"Between a Clot and a Hard Place: Unraveling a Calf Hematoma Disguised as DVT": A Case Report

Case Diagnosis: 83 male with CAD s/p cardiac stent on DAPT and recent intracranial hemorrhage due to ground level fall with R calf pain

Case Description or Program Description: An 83 Y.O male with a history of hypertension, CAD s/p cardiac stenting on DAPT was admitted to acute inpatient rehabilitation following a glf resulting in a right SDH with 5mm midline shift, necessitating craniotomy and hematoma evacuation.
During rehabilitation, he reported persistent right calf pain for two weeks, which began upon ambulation in the morning. Examination revealed swelling and tenderness of right calf. Duplex ultrasound negative for (DVT) but identified focal fluid collection. POC ultrasound detected 3 cm heterogeneous fluid collection within right medial gastrocnemius versus soleus muscle, prompting conservative management. He continued to participate in therapy and his R calf pain improved.
Subsequently, he developed a LLE DVT, requiring therapeutic enoxaparin. Following discharge to subacute rehabilitation, his right calf pain worsened significantly, accompanied by a drop in hemoglobin, prompting emergent evaluation. Given the severity of his pain and concern for ongoing hemorrhage, vascular surgery performed a RLE fasciotomy with hematoma evacuation, yielding 400cc of blood from the right soleus and medial gastrocnemius. The procedure was successful, and he was discharged back to a SNF for continued rehabilitation.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: Following fasciotomy and hematoma evacuation, a wound VAC was applied to the right calf. The patient progressed to ambulation with a walker in physical therapy, with significant improvement in right leg pain

Discussion (relevance): This case highlights the utility of poc ultrasound in the inpatient rehabilitation setting for evaluating intramuscular pathology and underscores the critical need to consider compartment syndrome in a persistent, worsening intramuscular hematoma.

Conclusions: Intramuscular hematoma should be recognized as a potential cause of unilateral calf swelling and tenderness. If pain persists or worsens, vascular evaluation for possible fasciotomy and hematoma evacuation should be considered.