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Age / Sex : 42 / F
Chief complaint: left hip pain 1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case.
(Quiz는 quiz일 뿐이오니 답안은 한개만 보내주시기 바라오며, 복수의 답안을 보내주시는 분은 정답이 포함되어 있더라도 부득이 semi-correct answer로 처리토록 하겠습니다.) Courtesy: 윤영철(Young Cheol Yoon), 성균관대 삼성서울병원(Samsung Medical Center)
* 최다정답자 및 응모자 시상과 관련해서 '전문의' 및 '전공의' 구분이 필요하오니, 변동이 있으신 분들께서는 홈페이지 '개인 정보'의 수정 또는 답안 제출시 정확한 정보 기입을 부탁드립니다.
Diagnosis: Partial tear of ligamentum teres, left
Discussion
Findings:
Increased signal intensity with
increased thickness of left ligamentum teres associated with mild synovitis
Differential Diagnosis:
Normal variation of ligamentum teres
Synovitis
Diagnosis:
Tear of ligamentum teres
Discussion:
The ligamentum teres femoris
attaches distally and medially to the transverse ligament of the acetabulum and
to several surrounding structures. It attaches proximally and laterally to the
fovea capitis, a depression in the medial superior femoral head. The ligamentum
teres is a conduit for a small branch of the obturator artery, but that branch
is often occluded in adults. At MRI, the ligament may appear striated and have
two to three bundles with a slightly bilobed appearance. This ligament is
thought to provide some stability to the hip. Tears of the ligamentum teres may
occur in the presence or absence of osteoarthritis.
Ligamentum teres abnormalities have
been classified into three distinct patterns: complete ligamentum teres
ruptures, partial tears, and degeneration. Patients with complete tears
typically have a history of trauma or surgery and have associated intraarticular
pathology, such as labral tears and chondrosis. These patients have groin pain,
and the onset of their hip symptoms is date-specific and related to an inciting
event. Those with partial tears have a long history of symptoms and minimal
clinical findings. Patients with ligamentum teres degeneration typically have
associated osteoarthritis and have symptoms similar to other patients with
osteoarthritis. Treatment of ligamentum teres tears consists of débridement of
the disrupted fibers. Partial tears of the ligamentum teres have been described
on MR arthrography as showing abnormal intrasubstance SI and concomitant
morphologic alterations that include thickening, abnormal attenuation of the
ligament, and focal partial loss of continuity. There are some overlaps in the
imaging appearance of the intact and partially torn ligamentum teres. When the
ligamentum teres has two or three bundles, the normal appearance can be
striated and should not be misinterpreted as a partial tear.
References:
1.
Donna G.
Blankenbaker1, Arthur A. De Smet1, James S.
Keene2 and Alejandro Munoz. Imaging Appearance of the Normal and Partially Torn Ligamentum Teres on
Hip MR Arthrography. AJR 2012; 199:1093–1098
2.
Cerezal L,
Kassarjian A, Canga A, et al. Anatomy, biomechanics, imaging, and management of
ligamentum teres injuries. RadioGraphics 2010; 30:1637–1651
3.
Rao J, Zhou
YX, Villar RN. Injury to the ligamentum teres: mechanism, findings and results
of treatment. Clin Sports Med 2001; 20:791–799
4.
Bardakos NV,
Villar RN. The ligamentum teres of the adult hip. J Bone Joint Surg Br 2009;
91:8–15
5.
Byrd JW,
Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain.
Arthroscopy 2004; 20:385–391
6.
Gray AJ,
Villar RN. The ligamentum teres of the hip: an arthroscopic classification of
its pathology. Arthroscopy 1997; 13:575–578
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