8/22/2014

Ultrasound Evaluation of the Hip

Disclosures

•No Financial Disclosures

•No Commercial Relationships

Colin Strickland, MD
Assistant Professor
University of Colorado School of Medicine
Department of Radiology, Musculoskeletal Division

Objectives Diagnostic Hip Ultrasound

•Hip
•Anterior
•Demonstrate basic anatomy of the hip •Hip Joint
•Anterior Hip Muscle
•Describe a systematic approach to sonographic Origins
evaluation of the hip •Anterior Thigh
•Lateral
•Discuss common ultrasound guided interventional •Medial
procedures •Adductor
Musculature
•Demonstrate common pathology •Posterior

Ultrasound Guided Intervention Diagnostic Hip Ultrasound

•Hip Joint Injection
•Examination is typically tailored
•Iliopsoas Bursa Injection to answer a specific question

•Trochanteric Bursa •High and low frequency

Injection transducers may be required to
adequately evaluate the
•Targeted injection superficial and deep structures
•Hamstring origin PRP
•Gluteus medius •Comparison with other imaging
calcific tendonitis modalities is critical
lavage

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Anterior Hip: Anterior Hip:

•Hip Joint •Hip Joint

•Femoral head •Femoral head
•Acetabulum •Acetabulum
12 MHz
•Labrum •Labrum
•Anterior joint •Anterior joint
recess recess
•Iliopsoas tendon •Iliopsoas tendon
•Patient Positioning: Supine with leg straight •Rectus femoris 5 MHz
•Rectus femoris
•Transducer: •Identify the femoral neck in the oblique axial plane
• 12 MHz linear
• 5 MHz curvilinear

Anterior Hip: Anterior Hip:

•Hip Joint •Hip joint

•Femoral head •Femoral head
•Acetabulum •Acetabulum
•Labrum •Labrum
•Anterior joint •Anterior joint
recess recess
12 MHz
•Iliopsoas tendon •Iliopsoas tendon
•Rectus femoris •Rectus femoris
•Cartilage is demonstrated as a thin anechoic layer
over the echogenic bony cortex •In thin patients the labrum may be well demonstrated

Anterior Hip: Anterior Hip:

•Hip joint •Hip joint

•Femoral head •Femoral head
•Acetabulum •Acetabulum
•Labrum •Labrum
•Anterior joint •Anterior joint
recess recess
•Iliopsoas tendon •Iliopsoas tendon
•Rectus femoris •The iliopsoas tendon is identified along the
•Rectus femoris
•Effusion is best demonstrated in the oblique axial plane anterior aspect of the hip joint
•The tendon passes medially and then dives deep
•Physiologic fluid in the anterior joint recess measures less
than 2 mm in thickness to the lesser trochanter

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Anterior Hip: Anterior Hip:

Tensor •Hip joint •Hip joint

Fasciae
Latae
•Femoral head •Femoral head
•Acetabulum •Acetabulum
•Labrum •Labrum
•Anterior joint •Anterior joint
recess recess
•Iliopsoas tendon •Iliopsoas tendon
•Rectus femoris •Rectus femoris
•Anterior pelvic muscle origins •Anterior pelvic muscle origins

•Anterior Superior Iliac Spine •Anterior Inferior Iliac Spine

Anterior Hip: Pathology: Labral Tear

•Hip joint
•Femoral head
•Acetabulum
•Labrum
•Anterior joint
recess
•Iliopsoas tendon
•Rectus femoris
•May see a tear if a large defect is present, but typically better
•Anterior pelvic muscle origins
depicted by MRI
•Secondary sign of paralabral cyst is helpful in detection
•Anterior Inferior Iliac Spine

Pathology: Labral Tear Pathology: Labral Tear

•May see a tear if large •May see a tear if a large defect is present, but typically better depicted by
•Secondary sign of paralabral cyst is helpful in MRI
detection •Secondary sign of paralabral cyst is helpful in detection
•Important to distinguish from iliopsoas bursa •Important to distinguish from iliopsoas bursitis

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Anterior Thigh: Anterior Thigh:

•Quadriceps •Quadriceps
•Rectus femoris •Rectus femoris
•Vastus medialis •Vastus medialis
•Vastus •Vastus
intermedius intermedius
•Vastus lateralis •Vastus lateralis
•Patient Positioning: Supine with hip straight •Rectus femoris is the most superficial muscle

•Transducer: •Evaluate the proximal attachments of the direct

• 12 MHz linear and indirect heads

Lateral Hip: Lateral Hip:

Gluteus Medius • Musculature • Musculature
•Gluteus minimus •Gluteus minimus
•Gluteus medius •Gluteus medius
•Gluteus maximus •Gluteus maximus
•Tensor fasciae •Tensor fasciae
latae latae
Gluteus Minimus
•Bursae •Bursae
•Greater •Greater
Gluteus Maximus trochanteric bursa trochanteric bursa
•Gluteus medius •Gluteus medius
•Identify the greater trochanteric facets and
Bursa •Identify the greater trochanteric facets and
Bursa
muscles muscles
•Gluteus muscle overlies the posterolateral hip •Gluteus muscle overlies the posterolateral hip

Lateral Hip: Lateral Hip:

• Musculature • Musculature
Gluteus Minimus •Gluteus minimus •Gluteus minimus
•Gluteus medius Tensor Fasciae Latae •Gluteus medius

•Gluteus maximus •Gluteus maximus

•Tensor fasciae •Tensor fasciae
latae latae
•Bursae •Bursae
Rectus Femoris
•Greater •Greater
trochanteric bursa trochanteric bursa
Gluteus Medius •Gluteus medius •Gluteus medius
Bursa •Identify the tensor fasciae latae at the lateral
Bursa
•Evaluate the Gluteus minimus and medius in
sequence moving anterior to posterior margin of the rectus femoris

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Lateral Hip: Pathology: Greater

• Musculature
Trochanteric Bursitis
•Gluteus minimus
•Gluteus medius
•Gluteus maximus
•Tensor fasciae
latae
•Bursae
•Greater
trochanteric bursa
Longitudinal orientation Normal comparison -
•Gluteus medius Longitudinal orientation

Bursa •May see fluid in bursa

•Evaluate the trochanteric bursa deep to the gluteus •Hyperemia occasionally present
maximus muscle •Frequently associated with tendinosis
•Identify the gluteus medius bursa deep to the muscle Kong et al. Eur Radiol (2007) 17:1772-1783.

and tendon

Medial Hip: Pathology: Muscle Tear

•Neurovascular
Adductor longus
structures
partial tear
•Femoral artery
•Femoral vein
•Femoral nerve
•Sartorius
•Gracilis
•Adductor
musculature Longitudinal orientation

•Patient Positioning: Supine with leg abducted

•Adductor longus
•Adductor brevis
•Transducer: •Disruption of normal muscle and tendon architecture
• 12 MHz linear
•Adductor magnus
• 5 MHz curvilinear

Posterior Hip: Posterior Hip:

•Hamstring muscles •Hamstring muscles

•Semimembranosus •Semimembranosus
•Semitendinosus •Semitendinosus
•Biceps femoris •Biceps femoris
•Sciatic nerve •Sciatic nerve

•Patient Positioning: Prone

•Identify muscles in posterior thigh
•Transducer: •Identify the proximal hamstring tendons
• 12 MHz linear

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Ultrasound Guided
Ultrasound Guided Intervention:
Intervention:
Hip Aspiration

•Aspiration for possible

infection
•Diagnostic injection
•Therapeutic injection

•Patient Positioning: Supine

•Transducer:
• 12 MHz linear
• 5 MHz curvilinear

Ultrasound Guided Ultrasound Guided

Intervention: Intervention:
Hip Aspiration Hip Aspiration

•Aspiration for possible •Aspiration for possible

infection infection
•Diagnostic injection •Diagnostic injection
•Therapeutic injection •Therapeutic injection

•Hip joint evaluated in the oblique axial plane •Hip joint evaluated in the oblique axial plane
•> 2mm of fluid consistent with effusion

Ultrasound Guided
Pathology: Hip Prosthesis
Intervention:
Hip Aspiration

•Aspiration for possible

infection
•Diagnostic injection
•Therapeutic injection

•Hip joint evaluated in the oblique axial plane •Metal components visible by ultrasound
•> 2mm of fluid consistent with effusion •Ultrasound may be used to aspirate or guide biopsy
18g 3.5 inch spinal needle for aspiration

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Pathology: Septic Arthritis Pathology: Septic Arthritis

•Ultrasound useful to evaluate and guide intervention •Ultrasound useful to evaluate and guide intervention
•Metal components make helpful landmarks

Ultrasound Guided Ultrasound Guided

Intervention: Intervention:
Iliopsoas Bursa Iliopsoas Bursa
Injection Injection

•Diagnostic injection •Diagnostic injection

•Therapeutic injection •Therapeutic injection
12 MHz

•Patient Positioning: Supine •Patient Positioning: Supine 5 MHz

•Transducer: •Transducer:
• 12 MHz linear • 12 MHz linear
• 5 MHz curvilinear • 5 MHz curvilinear

Ultrasound Guided Ultrasound Guided

Intervention: Intervention:
Iliopsoas Bursa Iliopsoas Bursa
Injection Injection

•Diagnostic injection •Diagnostic injection

•Therapeutic injection •Therapeutic injection

•Important to inject in transverse plane above the •Important to inject in transverse plane above the
femoral head femoral head
•Make contact with bone posterior to the iliopsoas •Make contact with bone posterior to the iliopsoas
tendon tendon

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Ultrasound Guided Ultrasound Guided

Intervention: Intervention:
Iliopsoas Bursa Trochanteric Bursa
Injection Injection

•Diagnostic injection •Diagnostic injection

•Therapeutic injection •Therapeutic injection

•Patient Positioning: Supine or Decubitus

•Important to inject in transverse plane above the
femoral head •Transducer:
•Injected bursa often raises the tendon visibly • 12 MHz linear
during procedure

Ultrasound Guided Ultrasound Guided

Intervention: Intervention:
Trochanteric Bursa Trochanteric Bursa
Injection Injection

•Diagnostic injection •Diagnostic injection

•Therapeutic injection •Therapeutic injection

Longitudinal
Longitudinal
•Evaluate in longitudinal and transverse planes for
tendon tear or bursitis •Injected fluid accumulates superficial to the
gluteus medius tendon
•Rare to see extensive fluid

Summary Acknowledgements

•Kenneth Lee, MD University of Wisconsin

•Examination is typically tailored
to answer a specific question •Sonographers at the University of Colorado Hospital

•References
•Highly adaptable technique
•Useful in guiding diagnostic
and therapeutic intervention
around the hip
•Blankenbaker DG, De Smet AA, Keene JS. Sonography of the
iliopsoas tendon and injection of the iliopsoas bursa for
diagnosis and management of the painful snapping hip. Skeletal
Radiol 2006; 35:565-571
•Kong A, Van der Vliet A, Zadow S. MRI and US of gluteal
tendinopathy in greater trochanteric pain syndrome. Eur Radiol
2007; 17:1772-1783
•Long SS, Surrey D, Nazarian LN. Common sonographic
findings in the painful hip after hip arthroplasty. J Ultrasound
Med 2012; 31:301-312
•Deslandes M, Guilin R, Cardinal E, Hobden R, Bureau NJ. The
snapping iliopsoas tendon: New mechanisms using dynamic
sonography. AJR 2008; 190:576-581