Outline Hip and Pelvis Imaging
Imaging Techniques
Joel Fallano, PT, DPT, MS, OCS Aimee Klein, PT, DPT, DSc, OCS CSM 2013 Imaging SIG January 24th, 2013
Plain films MRI MRA Sonography
Cases
www.warhols.com/ colored%20shoe%20and%20leg.JPG
Radiographs
OA Fracture/Trauma
Routine MRI
MR Arhtrography
Assess the intra-articular structures
Labrum Cartilage Intra-articular loose bodies Ligaments Capsule
Stress fracture Nonspecific hip pain Pubalgia Muscle/tendon injuries Osteonecrosis Tumor
Sonography
Snapping hip Bursitis Tendonpathy Labrum
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Structures of Interest – Hip Anterior View
Hip Sonography
Lower frequency soundhead
2.5 to 5 MHz
Positioning
Anterior View
Medial View
Lateral View
Posterior View
Pt is supine with hip externally rotated and knee in 45 deg of flexion (frog leg position)
Pt is supine with leg in slight external rotation
Pt is sidelying with pillows between knees
Pt is prone with legs extended. Pillow under hips if needed for comfort
Femoral head and neck Labrum Iliopsoas muscle, tendon and bursa Sartorius Rectus femoris Vastus lateralis, medialis and intermedius Femoral nerve and artery
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Femoral Head and Neck
www.ESSR.org
Labrum/Iliopsoas
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www.ultrasoundcases.info
Quadriceps Group
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Femoral Nerve and Artery
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www.ESSR.org
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Structures of Interest – Hip Medial View
Adductor Group
Distal iliopsoas Adductor group Pubic symphysis Rectus abdominus insertion
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Structures of Interest – Hip Lateral View
www.ultrasoundcases.info
Greater Trochanter/Bursa/ITB
Greater trochanter and bursa Glut max Glut med Glut min Tensor fasica lata Iliotibial band 15
www.ultrasoundcases.info
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Structures of Interest – Hip Posterior View
Glut Med/Glut Min
Garcia 2010
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Glut max, med and min Hamstrings Sciatic nerve Piriformis
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Hamstring Longitudinal
Transverse
HIP PATHOLOGY
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Greater Trochanteric Bursitis
www.ultrasoundcases.info
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AIIS Avulsion
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Gluteal Tendon Pathology
www.ultrasoundcases.info
Gluteal Tendon Tears
MRI
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Westacott 2011
Sensitivity of 33-100% Specificity of 92-100% Positive predictive value of 71-100% Negative predictive value of 50% False-positives were common
Ultrasonography
www.ultrasoundcases.info
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Sensitivity of 79-100% Positive predictive value of 95-100% 24
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Snapping Hip
Snapping Hip
Deslandes 2008
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Labral Cysts
www.ultrasoundcases.info
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Labral Tears
Troelsen 2007
Normal Labrum
Prosepctively examined 20 dysplastic hip with US and MRI US exam
Labral Cyst www.ultrasoundcases.info
Sensitivity 44% Specificity 75% Positive Predictive Value 88% Negative Predictive Value 24%
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Normal Hip Imaging
Radiography
HIP IMAGING ANATOMY
Bilateral AP Hip/Pelvis AP Hip Frog
MRI CT
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Radiography
B AP Hip/Pelvis view Unilateral AP Hip view
Ilioischial Line
Iliopubic line
Herniation Pit Teardrop Pelvis / B Hip AP View
Ilial Wing
Sacrum
Acetabular Lines
L AP View Oblique AP View
Manaster BJ. Radiographics. 2000
AP in ER View
Gluteal
AP View
Psoas
Obturator Internus Manaster BJ. Radiographics. 2000
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Lateral View (aka Frog View)
MRI anatomy: Muscles
http://www.google.com/imgres?q=lateral+hip+radiograph&um=1&hl=en&client=firefoxa&sa=N&rls=org.mozilla:enUS:official&biw=1280&bih=870&tbm=isch&tbnid=h1HaeCKEyKG2DM:&imgrefurl=http://image s.rheumatology.org/viewphoto.php%3FimageId%3D2861938%26albumId%3D75682&docid=RMQ LGimvPZBa4M&w=366&h=549&ei=EDWGTr-MLcHk0QHoaDsDw&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
Coronal imaging
http://www.e-radiography.net/technique/pelvis/Pelvis_hip_lat_anatomy2.jpg
Sacrum Sacro-iliac joint Piriformis
Ischial tuberosity
Gluteus maximus
Semimembranosus
Psoas Iliacus
Gluteus Medius Vastus lateralis
Gluteus Minimus Greater and Lesser trochanters
Obturator internus Obturator externus and quadratus femoris
IT band
Gracilis Adductors
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Anterior superior iliac spine
Anterior inferior iliac spine Iliopsoas Obturator internus Obturator externus
Tensor fascia lata
Tensor fascia lata
Rectus femoris
Adductors Sartorius
MRI anatomy: Muscles Rectus abdominus
Axial Imaging
Sartorius
Iliopsoas Anterior inferior iliac spine
Gluteus minimus
Gluteus medius
Gluteus maximus Sacrum
Piriformis
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Rectus abdominus Acetabular roof Rectus femoris
Superior pubic rami Femoral head
Sartorius
Symphysis pubis
Rectus femoris
Greater trochanter
Gemelli
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Sciatic nerve
Obturator internus
Pectineus Tensor fascia lata
Obturator externus
Sartorius Iliopsoas
Rectus femoris Tensor fascia lata
Iliotibial band
Quadratus femoris
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Inferior pubic rami
Semimembranosus
Biceps Femoris Semitendinosus
Iliopsoas
Lesser trochanter
Adductor longus Gracilis
Vastus intermedius Vastus lateralis
Adductor brevis Adductor magnus
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CT Imaging
Axial
Patient Profile
60 yo female HPI
10/10 walking at conference, sat on bench, went to get up and has severe pain x 4 hours, then resolved Mid 11/10, rolled over in bed and felt sharp pain in L hip
PMH: Osteoporosis Referred by PCP to address L hip pain and decreasing functional status Functionally
Increased pain with walking AM stiffness Inability to play golf or exercise
Evaluation/Plan of Care
Differential Pathologic Diagnosis:
OA L hip Stress Fx due to underlying h/o osteoporosis
Osteoarthritis
PT Examination R/i L Hip OA Cluster for the Identification of Hip OA
Cluster 2
Painful hip with IR > 50 yo Morning stiffness < 60 min
Diagnostic Accuracy
All 3 component of cluster are present: + LR = 3.4
Non-trauma Hip Pain Imaging Pathway
Referred to Orthopedist for medical work-up
Radiography MRI www.imagingpathways.health.wa.gov.au
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Selection of Imaging Studies
Plain Films
Radiography
Integrity of joint structures R/i or R/o DJD
2010
2011
MRI
AP & Lat AP B Hip / Pelvis Unilateral AP
Integrity of soft tissue structures R/i or R/o insufficiency fx
Plain Films - 2010
AP Unilateral Lat View
Plain Films 2011
Plain Films 2011
AP L Hip AP Pelvis
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Radiology
Evidence Based Practice
Radiograph – strong additional value
Kellgren - Lawrence Scores
Lat View 2011
Least expensive study Ability to assess osseous structures and evidence of pathology
Those at high risk for progression of hip OA Strongest predictor for progression of hip OA
Pts with existing hip pain Reijman et al: BMJ, 2005
MRI – T1 Coronal
MRI T2 Coronal
MRI
Use of Imaging Studies
Evidence Based Practice
Possible associations between MRI –detected pathology and clinical sx Severe OA
Differential Pathologic Diagnosis
Appropriate PT management
Strong association with radiographic finding
Confirmation of Hip OA Joint Distraction vs. Glides Core Strengthening
Surgical Candidate
Pt decided to wait and utilize conservative PT management
Roemer et al: Osteoarthritis Cartilage. 2011
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S/p THA Acetabular Labral Tear
Patient Profile
25 yo male Training for Boston Marathon Referred for dx of L post-medial shin splints by PCP During history, reported increasing R hip pain over past 5 weeks which also limited his ability to run.
Evaluation/Plan of Care
Differential Pathologic Diagnosis:
Radiography MRI (with/without contrast)
R/i post-medial shin splints Examination of R hip:
ROM WNL except for c/o pain with OP into hip flexion, ER>IR Muscle Performance 5/5 + pain with flexion + Scour Test + Anterior Labral test
Selection of Imaging Studies
Anterior labral tear DJD R hip
Referred to Orthopedist for medical work-up
PT Examination
Radiography
Integrity of joint structures R/i or R/o DJD
MRI
Integrity of soft tissue structures ? Acetabular Cyst vs. Labral Tear
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Radiography
Radiography
Evidence Based Practice
AP View
Least expensive study Ability to assess osseous structures and evidence of pathology
Bilateral AP View
MRI – T2 Weighted
MRI
Evidence Based Practice
Strong correlation between MR imaging and pathology
Holder et al: Am J Roetgenol, 1995
Axial View
MR Arthrography
MR Arthrography
Exploits the natural advantages gained from joint effusion
Evidence Based Practice
T2-weighted images
Use of Contrast
Cadaveric Study (Holder et al: Am J Roetengenol, 1992)
Sensitivity: 75-85% Specificity: 94-97%
40 patients
(Schmid et al: Radiology, 2003)
2 observers Sensitivity: 50 & 79% Sensitivity: 77 & 84%
Coronal View
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Use of Imaging Studies
Differential Pathologic Diagnosis
Confirmation of Anterior Labral Tear
Not appropriate PT management Surgical Candidate
Hip Fx Imaging Pathway
Osseous Injuries
Stress Reaction Response Stress (Fatigue) Fx Insufficiency Fx
Stress reaction (response)
Represents microtrabecular fracture Normal or near normal radiographs Bone marrow edema pattern on MR Typically on inferomedial aspect of femoral neck No discrete linear component
www.imagingpathways.health.wa.gov.au
T2 Fat Suppressed Axial
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Bone Scan
Fatigue (Stress) fracture
MR Round or ovoid hypointensity on T1 and hyperintensity on T2 Associated linear signal abnormality Linear component may be most visible on T1 or T2
Fatigue Fracture
T1
Superior Ramus Fracture
T2
Insufficiency fractures
Manaster BJ. Radiographics. 2000
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Subcapital Fracture
Manaster BJ. Radiographics. 2000
Nondisplaced Fracture
Manaster BJ. Radiographics. 2000
Bilateral Acetabular Roof Fractures
T1
T2
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