Gray scale ultrasound: evaluation of iliopsoas hematomas in hemophiliacs

Musculoskeletal ultrasound: a technical and historical perspective

During the past four decades, musculoskeletal ultrasound has become popular as an imaging modality due to its low cost, accessibility, and lack of ionizing radiation. The development of ultrasound technology was possible in large part due to concomitant advances in both solid-state electronics and signal processing. The invention of the transistor and digital computer in the late 1940s was integral in its development. Moore's prediction that the number of microprocessors on a chip would grow exponentially, resulting in progressive miniaturization in chip design and therefore increased computational power, added to these capabilities. The development of musculoskeletal ultrasound has paralleled technical advances in diagnostic ultrasound. The appearance of a large variety of transducer capabilities and rapid image processing along with the ability to assess vascularity and tissue properties has expanded and continues to expand the role of musculoskeletal ultrasound. It should also be noted that these developments have in large part been due to a number of individuals who had the insight to see the potential applications of this developing technology to a host of relevant clinical musculoskeletal problems. Exquisite high-resolution images of both deep and small superficial musculoskeletal anatomy, assessment of vascularity on a capillary level and tissue mechanical properties can be obtained. Ultrasound has also been recognized as the method of choice to perform a large variety of interventional procedures. A brief review of these technical developments, the timeline over which these improvements occurred, and the impact on musculoskeletal ultrasound is presented below.

Ultrasonography Facilitates the Diagnosis of Traumatic Iliopsoas Hemorrhage: A Report of Two Cases with Different Patterns

We report two cases of traumatic iliopsoas hemorrhage, without hemoperitoneum, initially detected by ultrasound. Flexion hip contracture in the first case and incomplete femoral nerve palsy in the second case alerted the sonographer to the possibility of traumatic iliopsoas hemorrhage. The first case involved a 54-year-old man who complained of progressive right flank pain and difficulty in walking after falling to the ground. The second case involved a 34-year-old man who complained of severe lower back pain and numbness and weakness of the left leg after a motorcycle accident. In both cases, iliopsoas hemorrhage was confirmed on subsequent multidetector computed tomography.

Iliopsoas hematomas in people with hemophilia: diagnosis and treatment

INTRODUCTION

Iliopsoas muscle hemorrhage in patients with hemophilia is a serious complication with relevant related morbidity.

AREAS COVERED

A Cochrane Library and PubMed (MEDLINE) search of studies related to iliopsoas hematomas in hemophilia was analyzed. Pain in the hip joint area and femoral nerve involvement in people with hemophilia should alert physicians to the likelihood of a hemorrhage of the iliopsoas muscle. Clinically, reduced hip range of motion and deficient motor and sensory function of the femoral nerve can be found. Imaging studies, such as ultrasonography (US), CT scan, and MRI will confirm the diagnosis. The first-line therapy for iliopsoas hematoma must be conservative (hematological treatment using high-dose replacement therapy until full resorption monitored by means of imaging studies). Related femoral nerve involvement typically resolves with conservative treatment (rehabilitation). Pelvic hemophilic pseudotumors can occur in patients with hemophilia due to recurrent iliopsoas muscle bleeding, often related to late diagnosis and poor hemostasis.

EXPERT OPINION

Long-term clotting factor replacement is the pillar of the management of iliopsoas hematomas. Percutaneous US-guided aspiration of blood can be performed in hematomas of large size. However, the rate of failed aspirations and hematoma repetition is substantial (13%).

The development and clinical applications of musculoskeletal ultrasound

Musculoskeletal ultrasound has come a long way in 40 years. Reflecting changes in computer technology, ultrasound equipment has developed from machines that have filled examination rooms with mechanical probes linked by hinged arms for spatial localisation, to high-resolution machines that are the size of laptops using compact hand-held probes designed for both external and internal imaging.

Paediatric musculoskeletal US beyond the hip joint

US is a technique particularly suited to the investigation of musculoskeletal disorders in children and adolescents. This review paper describes a range of clinical settings beyond the hip joint where US has a significant role to play, including sports injuries, infectious diseases, inflammatory and degenerative conditions, congenital and developmental disorders, acute trauma of bone and joints, and peripheral nerve injuries. In some circumstances, US can be regarded as the most effective means of diagnostic imaging, whereas in other instances, it is an alternative or supplement to other more comprehensive imaging modalities, like MRI and CT. Although MRI offers superior soft-tissue contrast resolution, US is low-cost, non-invasive and has higher spatial resolution and real-time capability for the assessment of musculoskeletal structures during joint movement and stress manoeuvres.

Diagnosis of traumatic iliopsoas hematoma using point-of-care ultrasound

Case 1 involved a 24-year-old man who complained of severe right groin pain and difficulty of walking after falling to the ground while snowboarding. The patient manifested flexion hip contracture on the right side. Abdominal examination detected tenderness in the right lower quadrant. Point-of-care ultrasound identified swelling of the right psoas major, compressing the right kidney. Case 2 involved a 74-year-old woman who complained of severe left lower quadrant and left groin pain after falling down. This patient also manifested flexion hip contracture, on the left side. Abdominal examination detected tenderness mainly in the left lower quadrant and a palpable mass accompanied by tenderness, lateral to the left femoral artery. Point-of-care ultrasound identified swelling of the left psoas major and of the iliopsoas musculotendinous unit at the level of the groin. Point-of-care ultrasound after obtaining precise history and the physical examination is a very useful modality for the quick diagnosis of iliopsoas hematoma in the emergency rooms.

Iliopsoas hematoma in patients with hemophilia: a single-center study

Six cases of iliopsoas hematoma were diagnosed in 5 patients with hemophilia over the last 5 years at our hemophilia center. We reviewed these cases to determine the incidence and precipitating factors of iliopsoas hematoma in hemophilia. Of the 5 patients, 4 had severe hemophilia A and 1 had moderate hemophilia A with a history of inhibitors to factor VIII concentrates. The age range was 13 to 33 years. The hematoma was posttraumatic in 2 cases and spontaneous in 4 cases. Femoral nerve compression developed in 2 cases. There were four recurrences. At the time of the hematoma, 2 patients were receiving long-term prophylactic factor VIII concentrate therapy but one of them had stopped the injections of his own accord. The treatment consisted of recombinant factor VIII concentrates, a brief course of glucocorticoid therapy in the 2 cases with femoral nerve involvement, lower limb traction in 3 patients, and rehabilitation therapy. The annual incidence rate of iliopsoas hematoma was 2.9/1000 patients with severe or moderate hemophilia A. The use of prophylactic factor VIII therapy and compliance with recommendations about avoiding activities that put strain on the hip flexor muscles probably explain the low rate of iliopsoas muscle hematoma in patients with hemophilia in France. An early diagnosis allows early Factor VIII therapy, which decreases the risk of femoral nerve involvement and recurrence.

Iliopsoas hematoma with femoral neuropathy presenting a diagnostic dilemma after spinal decompression

STUDY DESIGN

Case report of an iliopsoas hematoma with femoral neuropathy appearing 8 weeks after a posterior spinal decompression procedure.

OBJECTIVES

To describe a potential complication and differential diagnosis for nerve root symptoms following spinal decompression.

SUMMARY OF BACKGROUND DATA

Iliopsoas hematoma is usually a complication of anticoagulation, hemophilia, or trauma. It has not been described previously as a complication of posterior spinal decompression. Femoral neuropathy results from compression within the iliopsoas compartment.

METHODS

A 53-year-old woman reported pain in the right side of her groin and an increasing fixed flexion deformity of the right hip 8 weeks after a posterior, midline, spinal decompression. A femoral neuropathy later developed. Magnetic resonance imaging and computed tomography were performed.

RESULTS

Imaging studies demonstrated a diffusely enlarged iliopsoas. Exploration revealed a large hematoma, which was evacuated. The compartment was fully decompressed with resolution of the nerve root symptoms within 48 hours.

CONCLUSIONS

Iliopsoas pathology is a rare cause of nerve root symptoms and presented diagnostic difficulties after an apparently successful spinal decompression.

Applications of musculoskeletal sonography

To successfully examine the musculoskeletal system sonographically, one must understand the normal musculoskeletal anatomy and function and be aware of the abnormal processes that affect the musculoskeletal structures. The goal of this review article is to provide a systematic approach to sonographic examination of the musculoskeletal system. The general sonographic appearances of normal and abnormal muscles, tendons, ligaments, bursae, and nerves are reviewed. The article then applies this general information to specific clinical applications by reviewing the normal anatomy of and specific pathologic conditions that affect the shoulder, elbow, hand, wrist, hip, knee, ankle, and foot.

CT diagnosis of concurrent hematomas of the psoas muscle and rectus sheath: case reports and review of anatomy, pathogenesis, and imaging

Two cases are presented in which psoas muscle and rectus sheath hematomas occurred concurrently. The case presentations are followed by a review of anatomy, pathogenesis, and imaging modalities involved in the cause and diagnosis of such hematomas.

Warfarin-induced iliopsoas hemorrhage with subsequent femoral nerve palsy

We present the case of a 28-year-old man on chronic warfarin therapy who sustained a minor muscle tear and developed increasing pain and a flexure contracture of the right hip. Surgical exploration revealed an iliopsoas hematoma and femoral nerve entrapment, resulting in a femoral nerve palsy and partial loss of quadriceps functions. Anticoagulant-induced femoral nerve palsy represents the most common form of warfarin-induced peripheral neuropathy; it is characterized by severe pain in the inguinal region, varying degrees of motor and sensory impairment, and flexure contracture of the involved extremity.

Ultrasonographic examinations of muscle hematomas in hemophiliacs

Twenty-one ultrasonographic examinations were performed in 14 hemophiliacs with suspected intramuscular bleeding. In all patients who had an ultrasonographic examination within the first days after the onset of the symptoms, a hematoma was identified, and its resolution during transfusion therapy was possible to follow. In patients who had their first examination 3 to 5 weeks after the onset of symptoms and who had received transfusion therapy during this period, no hematoma was detectable. It is concluded that ultrasonography provides all necessary information needed for diagnosis and follow-up of treatment. Being a safe method, and giving no radiation, it should be the method of choice in the evaluation and follow-up of muscle hematomas in this patient group.

Computed tomography of the iliopsoas muscle

Computed tomography (CT) is an ideal method for the imaging of the psoas muscle. The authors present 13 cases of patients with psoas abnormalities diagnosed by CT. The CT features of the different pathologic entities and comparison of CT with other imaging modalities are discussed.