A lump on the hip

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A lump on the hip
Author(s)
Morteza Khodaee, MD, MPH
Seth Mathern, MD
Wendy S. Madigosky, MD, MSPH
Jonathan T. Bravman, MD

A 42-year-old man presented with a lump on the side of his left hip, which had developed after he fell on his hip while playing basketball about 2 weeks earlier. He was able to continue playing and finished the game. After the game he noticed a lump, which rapidly increased in size. Significant bruising developed afterwards, and the area was mildly painful. The lump did not interfere with his daily activities, but it was annoying.

Left lateral hip 2 weeks after a fall.
Figure 1. Left lateral hip 2 weeks after a fall.
His medical, surgical, social, and family histories were unremarkable. Physical examination revealed a significant oval-shaped local swelling in the lateral aspect of his left hip with extensive surrounding ecchymosis (Figure 1). On palpation the swelling was mildly tender and fluctuant. Range of motion of the hip was normal and did not aggravate his pain.

Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter.
Figure 2. Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter (GT).
Ultrasonography to evaluate for fluid collection revealed a subcutaneous heterogeneous and hypoechoic area superficial to the greater trochanter, muscular structure, and the fascia (Figure 2). There was no enlargement of the greater trochanter bursa. Aspiration with an 18-gauge needle under ultrasonographic guidance provided no fluid. Based on the clinical presentation and imaging, the diagnosis of Morel-Lavallée lesion was made.

THE DIFFERENTIAL DIAGNOSIS

Differential diagnosis of a traumatic lateral hip lump
Traumatic swelling of the lateral hip is an uncommon condition with few possible causes (Table 1).1–5 A comprehensive evaluation beginning with a history and physical examination is essential.

Morel-Lavallée lesion is an uncommon condition resulting from shearing trauma and collection of fluid in the space between deep fatty tissue and superficial fascia.6 It is usually the result of severe trauma, as in a motor vehicle accident, but it can also result from sports-related trauma, as in our patient.6–8 Lateral hip, gluteal, and sacral regions are the most common locations for Morel-Lavallée lesions and are often associated with an underlying fracture.6,9

Morel-Lavallée lesions usually develop hours or days after trauma, although they may develop weeks or even months later.2 Symptoms include bulging, pain, and loss of cutaneous sensation over the affected area. Although ultrasonography can be used, magnetic resonance imaging (MRI) is the gold standard for diagnosis and staging.6,10 If there is concern for fracture, plain radiography should be performed.

Mellado and Bencardino classified Morel-Lavallée lesions into 6 types based on their morphology, presence or absence of a capsule, signal behavior on MRI, and enhancement pattern.10 The exact rate of infection in patients with Morel-Lavallée lesions is unknown; however, the risk of infection seems to be highest after surgical intervention or aspiration.5,6

Another potential complication is fluid reaccumulation, which most often occurs with large lesions (> 50 mL) and lesions with a fibrous capsule or pseudocapsule.5 Large lesions can compromise adjacent neurovascular structures, particularly in the extremities.5 Potential consequences include dermal necrosis, compartment syndrome, and tissue necrosis.5

MANAGEMENT APPROACH

Aspiration of a fluid-filled mass is useful in both diagnosis and management of Morel-Lavallée lesions. Treatment includes watchful waiting; compression and pressure wraps; injection of a sclerosing agent (eg, doxycyline, alcohol); needle aspiration; percutaneous drainage with debridement, irrigation, and suction; and incision and evacuation.6

The approach to treatment depends on the stage of the lesion and whether an underlying fracture is present. Depending on the amount of blood and lymphatic products and the acuity of the collected fluid (hours to days post-trauma), aspiration with a large-bore needle (eg, 14 to 22 gauge) may or may not be successful.7 In general, traumatic serosanguinous fluid collections are less painful and resolve faster than well-formed coagulated hematomas.

Patients who have a large lesion, significant pain, or decreased range of motion should be referred to an orthopedic surgeon.

Our patient was managed conservatively, and his symptoms completely resolved in 2 months.

References
  1. Ahmad Z, Tibrewal S, Waters G, Nolan J. Solitary amyloidoma related to THA. Orthopedics 2013; 36:e971–e973.
  2. Harris-Spinks C, Nabhan D, Khodaee M. Noniatrogenic septic olecranon bursitis: report of two cases and review of the literature. Curr Sports Med Rep 2016; 15:33–37.
  3. Price MD, Busconi BD, McMillan S. Proximal femur fractures. In: Miller MD, Sanders TG, eds. Presentation, Imaging and Treatment of Common Musculoskeletal Conditions. Philadelphia, PA: Saunders; 2011:365–376.
  4. Stanton MC, Maloney MD, Dehaven KE, Giordano BD. Acute traumatic tear of gluteus medius and minimus tendons in a patient without antecedant peritrochanteric hip pain. Geriatr Orthop Surg Rehabil 2012; 3:84–88.
  5. Khodaee M, Deu RS, Mathern S, Bravman JT. Morel-Lavallée lesion in sports. Curr Sports Med Rep 2016; 15:417–422.
  6. Bonilla-Yoon I, Masih S, Patel DB, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2014; 21:35–43.
  7. Khodaee M, Deu RS. Ankle Morel-Lavallée lesion in a recreational racquetball player. J Sports Med Phys Fitness 2016. Epub ahead of print.
  8. Shmerling A, Bravman JT, Khodaee M. Morel-Lavallée lesion of the knee in a recreational frisbee player. Case Rep Orthop 2016; 2016:8723489.
  9. Miller J, Daggett J, Ambay R, Payne WG. Morel-Lavallée lesion. Eplasty 2014; 14:ic12.
  10. Mellado JM, Bencardino JT. Morel-Lavallée lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am 2005; 13:775–782.
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Author and Disclosure Information

Morteza Khodaee, MD, MPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Seth Mathern, MD
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Wendy S. Madigosky, MD, MSPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Jonathan T. Bravman, MD
Department of Orthopedic Surgery, University of Colorado School of Medicine, Denver, CO

Address: Morteza Khodaee, MD, MPH, Department of Family Medicine, University of Colorado School of Medicine, AFW Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected]

Issue
Cleveland Clinic Journal of Medicine - 84(8)
Publications
Cleveland Clinic Journal of Medicine
Topics
Emergency Medicine
Rheumatology
Page Number
594-596
Legacy Keywords
lump, hip, sports injury, Morel-Lavallee lesion, bursa, bursitis, Morteza Khodaee, Seth Mathern Wendy Madigosky, Jonathan Bravman
Sections
The Clinical Picture
Author(s)
Morteza Khodaee, MD, MPH
Seth Mathern, MD
Wendy S. Madigosky, MD, MSPH
Jonathan T. Bravman, MD
Author(s)
Morteza Khodaee, MD, MPH
Seth Mathern, MD
Wendy S. Madigosky, MD, MSPH
Jonathan T. Bravman, MD
Author and Disclosure Information

Morteza Khodaee, MD, MPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Seth Mathern, MD
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Wendy S. Madigosky, MD, MSPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Jonathan T. Bravman, MD
Department of Orthopedic Surgery, University of Colorado School of Medicine, Denver, CO

Address: Morteza Khodaee, MD, MPH, Department of Family Medicine, University of Colorado School of Medicine, AFW Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected]

Author and Disclosure Information

Morteza Khodaee, MD, MPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Seth Mathern, MD
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Wendy S. Madigosky, MD, MSPH
Department of Family Medicine, University of Colorado School of Medicine, Denver, CO

Jonathan T. Bravman, MD
Department of Orthopedic Surgery, University of Colorado School of Medicine, Denver, CO

Address: Morteza Khodaee, MD, MPH, Department of Family Medicine, University of Colorado School of Medicine, AFW Clinic, 3055 Roslyn Street, Denver, CO 80238; [email protected]

Article PDF
khodaee_lumponhip.pdf
Article PDF
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A 42-year-old man presented with a lump on the side of his left hip, which had developed after he fell on his hip while playing basketball about 2 weeks earlier. He was able to continue playing and finished the game. After the game he noticed a lump, which rapidly increased in size. Significant bruising developed afterwards, and the area was mildly painful. The lump did not interfere with his daily activities, but it was annoying.

Left lateral hip 2 weeks after a fall.
Figure 1. Left lateral hip 2 weeks after a fall.
His medical, surgical, social, and family histories were unremarkable. Physical examination revealed a significant oval-shaped local swelling in the lateral aspect of his left hip with extensive surrounding ecchymosis (Figure 1). On palpation the swelling was mildly tender and fluctuant. Range of motion of the hip was normal and did not aggravate his pain.

Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter.
Figure 2. Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter (GT).
Ultrasonography to evaluate for fluid collection revealed a subcutaneous heterogeneous and hypoechoic area superficial to the greater trochanter, muscular structure, and the fascia (Figure 2). There was no enlargement of the greater trochanter bursa. Aspiration with an 18-gauge needle under ultrasonographic guidance provided no fluid. Based on the clinical presentation and imaging, the diagnosis of Morel-Lavallée lesion was made.

THE DIFFERENTIAL DIAGNOSIS

Differential diagnosis of a traumatic lateral hip lump
Traumatic swelling of the lateral hip is an uncommon condition with few possible causes (Table 1).1–5 A comprehensive evaluation beginning with a history and physical examination is essential.

Morel-Lavallée lesion is an uncommon condition resulting from shearing trauma and collection of fluid in the space between deep fatty tissue and superficial fascia.6 It is usually the result of severe trauma, as in a motor vehicle accident, but it can also result from sports-related trauma, as in our patient.6–8 Lateral hip, gluteal, and sacral regions are the most common locations for Morel-Lavallée lesions and are often associated with an underlying fracture.6,9

Morel-Lavallée lesions usually develop hours or days after trauma, although they may develop weeks or even months later.2 Symptoms include bulging, pain, and loss of cutaneous sensation over the affected area. Although ultrasonography can be used, magnetic resonance imaging (MRI) is the gold standard for diagnosis and staging.6,10 If there is concern for fracture, plain radiography should be performed.

Mellado and Bencardino classified Morel-Lavallée lesions into 6 types based on their morphology, presence or absence of a capsule, signal behavior on MRI, and enhancement pattern.10 The exact rate of infection in patients with Morel-Lavallée lesions is unknown; however, the risk of infection seems to be highest after surgical intervention or aspiration.5,6

Another potential complication is fluid reaccumulation, which most often occurs with large lesions (> 50 mL) and lesions with a fibrous capsule or pseudocapsule.5 Large lesions can compromise adjacent neurovascular structures, particularly in the extremities.5 Potential consequences include dermal necrosis, compartment syndrome, and tissue necrosis.5

MANAGEMENT APPROACH

Aspiration of a fluid-filled mass is useful in both diagnosis and management of Morel-Lavallée lesions. Treatment includes watchful waiting; compression and pressure wraps; injection of a sclerosing agent (eg, doxycyline, alcohol); needle aspiration; percutaneous drainage with debridement, irrigation, and suction; and incision and evacuation.6

The approach to treatment depends on the stage of the lesion and whether an underlying fracture is present. Depending on the amount of blood and lymphatic products and the acuity of the collected fluid (hours to days post-trauma), aspiration with a large-bore needle (eg, 14 to 22 gauge) may or may not be successful.7 In general, traumatic serosanguinous fluid collections are less painful and resolve faster than well-formed coagulated hematomas.

Patients who have a large lesion, significant pain, or decreased range of motion should be referred to an orthopedic surgeon.

Our patient was managed conservatively, and his symptoms completely resolved in 2 months.

A 42-year-old man presented with a lump on the side of his left hip, which had developed after he fell on his hip while playing basketball about 2 weeks earlier. He was able to continue playing and finished the game. After the game he noticed a lump, which rapidly increased in size. Significant bruising developed afterwards, and the area was mildly painful. The lump did not interfere with his daily activities, but it was annoying.

Left lateral hip 2 weeks after a fall.
Figure 1. Left lateral hip 2 weeks after a fall.
His medical, surgical, social, and family histories were unremarkable. Physical examination revealed a significant oval-shaped local swelling in the lateral aspect of his left hip with extensive surrounding ecchymosis (Figure 1). On palpation the swelling was mildly tender and fluctuant. Range of motion of the hip was normal and did not aggravate his pain.

Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter.
Figure 2. Ultrasonography with a curvilinear 2- to 5-MHz probe and a long-axis view revealed a superficial heterogeneous and hypoechoic area (asterisk) at the greater trochanter (GT).
Ultrasonography to evaluate for fluid collection revealed a subcutaneous heterogeneous and hypoechoic area superficial to the greater trochanter, muscular structure, and the fascia (Figure 2). There was no enlargement of the greater trochanter bursa. Aspiration with an 18-gauge needle under ultrasonographic guidance provided no fluid. Based on the clinical presentation and imaging, the diagnosis of Morel-Lavallée lesion was made.

THE DIFFERENTIAL DIAGNOSIS

Differential diagnosis of a traumatic lateral hip lump
Traumatic swelling of the lateral hip is an uncommon condition with few possible causes (Table 1).1–5 A comprehensive evaluation beginning with a history and physical examination is essential.

Morel-Lavallée lesion is an uncommon condition resulting from shearing trauma and collection of fluid in the space between deep fatty tissue and superficial fascia.6 It is usually the result of severe trauma, as in a motor vehicle accident, but it can also result from sports-related trauma, as in our patient.6–8 Lateral hip, gluteal, and sacral regions are the most common locations for Morel-Lavallée lesions and are often associated with an underlying fracture.6,9

Morel-Lavallée lesions usually develop hours or days after trauma, although they may develop weeks or even months later.2 Symptoms include bulging, pain, and loss of cutaneous sensation over the affected area. Although ultrasonography can be used, magnetic resonance imaging (MRI) is the gold standard for diagnosis and staging.6,10 If there is concern for fracture, plain radiography should be performed.

Mellado and Bencardino classified Morel-Lavallée lesions into 6 types based on their morphology, presence or absence of a capsule, signal behavior on MRI, and enhancement pattern.10 The exact rate of infection in patients with Morel-Lavallée lesions is unknown; however, the risk of infection seems to be highest after surgical intervention or aspiration.5,6

Another potential complication is fluid reaccumulation, which most often occurs with large lesions (> 50 mL) and lesions with a fibrous capsule or pseudocapsule.5 Large lesions can compromise adjacent neurovascular structures, particularly in the extremities.5 Potential consequences include dermal necrosis, compartment syndrome, and tissue necrosis.5

MANAGEMENT APPROACH

Aspiration of a fluid-filled mass is useful in both diagnosis and management of Morel-Lavallée lesions. Treatment includes watchful waiting; compression and pressure wraps; injection of a sclerosing agent (eg, doxycyline, alcohol); needle aspiration; percutaneous drainage with debridement, irrigation, and suction; and incision and evacuation.6

The approach to treatment depends on the stage of the lesion and whether an underlying fracture is present. Depending on the amount of blood and lymphatic products and the acuity of the collected fluid (hours to days post-trauma), aspiration with a large-bore needle (eg, 14 to 22 gauge) may or may not be successful.7 In general, traumatic serosanguinous fluid collections are less painful and resolve faster than well-formed coagulated hematomas.

Patients who have a large lesion, significant pain, or decreased range of motion should be referred to an orthopedic surgeon.

Our patient was managed conservatively, and his symptoms completely resolved in 2 months.

References
  1. Ahmad Z, Tibrewal S, Waters G, Nolan J. Solitary amyloidoma related to THA. Orthopedics 2013; 36:e971–e973.
  2. Harris-Spinks C, Nabhan D, Khodaee M. Noniatrogenic septic olecranon bursitis: report of two cases and review of the literature. Curr Sports Med Rep 2016; 15:33–37.
  3. Price MD, Busconi BD, McMillan S. Proximal femur fractures. In: Miller MD, Sanders TG, eds. Presentation, Imaging and Treatment of Common Musculoskeletal Conditions. Philadelphia, PA: Saunders; 2011:365–376.
  4. Stanton MC, Maloney MD, Dehaven KE, Giordano BD. Acute traumatic tear of gluteus medius and minimus tendons in a patient without antecedant peritrochanteric hip pain. Geriatr Orthop Surg Rehabil 2012; 3:84–88.
  5. Khodaee M, Deu RS, Mathern S, Bravman JT. Morel-Lavallée lesion in sports. Curr Sports Med Rep 2016; 15:417–422.
  6. Bonilla-Yoon I, Masih S, Patel DB, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2014; 21:35–43.
  7. Khodaee M, Deu RS. Ankle Morel-Lavallée lesion in a recreational racquetball player. J Sports Med Phys Fitness 2016. Epub ahead of print.
  8. Shmerling A, Bravman JT, Khodaee M. Morel-Lavallée lesion of the knee in a recreational frisbee player. Case Rep Orthop 2016; 2016:8723489.
  9. Miller J, Daggett J, Ambay R, Payne WG. Morel-Lavallée lesion. Eplasty 2014; 14:ic12.
  10. Mellado JM, Bencardino JT. Morel-Lavallée lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am 2005; 13:775–782.
References
  1. Ahmad Z, Tibrewal S, Waters G, Nolan J. Solitary amyloidoma related to THA. Orthopedics 2013; 36:e971–e973.
  2. Harris-Spinks C, Nabhan D, Khodaee M. Noniatrogenic septic olecranon bursitis: report of two cases and review of the literature. Curr Sports Med Rep 2016; 15:33–37.
  3. Price MD, Busconi BD, McMillan S. Proximal femur fractures. In: Miller MD, Sanders TG, eds. Presentation, Imaging and Treatment of Common Musculoskeletal Conditions. Philadelphia, PA: Saunders; 2011:365–376.
  4. Stanton MC, Maloney MD, Dehaven KE, Giordano BD. Acute traumatic tear of gluteus medius and minimus tendons in a patient without antecedant peritrochanteric hip pain. Geriatr Orthop Surg Rehabil 2012; 3:84–88.
  5. Khodaee M, Deu RS, Mathern S, Bravman JT. Morel-Lavallée lesion in sports. Curr Sports Med Rep 2016; 15:417–422.
  6. Bonilla-Yoon I, Masih S, Patel DB, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2014; 21:35–43.
  7. Khodaee M, Deu RS. Ankle Morel-Lavallée lesion in a recreational racquetball player. J Sports Med Phys Fitness 2016. Epub ahead of print.
  8. Shmerling A, Bravman JT, Khodaee M. Morel-Lavallée lesion of the knee in a recreational frisbee player. Case Rep Orthop 2016; 2016:8723489.
  9. Miller J, Daggett J, Ambay R, Payne WG. Morel-Lavallée lesion. Eplasty 2014; 14:ic12.
  10. Mellado JM, Bencardino JT. Morel-Lavallée lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am 2005; 13:775–782.
Issue
Cleveland Clinic Journal of Medicine - 84(8)
Issue
Cleveland Clinic Journal of Medicine - 84(8)
Page Number
594-596
Page Number
594-596
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Emergency Medicine
Rheumatology
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A lump on the hip
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A lump on the hip
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lump, hip, sports injury, Morel-Lavallee lesion, bursa, bursitis, Morteza Khodaee, Seth Mathern Wendy Madigosky, Jonathan Bravman
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lump, hip, sports injury, Morel-Lavallee lesion, bursa, bursitis, Morteza Khodaee, Seth Mathern Wendy Madigosky, Jonathan Bravman
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