Delayed presentation of a non-resorbing postpartum vulvar hematoma: A case report

Vulvar hematomas are more common in the obstetric population, and usually present within 24 h of delivery. Small, nonexpanding vulvar hematomas will often resolve with conservative management. In a rural setting in the USA, a 35-year-old woman, G3P3, presented to clinic 26 days after a home vaginal delivery attended by a midwife, which was complicated by postpartum hemorrhage secondary to retained placenta. Ten days after her delivery she developed intense pressure in her inferior right vulva. On examination a 4-5 cm well defined right vulvar mass was observed. Incision and drainage were performed and the mass was determined to be a hematoma that had not resorbed. Four days later, the patient returned to clinic as the mass had reformed. Computerized tomography did not show extravasation of contrast. As examination showed the mass was now 1 cm smaller, no intervention was undertaken and after one month the hematoma had completely resolved. This case provides a rare example of the delayed development of a vulvar hematoma. In the literature, the vast majority are reported to present within 24 h of delivery. Smaller hematomas, such as this one, which was 4-5 cm, are treated conservatively, as they typically absorb. This hematoma was present for approximately two weeks without resorbing.

Delayed hematoma in gluteus medius caused by Gamma nail protrusion over the greater trochanter

Aside from cases of mechanical complications or infection short femoral nails (SFNs) are not removed after open reduction and internal fixation (ORIF) because femoral trochanteric fractures often occur in older osteoporotic females. Occasionally, SFN removal is performed because of severe chronic hip and thigh pain after surgery. However, cases of large hematoma formation in the gluteus medius with associated severe pain have not been reported in patients after ORIF.

A 58-year-old healthy woman fell and incurred a femoral trochanteric fracture at work. ORIF was performed using Gamma nail for the fracture, which was classified as AO31-1.2 according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification. The bone healed sufficiently. The patient reported chronic hip and thigh pain after ORIF, but the SFN was not removed because of concerns about further fractures. After 1 year and 8 months, she suddenly experienced severe hip and thigh pain with hip swelling, but without prior trauma. Magnetic resonance imaging (MRI) showed a large hematoma in the gluteus medius near the greater trochanter. Under general anesthesia, SFN removal was performed because of the persistent pain. After SFN removal, the chronic pain resolved without any complications, such as a femoral neck fracture.

In this case, chronic hip and thigh pain and delayed hematoma may have been caused by SFN protrusion over the greater trochanter, damaging soft tissues around the gluteus medius. Thus, soft tissue injury and hematoma are possible in patients with chronic hip and thigh pain after ORIF using SFN. In using SFN for femoral trochanteric fractures, it is important to prevent protrusion of SFN over the greater trochanter. Further careful follow-up with MRI and/or ultrasonography is needed to study delayed hematoma after ORIF using SFN.

[Clinical efficacy of acute intraoperative encephalocele prevention strategy for severe traumatic brain injury]

Objective: To explore the clinical efficacy of prevention strategy for acute intraoperative encephalocele of patients with severe traumatic brain injury (sTBI). Methods: A total of 173 patients with sTBI, who treated in Emergency Neurosurgery Department of Shandong University Qilu Hospital from January, 2011 to September, 2015 were collected and divided into research group and control group, according to their therapeutic strategy.The clinical data during hospitalization and prognosis 1 year after injury was analyzed retrospectively to clarify the effect of acute encephalocele prevention strategy. Results: There were no statistically significant differences in sex, age, preoperative Glasgow coma scale score and imaging type of lesion between patients from the two groups.The highest intraoperative intracranial pressure in the research group and control group were (35.71±4.13) mmHg and(34.85±3.81) mmHg, respectively.The acute encephalocele incidence of the research group (7 cases, 6.5%) was significantly lower than that of the control group (13 cases, 19.7%) (P<0.01). Subgroup analysis showed that the incidence of acute encephalocele in patients with only unilateral lesions was low (1.3%), while higher (19.4%) in patients with both unilateral lesions and other secondary lesions or diffuse brain swelling.The prognosis of the patients was evaluated by Glasgow Outcome Scale according to the follow-up 1 year after injury, and it was suggested that the percentage of patients with good outcome in the research group (62 cases, 57.9%) was remarkably higher than that in the control group (26 cases, 39.4%) (P=0.018). Conclusions: For sTBI patients with high risk of acute encephalocele, prevention strategy was found to be able to retard the progression of delayed hematoma and diffuse brain swelling, prevent the acute encephalocele during operation, and then significantly improve the prognosis.

The Clinical Value of Intraoperative Mobile Computed Tomography in Managing High-Risk Surgical Patients with Traumatic Brain Injury-A Single Tertiary Trauma Center Experience

OBJECTIVE

A subset of surgically treated patients with traumatic brain injury (TBI) cannot be stabilized by initial surgery. Mobile computed tomography (CT) provides real-time information for diagnosis in these TBI surgically high-risk (TBI-SHR) patients. The objective of this study was to analyze a 5-year series of TBI-SHR patients to evaluate the impact of intraoperative mobile CT (imCT) on prognosis.

METHODS

Of 1017 surgically treated patients with TBI retrospectively reviewed over a 5-year period (2009-2013), 59 patients required second operations within 72 hours of their initial surgery because of progressive or delayed hematomas (TBI-SHR group). Their clinical, radiographic, and intraoperative findings were compared among 19 patients who received imCT versus 40 patients who received fixed-unit CT.

RESULTS

Our TBI-SHR group accounted for 5.8% of all surgically treated patients with TBI. The use of imCT led to a change in surgical plan in 56% of patients with TBI intraoperatively. Younger patients (≤55 years; P < 0.05) with multifocal hemorrhage on preoperative CT (P = 0.033) and with an intraoperative unexpected event such as intraoperative intracranial pressure >20 mm Hg or acute brain swelling after adequate decompression (P = 0.003 and 0.004, respectively) significantly benefited from imCT in the TBI-SHR group. imCT also provided a quicker diagnosis (P < 0.001), led to a trend toward shorter intensive care unit stays (P = 0.077), and was associated with better neurologic outcomes at discharge days (P = 0.044).

CONCLUSIONS

The use of imCT is associated with better neurologic outcomes at discharge days compared with the use of fixed-unit CT in TBI-SHR patients.