hernia pathology
femoral hernia
- a herniation of tissue medial to the common femoral vein and lateral to the lacunar ligament.
- more common in females.
- high risk of becoming strangulated due to the narrow neck, so any bowel involvement should be treated as a potential emergency.
ultrasound image- fluid and some haemorrhage in a femoral hernial sac.
the common femoral vein is being compressed but colour doppler confirms it is patent.
ultrasound image- the femoral hernia (red) with superficially displace lymph nodes (green).
ultrasound image- a large complicated femoral hernia sac..
ultrasound image- femoral hernia medial to the common femoral vessels.
direct inguinal hernia
- has a neck medial to the inferior epigastric vessels.
transverse ultrasound view of a direct inguinal hernia with its neck medial to the inferior epigastric vessels.
para-sagittal ultrasound view of the same direct inguinal hernia with its neck medial to the inferior epigastric vessels.
indirect inguinal hernia
- has a neck lateral to the inferior epigastric vessels
ultrasound image- rt indirect hernia.
an oblique ultrasound view of an indirect hernia with it’s neck lateral to the inferior epigastric vessels.
ultrasound image- a hernia within the spermatic cord of a 10month old baby. transverse view.
ultrasound image- the same hernia in longitudinal. note that bowel rather than merely fat is involved.
ultrasound image- ovary herniating into the inguinal canal.
a patent processus vaginalis may be larger than normal thus allowing the ovary to pass into the inguinal canal.
ultrasound image- marked ascites projecting into the inguinal canal and a hernial sac.
spigelian hernia
- a herniation (usually bowel) lateral to the rectus abdominis at the linea semi-luninaris. this is the aponeurosis between transversus abdominis and the internal oblique.
- predominantly right sided (ref http://www.ncbi.nlm.nih.gov/pubmed/23763857)
- high risk of strangulation, so should be reviewed surgically.
- may not be clinically palpable, particularly when supine.
anatomical diagram of a spigelian hernia.
ref: gog.net.nz
ultrasound image- a prominent spigelian hernia containing a fluid filled loop of bowel.
see the video below to see this reduced.
ultrasound image- a suspected appendix contained within a spigelian hernia.
ultrasound image- when supine, a spigelian hernia may be entirely invisible and not producible with straining.
types of spigelian hernias.
ref: gog.net.nz
video of a spigelian hernia being reduced.
round ligament varices
as a pregnancy progresses, more commonly in the 3rd trimester, the pressure on the veins in the pelvic region increases. if there is a history of incompetence then it is inevitable that varicosities will increase with dilatation of the veins surrounding the uterus.
the following case was a 24 week gestation with noticeable swelling in the pubic region. it was painful and more noticeable erect. it mimics an inguinal hernia in clinical appearance.
ultrasound image- these are varicosities in the round ligament.
ultrasound image- there is no inguinal hernia present.
ultrasound image- the veins can be traced from the right adnexal region into the labium majora.
ultrasound image- colour doppler was an important tool to use to help distinguish it from an inguinal hernia.
groin lipoma
this patient was sent for a dvt study as her leg would be swollen at the end of every day but was not swollen when she first got out of bed. the lipoma would push on the vein during the day causing the swelling. luckily for this patient not dvt was found.
ultrasound image- a lipoma in either the inguinal or in this case femoral canal may mimic a hernia. this example shows the lipoma between the vessels rather than medially where a hernia normally descends.
ultrasound image- lipoma within the inguinal canal. it can be difficult to distinguish between a herniation of omental fat. a lipoma will not be able to be reduced back through the internal inguinal ring, and a proximal end is often visible. it generally has a rounded end and is partially compressible.
incisional hernia
- results from an incompletely/improperly healed surgical wound.
- often the sequel of post-operative complications such as infection or haematoma.
video-clips of hernias
canal of nuck ('female hydrocele')
- a patent vestigal remnant of the processus vaginalis.
- presents as a palpable possibly transient groin lump in females. this can extend to the labia majora.
- it is usually assymptomatic.
- is more medial and superficial to the femoral canal.
- seen as an anechoic superficial cystic area is visible in the groin, usually with a tapering neck up into the inguinal canal.
- always check for ascites in the pelvis.
the following case was a 45 year old female with a painful lump in the groin. the ultrasound showed a cystic mass at the level of the superficial inguinal ring. there is no communication with the peritoneum. when the patient was erect there was no change.
ultrasound image- canal of nuck: a ‘female hydrocele’. the tapered neck is visible from the pelvis.
ultrasound image- the same canal of nuck ‘cyst’ when erect.
hip effusion
ultrasound image- there is fluid along the femoral neck.
scan the patient supine with the leg slightly externally rotated and run the transducer along the nof.
ultrasound image- hip effusion
iliopsoas bursitis, tendonitis or ascess.
- the iliopsoas tendon is the common tendon of the iliacus and psoas muscles of the lateral pelvis and spine. it is a hip flexor and external rotator.
- as it crosses the tendon tendon passes immediately anterior to the medial edge of the hip joint. it then curves and dives to insert onto the lesser trochanter of the femur.
- the iliopsoas bursa is the largest bursa in the body.
ultrasound image- a normal iliopsoas tendon.
ultrasound showing an edematous iliopsoas tendon and bursal thickening/fluid.
ultrasound image-iliopsoas abscess.
ultrasound image-iliopsoas bursitis.
ultrasound image-a large simple iliopsoas bursa.
ultrasound image-the bursa was easily aspirated.
red arrow indicates the needle tip.
ultrasound image-a comparison image showing a normal rt iliopsoas insertion and the abnormal left.
ultrasound image-iliopsoas tendon insertional tear.
trochanteric bursitis
- the trochanteric bursa is the most superficial and posterolateral of the many bursa that surround the hip joint.
- it lies just below the level of the top of the greater trochanter and deep to the gluteus maximus and iliotibial band.
- it is a large bursa and can extend significantly laterally and inferiorly.
importantly, absence of fluid on ultrasound, does not exclude trochanteric bursitis.
ultrasound image- trochanteric bursitis is visualised as a linear anechoic line coursing along the gluteus medius.
this is often only a thin layer of fluid and is often best visualised initially with the patient supine and scanning in a transverse plane postero-laterally.
(placing the patient on their side may disperse the fluid making the diagnosis more difficult)
ultrasound image- superficial trochanteric bursitis.
the following patient experienced relief from a cortico-steroid injection and had 10 cc of purulent fluid aspirated.
ultrasound image example of marked trochanteric bursal fluid (> 15cc).
ultrasound image -axial view of superficial trochanteric bursitis.
haematoma
this patient sustained a fall 3 weeks before and a lump had formed. it was only painful on palpation.
ultrasound image- the haematoma tracks over the iliotibial band at the level of the greater trochanter.
tears
gluteus medius tendon tear.
transverse ultrasound view of the same gluteus medius tear.
coronal ultrasound view of the tear in the gluteus medius tendon.
there is fluid in the region and the tendon has retracted.
mouse over highlights the vascularity.
gluteal tendinopathy
- tendinopathy is caused by the inability of a tendon to adapt to loading. there is microtrauma and attempted healing.
tendinopathy and bursitis of the gluteal insertions is another common disorder of the middle aged and elderly. it may also occur in younger more athletic patients possibly because there is a core imbalance.
the gluteus medius tendon inserts onto the greater trochanter, with two insertions one to the superior facet and one to the lateral. deep to the tendon is the sub gluteus medius bursa. gluteus minimus inserts anteriorly and also has its own bursa.
ultrasound image- gluteus medius tendinopathy. there is a loss of normal architecture. there is often an increase in vascularity. often it is chronic so enthesopathy will be seen ie intrasubstance calcification within the tendon, often at the insertion.
enthesopathy
this is usually seen in patients with chronic lateral hip pain and tenderness on palpation. generally over the tip of the greater trochanter at the gluteus minimus and medius tendons.
enthesopathy is a process rather than a disease. it is a disorder at the site of the insertion of ligaments, tendons, fascia, or articular capsule into bone (enthesis) .this process also may promote abnormal calcification or ossification of the tendon or ligament at the insertion into the bone.
tears of the tendon may also be seen. gluteus medius and minimus enthesopathy is a distinct clinical entity.
ultrasound image- enthesopathy.
calcification at the gluteus minimus and medius tendon insertion
snapping hip
snapping can have intra-articlar causes such as osteo-arthritis, labral tears or cysts. these may not be visible on ultrasound.
the 2 most likely forms of snapping hip encountered with ultrasound are:
- lateral snapping hip syndrome.
this involves the ilio-tibial band catching on the greater trochanter or gluteal tendon insertions. to evaluate this, roll the patient onto the unaffected side and scan transversely over the greater trochanter. with the leg flexed, ask the patent to lift their feet apart, whilst keeping their knees together. watch the itb. it should slide smoothly over the trochanter and gluteals. (see normal video here)
- anterior snapping hip syndrome.
this occurs less commonly. it involves the ilio-psoas musculo-tendinous junction catching on ilio-pectineal ridge. this occurs during movement from hip flexion to extension.
with the patient supine, ask the patient to flex, then abduct the hip (frog-leg position). then return to full extension so the feet are side-by-side. it is on this return to extension that the click will occur.
to observe this on ultrasound, scan the iliopsoas tendon in transverse at the level of the pubis.
probe position to assess the iliopsoas tendon for anterior snapping hip.
ultrasound image- a normal iliopsoas tendon in transverse.
vastus lateralis lipoma
this patient was sent for an ultrasound because he felt a lump in his leg and had pain overnight.
an intramuscular echogenic well circumbscribed mass was present within the vastus lateralis muscle belly of the quadricep group.
when a fatty tumour is seen in a muscle a liposarcoma should be considered . they are malignant and can metastasize.
within the central muscle belly of the vastus lateralis muscle in the mid thigh , there is a well defined ovoid shape hyperechoic lesion. it measures 7.6×2.7×10.4 cm. there was no significant internal vasculature seen.
due to the size and the intramuscular position a ct was performed with and without contrast. it showed that the lesion was a intramuscular lipoma with no aggressive features detected.
labral pathology
- labral tears and labral cysts.
- labral cysts are generally the sequelae from labral tears, with synovial fluid extending through the defect.
ultrasound image- complicated, chronic labral cysts.
ultrasound image- the labral cysts are swelling the labrum. the patient had groin pain, but also muscular thigh pain, likely due to the combination of altered gait and pressure on the muscle origins by the thickened labrum.
femoro-acetabular impingement ( fai ) cam lesions
- involves entrapment of the anterior labrum and capsule of the hip, secondary to boney irregularity of the acetabular margin, and or femoral neck reducing the natural range of movement.
subtypes :
- cam: where there is loss of the femoral head/neck concavity.
- pincer: where there is bossing of the actetabular margin.
- mixed: a combination of cam and pincer types.
the sub-types of femoro-acetabular impingement.
ref: lavine et al 2004
the sub-types of femoro-acetabular impingement.
ref: lavine et al 2004
the sub-types of femoro-acetabular impingement.
ref: lavine et al 2004
the sub-types of femoro-acetabular impingement.
ref: lavine et al 2004
this ultrasound image shows a pincer type cam lesion. the arrows indicate the irregular neck of femur. the loss of head-neck shape is also evident.
ultrasound image- the normal right hip and abnormal left hip.
osteophyte off acetabulum (blue arrow) and the cam-lesion on the anterior femoral neck (red arrow)
ultrasound image- osteophytic lipping of the acetabulum and the cam-lesion on the anterior femoral neck (red arrow) support the diagnosis of femoro-acetabular impingement (fai).
ultrasound image- tendinopathy of the tensor fasciae latae at the origin .the patient was an elite karate competitor.
ultrasound image of a thickened ilio-tibial band.
this was an elderly man with a severe scoliosis creating chronic pressure on the lateral hip .
lymph nodes
the same principles apply to lymph nodes anywhere:
- height should be less than length.
- an echogenic fatty hilum should be present.
- should have a homogeneous, smooth hypoechoic cortex.
- only subtle vascularity with a single hilum.
ultrasound image- this lymph node has lost its fatty hilum. it has become rounded and not elongated like a normal lymph node. it is heterogeneous and hypoechoic. abnormal lymph nodes can become anechoic and appear cystic.
ultrasound image- increased vascularity in an abnormal lymph node.
fibromatosis
this patient felt a lump in her groin which was growing .the overlying skin is normal. it was painful.
a biopsy was done and the diagnosis was as follows:
“this may represent reactive fibroblastic proliferation at the periphery of an old haematoma, but also raises consideration of the possibility of old haemorrhage into a spindle cell lesion, a form of fasciitis or fibromatosis.”
these tumours often appear as infiltrative, usually well-differentiated, firm overgrowths of fibrous tissue, and they are locally aggressive. they may recur after excision.
they commonly arise from the rectus abdominis muscle in postpartum women and in scars due to abdominal surgery, they may arise in any skeletal muscle.
ultrasound image- inguinal ligament is adjacent to the groin lump. the lump lies within the aponeurosis of the rectus abdominis muscle distally.
ultrasound image- fibromatosis is hyperaemic.infiltration of the adjacent muscle bundles to entrap them and cause degeneration is commonly seen.
myositis ossificans vastus intermedius
this patient is 17 years old and sustained trauma during a rugby match 6 weeks ago.
a lump had formed and it was still painful. under ultrasound a large 12cm long heterogeneous mass with calcification was present in the vastus intermedius. this is consistent with the growth of bone and cartilage within the skeletal muscle after a contusion injury from blunt trauma. myositis ossificans traumatica makes up 65-75% of all cases.
ultrasound image- vastus intermedius myositis ossificans long.
ultrasound image- myositis ossificans trans.
dvt
aneurysm
references
sonographic findings of groin masses j ultrasound med may 1, 2007 26:605-614
imaging of abdominal wall hernias imaging december 1, 2006 18:268-277
van den berg jc, rutten mj, de valois jc, jansen jb, rosenbusch g. masses and pain in the groin: a review of imaging findings. eur radiol 1998; 8:911-921.
ovary-containing hernia in a premature infant: sonographic diagnosis j ultrasound med july 1, 2007 26:985-987