Acute Compartment Syndrome from Spontaneous Intramuscular Hemorrhage in the Setting of Converging Hemostatic Risk Factors: A Case Report
Year: 2026
Type: article
Abstract: Introduction: Acute compartment syndrome secondary to spontaneous intramuscular hemorrhage is an uncommon but limb-threatening complication of anticoagulation. Severe hemorrhagic complications during anticoagulation are frequently multifactorial. Yet, clinical attention often focuses narrowly on anticoagulant transition timing rather than the full burden of concurrent hemostatic risk factors an orthopedic surgeon must weigh when managing these patients surgically. Case Report: A 50-year-old male with prior deep venous thrombosis (DVT), coronary artery disease, long-term exogenous testosterone use, and a personal history of prolonged post-dental bleeding presented with acute left calf pain and was diagnosed with popliteal DVT. He received enoxaparin 90 mg subcutaneously (one dose) and was prescribed rivaroxaban 15 mg twice daily; he also continued aspirin 81 mg daily, fish oil, and high-dose cayenne pepper supplementation. Approximately 13 h after enoxaparin and 1 h after his first rivaroxaban dose, he returned with worsening pain. Imaging revealed a rapidly expanding intramuscular hematoma progressing to acute compartment syndrome, necessitating emergent four-compartment fasciotomy and reoperation for diffuse soft-tissue hemorrhage without a discrete vascular source. Conclusion: At least six concurrent patient-intrinsic hemostatic risk factors were identified: antiplatelet therapy, platelet-modifying supplementation, exogenous testosterone with potential pharmacokinetic interaction, testosterone-associated erythrocytosis, mildly reduced renal clearance, and a personal bleeding history consistent with an incompletely evaluated bleeding diathesis. The same outcome could plausibly have resulted from rivaroxaban alone. Orthopedic surgeons managing anticoagulated patients should conduct systematic, individualized hemostatic risk assessment rather than focusing narrowly on anticoagulant transition timing.
Authors: Jade Griffin, Daniel Komlos
Institutions: Texas A&M University, Houston Methodist
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $250
OpenAlex ID: W7225595982
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