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Imaging in hip disorders
- 1. JSS Medical College, Mysuru IMAGING IN HIP DISORDERS Dr. Sanjana B C Resident, JSS Medical College,Mysuru For more Radiology Education visit www.jssmcradiology.com
- 2. JSS Medical College, Mysuru ANATOMY • Ball and socket type of Synovial joint • One of most stable joints in the body • Articulation between acetabulum and femoral head.
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- 4. JSS Medical College, Mysuru Movements & Muscles • Psoas major • Iliacus • Gluteus Maximus • Hamstring muscles • Adductor Longus, Brevis, Magnus • Gluteus Minimus and Medius • Tensor Fascia Lata, gluteus Medius and Minimus • Two Obturators ,two Gamelli & Quadratus femoris. FLEXION EXTENSION ADDUCTION ABDUCTION MEDIAL ROTATION LATERAL ROTATION
- 5. JSS Medical College, Mysuru FROG LEG LATERAL VIEW RADIOGRAPHIC VIEWS AP VIEW
- 6. JSS Medical College, Mysuru JUDET VIEW
- 7. JSS Medical College, Mysuru LINES AND ANGLES OF HIP KLEIN’S LINE. AP and frog-leg projections of the hip in slipped femoral capital epiphysis. Note the lack of overlap across the line by the femoral head.
- 8. JSS Medical College, Mysuru Coxa Vara. Decreased angle (double-headed arrow). Skinner’s Line FEMORAL ANGLE. LINES AND ANGLES OF HIP
- 9. JSS Medical College, Mysuru SHENTON’S LINE. Hip Dislocation. Note the interruption in the smooth arc of Shenton’s line. LINES AND ANGLES OF HIP
- 10. JSS Medical College, Mysuru Protrusio Acetabuli The medial displacement of the acetabulum and femoral head in relation to the line. LINES AND ANGLES OF HIP
- 11. JSS Medical College, MysuruFor more Radiology Education visit www.jssmcradiology.com ACETABULAR ANGLE. Observe the abnormally wide angle (double-headed arrows) on the left in association with congenital hip dislocation. SYMPHYSIS PUBIS WIDTH- traumatic diastasis. LINES AND ANGLES OF HIP
- 12. JSS Medical College, MysuruFor more Radiology Education visit www.jssmcradiology.com LINES AND ANGLES OF HIP
- 13. JSS Medical College, MysuruFor more Radiology Education visit www.jssmcradiology.com TEARDROP DISTANCE The abnormality is the result of early Legg- Calvé-Perthes disease. Observe the crescent sign in the femoral capital epiphysis (thick arrow). LINES AND ANGLES OF HIP
- 14. JSS Medical College, Mysuru DEVELOPMENTAL DYSPLASIA OF THE HIP • Congenital or developmental deformation or misalignment of the hip joint.
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- 16. JSS Medical College, Mysuru DEVELOPMENTAL DYSPLASIA OF THE HIP • On radiography– Disruption of Shenton’s line and/or the iliofemoral line. • CT arthrography with intra- articular contrast to assess the attempted concentric positioning of the head within the acetabulum. • MRI is employed in adult DDH to assess for avascular necrosis and for presurgical planning. Small hypoplastic femoral capital epiphysis, lateral and superior subluxation of the femoral head, and a shallow acetabulum (Putti’s triad ).
- 17. JSS Medical College, Mysuru PROXIMAL FOCAL FEMORAL DEFICIENCY • Proximal focal femoral deficiency (PFFD) - a congenital disorder characterized by varying severity of shortening and dysplasia of the femur and acetabulum, and varus angulation of the proximal femur. Classification system : -In type A, the femur is shortened compared with the normal size, but the femoral head is present and located within the acetabulum. -In type B, the femur is short with a varus angulation, and there is a gap between the femoral head, which is located within the acetabulum, and the femoral neck. -In type C, the femoral head is rudimentary or absent. The femur is markedly short, and the acetabulum is dysplastic. -In type D, the entire femur is rudimentary, with absent femoral head and acetabulum.
- 18. JSS Medical College, MysuruFor more Radiology Education visit www.jssmcradiology.com •SCFE represents a Salter type I fracture, through the physis, resulting in the femoral head “slipping” inferomedially with respect to the femoral neck. SLIPPED CAPITAL FEMORAL EPIPHYSIS •Onset of a limp accompanied by hip pain referred to knee in an obese adolescent boy.
- 19. JSS Medical College, Mysuru • Frayed metaphyseal margin • Beaked inferior-medial epiphysis • Increased teardrop distance • Medial buttressing on the femoral neck • Lateral buttressing on the femoral neck (Herndon’s hump) • Curved contour of deformed proximal femur (pistol-grip deformity)
- 20. JSS Medical College, Mysuru LEGG-CALVÉ-PERTHES DISEASE • An idiopathic avascular necrosis of the proximal femoral epiphysis and occurs in the 3- to 12-year age group; 5:1 male predominance. STAGE I: EARLY asymmetric femoral epiphyseal size (smaller on affected side) apparent increased density of the femoral head epiphysis widening of the medial joint space blurring of the physeal plate radiolucency of the proximal metaphysis STAGE II: FRAGMENTATION subchondral lucency femoral epiphysis fragments femoral head outline is difficult to make out mottled density thickened trabeculae STAGE III: REPARATIVE re-ossification begins shape of the femoral head becomes better defined bone density begins to return STAGE IV: HEALED changes depend on severity the femoral head may be nearly normal or may demonstrate flattening of the articular surface, especially superiorly widening of the head and neck of the femur
- 21. JSS Medical College, MysuruFor more Radiology Education visit www.jssmcradiology.com • MRI excellent for early detection and identifying status of articular cartilage. Diminished bright signal of marrow fat following loss of normal ciculation and thickening of non ossified femoral cartilage and acetabular labrum. • Coronal T1-weighted spin-echo MR image shows flattening and fragmentation of left proximal femoral ossific nucleus (arrowheads) as well as mild loss of containment. All ossific fragments show abnormal signal hypointensity. • Isotopic scans cold in early phase before plain film changes.
- 22. JSS Medical College, Mysuru CATTERALL CLASSIFICATION
- 23. JSS Medical College, Mysuru TRANSIENT SYNOVITIS • An aseptic inflammation of the hip, presumably of post viral etiology. • It is the most common cause of hip pain or a limp in children under the age of ten years. • The condition is self-limiting and treated with rest and analgesics. • Ultrasound - presence of a joint effusion.
- 24. JSS Medical College, Mysuru • Septic joint occurs most commonly from pyogenic infection and may result from haematogenous dissemination, contiguous spread of infection from local tissues, direct inoculation, or contamination at surgery. SEPTIC ARTHRITIS • Radio graphically with increased teardrop distance or elevation of the gluteus minimus fat stripe. • Sub acute or chronic infections demonstrate bone erosions, loss of joint space and areas of avascular necrosis. • MRI is sensitive and more specific for early cartilaginous damage T1: low signal within subchondral bone T2: perisynovial edema C+ (Gd): synovial enhancement For more Radiology Education visit www.jssmcradiology.com
- 25. JSS Medical College, Mysuru ACETABULAR FRACTURES • Signs of capsular distension. • widening of the teardrop space, and distorted fascial planes of the psoas and gluteus medius muscles. • obturator internus sign. • Approximately 20% of all pelvic fractures in adults involve the acetabulum. • Almost all acetabular fractures are the result of indirect injury (injury to the foot, knee, or greater trochanter of the femur).
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- 27. JSS Medical College, Mysuru FEMORAL HEAD FRACTURE
- 28. JSS Medical College, Mysuru POSTERIOR DISLOCATION • Most commonly caused by impact of dashboard on knee. • Hip flexed, internally rotated, adducted. • X Ray - femoral head is usually displaced posterior, superior, and slightly lateral to the acetabulum and also internally rotated hence the lesser trochanter is usually obscured on AP view. • Generally results from axial load applied to femur, while hip is flexed.
- 29. JSS Medical College, Mysuru ANTERIOR DISLOCATION • Extreme external rotation, less-pronounced abduction and flexion. X-ray signs – • The lesser trochanter being more visible due to external rotation. • The hip is abducted and the femur head is usually inferior to the acetabulum. • Shenton's line is also broken.
- 30. JSS Medical College, Mysuru AVASCULAR NECROSIS NECROSISAVASCULAR NECROSIS • Most commonly seen on anterolateral aspect • Causes – trauma, fat embolism, caissons disease, alcoholism, steroid therapy, collagen vascular diseases
- 31. JSS Medical College, Mysuru AVASCULAR NECROSIS Femoral head AVN represents ischemic injury of femoral head. The Ficat classification : stage 0 plain radiograph: normal MRI: normal clinical symptoms: nil stage I plain radiograph: normal or minor osteopaenia MRI: oedema bone scan: increased uptake clinical symptoms: pain typically in the groin stage II plain radiograph: mixed osteopenia and/or sclerosis and/or subchondral cysts, without any subchondral lucency (crescent sign: see below) MRI: geographic defect bone scan: increased uptake clinical symptoms: pain and stiffness stage III plain radiograph: crescent sign and eventual cortical collapse MRI: same as plain film clinical symptoms: pain and stiffness+/- radiation to knee and limp stage IV plain radiograph: end stage with evidence of secondary degenerative change MRI: same as plain radiograph clinical symptoms: pain and limp
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- 33. JSS Medical College, Mysuru • MRI – focal lesion in the anterosuperior portion of femoral head that is well demarcated but is inhomogeneous T1- low signal intensity T2- double line sign, made of two concentric low signal intensity bands with central hyperintense line which may represent hypervascular granulation tissue.
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- 36. JSS Medical College, Mysuru FEMOROACETABULAR IMPINGEMENT • The theory behind femoroacetabular impingement is that certain anatomic variations lead to impingement between the proximal femur and acetabular rim with flexion and internal rotation. • Two types- Cam type Pincer type
- 37. JSS Medical College, Mysuru Laterally prominent femoral head margins create femoral head asphericity bilaterally. The superior portions of the acetabular labra are partially detached bilaterally
- 38. JSS Medical College, Mysuru HERNIATION PIT OF THE FEMORAL NECK • The majority of these lesions are asymptomatic, though larger lesions, especially in runners, have been linked with hip symptoms It represents a herniation of synovium or soft tissues into the bone through a cortical defect, hence the alternate name synovial herniation pit Radiologic Features- a discrete, sharply marginated geographic lesion at the antero-superior aspect of the femoral neck.
- 39. JSS Medical College, Mysuru Thin-section CT - subcortical cyst with a thin sclerotic border but may demonstrate defects in the cortical surface. Hounsfield values vary from 30 to 50 HU with no significant contrast enhancement. MRI shows features consistent with fluid (high signal on T2- and intermediate on T1-weighted images.)
- 40. JSS Medical College, Mysuru Thank You For more Radiology Education visit www.jssmcradiology.com
Editor's Notes
- ACETABULUM Y-shaped epiphyseal cartilage Start to ossify at 12 years Fuse 16-17 years The articular surface of the acetabulum is horseshoe shaped and is deficient inferiorly at the acetabular notch Nonarticular floor is called acetabular fossa Head of femur 2/3rd of sphere, Pit just below and behind the centre of the head called fovea for ligamentum teres
- The capsule encloses the joint and is attached to the acetabular labrum medially, Laterally it is attached to the intertrochanteric line of the femur in front and along the posterior aspect of the neck of the bone behind Iliofemoral Ligaments- It is a strong, inverted Y-shaped ligament Its base is attached to the anterior inferior iliac spine above. Below the two limbs of Y are attached to the upper and lower parts of the intertrochanteric line of the femur.The strong ligament prevents overextension during standing Pubofemoral Ligament- It is a triangular ligament. The base of the ligament is attached to the superior ramus of the pubis. The apex is attached below to the lower part of the intertrochanteric line. This ligament limits extension and abduction Ischiofemoral Ligament-It is a spiral shaped ligament. Attached to the body of the ischium near the acetabular margin. Fibers pass upward and laterally and attached to the greater trochanter.This ligament limits the extension Ligament of Head of Femur- It is flat and triangular ligament. It is attached by its apex to the pit on the head of the femur (fovea capitis), Attached by its base to the transverse ligament and the margins of the acetabular notch. The cavity of acetabulum is deepened by the presence of a fibrocartilaginous rim called acetabular labrum Transverse Acetabular Ligament- It is formed by the acetabular labrum as it bridges the acetabular notch. It converts the notch into a tunnel through which blood vessels and nerves enter the joint Nerve supply- Femoral nerve, Obturator nerve, Sciatic nerve and Nerve to the quadratus femoris Blood supply- obturator artery, medial and lat circumflex fem art, two gluteal arteries
- On physical examination of the newborn, a palpable hip “click” can be elicited when combined external rotation–abduction and internal rotation–adduction are alternately applied to the flexed hip (Ortolani’s test and Barlow’s test). Diagnostic ultrasound is the first choice for imaging investigation. The pathophysiology of DDH is multifactorial, including shallow bony margin; delayed ossification of the acetabulum or femoral head; ligamentous laxity; and neuromuscular disease with shortening, weakness, or contractures. (6). Hip flexion associated with breech presentation induces DDH by causing shortening of the psoas and decentering of the femoral head, a mechanism that also results from other deformities and neuromuscular disorders. Plain films are most useful from 2 to 8 months (4,5) and reliable depiction of DDH can often be made after 4–6 months. In adolescents and adults, long-standing dislocation manifests as a shallow acetabulum and a large, flattened femoral head with superior and lateral displacement. The head is at risk for complicating avascular necrosis. On occasions a neo- or pseudoacetabulum is formed on the posterosuperior surface of the iliac wing. (Figs. 3-106 and 3-107) The degree of secondary osteoarthritis is often surprisingly low grade or even absent. Ultrasound allows visualization of the bony and cartilaginous acetabular margins, the cartilaginous femoral head, the amount of femoral head coverage by the acetabulum, and with stress testing assessment of hip stability. (3–5,7) The hip is scanned in the coronal plane, and the bony (α) and cartilaginous (β) roof angles are measured. The critical measurement is the cartilaginous (α) angle and is the basis for classifying the degree of dysplasia. (3) (Table 3-4) Dynamic hip ultrasound may show no movement, slight movement, true subluxation, and frank dislocation. (7) Following the application of the harness sonographic reassessment at 4- to 6-week intervals over 2–3 months are performed to monitor and document the therapeutic response.
- Causes - Frohlich;s syndrome, renal osteodystrophy, trauma, rickets and radiotherapy. Complications – AVN, OA, chondrolysis, coxa vara deformity.
- Metaphyseal blanch sign of steel
- According to the degree of epiphyseal involvement as assessed radiographically. Group I and II patients have good prognosis.
- Affected children are only mildly ill or have recently sustained a low grade respiratory tract infection.
- A joint aspiration is typically necessary to confirm the diagnosis.
- The fat plane overlying the obturator internus muscle should be observed for medial displacement or asymmetry. This indicates a hematoma beneath or within the obturator internus.
- Judet and letournel classification
- type I: fracture inferior to the fovea capitis, a small fracture not involving the weightbearing surface type II: fracture superior to the fovea capitis, a large fracture involving the weightbearing surface type III: type I or II fracture with a fracture of the femoral neck, has an increased risk of AVN type IV: type I or II fracture with a fracture of the acetabular wall, usually the posterior wall
- Posterior dislocation may have associated fractures of the posterior lip of the acetabulum and/or injury to the acetabular labrum. AP x-rays will usually be sufficient for the diagnosis, although associated acetabular fractures will require CT to fully characterise. Anterior and posterior dislocations may appear similar as both demonstrate loss of the normal joint congruency between the femoral head and the acetabulum. In a well centred AP film the posteriorly dislocated femoral head will appear smaller than the contralateral hip, and vice versa, on account of geometric magnification 2
- CT Most helpful after hip reduction. Reveals: Non-displaced fractures. Congruity of reduction. Intra-articular fragments. Size of bony fragments.
- By convention, the term avascular (ischemic) necrosis generally is applied to areas of epiphyseal or subarticular involvement, whereas "bone infarct" usually is reserved for metaphyseal and diaphyseal involvemen Avascular necrosis is characterized by osseous cell death due to vascular compromise [1]. Avascular necrosis of bone results generally from corticosteroid use, trauma, pancreatitis, alcoholism, radiation, sickle cell disease, infiltrative diseases (e.g. Gaucher’s disease), and Caisson disease
- Cresent sign, osteoporosis, sclerosis, cystic chnages, partial collapse of head, secondary osteoarthritis
- This leads to shearing and impaction of the anterior articular cartilage of the femoral head, as well as anterior labral tears. The first is the “, thought to be caused by an enlarged femoral head or an abnormal contour of the femoral head/neck junction, which causes impingement anteriorly against a normal acetabulum (Fig. 6). The second, or “, is thought to be due to “over-coverage” of the femoral head anteriorly from either coxa profunda or a retroverted acetabulum
- There is some evidence that they may result from femoroacetabular impingement