Soft tissue bleeding is common in hemophila. Following a direct injury, a large hematoma may accumulate in the subcutaneous tissues. This generally is resorbed spontaneously occasionally ulceration occurs, commonly on the forehead, the olecranon process, or the prepatellar area.
Superficial soft-tissue hemorrhage in the form of ecchymosis is common in the severe hemophiliac. It is of no clinical significance.
Intramuscular and Intermuscular Hemorrhage
Quadriceps is most common site of bleeding in lower limb. Other comon sites are triceps surae,adductors of the thigh, hamstrings , and sartorius.
In the upper limb the most common site of bleeding is deltoid, followed by wrist and finger flexors in the forearm, brachio-radialis, biceps, wrist and finger extensors in the forearm, and triceps.
The presenting complaint is pain on movement or at rest.
However, hemorrhage in the quadriceps muscle may present only as stiffness or weakness of the knee.
- Bleeding in the deltoid muscle will restrict shoulder motion.
- Bleeding in the forearm flexors will restrict motion of the fingers, or elbow either alone or in combination.
- Hemorrhage into the iliopsoas muscle or retroperitoneum may mimic a variety of surgical or medical emergencies such as appendicitis or renal colic.
- Hemorrhage within the calf muscles will produce fixed equines deformity.
- Bleeding in the volar surface of the forearm may produce Volkmann’s ischemic contracture with flexion deformity of the digits and wrists..
Diagnostic ultrasound is carried out routinely in hemophiliac patients in whom hemorrhage into joints or soft tissues is suspected. It is noninvasive and can be performed at the bedside with minimal disturbance of the patient.
Hemorrhage into superficial joints-such as the knee, elbow, ankle, or wrist is readily determined by physical examination.
The diagnostic value of ultrasound is in identification of bleeding into the hip, shoulder, and deep soft tissues such as the iliopsoas or retroperitoneum. Effusions into these deep anatomic sites are readily detected by ultrasound.
A sudden increase in echogenicity indicates a fresh hemorrhage.
The echo pattern of bleeding into joints depicts a mixture of echo-free fluid within the joint and a variable amount of echogenic material floating free.
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