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Hip and Groin Ultrasound Hip and Groin Ultrasound

Jon A Jacobson M DJon A Jacobson M DJon A. Jacobson, M.D.Jon A. Jacobson, M.D.

Professor of RadiologyProfessor of Radiology

Director, Division of Musculoskeletal RadiologyDirector, Division of Musculoskeletal Radiology

University of MichiganUniversity of Michigan

Disclosures:Disclosures:

•• Consultant: Consultant: BioclinicaBioclinica

•• Book Book Royalties: ElsevierRoyalties: Elsevier

•• Grant: AIUM HarvestGrant: AIUM Harvest•• Grant: AIUM, HarvestGrant: AIUM, Harvest

Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted

by Elsevier Inc.

Objectives:Objectives:

•• Understand regional anatomyUnderstand regional anatomy

•• Familiar with common pathology Familiar with common pathology and ultrasound appearancesand ultrasound appearances

•• Recognize the importance of Recognize the importance of dynamic imagingdynamic imaging

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Goals:Goals:

•• Sonographic techniqueSonographic technique

•• Normal anatomyNormal anatomyNormal anatomyNormal anatomy

•• MR imaging correlationMR imaging correlation

•• PathologyPathology

Pathology:Pathology:

•• Joint abnormalitiesJoint abnormalities

•• Soft tissue infectionSoft tissue infection

M l d t d i jM l d t d i j•• Muscle and tendon injuryMuscle and tendon injury

•• Snapping hip syndromeSnapping hip syndrome

•• Peripheral nerve abnormalitiesPeripheral nerve abnormalities

•• MassesMasses

Hip: anterior recessHip: anterior recess

•• Anterior +posterior layersAnterior +posterior layers

–– Fibrous tissue + Fibrous tissue + minute layer of minute layer of synoviumsynovium

AnteriorAnterior

P t iP t isynoviumsynovium

–– HyperechoicHyperechoic

–– Each 2 Each 2 -- 4 mm thick4 mm thick

Radiology Radiology 1999; 210:4991999; 210:499

PosteriorPosterior

FemurFemur

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Hip Effusion:Hip Effusion:

•• Separation of anterior and posterior layersSeparation of anterior and posterior layers11

•• Capsule distention at femoral neck > 7 mm or Capsule distention at femoral neck > 7 mm or difference of 1 mm from opposite sidedifference of 1 mm from opposite side22

•• Extension & abduction improves Extension & abduction improves visualizationvisualization33

•• Do not internally rotate hip: capsule thickensDo not internally rotate hip: capsule thickens

11Radiology 1999; 210:449Radiology 1999; 210:44922Scand J Rheumatology 1989; 18:113Scand J Rheumatology 1989; 18:113

33Acta Radiologica 1997; 38:867Acta Radiologica 1997; 38:867

Hip Joint: septic effusionHip Joint: septic effusion

Long AxisLong Axis

NeckNeckFHFH **

**

****

Hip Joint: aseptic effusionHip Joint: aseptic effusion

FHFH**

Sagittal

NeckNeck

AcetAcetFHFH **

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Hip Joint: aseptic effusionHip Joint: aseptic effusion

Axial

Femoral NeckFemoral Neck

NeckNeck

Hip Effusion:Hip Effusion:

•• Cannot predict Cannot predict infection by ultrasoundinfection by ultrasound

•• Negative power color Negative power color Doppler does notDoppler does not

**

Doppler does not Doppler does not exclude infection*exclude infection*

•• Guided aspirationGuided aspiration

Head

Neck

**

* AJR 1998; 206:731* AJR 1998; 206:731

Hip JointHip Joint

•• Anterior recessAnterior recess

•• Longitudinal to Longitudinal to f l kf l k

XX

femoral neckfemoral neck

FF

AA

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Pitfall: synovitisPitfall: synovitis

•• Anterior and posterior layers of anterior Anterior and posterior layers of anterior capsule should not be misinterpreted capsule should not be misinterpreted as synovitisas synovitis

•• Transient synovitis:Transient synovitis:–– Joint effusionJoint effusion–– Synovial thickening too small to seeSynovial thickening too small to see

Radiology 1999; 210:499Radiology 1999; 210:499

Hip EffusionHip Effusion

*

Longitudinal

*

Hip SynovitisHip Synovitis

Longitudinal color Doppler

Head

Acet

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Hip LabrumHip Labrum

•• Normal:Normal:–– Hyperechoic, triangularHyperechoic, triangular

•• Degeneration: hypoechoicDegeneration: hypoechoic•• Tear:Tear:

ff

Labral TearLabral Tear

–– Anechoic cleftAnechoic cleft–– Most common anteriorMost common anterior–– Possible paralabral cystPossible paralabral cyst–– Sensitivity 44%, Sensitivity 44%,

specificity 75%*specificity 75%*

Femoral Femoral HeadHead

AcetabAcetab

SagittalSagittal--obliqueoblique

*Acta Radiologica 2007; 9:1004

Labral tear & paralabral cyst

Courtesy of D. Fessell, Ann Arbor, MICourtesy of D. Fessell, Ann Arbor, MI

Femoroacetabular Impingement:Femoroacetabular Impingement:

•• PincerPincer--type: deep acetabulumtype: deep acetabulum

•• CamCam--typetype

–– Broad irregular femoral neckBroad irregular femoral neck

–– Possible cortical irregularity at USPossible cortical irregularity at US

•• Associated with anterior labrum tearAssociated with anterior labrum tear

•• Consider dynamic evaluationConsider dynamic evaluation

Radiology 2005; 236:588Radiology 2005; 236:588

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CAM ImpingementCAM Impingement

Courtesy of M. van Holsbeeck, Courtesy of M. van Holsbeeck, Detrioit, MIDetrioit, MI

Femoroacetabular ImpingementFemoroacetabular Impingement

SagittalSagittal--obliqueoblique

Hip Arthroplasty:Hip Arthroplasty:

•• Prosthesis identifiableProsthesis identifiable

•• May use sonography to guide hip May use sonography to guide hip y g p y g py g p y g paspirationaspiration

•• Most useful: nonMost useful: non--communicating communicating abscess, bursitis, incision infectionabscess, bursitis, incision infection

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Total Hip Total Hip Arthroplasty:Arthroplasty:

•• Metal components Metal components demonstrate posterior demonstrate posterior reverberationreverberation

A tif t d tA tif t d t AcetAcet FemurFemur•• Artifact occurs deep to Artifact occurs deep to prosthesis away from prosthesis away from fluid collection (unlike fluid collection (unlike MRI, CT)MRI, CT)

AcetAcetHH NeckNeck

FemurFemur

Total HipTotal HipArthroplasty:Arthroplasty:•• PseudocapsulePseudocapsule distention:distention:

> 3.2 mm: suspect infection*> 3.2 mm: suspect infection*•• ExtraExtra--articular fluid articular fluid

collection:collection: AAcollection:collection:–– Suspect infectionSuspect infection–– Not visualized with Not visualized with

arthrography if nonarthrography if non--communicationcommunication

*AJR 1994; 163:381*AJR 1994; 163:381

NeckNeck

HeadHead> 3.2 mm> 3.2 mm

Total Hip Arthroplasty: infectionTotal Hip Arthroplasty: infection

SuperiorSuperior InferiorInferior

SagittalSagittal

Native Native FemurFemur

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Pathology:Pathology:

•• Joint abnormalitiesJoint abnormalities

•• Soft tissue infectionSoft tissue infection

M l d t d i jM l d t d i j•• Muscle and tendon injuryMuscle and tendon injury

•• Snapping hip syndromeSnapping hip syndrome

•• Peripheral nerve abnormalitiesPeripheral nerve abnormalities

•• MassesMasses

CellulitisCellulitis

•• EarlyEarly: thickened and hyperechoic : thickened and hyperechoic subcutaneous fatsubcutaneous fat

•• LateLate: anechoic channels (distended: anechoic channels (distendedLateLate: anechoic channels (distended : anechoic channels (distended lymphatics)lymphatics)

•• May appear similar to simple edemaMay appear similar to simple edema

J Ultrasound Med 2000; 19:743J Ultrasound Med 2000; 19:743

Cellulitis: acuteCellulitis: acute

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Cellulitis: chronicCellulitis: chronic

Coronal Coronal T2w

TrochantericTrochanteric Pain Syndrome:Pain Syndrome:

•• Most commonly caused by gluteus Most commonly caused by gluteus minimusminimus and medius tendon and medius tendon abnormalitiesabnormalities11

T h t iT h t i b itib iti•• TrochantericTrochanteric bursitis: bursitis: rarerare

–– Not actually inflamedNot actually inflamed22

–– Not associated with painNot associated with pain33

11Eur Eur RadRad 2007; 17:1772.2007; 17:1772.22J J ClinClin RheumatolRheumatol 2008; 14:822008; 14:82

33Skeletal Skeletal RadiolRadiol 2008; 37:9032008; 37:903

Trochanteric Bursal Fluid:Trochanteric Bursal Fluid:

•• Bursal fluid not normally seenBursal fluid not normally seen

•• Fluid distention:Fluid distention:–– simple fluid: anechoicsimple fluid: anechoic

–– complicated fluid: mixed echogenicitycomplicated fluid: mixed echogenicity

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Greater TrochanterGreater Trochanter

Pfirrmann et al. Radiology 2001; 221:469

Greater Trochanter: Greater Trochanter: BursaeBursae

Subgluteus Minimus: SGMiBSubgluteus Medius: GMeB

Trochanteric: TrB

Pfirrmann et al. Radiology 2001; 221:469

Greater TrochanterGreater Trochanter

AFAF LFLF

Gluteus Gluteus MinimusMinimus Gluteus Gluteus MediusMedius