Medical Imaging Analysis Report

I. Imaging Findings

Based on the provided imaging (including X-ray, CT, and MRI) and the patient’s history, the main radiologic findings are as follows:

• The lesion is located in the right gluteal region within the soft tissue layer, specifically between the subcutaneous fat layer and the deep fascial (muscle fascial) layer.
• On MRI, a relatively regular or cystic fluid signal may be observed; in some cases, there may be septations or a pseudo-capsule. T1-weighted images typically show low or mixed signal intensity, while T2-weighted images typically show high or mixed signal intensity.
• In subacute or chronic stages, the lesion margin may exhibit a capsular structure containing relatively homogeneous fluid signals. In acute stages, it may demonstrate an irregular soft tissue density or more heterogeneous fluid attenuation.
• No obvious osseous abnormalities or signs of fracture are observed in the surrounding area; the lesion primarily involves the soft tissue interface.
• On CT or ultrasound, fluid accumulation can also be seen between the fascial layer and subcutaneous tissue. Depending on the course of the disease, varying degrees of layering, mixed blood products, or fat droplets may appear.

II. Possible Diagnoses

Taking into account the clinical history (the patient had a previous trauma, presenting with chronic local swelling but no obvious signs of skeletal injury) and the imaging features (fluid or blood accumulation between fascial layers, with a possible pseudo-capsule), the following diagnoses or differential diagnoses should be considered:

1. Morel-Lavallée lesion (Morel-Lavallée syndrome)
   Caused by trauma leading to separation of the subcutaneous tissue from the deep fascia, forming a cystic or cavitary fluid collection often containing blood, lymph, and fat. Imaging typically shows a characteristic cystic lesion with blood layering and a pseudo-capsule.
2. Simple Soft Tissue Hematoma
   Post-traumatic local bleeding in soft tissue. However, if it is a simple hematoma, it typically appears as a single-chamber or relatively simple cystic lesion on ultrasound or CT, and it usually decreases in size over several weeks. Pronounced capsule formation is less common.
3. Lipoma or Complex Fatty Lesion
   These can appear cystic or low density on imaging, but they usually have more fat-specific signals internally and do not commonly present with blood elements or internal septations. The history of trauma and clinical manifestations do not primarily support lipoma.
4. Other Soft Tissue Masses (e.g., cysts, neoplastic lesions)
   For instance, bursitis or ganglion cysts. However, these often have a more definitive anatomical correlation and are not typically associated with trauma or hemorrhagic components.

III. Final Diagnosis

Considering the patient’s age (40-year-old female), history of trauma over two years ago, gradual local swelling, and the imaging findings (a distinct fluid-filled lesion between the deep fascia and subcutaneous tissue with signs of a pseudo-capsule), the diagnosis most likely is:

Morel-Lavallée lesion (Morel-Lavallée syndrome)

This condition results from blunt or shear trauma that causes detachment between the subcutaneous layer and the deep fascial layer, leading to fluid accumulation. Clinical and imaging features are quite characteristic. If further confirmation is needed or to assess inflammatory activity, gadolinium-enhanced MRI or ultrasound-guided aspiration may be considered. In cases of persistent fluid leakage or suspected infection, laboratory tests (such as white blood cell count, C-reactive protein, etc.) can help in distinguishing potential complications.

IV. Treatment Plan and Rehabilitation

Based on the characteristics of this lesion and the patient’s current presentation, potential treatment options and rehabilitation considerations include:

1. Treatment Strategy
   • Early and Conservative Management: If the lesion is small, symptoms are mild, or the disease course is relatively short, compression dressings and ultrasound-guided aspiration may help reduce local tension and relieve symptoms. Sclerotherapy (using agents such as alcohol or sclerosant powders) may be considered to facilitate closure of the lesion cavity.
   • Open Surgery or Debridement: In longstanding cases with a well-formed pseudo-capsule or recurrent fluid accumulation that is not controlled by aspiration alone, surgical intervention to remove the fluid and excise the capsule may be required to prevent recurrence. In addition, infection or other complications may necessitate prompt surgical intervention.
2. Rehabilitation and Exercise Prescription

   During recovery, to promote local soft tissue healing while maintaining overall function, an individualized exercise prescription following the FITT-VP principle may be considered:

   • Frequency: Begin with 2-3 sessions per week at low to moderate intensity; as tissue healing progresses, gradually increase frequency to 3-5 sessions per week.
   • Intensity: Start with light to moderate intensity (such as maintaining heart rate at 40-60% of maximum). Progress carefully without placing excessive impact or traction on the affected gluteal area.
   • Time: Each session may begin at 15-20 minutes and gradually increase to 30-40 minutes. If significant local swelling occurs, reduce exercise duration and increase rest intervals.
   • Type: Focus on low-impact aerobic activities (e.g., walking, stationary cycling) and moderate functional training (e.g., gentle exercises for the gluteal muscles and lower limb core). Avoid running, jumping, or high-intensity resistance exercises in the early phase.
   • Progression: Increase load and duration only after ensuring no significant local pain or swelling. If discomfort arises, reduce exercise and re-evaluate the lesion.
   • Volume & Individualization: Adjust according to the patient’s fitness level, cardiorespiratory reserve, and the rate of soft tissue recovery. Patients with osteoporosis or poor cardiovascular function may require additional risk assessment and stricter intensity control.

In the early rehabilitation phase, begin with simple isometric contractions of the lower limb muscles or leg elevation exercises, combined with daily walking. Gradually incorporate moderate resistance or light load training (e.g., resistance band exercises). In the later phase, consider stability and balance training to enhance overall functional capacity and reduce the risk of recurrence.

Disclaimer: This report is for reference only and does not replace a face-to-face medical consultation or the professional diagnosis and treatment advice of a physician. The patient should work with a specialist to develop an individualized treatment and rehabilitation plan based on clinical findings.