyang University Hospital

Seoul 133-792, South Korea

Adam J. Singer MD

Department of Emergency Medicine Center for International Emergency Medicine Stony Brook University Medical Center

Stony Brook, NY 11794, USA

doi:10.1016/j.ajem.2009.01.011

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