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ILIACUS
SADHAN
From
This
Case
1-A
pain
around
the
left
paper
reports
flexion
symptoms.
side.
The
Orthopaedic
two
cases
deformity
GLASGOW,
aizcl Accident
of iliacus
of the
On examination
temperature
was
90 a minute.
were normal.
There
was
Examination
movements
slight
were
MUKHERJEE,
Division,
SCOTLAND
Glasgow
haematoma
Royal
Infir,nary
complicating
closed
injury.
boy aged nine years
was
admitted
in August
1969
with
difficulty
in walking
and
the left hip after a fall from a wall three
weeks
before,
in which
he had injured
side of the lower
abdomen.
The symptoms
gradually
worsened
and he developed
increasing
but
the
KUMAR
HAEMATOMA
were
left
hip.
There
the child was
364
degrees
a mass in the left iliac
ofthe
spine revealed
normal.
lateral
rotation,
but
only slightly
restricted,
There
was
was
obviously
Celsius
no
history
of gastro-intestinal
in pain and
(975
degrees
fossa which was
slight tenderness
a 60 degrees
flexion
acutely
over
tender.
Bowel
the left sacro-iliac
deformity
of the
left
the hip could
be actively
flexed
to 90 degrees.
Other
by pain.
Radiographs
of the lumbar
spine, pelvis and
to show any abnormality.
Intravenous
pyelography
was normal.
Investigations
showed
haemoglobin
to be lll
grammes
per 100 millilitres,
count
to be 8,200 per cubic millimetre.
There
was anisocytosis
with variation
rouleaux
formation
was noted ; neutrophils
showed
toxic
granulation
The erythrocyte
sedimentation
rate was 80 millimetres
in the first
not
yield any organism.
The Mantoux
test was negative.
Treatment
developed
or urinary
tended
to lie curled
on his
Fahrenheit)
and the pulse
andprogress-Treatment
pyrexia
of 388
was
degrees
initially
Celsius
by bed rest until
(l0l8
degrees
cloxacillin
and penicillin
were begun
parenterally.
under
local anaesthesia
was unsuccessful.
On the eighth
day the patient
was examined
revealed
a hard mass filling the whole
of the left
Attempted
hip
with
movements
chest failed
and the white
in haemoglobin;
; platelets
hour.
were
Blood
the sixth day,
Fahrenheit).
aspiration
sounds
joint,
present.
culture
when
At
of the
under
anaesthesia.
Abdominal
iliac fossa and extending
from
cell
did
the patient
this point
left
iliac
fossa
examination
just above
the
iliac crest to the inguinal
ligament.
Rectal
examination
did not reveal
any abnormality
apart
from a loaded
rectum.
There
was a 45 degrees
fixed flexion
deformity
of the left hip : rotation
was full.
Under
the anaesthetic
aspiration
of the mass in the left iliac fossa was carried
out
with
a wide
bore
needle:
150 millilitres
of fluid-pus
mixed
with
blood
and clot-were
aspirated.
Bacteriological
positive
cocci,
yielded
a
mainly
heavy
examination
in clusters,
growth
of
but
of the
a few
staphylococcus
streptococci
(Lancefield
Group
A).
Cloxacillin-to
which
both
organisms
condition
continued
Operation-At
the abdomen
to the mass
to
fluid
in chains.
numerous
Acid-fast
aureus
were
showed
and
sensitive-was
bacilli
a
light
pus
were
growth
continued,
cells
not
of
but
and
seen.
gramCulture
B haemolytic
the
patient’s
deteriorate.
operation
two weeks after the patient’s
admission
and five weeks after the injury
was opened
through
a left paramedian
incision.
The pelvic colon
was adherent
but was normal,
as were the other
abdominal
viscera.
The psoas
tendon
ran
through
the posterior
part of the tough
fibrous
wall of the haematoma,
this accounting
for
the flexion
deformity
of the left hip.
The wound
was closed
with drainage.
It was thought
likely
that the haematoma
in the iliac fossa
was a consequence
of the injury,
and that
it
subsequently
became
infected,
tying the pelvic colon
to the haematoma.
Further
progress-Antibiotic
therapy
was continued
and the patient
progress
towards
full recovery.
Subsequent
investigation
failed
to
blood
VOL.
made
show
steady
but
any evidence
slow
of
dyscrasia.
53 B,
NO.
4,
NOVEMBER
1971
729
730
s.
Case
2-A
man
walking
and pain
gradually
left
worsened
hip
was
of twenty-four
in the left groin
joint
and
and
good,
with
(99 degrees
in the left
a
barely
pulse
Fahrenheit).
iliac fossa.
very
tender
was
a 90-degree
at the
was
swelling
K.
MUKHERJEE
was admitted
after twisting
time
of admission
able
rate
in January
1970 complaining
the limb two weeks previously.
to walk.
of
74
per
he had
developed
On
examination
minute
and
a flexion
the
in
flexion
deformity
Investigations-Examination
the
there
was
erythrocyte
Radiographs
Treatment
temperature
and
a slight
lateral
rate was 70 millimetres
lumbar
spine and left
and progress-The
Four
patient
However,
Fahrenheit)
was
he started
daily.
fully and other
movements
70 millilitres
of pus were
and culture
tetracycline
were
aspirated.
rotation
initially
(2 grammes
groin
6-hourly
by
and
in the left
anaesthesia
Operation-A
week
after
admission
swelling
below
the inguinal
ligament.
released
after sustained
pressure
on
patient’s
was no
weakness
residual
and
reported
that
progress
was
good,
had
no
symptoms
left
hip.
flexion
pain.
100
and
and
to 39#{149}2
degrees
bilateral
Celsius
groin
had increased
in size and had
the left hip joint
could
be extended
in the left groin
was aspirated
and
cocci were seen in this material,
was
started,
sensitive
but
to cloxacillin
pyrexia
continued
and
and
the
larger.
incision
was
About
04 litre
left iliac fossa.
A
and by the end of
movements
muscle.
and
the
analgesics
of up
aureus
an
collection
of pus and
wasting
of the quadriceps
he
injection)
became
of
mass
was a
There
of 14’S grammes
per
cell count
of 27,100,
rest,
pyrexia
almost
full.
The swelling
Pus cells and gram-positive
reappeared
Celsius
tender
There
fossa.
intense
pain, but full
Active
flexion
caused
of pain.
by bed
intermittent
swelling
under
of the
condition
degrees
deformity
in
in one hour.
hip showed
no abnormality.
yielded
a moderate
growth
of staphylococcus
but resistant
to penicillin
and ampicillin.
Cloxacillin
swelling
in the
The
treated
having
days after
admission
the
fluctuant.
At examination
become
general
of 372
of the blood
showed
haemoglobin
neutrophil
leucocytosis
with
total
white
a
sedimentation
of the chest,
leg traction.
( 1026 degrees
deformity
patient’s
Abdominal
examination
showed
an ill-defined
but very
The spine showed
a moderate
degree
of lumbar
lordosis.
the left femoral
triangle
and adjoining
part of the left iliac
Attempts
at passive
correction
of the flexion
deformity
produced
of the hip joint
beyond
90 degrees
could
be achieved
passively.
Passive
rotation,
abduction
and adduction
were restricted
because
millilitres:
of difficulty
The symptoms
was
made
over the prominent
part
of the
of pus mixed
with altered
blood
was
drain
was inserted.
February
the wound
was healed ; there
of the
Eight
fully
hip were full.
months
after
There
were, however,
operation
the patient
active.
DISCUSSION
Iliacus
haematoma
compartment
ilium.
bounded
It
is
rare,
anticoagulant
but
therapy.
is a collection
anteriorly
it
by
of
the
may
occur
in
It has
also
been
blood
fascia
patients
the
in
muscle-that
iliacus
covering
the
with
haemophilia
reported
muscle
or
in individuals
is,
and
as
with
in a closed
posteriorly
by
the
a complication
blood
of
dyscrasia
since
the original
publication
of Getting’s
case by Bulloch
and Fildes
in 1911.
It is extremely
unusual
after
injury
in a patient
with a normal
blood
picture.
Fisher
(1968)
reported
one
instance
of traumatic
iliacus
haematoma
in a boy of sixteen
who had a comminuted
fracture
of the anterior
superior
iliac spine,
but I have
been unable
to find any reference
to such a
complication
arising
from
closed
trauma,
without
bony
injury,
in an otherwise
normal
individual.
The
presenting
symptom
is pain
in the groin,
spreading
to the lumbar
region
or thigh,
and
in
steadily
tender
increasing
and
flexion
mass
slight
is always
until
lateral
present
it is severe
rotation.
in the
and
Extension
iliac
fossa.
constant.
of the
Femoral
The
hip
hip
makes
nerve
THE
on
the
the
palsy
JOURNAL
affected
pain
side
worse.
develops
OF
BONE
in most
AND
JOINT
is held
A
very
cases.
SURGERY
ILIACUS
The
syndrome
instance
is relatively
of this
haemophilia.
iliopsoas
was
Getting’s
Tallroth
(1939)
compartment
common
case
in patients
reported
suffering
by
Bulloch
haemophiliac
patients.
on
They
a cadaver
described
how
the
pressure
the
blood
Fildes
dyscrasia.
(191
large spontaneous
Davidson,
Epstein,
in a series
twenty-four
clinical
on
from
and
reported
a case in which
noted
on two occasions.
were
(1949)
reported
fifteen
cases of iliacus
haematoma
Goodfellow,
Fearn
and Matthews
(1967)
reported
experiment
731
HAEMATOMA
first
with
haemorrhages
Miller
and
in the
Taylor
of forty haemophiliac
patients.
cases of iliacus
haematoma
in
condition
femoral
The
1) in a patient
and
nerve
showed
was
by
produced
an
injection
by overflow
of
fluid from the iliacus
compartment.
The femoral
nerve was clearly
affected
in the second
of
the two cases described
here.
In both cases reported
here the haematomata
were infected
by
staphylococcus
aureus,
and in both
the classical
syndrome
appeared
relatively
late.
The
haematomata
were
The experience
individuals
presumably
produced
gained
from
these
should
infection
and
be
the
drained
possible
by
by rupture
of muscle
two cases suggests
that
operation
consequence
once
of
fixed
the
fibres at the time
iliacus
haematoma
diagnosis
flexion
contracture
is made,
in
of the
hip.
of the injury.
in healthy
order
to
avoid
SUMMARY
I
.
Two
cases
are
reported.
2.
Both
full
recovery
cases
iliacus
were
after
I am grateful
thank
of
haematoma
occurring
complicated
by
after
infection
of
injury
the
in otherwise
haematoma,
but
healthy
both
individuals
patients
made
to Mr S. Alexander
Mr J. White
and
and
Mr
Mr A. B. Young
K. Protheroc
for allowing
for their
in the preparation
help
me to report
of this
their
cases.
I would
like
paper.
REFERENCES
W.,
BULLOCH,
and
C. S.,
DAVIDSON,
of
Forty
P. (1911):
FILDES,
R. D.,
EPSTEIN,
Patients.
Blood,
MILLER,
T. R. (1968):
Iliacus
Haematoma
J., FEARN, C. B. d’A., and
FISHER,
tion
of
A. (1939):
TALLROTH,
to
Haemophilia.
the
53 B,
Femoral
NO.
Jourizal
Hemophilia
Nerve.
4,
NOVEMBER
(Eugenics
XIVa.
G. F., and
TAYLOR,
Laboratory
Memoirs,
F. H. L. (1949):
12).
Haemophilia:
Treasury
of
Human
A Clinical
Study
4, 97.
GOODFELLOW,
VOL.
Haemophilia.
Parts V and VI, Section
Inheritance,
a
operation.
Acta
1971
and
Nerve
Medical
Journal,
4, 391.
Iliacus Haematoma:
A Common
of Boize and Joint
Surgery,
49-B, 748.
with Spontaneous
Hemorrhage
in the Iliopsoas
Muscle
Followed
Chirurgica
Scauidinavica,
82, 1.
MATFHEWS,
Palsy.
British
J. M. (1967):
Compliaby Injury
to