Outline Hip and Pelvis Imaging · 2012-12-26 · 5 Snapping Hip 25 Deslandes 2008 Snapping Hip 26 Labral Cysts 27 Normal Labrum Labral Cyst Labral Tears Troelsen 2007 Prosepctively

1

Hip and Pelvis Imaging

www.warhols.com/ colored%20shoe%20and%20leg.JPG

Joel Fallano, PT, DPT, MS, OCSAimee Klein, PT, DPT, DSc, OCSCSM 2013Imaging SIGJanuary 24th, 2013

Outline

Imaging TechniquesPlain filmsMRIMRASonography

Cases

Radiographs

OAFracture/Trauma

Routine MRI

Stress fracture Nonspecific hip painPubalgiaMuscle/tendon injuriesOsteonecrosisTumor

MR Arhtrography

Assess the intra-articular structuresLabrumCartilageIntra-articular loose bodiesLigamentsCapsule

Sonography

Snapping hipBursitisTendonpathyLabrum

2

Hip SonographyLower frequency soundhead

2.5 to 5 MHz

PositioningAnterior View

Pt is supine with leg in slight external rotationMedial View

Pt is supine with hip externally rotated and knee in 45 deg of flexion (frog leg position)

Lateral ViewPt is sidelying with pillows between knees

Posterior ViewPt is prone with legs extended. Pillow under hips if needed for comfort

7

Structures of Interest – HipAnterior View

Femoral head and neckLabrumIliopsoas muscle, tendon and bursaSartoriusRectus femorisVastus lateralis, medialis and intermediusFemoral nerve and artery

8

Femoral Head and Neck

9www.ESSR.org

Labrum/Iliopsoas

10www.ultrasoundcases.info

Quadriceps Group

11

Femoral Nerve and Artery

12www.ESSR.org

3

Structures of Interest – HipMedial View

Distal iliopsoasAdductor groupPubic symphysisRectus abdominus insertion

13

Adductor Group


Structures of Interest – HipLateral View

Greater trochanter and bursaGlut maxGlut medGlut minTensor fasica lataIliotibial band

15

Greater Trochanter/Bursa/ITB


Glut Med/Glut Min

17Garcia 2010

Structures of Interest – HipPosterior View

Glut max, med and minHamstringsSciatic nervePiriformis

18

4

Hamstring

19

Longitudinal Transverse

HIP PATHOLOGY

20

Greater Trochanteric Bursitis


AIIS Avulsion


Gluteal Tendon Pathology


Gluteal Tendon TearsMRI

Sensitivity of 33-100%Specificity of 92-100%Positive predictive value of 71-100% Negative predictive value of 50%False-positives were common

UltrasonographySensitivity of 79-100%Positive predictive value of 95-100%

24Westacott 2011

5

Snapping Hip

25Deslandes 2008

Snapping Hip


Labral Cysts


Normal Labrum

Labral Cyst

Labral Tears

Troelsen 2007Prosepctively examined 20 dysplastic hip with US and MRI

US examSensitivity 44%Specificity 75%Positive Predictive Value 88%Negative Predictive Value 24%

28

HIP IMAGING ANATOMY

Normal Hip Imaging

RadiographyBilateral AP Hip/PelvisAP HipFrog

MRICT

6

Radiography

B AP Hip/Pelvis viewUnilateral AP Hip view

Iliopubic lineIlioischial Line

Teardrop

Herniation Pit

Pelvis / B Hip AP View

Acetabular Lines

L AP View

Manaster BJ. Radiographics. 2000Oblique AP View

Sacrum

Ilial Wing

AP View

Obturator Internus

Gluteal

Psoas

Manaster BJ. Radiographics. 2000

AP in ER View

7

Lateral View (aka Frog View)

http://www.google.com/imgres?q=lateral+hip+radiograph&um=1&hl=en&client=firefox-a&sa=N&rls=org.mozilla:en-US:official&biw=1280&bih=870&tbm=isch&tbnid=h1HaeCKEyKG2DM:&imgrefurl=http://images.rheumatology.org/viewphoto.php%3FimageId%3D2861938%26albumId%3D75682&docid=RMQLGimvPZBa4M&w=366&h=549&ei=EDWGTr-MLcHk0QH-oaDsDw&zoom=1&iact=hc&vpx=384&vpy=396&dur=287&hovh=143&hovw=95&tx=101&ty=154&page=4&tbnh=143&tbnw=95&start=70&ndsp=24&ved=1t:429,r:1,s:70

http://www.e-radiography.net/technique/pelvis/Pelvis_hip_lat_anatomy2.jpg

MRI anatomy: Muscles

Coronal imaging

Gluteus maximus

Piriformis

Semimembranosus

Sacrum

Sacro-iliac joint

Ischial tuberosity

Gluteus Medius

Vastus lateralis

Greater andLessertrochanters

Psoas

Iliacus

Gluteus Minimus

Obturatorinternus

Obturatorexternus andquadratusfemoris

IT band

Gracilis

Adductors

8

Adductors

Obturatorinternus

ObturatorexternusTensor

fascia lata

Anteriorsuperior iliac spine

Tensor fascia lata

Sartorius

Iliopsoas

Anteriorinferior iliac spine

Rectus femoris

Sartorius

Rectus abdominus

MRI anatomy: Muscles

Axial Imaging

Piriformis

Gluteus maximus

Gluteus medius

Gluteus minimus

Sacrum

Iliopsoas

Anteriorinferior iliac spine

9

Rectus abdominus

Rectus femoris

Acetabular roof

SartoriusFemoral head

Superior pubic rami

Rectus femoris

Gemelli

Symphysis pubis

Greater trochanter

10

Obturator internusSciatic nerve

Pectineus

Tensor fascia lata

Obturator externus

Quadratus femoris

Tensor fascia lata

Iliotibialband

Iliopsoas

SartoriusRectus femoris

11

SemimembranosusSemitendinosus

Biceps Femoris

Inferior pubic rami

IliopsoasLesser trochanter

Vastus lateralis

Vastus intermedius GracilisAdductor brevis

Adductor magnus

Adductor longus

12

CT Imaging

Axial Osteoarthritis

Patient Profile60 yo femaleHPI

10/10 walking at conference, sat on bench, went to get up and has severe pain x 4 hours, then resolvedMid 11/10, rolled over in bed and felt sharp pain in L hip

PMH: OsteoporosisReferred by PCP to address L hip pain and decreasing functional statusFunctionally

Increased pain with walkingAM stiffnessInability to play golf or exercise

PT Examination

R/i L Hip OA Cluster for the Identification of Hip OA

Cluster 2Painful hip with IR> 50 yoMorning stiffness < 60 min

Diagnostic AccuracyAll 3 component of cluster are present: + LR = 3.4

Evaluation/Plan of Care

Differential Pathologic Diagnosis:OA L hipStress Fx due to underlying h/o osteoporosis

Referred to Orthopedist for medical work-upRadiographyMRI

Non-traumaHip Pain ImagingPathway

www.imagingpathways.health.wa.gov.au

13

Selection of Imaging Studies

RadiographyIntegrity of joint structuresR/i or R/o DJD

MRIIntegrity of soft tissue structuresR/i or R/o insufficiency fx

Plain Films

2010AP & Lat

2011AP B Hip / PelvisUnilateral AP

Plain Films - 2010

AP UnilateralLat View

Plain Films 2011

AP Pelvis

Plain Films 2011

AP L Hip

14

Lat View 2011

RadiologyEvidence Based Practice

Least expensive studyAbility to assess osseous structures and evidence of pathology

Radiograph – strong additional valueThose at high risk for progression of hip OA

Kellgren - Lawrence ScoresStrongest predictor for progression of hip OA

Pts with existing hip painReijman et al: BMJ, 2005

MRI – T1 Coronal MRI T2 Coronal

MRI

Evidence Based PracticePossible associations between MRI –detected pathology and clinical sx Severe OA

Strong association with radiographic finding

Roemer et al: Osteoarthritis Cartilage. 2011

Use of Imaging StudiesDifferential Pathologic Diagnosis

Confirmation of Hip OAAppropriate PT management

Joint Distraction vs. GlidesCore Strengthening

Surgical Candidate Pt decided to wait and utilize conservative PT management

15

S/p THA

Acetabular Labral Tear

Patient Profile

25 yo male Training for Boston MarathonReferred for dx of L post-medial shin splints by PCPDuring history, reported increasing R hip pain over past 5 weeks which also limited his ability to run.

PT Examination

R/i post-medial shin splintsExamination of R hip:

ROM WNL except for c/o pain with OP into hip flexion, ER>IRMuscle Performance 5/5 + pain with flexion+ Scour Test+ Anterior Labral test

Evaluation/Plan of Care

Differential Pathologic Diagnosis:Anterior labral tearDJD R hip

Referred to Orthopedist for medical work-upRadiographyMRI (with/without contrast)

Selection of Imaging Studies

RadiographyIntegrity of joint structuresR/i or R/o DJD

MRIIntegrity of soft tissue structures? Acetabular Cyst vs. Labral Tear

16

Radiography

AP View Bilateral AP View

Radiography

Evidence Based PracticeLeast expensive studyAbility to assess osseous structures and evidence of pathology

MRI – T2 Weighted

Axial View

MRI

Evidence Based PracticeStrong correlation between MR imaging and pathology

Holder et al: Am J Roetgenol, 1995

MR ArthrographyExploits the natural advantages gained from joint effusion

Use of Contrast

Coronal View

MR ArthrographyEvidence Based Practice

T2-weighted imagesCadaveric Study (Holder et al: Am J Roetengenol, 1992)

Sensitivity: 75-85%Specificity: 94-97%

40 patients (Schmid et al: Radiology, 2003)

2 observersSensitivity: 50 & 79%Sensitivity: 77 & 84%

17

Use of Imaging Studies

Differential Pathologic DiagnosisConfirmation of Anterior Labral Tear

Not appropriate PT managementSurgical Candidate

Osseous Injuries

Stress Reaction ResponseStress (Fatigue) FxInsufficiency Fx

Hip Fx Imaging Pathway

www.imagingpathways.health.wa.gov.au

Stress reaction (response)

Represents microtrabecular fractureNormal or near normal radiographsBone marrow edema pattern on MRTypically on inferomedial aspect of femoral neckNo discrete linear component

T2 Fat Suppressed Axial

18

Bone Scan Fatigue (Stress) fracture

MRRound or ovoid hypointensity on T1 and hyperintensity on T2Associated linear signal abnormalityLinear component may be most visible on T1 or T2

Fatigue Fracture

T1 T2


SuperiorRamus Fracture

Insufficiency fractures

19


SubcapitalFracture


NondisplacedFracture

Bilateral Acetabular Roof Fractures

T1 T2

Documents

Outline Hip and Pelvis Imaging · 2012-12-26 · 5 Snapping Hip 25 Deslandes 2008 Snapping Hip 26 Labral Cysts 27 Normal Labrum Labral Cyst Labral Tears Troelsen 2007 Prosepctively