(HRUS) of the hip: a detailed didactic approach

Transcript

Dynamic ultrasound evaluation (HRUS) of the hip: a detailed
didactic approach
Poster No.:
C-1589
Congress:
ECR 2011
Type:
Educational Exhibit
Authors:
E. Fabbro , C. Martini , D. Orlandi , G. Ferrero , A. Arcidiacono ,
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E. Silvestri ; Genova/IT, genova/IT, Genoa/IT
Keywords:
Ultrasound, Musculoskeletal joint
DOI:
10.1594/ecr2011/C-1589
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Learning objectives
The purpose of our educational exhibit is to:
1. illustrate the normal anatomy and normal HRUS appearance of hip compartments;
2. describe a systematic technique for HRUS evaluation of such structures;
3. produce anatomical schemes with didactic purpose and show correlations with
sonographic imaging.
Background
The hip joint anatomy can be subdivided into four compartments, each of those including
a group of structures that are extremely important for hip stability.
Currently, HRUS represents the first level imaging in the hip evaluation.
The protocol provides hip breakdown in 4 sections: anterior, medial, lateral and posterior.
For each of the following structures we will provide a dedicated HRUS image compared
with a detailed anatomic scheme, and a practical guide on "how we do" a HRUS scan:
ANTERIOR HIP
•
•
•
•
•
sartorius and tensor fasciae latae muscles
rectus femoris muscle
iliopsoas muscle
femoral neurovascular bundle
coxo-femoral joint
MEDIAL HIP
•
adductor tendons and muscles
LATERAL HIP
•
gluteus tendons and muscles
POSTERIOR HIP
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•
ischiocrural tendons (hamstrings)
•
sciatic nerve
Imaging findings OR Procedure details
The protocol provides hip breakdown in 4 sections: anterior, medial, lateral and posterior.
ANTERIOR HIP
Check-list:
•
•
•
•
•
sartorius and tensor fasciae latae muscles
rectus femoris muscle
iliopsoas muscle
femoral neurovascular bundle
coxo-femoral joint
Patient supine, with lower limb in neutral position.
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Fig.: Fig.1 Lower limb position for anterior hip evaluation.
References: E. Fabbro; DIMI, Dipartimento di Medicina Interna, Servizio di
Diagnostica per Immagini, Università degli Studi di Genova, Genova, ITALY
1) SARTORIUS AND TENSOR FASCIAE LATAE
With the patient supine, find the Anterior-Superior Iliac Spine (ASIS) with palpation and
place the probe on it in axial position (Fig.4.2A). Highlight the typical "pseudo-thyroid"
aspect (Fig.4.2B) with ASIS hyperechoic at the centre, next to the short tendineous
insertions of the sartorius (medial) and the tensor fasciae latae (lateral) muscles. The
tensor fasciae latae muscle courses distally on the lateral side of the thigh, whereas the
sartorius muscle can be seen with medial orientation, superficially to the rectus femoris
muscle (Fig.4.2C). Examine muscle bellies using both axial and longitudinal scans.
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Fig.: Fig.2A Probe positioning for sartorius and tensor fasciae latae insertions
evaluation.
Fig.: Fig.2B The ultrasound scan shows the tendinous insertions of sartorius (Sa) and
tensor fasciae latae (TFL) muscles on the antero-superior iliac spine (SIAS).
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Fig.: Fig.2C Anatomical scheme: proximal insertion of sartorius (Sa) and tensor
fasciae latae (TFL) and respective muscle bellies. SIAS: Anterior-superior iliac spine.
2) RECTUS FEMORIS
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Starting from the position previously described at ASIS level and shifting the transducer
caudally, reach the Anterior-Inferior Iliac Spine (AIIS) (Fig.3A), There, the direct tendon
of the rectus femoris muscle inserts on the lateral side, deeply to the ilio-psoas muscle
(Fig.3B). From this position, translate the transducer caudally to reach the muscle belly
of the rectus femoris (Fig.3C).
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Fig.: Fig.3A Probe positioning for rectus femoris proximal insertion evaluation.
Fig.: Fig.3B The axial scan shows the tendinous insertion of rectus femoris
(arrowheads) into the SIAI. Ps= iliopsoas muscle; SIAI= Anterior-Inferior Iliac Spine.
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Fig.: Fig.3C Anatomical scheme: proximal insertion of rectus femoris (RF) and its
connections with psoas muscle (Ps). SIAI= Anterior-Inferior Iliac Spine.
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Rotate the transducer by 90° to evaluate, by longitudinal scans, the myo-tendineous
junctions of the rectus up to the insertion onto the AIIS (Fig.4A, Fig.4B).
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Fig.: Fig.4A Probe positioning for the longitudinal analysis of rectus femoris tendon
insertion onto the AIIS.
Fig.: Fig.4B The ultrasound scan shows the tendinous insertion of rectus femoris
(arrowheads) onto the AIIS. RF= muscle belly of rectus femoris ; Ps= psoas muscle;
SIAI= Anterior-Inferior Iliac Spine.
Evaluate the direct and indirect tendon of the rectus femoris (Fig.5), using longitudinal
(Fig.6A, Fig.6B) and axial scans (Figg.7A,7B,7C,7D).
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Fig.: Fig.5 Anatomical scheme: tendons of the rectus femoris muscle. d= direct
tendon; i= indirect tendon; r= reflected tendon; RF= rectus femoris muscle.
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Fig.: Fig.6A Probe positioning for rectus femoris tendon evaluation on
longitudinal scans.
Fig.: Fig.6B The longitudinal scan shows the direct (arrowheads) and indirect
(asterisk) tendons of rectus femoris muscle. Note the hypoechoic appearance of
the indirect tendon cranial portion, determined by the change in orientation of
the tendon (anisotropy), which courses externally and obliquely compared to the
direct tendon.
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Fig.: Fig.7A Probe positioning for the axial evaluation of rectus femoris direct and
indirect tendons.
Fig.: Fig.7B Axial evaluation of direct (arrowheads) and indirect (asterisk)
tendons of rectus femoris muscle. Sa= sartorius; F= femur.
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Fig.: Fig.7C Probe positioning for rectus femoris distal aponeurosis evaluation.
Fig.: Fig.7D The axial scan shows the distal tendineous aponeurosis
(arrowhead) of rectus femoris muscle (RF) shaped like a "C". Vi= vastus
intermedius muscle; F= femur.
3) ILIOPSOAS
The ilio-psoas muscle can be seen by means of a series of axial scans, medial to
the rectus femoris. On these images, the hyperechoic tendon is located in an eccentric
postero-medial position within the muscle belly (Fig.8A, Fig.8B). The muscle can be
followed using both axial and longitudinal scans up to the insertion into the lesser
trochanter.
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Fig.: Fig.8A Probe positioning for psoas muscle myotendinous junction evaluation.
Fig.: Fig.8B The axial scan shows the myotendinous junction (asterisk) of psoas
muscle (Ps). F= femoral head.
4) FEMORAL NEURO-VASCULAR BUNDLE
Medial to the rectus femoris muscle, neuro-vascular bundle can be identified using axial
scans: lateral to medial, the femoral nerve, the common femoral artery, and the common
femoral vein can be seen (Fig.9A, Fig.9B).
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Fig.: Fig.9A Probe positioning for femoral neurovascular bundle evaluation.
Fig.: Fig.9B The axial scan shows the femoral neurovascular bundle: femoral artery
(Af), femoral vein (Vf) and femoral nerve (Nf). Pe= pectineus muscle.
5) HIP JOINT
Medially and distally to the ASIS, the hip joint can be seen by an oblique sagittal
scan to assess the femoral acetabulum with the anterior portion of the labrum, the
anterior capsular profile and the femoral head covered by the articular cartilage (Fig.10A,
Fig.10B). At the bottom of the femoral head there's the anterior synovial recess that is
not detectable when normal. Conversely, the anterior capsular profile is almost constantly
visualized as an hyperechoic linear structure superficial to the joint space.
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Fig.: Fig.10A Probe positioning for coxo-femoral joint evaluation.
Fig.: Fig.10B The scan shows the femoral head (F) covered by the articular cartilage,
the acetabulum (Ac), the acetabular labrum (asterisk), and the anterior capsular profile
(empty arrowheads). Ps= psoas muscle.
MEDIAL HIP
1) ADDUCTOR TENDONS AND MUSCLES
Patient supine, with lower limb slightly externally rotated (Fig.11, Fig.12).
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Fig.: Fig.11 Lower limb position for medial hip evaluation.
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Fig.: Fig.12 Anatomical scheme: adductor muscles. The adductor longus is the most
superficial and it is represented in semitransparence. The adductor brevis and magnus
are respectively represented in deepest planes.
By a sagittal scan, the bony landmark of the anterior surface of the pubis can be seen
to detect the insertional components of the adductor muscles (Fig.13A, Fig.13B). Three
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muscle layers can be seen: from the most superficial to the deepest, the adductor longus
msucle., the adductor brevis muscle and the adductor magnus muscle. Orientate the
probe over the course of a single muscle belly, according to axial and longitudinal planes.
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Fig.: Fig.13A Probe positioning for adductor muscles proximal insertion
evaluation.
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Fig.: Fig.13B The longitudinal scan shows the tendon insertion (asterisk) of
adductor longus (AL), adductor brevis (AB) and adductor magnus (GA) muscles in
correspondence of the pubic symphisis.
LATERAL HIP
1) GLUTEUS TENDONS AND MUSCLES
Patient in lateral position (Fig.14).
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Fig.: Fig.14 Patient in lateral position for lateral hip analysis.
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Fig.: Fig.15 The anatomical pattern shows, in an antero-posterior sense, minimus,
medius and maximus gluteus (represented in transparence).
With the patient lying on the contra-lateral hip, find the greater trochanter with an
axial scan, then slightly shift cranially the probe (Fig.16A). Similarly to the shoulder
rotator cuff analysis, three musculargroups can be encountered with their myotendinous
junctions: from the front to the back, the gluteus minimus muscle. (deep), the gluteus
medius muscle. and the gluteus maximus muscle. (more superficial) (Fig.15, Fig.16B).
Superficial to them there is the tendineous portion of tensor fasciae latae, that has a
ribbon-like hyperechoic appearance and is separated from the cuff by a synovial bursa
and from adipose cleavage planes .(Fig.17A, Fig.17B).
Fig.: Fig.16A Probe positioning for evaluation of gluteus muscles insertion onto the
greater trochanter.
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Fig.: Fig.16B The axial scan shows the tendinous insertion of gluteus minimus
(asterisk), medius (@) and maximus (#) into the femoral greater trochanter (GT).
Arrowheads = tensor fasciae latae tendon.
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Fig.: Fig.17A Probe positioning for the longitudinal evaluation of tensor fasciae latae
tendon.
Fig.: Fig.17B The longitudinal scan shows the tensor fasciae latae tendon
(arrowheads) superficial to the greater trochanter (GT).
POSTERIOR HIP
Check-list:
•
•
ischiocrural tendons (hamstrings)
sciatic nerve
1) ISCHIOCRURAL TENDONS (HAMSTRINGS)
Patient prone, with lower limb in neutral position (Fig.18).
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Fig.: Fig.18 Lower limb position for posterior hip evaluation.
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Fig.: Fig.19 Anatomical scheme: ischiocrural tendon insertion into
ischiatic tuberosity and course of sciatic nerve. BF= biceps femoris; SM=
semimembranosus; ST= semitendinosus; S= sciatic nerve.
With the patient prone and axial orientation of the probe, find the ischiatic tuberosity and
visualize the conjoined tendon insertion of the ischiocrural muscles on it. (Figg.20A, 20B,
21A, 21B).
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Fig.: Fig.20A Probe positioning for evaluation of hamstrings insertion into the
ischiatic tuberosity, according to an axial plane.
Fig.: Fig.20B The axial scan shows the tendinous insertion of long head of biceps
femoris (1), semitendinosus (2) and semimembranosus (3) muscles. Ti= ischiatic
tuberosity.
From lateral to medial, the conjoined tendon of long head of the biceps femoris and the
semitendinosus can be seen. More medially, the semimembranosus tendon is visible. It
has a very thin muscle and a very short proximal tendineous component.
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Fig.: Fig.21A Probe positioning for hamstrings insertion longitudinal evaluation.
Fig.: Fig.21B The longitudinal scan shows the tendinous insertion (asterisk) of
semitendinosus (St) and semimembranosus (Sm) into the ischiatic tuberosity (Ti).
2) SCIATIC NERVE
Lateral to hamstrings insertion, examine also the sciatic nerve, at first axially and then
longitudinally, (Fig.22A, 22B).
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Fig.: Fig.22A Probe positioning for sciatic nerve evaluation, according to an axial
plane.
Fig.: Fig.22B The axial scan shows the sciatic nerve, according to its short-axis.
Conclusion
HRUS allows a quick, real-time evaluation of such structures. In addition, dynamic
evaluation adds several important information about biomechanics of hip structures.
Personal Information
References
[1] Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, Kainberger
F, Klauser A, Martinoli C, McNally E, O'Connor PJ, Peetrons P, Reijnierse M, Remplik
P, Silvestri E. Musculoskeletal Ultrasound Technical Guidelines. European Society of
Musculoskeletal Radiology.
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[2] Martino F, Silvestri E, Grassi W. Musculoskeletal sonography: technique, anatomy,
semeiotics and pathological findings in rheumatic diseases. Springer, 2007.
[3] Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Springer 2007:
551-610.
[4] Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Saunders, 2008.
[5] Van Holsbeeck M, Introcaso J. Musculoskeletal Ultrasound 2nd ed. Mosby, 2000.
[6] McNally E. Practical Musculoskeletal Ultrasound. Elsevier, 2004.
[7] Chhem R, Cardinal E. Guidelines and Gamuts in Musculoskeletal Ultrasound.
Wiley-IEEE, 1999.
[8] Bradley M, O'Donnell P. Atlas of Musculoskeletal ltrasound Anatomy. Cambridge
University Press, 2002.
[9] Marcelis S, Daenen B, Ferrara MA. Peripheral Musculoskeletal Ultrasound Atlas.
Thieme, 1996.
[10] Balboni G, et al., Anatomia Umana III ed (2004): 21-358.
[11] Standring S. Anatomia del Gray. Le basi anatomiche per la pratica clinica. Elsevier,
2009: 1325-1388.
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(HRUS) of the hip: a detailed didactic approach

Transcript

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