ultrasound normal and pathological anatomy of the hip
TRANSCRIPT
Ultrasound Normal and Pathological
Anatomy of the Hip
Gi - young Park M.D., Ph.D.
Department of Rehabilitation Medicine
Daegu Catholic University School of Medicine
Learning Objectives
• Demonstration of the ultrasonographic
anatomy of the hip
• Demonstration of the routine ultrasonographic
evaluation of the hip
• To recognize the ultrasonographic appearances
of the hip pathology
• To learn ultrasonography-guided procedures
Hip Ultrasonography
Hip Joint Evaluation
• Longitudinal view
AH
Psoas
• A, acetabulum; H, femoral head;
fibrocartilage labrum (arrow);
iliofemoral ligament (arrow head)
Hip Joint Evaluation
• Longitudinal view• H, femoral head; collapsed
joint (arrow head)
H
Psoas
Hip Joint Evaluation
• Transverse view
Psoas
H
• H, femoral head; hyaline
cartilage (arrow); iliofemoral
ligament (arrow head)
Femur
Patella
Hip Joint Effusion
• Longitudinal (A) and transverse (B) ultrasonographic
images of the anterior hip demonstrate the hyperechoic
joint capsule (arrows), displaced from the echogenic
interface of the femoral neck (N) by a joint effusion
(asterisk). H (femoral head), I (iliopsoas).
• Left image: Longitudinal sonogram of the hip reveals a moderate joint effusion (yellow outline).
• Right image: Longitudinal sonogram acquired during ultrasound guided percutaneous aspiration demonstrates the needle (blue arrows) extending into the effusion.
Femur
Patella
Quadriceps tendon
Hip Effusion
Ultrasonography-guided Hip Injection
Ultrasonography-guided Hip Injection
Iliacus Hematoma
Iliacus Hematoma
Longitudinal view Transverse view
Iliacus Hematoma
Longitudinal view Transverse view
Iliacus Hematoma
Right Left
Snapping Hip Joint
Audible snap experienced during certain movement of the hip joint, which may or may not be painful
Ultrasound offers a distinct advantage over MRI for identifying the source of symptoms in patients who can reproduce their snapping
Intra-articular
Tears of acetabular labrum, osteophytes, osteochondromatosis, and loose bodies
Extra-articular
Lateral snapping: iliotibial band slides over greater trochanter
Medial snapping: iliopsoas tendon catching over iliopectineal eminence or body ridge of lesser trochanter
Alternate cause: long head of biceps snap over posterior aspect of ischial tuberosity
Causes of Snapping Hip Joint
Snapping Iliopsoas Tendon
When hip is flexed, externally rotated and abducted, iliopsoas
tendon shifts laterally relative to iliopectineal eminence (IE)
When hip return to extended position, iliopsoas tendon
impinges against iliopectineal eminence until snapping over it
and moving suddenly medially
Snapping Iliopsoas Tendon
Snapping Iliopsoas Tendon
Snapping Iliopsoas Tendon
Location of Three Greater
Trochanter Bursae
Gluteal Muscle and Bursa
Gluteus minimus
Gluteus medius
Gluteus maximus
Greater Trochanter Facet Anatomy
Greater Trochanter Facet Anatomy
Location of Three Greater
Trochanter Bursae
Greater Trochanter Evaluation
• Longitudinal view
• GT, greater trochanter; IT,
iliotibial tract; gluteus medius
tendon (arrows)
GT GT
ITIT
Greater Trochanter Evaluation
• GT, greater trochanter;
IT, iliotibial tract; gluteus
medius tendon (arrows)
GT
IT
Greater Trochanter Evaluation
• Transverse view • GT, greater trochanter; gluteus
medius tendon (arrows); gluteus
minimus tendon (arrow heads)
GT
Greater Trochanter Evaluation
• Longitudinal view • GT, greater trochanter;
iliotibial tract (arrows)
GT
Greater Trochanter Evaluation
• Longitudinal view• GT, greater trochanter; GM,
gluteus maximus muscle;
iliotibial tract (arrows)
GTGM
Greater Trochanter Evaluation
• Longitudinal view• GT, greater trochanter; GM,
gluteus medius muscle; gluteus
minimus tendon (arrows)
GT
GM
Greater Trochanteric Pain Syndrome
Trochanteric Tendinobursitis
Trochanteric Bursitis
Gluteal Bursitis
Typical Pain
Referred Pattern
Greater Trochanteric Pain Syndrome
• Defined as tenderness to palpation over the greater
trochanter with patient in side-lying position
Physical Examination
• Single-leg stance held for 30 seconds
• Resisted external derotation (resisted
realignment of the externally rotated hip)
• Active and resisted abduction of thigh
– Active abduction up to 25o, with thigh extended
– Resisted abduction with thigh successively
extended, then flexed at 45o and 90o
• Passive external rotation with thigh flexed 90o
Single Leg Stance
Resisted External Derotation Test
Diagnostic Value of Clinical Tests
Gluteus Tendon Tear
• Partial-thickness
tear of gluteus medius
• Full-thickness tear
of gluteus minimus
Gluteus Minimus Tendon Tear
Gluteus Medius Tendinosis
Gluteus Medius Tendinosis
Gluteal Bursitis
Gluteus Maximus
Gluteus Medius
Gluteal Bursitis
Gluteus Medius
Gluteus Maximus
Gluteus Maximus
Gluteus Medius
• Longitudinal sonogram shows a small anechoic focus
(arrows) in the superficial fibers of gluteus medius and
increased vascularity on power Doppler examination.
Partial Tear of Gluteus Medius Tendon
• 이 O O, M/55, C.C.: Rt. lateral hip pain for 1 year
• P/E: Atrophy at Rt. greater trochanter area, Rt. single leg
stance (+).
Partial Tear of Gluteus Medius Tendon
Partial Tear of Gluteus Medius Tendon
• Transverse ultrasound shows an anechoic focus (arrows) in
gluteus medius tendon. However, power Doppler examination
shows no increased vascularity.
• Small amount of fluid over right greater trochanter of femur
(under iliotibial band)
• No increased vascularity is noted
Subgluteus Maximus Bursitis
Subgluteus Maximus Bursitis
Rotator-cuff of Hip
• Iliopsoas and subscapularis: powerful internal
rotator which inserts into the lesser
trochanter/tuberosity
• Gluteus minimus and medius/supraspinatus and
infraspinatus: two abductors which insert into the
greater trochanter/tuberosity
• Reflected head of rectus femoris/long head of
biceps: tendon crossing the head
• Tears of the rotator cuff of the shoulder always
start in the supraspinatus tendon
• In the hip, such a tear starts in the insertion of
gluteus minimus and the anterior third of gluteus
medius near the digital fossa in the front of the
greater trochanter
• Pain attributed to trochanteric bursitis, however,
may be secondary to tearing of the gluteal muscles
Rotator-cuff Tear of Hip
Treatment
• Nonsteroidal anti-inflammatory drug
• Bed rest, physical therapy: ice, heat, ultrasound
• Hip & low-back muscle strengthening & stretching
exercise
• Local anesthetic injection with/without
corticosteroid
– 50 % of mixture at maximal tender point &
rest infiltrated widely around, needle length
(3.8 to 7.6 cm)
• Surgery for refractory cases
Injection
Ultrasonography Guided Injection
Ultrasonography Guided Injection
Iliopsoas Bursitis
• Pain felt the the groin, anterior thigh, knee
and leg
• Appears during walking and specific
movement, e.g. crossing the legs
• Untreated, the disorder can go on for years
•Generally overlooked, blamed on the slight
arthrosis on a radiograph
Location of Psoas and Ischial Bursae
Iliopsoas Bursa
Iliopsoas Bursitis
Injection
Injection
Necrotizing Fascitis
Necrotizing Fascitis
Necrotizing Fascitis
Necrotizing Fascitis
Necrotizing Fascitis
Necrotizing Fascitis
Necrotizing Fascitis
WFUMB 2011
WFUMB 2011
Dr. S. Bianchi
Dr. C. Martinoli
Thank Your for Your Attention