  |
|
|
|
|
|||
| Journal of the New Zealand Medical Association,
16-December-2005, Vol 118 No 1227
|
|||
|
Post-traumatic haematoma: a red herring to something more
sinister
Hisham Hurreiz, Irshad Hussain, Musa Barkeji
This case study describes the initial reporting of a
post-traumatic swelling as a haematoma following a relatively minor trauma,
which upon further investigation, was proven to be a high-grade
liposarcoma.
Post-traumatic haematomas occur commonly but the limits to
which another diagnosis should be sought needs to be clarified. . We present our
case study followed by a discussion on post-traumatic haematoma emphasising its
natural history as well as a brief account on soft tissue sarcomas and their
management.
Case reportA 48-year-old left-handed well-built information technology
consultant sustained a right arm bruise when he accidentally slipped onto the
edge of a workbench. This posterior mid-arm injury caused immediate pain and a
bruise. Two days later, he noticed a soft painless lump which continued to
increase in size. Two months later, his general practitioner referred him to the
surgical department due to a slow growing non-tender lump measuring 10×10.5
cm. His only significant past medical history was of well-controlled
hypertension and nasal polyps.
Initial examination suggested a haematoma but it was thought
important to rule out a false aneurysm. Duplex ultrasound scan suggested a
possible haematoma. MRI was the next investigation of choice but due to a delay
of 5 months a CT scan was requested. No muscle defect, calcification, or
intramuscular haematoma were detected on the CT scan.
Nine months after the initial injury, the patient began to
experience severe pain forcing him to seek urgent help. He presented to the
Accident and Emergency department complaining of a 1-month history of worsening
pain and paraesthesia of the right forearm and hand. Pain was now increasing
when he moved his elbow and wrist, which impeding him in his occupation; he had
been on sick leave for the last 3 weeks.
Examination revealed a 12×12×10 cm stony hard
circular lesion which was tender and immobile. There was decreased movement of
joints due to pain and right hand grip was recorded as 4/5. A subsequent
emergency MRI scan reported features which excluded the possibility of a lipoma,
with areas that could represent a haematoma with no evidence of
malignancy.
Exploration of the lesion revealed a 12×12×10 cm
smooth-surfaced, well-circumscribed, poorly encapsulated, multi-lobulated
intramuscular (triceps) mass weighing 515 grams. Histology revealed an
incompletely excised high-grade liposarcoma for which he was urgently referred
to a tertiary cancer specialist Unit. Plans were then being made for another
operation for a wide tumour clearance. This operation was performed the next
week followed by a course of radiotherapy and the patient is now recovering
well.
DiscussionPost-traumatic haematomas are commonly encountered in the
lower limbs following athletic injuries. Their clinical presentation is variable
but complete resolution usually occurs within 6 weeks of the injury.
In rare cases, the lump might persist for longer than
expected becoming hard and more circumscribed and leading to diagnostic
confusion with soft tissue sarcomas. There are reports in the literature of
ancient haematomas (up to 20 years old) clinically and radiologically mimicking
soft tissue sarcomas1 but there is no documented evidence to suggest that
long-standing haematomas have a potential to become malignant.
The occurrence of a soft tissue sarcoma developing on an
extremity following trauma in our case is probably a coincidence; usually a
minor accident or trauma draws attention to a pre-existing tumour. In these
cases, the diagnosis of a muscle haematoma should be considered if the swelling
fails to regress in size or continues to enlarge after a period of conservative
treatment; or if the history of trauma is vague and the size of the resultant
swelling does not correspond to the severity of the insult. In these cases other
sinister causes must be considered and excluded before assuming that the
swelling is due to trauma.
Soft tissue sarcomas are uncommon tumours comprising about
1% of all malignancies2 with liposarcomas constituting about 25–30% of all
sarcomas.3 They may present with diverse clinical and radiological
manifestations. The prognosis of soft tissue sarcomas is generally poor with
those affecting the extremities and trunk having a better prognosis than
visceral and retroperitoneal sarcomas.4,5 Early diagnosis is crucial if the
tumour is to be completely resected and total cure is to be achieved.
Although ultrasound and CT scans can be used as initial
radiological investigations in suspected cases of muscle haematoma, MRI is the
investigation of choice, especially if contrast is used. The diagnostic yield
from contrast MRI is high in cases of soft tissue sarcomas of the limbs as well
as in cases of post-traumatic muscle haematoma. This investigation is very
useful in the follow-up of patients with muscle injuries.6
The diagnosis of soft tissue sarcomas is usually established
by doing a core biopsy, although Singh et al showed that fine needle aspiration
biopsy (FNAB) can give results which are comparable to core biopsy, especially
when trying to differentiate between benign and malignant soft tissue tumours.
The yield from FNAB can be improved by combining it with other investigations
such as immunohistochemistry and electron microscopy.7
Sarcomas are ideally treated in specialised tertiary
referral centres by multidisciplinary teams. Treatment consists of surgical
excision (in the form of compartmental resection in case of extremity sarcomas),
combined with adjuvant radiotherapy and/or chemotherapy. The main aim of
treatment is to prevent recurrence. The expertise of plastic surgeons is needed
in cases involving the extremities to close the defect resulting after surgical
excision of the tumour.
ConclusionSoft tissue sarcomas are rare malignant tumours. Their
diagnosis is often missed due to confusion with other benign swellings. The
surgeon needs to keep an open mind in cases of limb swellings following trauma.
Moreover, all cases should be investigated thoroughly until a diagnosis of
either a benign or malignant lesion is reached.
Malignant lesions must be referred urgently to specialist
centres for further management as the consequences of delayed management are
usually serious with increased mortality and morbidity to patients.
Author information:
Hisham Hurreiz, Specialist Registrar in General Surgery; Irshad Hussain, Senior
House Officer in General Surgery; Musa Barkeji, Associate Specialist in General
Surgery, Department of Surgery, Newham General Hospital, London, United
Kingdom
Correspondence: Mr
Hisham Hurreiz,, Room 20, Pine House, Antrim Area Hospital, 45 Bush Road, Antrim
BT41 2RL, United Kingdom. Fax: +44 2894424519; email: hishamhurreiz@yahoo.co.uk
References:
|
|
|
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|