European Journal of Radiology. 10 (1990) 156-158
Elsevier
156
EURRAD
00042
An unusual swelling in the groin H. Wiese ‘, B.B.A.M. Niers 2, P.M. Huisman ’ and W.K. Taconis Departments of ‘Radiology and 20rthopaedic
(Received 5 November
Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam,
1989; revised version received 25 December
1989; accepted
’
The Netherlands
5 January
1990)
Key words: Bursa iliopsoas; Inguinal swelling
Case report A 53-year-old female presented at the orthopaedic outpatient department with a tender diffuse swelling of her right leg. The right leg was peripherally cyanotic with delayed capillary refill. A fluctuating unpainful swelling was palpable in the right groin. The femoral and popliteal pulses were normal, but the pulses of the posterior tibial and dorsalis pedis arteries were not palpable. Homan’s sign appeared to be negative. She had an antalgic gait. Deep venous thrombosis seemed the most likely clinical diagnosis. Radiologic examination of the right hip showed minor osteoarthritic changes. Phlebography of the right leg showed compression of the femoral vein (Fig. 1). There was no evidence of deep vein thrombosis. Ultrasound revealed a cystic mass just posterolateral to the common femoral artery. An ultrasound guided puncture of the cystic mass was carried out and 15 cc of yellow viscous liquid were aspirated. Bursography revealed the full extent and location of an enlarged iliopsoas bursa (Fig. 2). Arthrography revealed no communication between the hip joint and the cystic mass.
Address for reprints: H. Wiese, Department of Radiology, Onze Lieve Vrouwe Gasthuis, le Oosterparkstraat 179, 1091 HA Amsterdam, The Netherlands. 0720-048X/90/$03.50
0
1990 Elsevier
Science Publishers
Fig. 1. Phlebography of the right leg. The femoral vein compressed in the area of the femoral head.
B.V. (Biomedical
Division)
Fig. 3. Relationships ofthe iliopsoas bursa and the hip. (1) iliopsoas bursa, (2) femoral artery and vein, (3) iliofemoral ligament, (4) pubofemoral ligament, (5) divided tendon of the ihopsoas muscle, (6) inguinal ligament.
Discussion
Fig. 2. Bursography: lateral view. Contrast medium is seen in the iliopsoas bursa (2), located ventrally to the femoral head (1). Some extravasation (3) is seen anterior to the bursa.
Diagnosis: iliopsoas bursa At operation the iliopsoas bursa was found to be 10 cm in diameter, compressing the femoral artery and vein. The bursa was totally resected. After the operation the symptoms completely disappeared.
The iliopsoas bursa is located in front of the capsule of the hip joint and beneath the iliopsoas muscle. It is bounded laterally by the iliofemoral ligament, cranially by Poupart’s ligament, medially by the cotyloid ligament and inferiorly by the pubofemoral ligament (Fig. 3). A variety of names have been given to the iliopsoas bursa, such as the iliopectineal, iliofemoral, subpsoas and iliac bursa. The iliopsoas bursa is present in 98% of adults and is almost always bilateral [l-3]. A cadaver study performed by Chandler revealed a considerable variation in the size of the bursa. The average size was 3 x 6 cm [2,4]. In approx. 15 %, an anatomical communication was demonstrated between the bursa and the hip joint, in such cases the bursa may therefore be regarded as an outpouching of the synovial membrane of the hip joint. Trauma, abnormal hip joint motion, total hip arthroplasty, degenerative joint disease or rheumatoid arthritis may contribute to the enlargement of the bursa [2]. An enlarged bursa can be asymptomatic [ 51. On the other hand it can cause pain and restriction of hip motion. As a result of compression of the femoral vein and the lymphatics, oedema of the leg may occur [6].
158
Occasionally, symptoms are due to trauma or superimposed infection of the bursa [7]. Retroperitoneal extension of an enlarged bursa can also displace pelvic structures such as the ureter or the intestines [6,8]. These symptomatic bursae usually recur following aspiration, and subsequently require surgical excision. Melamed advised arthrography of the hip to demonstrate possible communication with the bursa. In our case no such communication was demonstrated. To facilitate planning of the operation we also performed a bursography guided by ultrasound. Although there was some extravasation of contrast medium, a fair idea of the location and the extent of the bursa was obtained.
References Witter JA, Swingle NE. Ilioinguinal swellings. Am J Surg 1957; 94: 653-651. Chandler SB. The iliopsoas bursa in man. Anat Ret 1934; 50: 235-240. Finder JG. Iliopectineal bursitis. Arch Surg 1938; 36: 519-530. Janus C, Hermann G. Enlargement of the iliopsoas bursa: unusual cause of cystic mass on pelvic sonogram. J Clin Ultrasound 1982; 10: 133-135. Armstrong P, Saxton H. Ilio-psoas bursa. Br J Radio1 1972; 45: 493-495. Melamed A, Bauer CA, Johnson JH. Iliopsoas bursal extension of arthritic disease of the hip. Radiology 1967; 89: 54-58. Samuelson C, Ward JR, Albo D. Rheumatoid synovial cyst of the hip. A case report. Arthritis Rheum 14: 105, 1971. Staple TW. Arthrographic demonstration of iliopsoas bursa extension of the hip joint. Radiology 1972; 102: 5 15-516.
Elsevier
156
EURRAD
00042
An unusual swelling in the groin H. Wiese ‘, B.B.A.M. Niers 2, P.M. Huisman ’ and W.K. Taconis Departments of ‘Radiology and 20rthopaedic
(Received 5 November
Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam,
1989; revised version received 25 December
1989; accepted
’
The Netherlands
5 January
1990)
Key words: Bursa iliopsoas; Inguinal swelling
Case report A 53-year-old female presented at the orthopaedic outpatient department with a tender diffuse swelling of her right leg. The right leg was peripherally cyanotic with delayed capillary refill. A fluctuating unpainful swelling was palpable in the right groin. The femoral and popliteal pulses were normal, but the pulses of the posterior tibial and dorsalis pedis arteries were not palpable. Homan’s sign appeared to be negative. She had an antalgic gait. Deep venous thrombosis seemed the most likely clinical diagnosis. Radiologic examination of the right hip showed minor osteoarthritic changes. Phlebography of the right leg showed compression of the femoral vein (Fig. 1). There was no evidence of deep vein thrombosis. Ultrasound revealed a cystic mass just posterolateral to the common femoral artery. An ultrasound guided puncture of the cystic mass was carried out and 15 cc of yellow viscous liquid were aspirated. Bursography revealed the full extent and location of an enlarged iliopsoas bursa (Fig. 2). Arthrography revealed no communication between the hip joint and the cystic mass.
Address for reprints: H. Wiese, Department of Radiology, Onze Lieve Vrouwe Gasthuis, le Oosterparkstraat 179, 1091 HA Amsterdam, The Netherlands. 0720-048X/90/$03.50
0
1990 Elsevier
Science Publishers
Fig. 1. Phlebography of the right leg. The femoral vein compressed in the area of the femoral head.
B.V. (Biomedical
Division)
Fig. 3. Relationships ofthe iliopsoas bursa and the hip. (1) iliopsoas bursa, (2) femoral artery and vein, (3) iliofemoral ligament, (4) pubofemoral ligament, (5) divided tendon of the ihopsoas muscle, (6) inguinal ligament.
Discussion
Fig. 2. Bursography: lateral view. Contrast medium is seen in the iliopsoas bursa (2), located ventrally to the femoral head (1). Some extravasation (3) is seen anterior to the bursa.
Diagnosis: iliopsoas bursa At operation the iliopsoas bursa was found to be 10 cm in diameter, compressing the femoral artery and vein. The bursa was totally resected. After the operation the symptoms completely disappeared.
The iliopsoas bursa is located in front of the capsule of the hip joint and beneath the iliopsoas muscle. It is bounded laterally by the iliofemoral ligament, cranially by Poupart’s ligament, medially by the cotyloid ligament and inferiorly by the pubofemoral ligament (Fig. 3). A variety of names have been given to the iliopsoas bursa, such as the iliopectineal, iliofemoral, subpsoas and iliac bursa. The iliopsoas bursa is present in 98% of adults and is almost always bilateral [l-3]. A cadaver study performed by Chandler revealed a considerable variation in the size of the bursa. The average size was 3 x 6 cm [2,4]. In approx. 15 %, an anatomical communication was demonstrated between the bursa and the hip joint, in such cases the bursa may therefore be regarded as an outpouching of the synovial membrane of the hip joint. Trauma, abnormal hip joint motion, total hip arthroplasty, degenerative joint disease or rheumatoid arthritis may contribute to the enlargement of the bursa [2]. An enlarged bursa can be asymptomatic [ 51. On the other hand it can cause pain and restriction of hip motion. As a result of compression of the femoral vein and the lymphatics, oedema of the leg may occur [6].
158
Occasionally, symptoms are due to trauma or superimposed infection of the bursa [7]. Retroperitoneal extension of an enlarged bursa can also displace pelvic structures such as the ureter or the intestines [6,8]. These symptomatic bursae usually recur following aspiration, and subsequently require surgical excision. Melamed advised arthrography of the hip to demonstrate possible communication with the bursa. In our case no such communication was demonstrated. To facilitate planning of the operation we also performed a bursography guided by ultrasound. Although there was some extravasation of contrast medium, a fair idea of the location and the extent of the bursa was obtained.
References Witter JA, Swingle NE. Ilioinguinal swellings. Am J Surg 1957; 94: 653-651. Chandler SB. The iliopsoas bursa in man. Anat Ret 1934; 50: 235-240. Finder JG. Iliopectineal bursitis. Arch Surg 1938; 36: 519-530. Janus C, Hermann G. Enlargement of the iliopsoas bursa: unusual cause of cystic mass on pelvic sonogram. J Clin Ultrasound 1982; 10: 133-135. Armstrong P, Saxton H. Ilio-psoas bursa. Br J Radio1 1972; 45: 493-495. Melamed A, Bauer CA, Johnson JH. Iliopsoas bursal extension of arthritic disease of the hip. Radiology 1967; 89: 54-58. Samuelson C, Ward JR, Albo D. Rheumatoid synovial cyst of the hip. A case report. Arthritis Rheum 14: 105, 1971. Staple TW. Arthrographic demonstration of iliopsoas bursa extension of the hip joint. Radiology 1972; 102: 5 15-516.
