AJR 2005; 185:S186-S187
© American Roentgen Ray Society
AJR Teaching File: Groin Pain
Catherine C. Roberts1
1 Department of Radiology, Mayo Clinic College of Medicine, 13400 E. Shea Blvd.,
Scottsdale, AZ 85259.
Received February 23, 2005;
accepted after revision March 18, 2005.
Address correspondence to C. C. Roberts
(roberts.catherine{at}mayo.edu).
Clinical History
This article discusses a 72-year-old woman with right groin pain, 5 years
status post–right total hip arthroplasty.
Radiologic Description
A sonogram performed at another institution shows a complex cystic mass,
which is misinterpreted as being adnexal in location
(Fig. 1A). CT and MR images
(Figs. 1B and
1C) obtained at another
institution show an elongated cystic structure extending along the anterior
border of the iliopsoas muscle to the level of the hip arthroplasty distally.
The mass displaces the right external iliac artery and vein medially. A
conventional hip arthrogram and CT arthrogram show extension of contrast from
the hip joint into the cystic mass (Figs.
1D and
1E).
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Fig. 1B —72-year-old woman with groin pain. Enhanced CT performed at outside
institution shows rounded, low-density lesion (arrows) lying between
right total hip arthroplasty and femoral vessels.
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Fig. 1C —72-year-old woman with groin pain. Coronal T2-weighted MRI through
anterior pelvis, performed at outside institution shows ovoid collection
extending along iliopsoas muscle and displacing femoral vessels.
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| QUESTION 1
What is the best diagnosis for this case?
- Ovarian neoplasm.
- Inguinal hernia.
- Distended iliopsoas bursa.
- Sarcoma.
|
Diagnosis
The iliopsoas bursa is the largest bursa in the body
[1]. This bursa communicates
with the hip joint in 15% of normal adults
[2–3].
Bursal communication with the hip is seen more commonly after hip
arthroplasty, possibly due to surgical disruption of the bursal wall or
increased intraarticular pressure from excess joint fluid. The iliopsoas bursa
may become distended due to any condition that causes excess joint fluid or
bursal synovial proliferation. Distended iliopsoas bursae have been associated
with hip arthroplasties, arthritis (inflammatory and degenerative), trauma,
overuse, osteomyelitis, and metastatic disease
[3–4].
A joint effusion is commonly, but not always, seen at presentation
[5].
The diagnosis of a distended iliopsoas bursa typically can be made with
standard CT or MRI with attention to the anatomic location and communication
with the hip joint [6]. On
sonography, the location and joint communication can be more difficult to
assess [2,
6,
7]. However, sonography best
evaluates for symptomatic mass effect on adjacent structures. When another
institution has labeled the mass as suspicious for a neoplasm or when the
bursal contents are complex in nature, it may be helpful to perform an
enhanced study to exclude a solid neoplasm. Alternatively, a conventional hip
arthrogram could be performed to prove that the bursa communicates with the
hip joint. If communication is not seen unequivocally, a few limited
postarthrogram CT images through the region can show more subtle contrast
extension [1,
8].
| QUESTION 2
If not considered in the differential diagnosis, a distended iliopsoas
bursa can be confused with:
- A sarcoma, if contrast is not administered.
- An ovarian neoplasm, if careful attention is not paid to location and
extent on sonogram.
- An inguinal hernia, if bowel or fat contents are not identified.
- All of the above.
|
| CONTINUING MEDICAL EDUCATION
The AJR Teaching File articles are available for 0.25 CME credit
(both articles must be completed). They are free to ARRS members and may be
purchased by nonmembers for $10.00 each. Detailed information including
objectives, disclosure information, and how to obtain CME credit can be found
at
www.arrs.org
by selecting AJR Integrative Imaging.
|
The multiple-choice options for Question 1 of ovarian neoplasm (Option
A), inguinal hernia (Option B), and sarcoma (Option D) are
less likely given the imaging studies provided. An ovarian neoplasm (Option
A) would be intraperitoneal in location. This was the original diagnosis
from a different institution. Careful attention must be paid to the location
and extent of the mass adjacent to the hip joint. An inguinal hernia
(Option B) would typically contain fat or bowel and should be
contiguous with the peritoneal cavity. A sarcoma (Option D) would be
expected to enhance. The anatomic location, extending from the hip joint
proximally to lie between the iliopsoas muscle and the external iliac vessels,
favors a distended bursa (Option C), as does communication of
intraarticular contrast.
Treatment usually is only necessary if the distended bursa is painful or is
impinging on adjacent structures, such as the external iliac or common femoral
veins. Treatment of the underlying cause of excess joint fluid (loose
prosthesis replacement), antiinflammatory medication, the use of sclerosing
agents, and surgical bursectomy are all therapeutic options
[6].
Objective
The educational objective of this article is to illustrate the typical
appearance of a distended iliopsoas bursa. This bursa can have a normal
communication with the hip joint and have complex contents.
Conclusion
Knowledge of the appearance and location of the iliopsoas bursa can help
differentiate it from other pathologic entities in this region.
References
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- Pritchard RS, Shah HR, Nelson CL, FitzRandolph RL. MR and CT
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K, Kainberger F. Imaging features of iliopsoas bursitis. Eur
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- Steinbach LS, Schneider R, Goldman AB, Kazam E, Ranawat CS, Ghelman
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arthrography and CT. Radiology 1985;156
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Clinical History
Radiologic Description
