Download Bursae around the hip: anatomy, pathology, and mimics

Bursae around the hip: anatomy, pathology, and mimics
Poster No.:
C-0476
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
P. M. E. Souza, E. B. G. D. Santos; Rio de Janeiro/BR
Keywords:
Inflammation, Normal variants, MR, Musculoskeletal soft tissue
DOI:
10.1594/ecr2014/C-0476
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Learning objectives
Bursae are fluid-filled sacs that provide cushioning between bony prominences and the
surrounding soft tissues. About 20 types of bursae have been described in the literature
around the hip and pelvic areas, with variable extents and prevalences. The purpose
of this poster is to characterize the clinically relevant bursae in this region focusing on
normal anatomy, common pathological processes and their mimics.
Background
Hip pain is a common symptom with a number of possible causes. Bursitis is an usual
clinical entity that can cause severe disabling hip pain and is often a result of inflammation
secondary to excessive local friction, infection, arthritides or direct trauma. It can clinically
be easily misdiagnosed as joint-, tendon- or muscle-related pain and treatment of these
conditions can be different. Therefore, it is very important to understand the anatomy and
pathology of the bursae to help clinicians making the correct diagnosis.
Findings and procedure details
A bursa is a fluid-filled sac lined with synovial cells that provide cushioning between bony
prominences and the surrounding soft tissues, in order to reduce friction between moving
structures.
Several bursae are located around the hip and we didactically divided them into
three groups: anterior compartment (iliopsoas bursa), lateral compartment (subgluteus
maximus, subgluteus medius, piriformis, subgluteus minimus and gluteofemoral bursae),
and posterior compartment (obturator externus, obturator internus and ischial bursae).
(Fig.1)
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Fig. 1
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
We also illustrate many conditions that simulate bursitis such as peritendinitis, tendon
rupture, hydroxyapatite deposition disease, ganglion and paralabral cysts, tears involving
the iliotibial band, Morel-Lavallée lesion, and ischiofemoral impingement with adventitous
bursa.
ANTERIOR COMPARTMENT
1) The Iliopsoas (or Iliopectineal) bursa
It is the largest bursa in the human body, presenting in 98% of individuals. It is
situated beneath the musculotendinous portion of the iliopsoas, bordered medially by the
pectineus muscle and laterally by the anterior inferior iliac spine. (Fig.2 and 3)
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Fig. 2
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
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Fig. 3
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
The Iliopsoas bursa lies anterior to the hip joint, with which it communicates in 15%
of normal asymptomatic individuals by way of a defect between the pubofemoral and
iliofemoral ligaments. (Fig. 4)
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Fig. 4
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
The incidence of this communication, and thus bursitis, is higher in the setting of hip
derangement, and is usually secondary to synovitis and/or increased intra-articular
pressures, which ultimately result in capsular thinning. (Fig. 5 and 6)
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Fig. 5
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
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Fig. 6
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
The differential diagnoses of the iliopsoas bursa include paralabral cyst (Fig.7 and 8),
ganglion cyst (Fig.9) and iliopsoas musculotendinous strain or rupture (Fig.10 and 11).
The correct diagnosis of an iliopsoas bursitis is made by following the fluid-filled structure
on successive axial images, recognizing that it is contiguous with the iliopsoas tendon
(Fig. 12).
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Fig. 7
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
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Fig. 8
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Fig. 9
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Fig. 10
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Fig. 11
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Fig. 12
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
LATERAL COMPARTMENT
Although pain over the lateral aspect of the hip has been commonly attributed to a
trochanteric bursitis, multiple bursae are associated with the greater trochanter (GT). An
understanding of the anatomy of the four facets of the greater trochanter is essential
because each facet has specific tendinous attachments and specific nearby bursae.
1) Trochanteric (or Subgluteus Maximus) Bursa
It covers the posterior facet of the GT (Fig.13) and it is located beneath the gluteus
maximus muscle and iliotibial tract. This bursa can be identified on axial MR images as
an elongated structure paralleling the posterior facet and usually it does not extend over
the anterior border of the lateral facet. (Fig.14 and 15)
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Fig. 13
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
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Fig. 14
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Fig. 15
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
2) Subgluteus Medius (or Anterior Subgluteus Medius) Bursa
It is situated anterior to the apex of the GT (Fig.16), deep to the lateral part of the gluteus
medius tendon, and proximal to its insertion, covering an area of the superior part of the
lateral facet of the GT. (Figs.17 to 20)
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Fig. 16
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Fig. 17
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Fig. 18
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Fig. 19
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Fig. 20
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
3) Subgluteus Minimus Bursa
It lies beneath the gluteus minimus tendon, medial to its insertion, in the area of the
anterior facet of the GT. (Fig.21 and 22)
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Fig. 21
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
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Fig. 22
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
4) Piriformis (or Posterior Subgluteus Medius) Bursa
It is situated posterior to the apex of the GT. The bursa lies on and follows the contour of
the insertion of the piriformis tendon. Its superficial surface is in contact with, and often
adhered to, the deep surface of the gluteus medius tendon. In daily practice, it is very
difficult to differentiate it from the anterior subgluteus medius bursa at MRI. (Fig.23)
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Fig. 23
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
5) Gluteofemoral Bursa
It is situated caudal to the GT and it lies beneath, and adhered to, the iliotibial band in
the area where the tendinous fibers of gluteus maximus inserts. It is positioned over the
posterior edge of the vastus lateralis, separating it from the iliotibial band. (Fig.24)
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Fig. 24
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
The differential diagnoses of lateral compartment bursae include gluteal tendinosis and
peritendinitis (Fig.25), hydroxyapatite deposition disease - HADD (Fig.26), gluteal tendon
rupture (Fig.27), tears involving the iliotibial band (Fig.28), and Morel-Lavallée lesion
(Fig.29).
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Fig. 25
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Fig. 26
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Fig. 27
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Fig. 28
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Fig. 29
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POSTERIOR COMPARTMENT
1) Obturator Externus Bursa
This bursa is thought to be formed by a protrusion of the posterior inferior hip synovium
between the ischiofemoral ligament and the zona orbicularis. It usually occurs in patients
with hip synovitis and chronically increased intra-articular pressure. When distended, this
bursa displaces the obturator externus muscle inferiorly while extending medially toward
the obturator foramen. (Fig.30)
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Fig. 30
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
2) Obturador Internus Bursa
It is a "boomerang"-shaped fluid distension between the obturator internus tendon and
the posterior grooved surface of the ischium. Normally, the obturator internus bursa is
in a collapsed state, and is only distended when it is inflamed or infected. The majority
of patients with obturator internus bursitis have been reported to respond adequately
to antibiotics without surgical drainage. Thus, knowledge of the imaging features of
obturator internus bursitis can avoid unnecessary surgery. (Fig.31)
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Fig. 31
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
3) Ischial (or Ischiogluteal) Bursa
It separates the gluteus maximus from the ischial tuberosity. Ischiogluteus bursitis is
usually related to intermittent pressure upon the ischial tuberosity from prolonged sitting.
Tuberculosis, gout, rheumatoid arthritis, systemic lupus erythematosus, ankylosing
spondylitis and Reiter's syndrome have also been reported to involve the ischiogluteal
bursa. As the bursa lies in close contact to the sciatic and posterior femoral cutaneous
nerve, ischiogluteal bursitis can mimic the symptoms of radiculopathy. It may have a very
heterogeneous appearance on imaging studies, usually related to bleeding with bloodfluid levels, synovial proliferation and internal septation. (Fig.32)
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Fig. 32
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
The differential diagnoses of posterior compartment bursae include hamstring
tendinopathy/peritendinitis and/or rupture (Fig.33), ischiofemoral impingement with
adventitous bursa, and ganglion cysts.
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Fig. 33
References: Fleury Medicina e Saúde - Rio de Janeiro/Brazil
Images for this section:
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Fig. 1
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Fig. 12
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Fig. 13
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Fig. 15
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Fig. 17
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Fig. 24
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Fig. 28
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Fig. 29
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Fig. 30
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Fig. 31
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Fig. 32
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Fig. 33
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Conclusion
Symptoms in the vicinity of the hip are very common and are frequently caused by bursitis.
The aim is to familiarize radiologists with the radiological features of bursitis and the
differential diagnoses.
Personal information
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