A 41-year-old male player presents with a history of recurring calf pain and swelling. He describes recurring calf pain after activity since an index injury 15 years previously. He has also noted an asymmetry in appearance between his calves. On examination there was an obvious swelling distal to the medial head of gastrocnemius and an increased calf circumference (4cm greater on the symptomatic side).
On the lateral x-ray view, there are two serpiginous foci of mineralisation within the posterior soft tissues in the right mid-calf. These appearances most likely reflect dystrophic calcification related to prior trauma. The ultrasound images show a large hypoechoic area with a smooth and regular border. The MRI sequences show a well-defined ovoid fluid collection at the distal myotendinous junction of medial gastrocnemius. It has a thin low signal margin and is predominantly filled with T1 and T2 high-signal fluid, suggestive of proteinaceous material. This is in keeping with a walled off haematoma with a haemosiderin rim and is consistent with a previous myotendinous junction tear.
The imaging findings were discussed with the player. A coagulation screen was performed and was found to be normal. There was a discussion about several different treatment options including further observation (given that his symptoms had not been too concerning), aspiration and surgical evacuation. It was decided that aspiration would be attempted. A total of 50mls of dark-red serous material was aspirated. This was found to contain moderate numbers of inflammatory cells, including macrophages, on a background of blood. It was felt that this was consistent with an inflamed cyst with haemorrhage. After three-month follow up there was no evidence of either infection or recurrence. The player had returned to sport and was satisfied with the results.
‘Ancient’ haematoma is one of several lesions that require differentiation from soft tissue neoplasms. This entity is a benign soft tissue tumour surrounded by a fibrous pseudo-capsule with inflammatory cells present inside the capsule. In most cases it gradually expands in size over time.
The vast majority of haematomas are easy to diagnose on the basis of a patient’s history, clinical examination and/or imaging studies. ‘Ancient’ haematomas are however very rare, and the diagnosis is based on the exclusion of other pathologies. The protracted time interval between the traumatic event (or sometimes surgery) and mass development can hinder the diagnosis. A recent case review only identified 208 cases of ‘ancient’ hematoma with only three cases involving the calf. In all these three cases surgery was performed.
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