Subperiosteal Hematoma of the Iliac Bone: An Unusual Cause of Acute Hip Pain after a Fall

Femoral Neuropathy Secondary to Compression by Spontaneous Iliac Hematoma

Introduction

Femoral neuropathy is a rare condition typically resulting from compression of the femoral nerve. While it is commonly associated with anticoagulated patients due to psoas hematomas, spontaneous iliacus muscle hematomas without any evident trauma or coagulation disorders are exceedingly uncommon. This case report details the occurrence and management of a spontaneous iliacus muscle hematoma in an adolescent patient. Such cases have been scarcely reported, making this documentation critical for enhancing clinical understanding and management strategies.

Case Report

A 16-year-old male of Caucasian ethnicity, with no significant medical history, presented with thigh muscle atrophy, decreased strength in the left lower limb, and progressive loss of weight-bearing capacity over a month. The patient reported no history of trauma. Clinical examination revealed hypoesthesia in the femoral nerve territory and significantly reduced quadriceps muscle strength. Imaging studies, including magnetic resonance imaging, identified a fusiform mass deep to the left iliac muscle, consistent with an encapsulated hematoma. The patient was treated conservatively with rest and analgesics, followed by physical rehabilitation. Follow-up assessments showed progressive improvement in muscle trophism and weight-bearing capacity, with complete recovery of femoral nerve conduction at 1 year.

Conclusion

This case underscores the importance of considering spontaneous iliacus muscle hematomas in the differential diagnosis of femoral neuropathy, even in the absence of trauma or anticoagulation therapy. The report highlights the necessity for thorough clinical evaluation and imaging to ensure accurate diagnosis. It adds valuable information to the orthopedic literature, particularly in managing rare presentations of femoral neuropathy, emphasizing the need for vigilance in monitoring and follow-up to prevent long-term complications. By detailing this unusual presentation, the report aims to enhance the understanding and treatment strategies for similar cases.

Neoplastic and Non-neoplastic Bone Lesions of the Knee

Numerous anatomical variants are described around the knee, many of which look like bony lesions, so it is important to know them to avoid unnecessary complementary tests and inadequate management. Likewise, several alterations in relation to normal development can also simulate bone lesions.However, numerous pathologic processes frequently affect the knee, including traumatic, inflammatory, infectious, and tumor pathology. Many of these entities show typical radiologic features that facilitate their diagnosis. In other cases, a correct differential diagnosis is necessary for proper clinical management.Despite the availability of increasingly advanced imaging techniques, plain radiography is still the technique of choice in the initial study of many of these pathologies. This article reviews the radiologic characteristics of tumor and nontumor lesions that may appear around the knee to make a correct diagnosis and avoid unnecessary complementary radiologic examinations and inadequate clinical management.

Initial Characterization of Focal Bone Lesions with Conventional Radiographs or Computed Tomography: Diagnostic Performance and Interobserver Agreement Assessment

Objectives: To ascertain the role of CT and conventional radiographs for the initial characterization of focal bone lesions.Methods: Images from 184 patients with confirmed bone tumors included in an ethics committee-approved study were retrospectively evaluated. The reference for benign-malignant distribution was based on histological analysis and long-term follow-up. Radiographs and CT features were analyzed by 2 independent musculoskeletal radiologists blinded to the final diagnosis. Lesion margins, periosteal reaction, cortical lysis, endosteal scalloping, presence of pathologic fracture, and lesion mineralization were evaluated. Results: The benign-malignant distribution in the study population was 68.5-31.5% (126 benign and 58 malignant). In the lesions that could be seen in both radiographs and CT, the performance of these methods for the benign-malignant differentiation was similar (accuracy varying from 72.8% to 76.5%). The interobserver agreement for the overall evaluation of lesion aggressiveness was considerably increased on CT compared to radiographs (Kappa of .63 vs .22). With conventional radiographs, 18 (9.7%) and 20 (10.8%) of the lesions evaluated were not seen respectively by readers 1 and 2. Among these unseen lesions, 50%-61.1% were located in the axial skeleton. Compared to radiographs, the number of lesions with cortical lysis and endosteal scalloping was 26-34% higher with CT. Conclusion: Although radiographs remain the primary imaging tool for lesions in the peripheral skeleton, CT should be performed for axial lesions. CT imaging can assess the extent of perilesional bone lysis more precisely than radiographs with a better evaluation of lesion fracture risk.

Report of a Rare Case of Beta-Thalassemia Major With Subperiosteal Hematomas

Beta-thalassemia represents a range of hemoglobinopathies that are a consequence of an impairment in the synthesis of beta-globin chains. They result in different degrees of hemolysis and ineffective erythropoiesis, depending on the underlying mutations. They can lead to severe complications mainly resulting from anemia. However, there is no bleeding tendency in this disorder, and it is uncommon to see hematoma formation in affected patients.

To our knowledge, subperiosteal hematomas have been rarely described in the context of beta-thalassemia. Herein, we report a unique case of a 19-year-old boy who was diagnosed with transfusion-dependent beta-thalassemia and secondary hemochromatosis and developed atraumatic subperiosteal hematomas along the humerus.

Comparative study of suction drainage placement in cementless hip replacement among patients undergoing extended thromboprophylaxis: a prospective randomized study

Background

The use of drains reportedly does not improve surgical outcomes after hip replacement. There is still a lack of strict recommendations for drain placement after primary hip replacement. This study aimed to assess the safety of not using suction drainage after primary hip replacement in a population of patients undergoing extended thromboprophylaxis.

Methods

In this prospective randomized study, all patients were qualified for primary hip replacement and were divided into two groups: with and without drainage. The inclusion criterion was idiopathic hip osteoarthritis. The exclusion criteria were secondary coxarthrosis, autoimmune disease, coagulopathy, venous/arterial thrombosis, hepatic/renal insufficiency, cement, or hybrid endoprostheses. We performed an intention-to-treat analysis. Clinical, laboratory, and radiographic parameters were measured for the first three days after surgery. Hematoma collection, due to extended thromboprophylaxis, in the joint and soft tissues was evaluated precisely. The patients underwent follow-up for 30 days.

Results

The final analysis included a total of 100 patients. We did not find any significant statistical differences between groups in terms of hip fluid collection (9.76 vs. 10.33 mm, with and without drainage, respectively; mean difference, 0.6 mm; 95 % confidence interval [CI] -2.8 to 3.9; p = 0.653), estimated blood loss (1126 vs. 1224 ml; mean difference, 97.1 ml; 95 % CI -84.1 to 278.2; p = 0.59), and hemoglobin levels on postoperative day 3 (11.05 vs. 10.85 g/dl; mean difference, 0.2; 95 % CI -2.1 to 2.5; p = 0.53). In addition, the other parameters did not show significant differences between groups. Notably, two cases of early infections were observed in the no-drainage group, whereas there were no such complications in the drainage group.

Conclusions

We conclude that the use of closed suction drainage after primary hip replacement is a safe procedure in patients undergoing extended thromboprophylaxis. Further research is warranted to validate these findings.

Trial registration

The study was successfully registered retrospectively at Clinicaltrial.gov with the identification number NCT04333264 03 April 2020.

Solitary bone tumor imaging reporting and data system (BTI-RADS): initial assessment of a systematic imaging evaluation and comprehensive reporting method

OBJECTIVES

Identify the most pertinent imaging features for solitary bone tumor characterization using a multimodality approach and propose a systematic evaluation system.

METHODS

Data from a prospective trial, including 230 participants with histologically confirmed bone tumors, typical "do not touch" lesions, and stable chondral lesions, were retrospectively evaluated. Clinical data, CT, and MR imaging features were analyzed by a musculoskeletal radiologist blinded to the diagnosis using a structured report. The benign-malignant distribution of lesions bearing each image feature evaluated was compared to the benign-malignant distribution in the study sample. Benign and malignant indicators were identified. Two additional readers with different expertise levels independently evaluated the study sample.

RESULTS

The sample included 140 men and 90 women (mean age 40.7 ± 18.3 years). The global benign-malignant distribution was 67-33%. Seven imaging features reached the criteria for benign indicators with a mean frequency of benignancy of 94%. Six minor malignant indicators were identified with a mean frequency of malignancy of 60.5%. Finally, three major malignant indicators were identified (Lodwick-Madewell grade III, aggressive periosteal reaction, and suspected metastatic disease) with a mean frequency of malignancy of 82.4%. A bone tumor imaging reporting and data system (BTI-RADS) was proposed. The reproducibility of the BTI-RADS was considered fair (kappa = 0.67) with a mean frequency of malignancy in classes I, II, III, and IV of 0%, 2.2%, 20.1%, and 71%, respectively.

CONCLUSION

BTI-RADS is an evidence-based systematic approach to solitary bone tumor characterization with a fair reproducibility, allowing lesion stratification in classes of increasing malignancy frequency.

TRIAL REGISTRATION

Clinical trial number NCT02895633 .

KEY POINTS

• The most pertinent CT and MRI criteria allowing bone tumor characterization were defined and presented. • Lodwick-Madewell grade III, aggressive periosteal reaction, and suspected metastatic disease should be considered major malignant indicators associated with a frequency of malignancy over 75%. • The proposed evidence-based multimodality reporting system stratifies solitary bone tumors in classes with increasing frequencies of malignancy.

Subperiosteal hematoma of the iliac wing presenting with leg weakness in a young adult footballer

We present the case of a 17 year old football player with a 2 week history of left leg weakness and difficulty weight-bearing. Magnetic resonance imaging revealed a well-circumscribed lesion deep to the left iliacus muscle. The patient proceeded to computed tomography-guided biopsy. The likely diagnosis was that of a subperiosteal haematoma of the iliac wing, which was exerting mass effect upon the left femoral nerve resulting in leg pain and weakness. Imaging was repeated at an interval of 1 month, at which time the lesion had almost entirely resolved. Subperiosteal haematoma of the iliac bone is a rare entity but should be considered as a potential diagnosis in young adults, particularly where there is a history of trauma or recent sports injury.