Dr Rene Tayar - Parkside Hospital
Dr Rene Tayar - Parkside Hospital
Dr Rene Tayar - Parkside Hospital
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
RADIOLOGY OF HIP PAIN<br />
René <strong>Tayar</strong>
THE IMAGING MODALITIES<br />
PLAIN RADIOGRAPHY<br />
NUCLEAR MEDICINE<br />
SPECT CT<br />
FLUOROSCOPY<br />
ULTRASOUND<br />
CT<br />
MR<br />
MR ARTHROGRAPHY
CAUSES OF HIP PAIN<br />
INTRA-ARTICULAR<br />
ARTHROPATHIES<br />
THE CAPSULE AND ILIOFEMORAL LIGAMENT ATTENUATION<br />
SYNOVIAL DISEASES<br />
LABRAL TEARS AND ARTICULAR CARTILAGE DELAMINATION<br />
LOOSE BODIES<br />
CAM AND PINCER IMPINGEMENT<br />
CONGENITAL MALFORMATIONS eg hip dysplasia<br />
EXTRA-ARTICULAR<br />
ILIOPSOAS IRRITATION,SNAPPING,BURSITIS<br />
ABDUCTOR TENDINOPATHIES AND TEARS<br />
EXTRA-ARTICULAR TRAUMA<br />
IMPINGEMENT SYNDROMES<br />
HERNIAS AND OTHER MISCELLANEOUS LESIONS
CONDITIONS TO BE CONSIDERED IN DAY<br />
TO DAY PRACTICE<br />
• ARTHROPATHIES<br />
• BURSITIS<br />
• TENDONITIS<br />
• DAMAGE TO ACETABULAR LABRUM AND ARTICULAR<br />
CARTILAGE<br />
• CAM AND PINCER IMPINGEMENT<br />
• MUSCLE AND TENDON IMPINGEMENT<br />
• HIP DYSPLASIA<br />
• REPLACEMENT PROBLEMS<br />
• TRAUMA<br />
• HERNIAS
ARTHROPATHIES
T1gd CORRELATES WELL WITH PAIN SCORE
TRANSIENT REGIONAL OSTEOPOROSIS
DEGENERATIVE DISEASE
DEGENERATIVE DISEASE<br />
jsw narrowing, denuded chondral surface, subchondral cysts,<br />
osteophytes and sclerosis. Intact labrum
ACETABULAR SYNOVIAL CYSTS
ACUTE R.A AND O.A.
ACUTE AND CHRONIC R.A.<br />
AND SECONDARY O.A.
GOUT
CALCIUM PYROPHOSPHATE DIHYDRATE<br />
DISEASE (CPPD) AND PSEUDOGOUT
CHAARCOT’S NEUROPATHY<br />
Neurotrauma: Loss of peripheral sensation and proprioception<br />
leads to repetitive microtrauma to the joint in question; this<br />
damage goes unnoticed by the neuropathic patient, and the<br />
resultant inflammatory resorption of traumatized bone renders<br />
that region weak and susceptible to further trauma. Indeed, it<br />
is a vicious cycle. In addition, poor fine motor control<br />
generates unnatural pressure on certain joints, leading to<br />
additional microtrauma.<br />
Neurovascular: Neuropathic patients have<br />
dysregulated autonomic nervous system reflexes, and desensitized<br />
joints receive significantly greater blood flow. The<br />
resulting hyperemia leads to increased osteoclastic resorption<br />
of bone, and this, in concert with mechanical stress, leads to<br />
bony destruction.<br />
In reality, both of these mechanisms probably play a role.
EARLY AND LATE CHARCOT’S NEUROPATHY
BURSITIS<br />
• TROCHANTERIC BURSITIS<br />
• ILIOTIBIAL BAND SYNDROME<br />
• PSOAS BURSITIS<br />
• GLUTEUS MEDIUS BURSITIS
ILIOPSOAS BURSITIS
PSOAS BURSITIS
TROCHANTERIC BURSITIS
PSOAS AND TROCHANTERIC BURSITIS IN<br />
PATIENT WITH TRO
ULTRASOUND GUIDED INJECTION OF<br />
TROCHANTERIC BURSA
GLUTEUS MEDIUS BURSITIS(white)<br />
TROCHANTERIC BURSITIS(blue)
GLUTEUS MEDIUS BURSITIS
GLUTEUS MINIMUS BURSITIS
TENDONITIS
THE ILIOPSOAS TENDON
RUPTURE OF RIGHT ILIOPSOAS AFTER THR<br />
LEFT ILIOPSOAS ATROPHIED BUT INTACT
ILIOPSOAS SYNDROME<br />
Iliopsoas bursitis and/or tendonitis occurs<br />
primarily in gymnasts, dancers and track athletes<br />
and is caused by repetitive hip flexion.<br />
Other pathologies such as iliopsoas abscess, bone<br />
and soft tissue tumours have to be considered.<br />
Iliopsoas tendonitis or rupture can occur after a<br />
THR and can manifest as a radiolucency in the<br />
lesser trochanter from disuse.<br />
Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of<br />
the lesser trochanter simulating a malignancy<br />
Aditya V Maheshwari 1* , Rajesh Malhotra 2* , Deepak Kumar 3* and J David Pitcher Jr<br />
Journal of Orthopaedic Surgery and Research 2010, 5:6
IMAGING THE ILIOPSOAS TENDON<br />
POST THR<br />
• Ultrasound can demonstrate bursitis, tendonitis or snapping<br />
of the tendon over the overhanging acetabular margin.<br />
• CT is also helpful to rule out component malpositiong.<br />
• MRI is emerging as an effective tool for assessment of<br />
periprosthetic soft tissues, osteolysis and particle disease.<br />
MR will show proximal muscle swelling and oedema,<br />
thickening and interruption of the tendon with an otherwise<br />
empty fluid-filled distal tendon sheath. Chronic cases will<br />
show muscle atrophy with fatty degeneration.
WELL FIXED HYBRID IMPLANT WITH<br />
RADIOLUCENCY IN LESSER TROCHANTER<br />
THAT COULD INDICATE ILIOPSOAS<br />
RUPTURE
ARTHRO MR SHOWING FILLING OF BURSA BOTH<br />
MEDIAL AND LATERAL TO TENDON IN PATIENT<br />
WITH HIP PAIN
ILIOPSOAS TENDON LATERAL TO BURSA
BONY SPUR IMPINGING ILIOPSOAS<br />
TENDON
SNAPPING HIP SYNDROME<br />
Snapping hip syndrome is characterized by an audible<br />
snap or click that occurs in or around the hip.<br />
External causes include snapping of the iliotibial band<br />
and bursitis or gluteus maximus over the greater<br />
trochanter.<br />
Internal causes include snapping of the iliopsoas<br />
tendon over the iliopectineal eminence resulting in<br />
iliopsoas tendinitis, iliopsoas tendinosis, iliopsoas<br />
bursitis or a combination, acetabular labral tears and<br />
intra-articular loose bodies.<br />
The latter are relatively uncommon causes of internal<br />
snapping hip syndrome
SNAPPING HIP
ILIOPSOAS SNAPPING OVER PARALABRAL<br />
CYST As hip is brought back from frogleg position to<br />
neutral extended position, tendon moves medially, suddenly<br />
flipping over paralabral cyst for second time.
ILIOPSOAS BURSA<br />
may cause snapping hip syndrome
SNAPPING HIP<br />
OEDEMA LATERAL TO TENDON
SNAPPING ILIOPSOAS TENDON<br />
At rest the<br />
hyperechoic psoas<br />
lies over the<br />
superior pubic<br />
ramus.<br />
The hypoechoic<br />
iliacus lies over the<br />
psoas
SNAPPING ILIOPSOAS TENDON<br />
With flexionabduction-external<br />
rotation the muscle<br />
rolls laterally<br />
getting trapped<br />
between the tendon<br />
and superior pubic<br />
ramus
ULTRASOUND OF SNAPPING ILIOPSOAS<br />
As the hip is progressively<br />
brought back to neutral<br />
position, the tendon and<br />
trapped component of<br />
muscle follow the reverse<br />
path
SNAPPING ILIOPSOAS TENDON<br />
The muscle is suddenly<br />
released laterally,<br />
allowing abrupt return<br />
of iliopsoas tendon<br />
against superior pubic<br />
ramus producing the<br />
audible snap.
DAMAGE TO ACETABULAR LABRUM AND<br />
ARTICULAR CARTILAGE
ACETABULAR LABRUM/ARTICULAR<br />
CARTILAGE INTERFACE<br />
a: labrum<br />
b: articular cartilage<br />
c: transition zone<br />
d: bony acetabulum<br />
e: tidemark<br />
f: capsule<br />
g: capsular recess<br />
h: vessels<br />
1: capsular recess<br />
2:labral thickness<br />
3:width of labrum
NORMAL; LABRAL TEAR; O.A.
ULTRASOUND OF NORMAL LABRUM<br />
FEMORAL HEAD ARTICULAR CARTILAGE<br />
AND JOINT EFFUSION
LARGE FIELD OF VIEW<br />
ILIOPSOAS AND LABRUM ARE INDISTINGUISHABLE.<br />
THIS PATIENT HAD A TORN LABRUM AT ARHTROSCOPY
PLAIN MR MAY NOT DEMONSTRATE A<br />
LABRAL TEAR
MR ARTHROGRAPHY OFFERS BEST IMAGES<br />
good definition of labrum and articular<br />
cartilage
LARGE SUPERIOR PERILABRAL RECESS<br />
LIGAMENTUM TERES-TRANSVERSE<br />
LIGAMENT COMPLEX
MYXOID DEGENERATION OF THE LABRUM
LABRAL TEAR AND PARALABRAL RECESS
LABRAL/ARTICULAR CARTILAGE<br />
JUNCTION TEAR AND ACETBULAR CYST
COMPLETE LABRAL TEAR ON CT ARTHRO
TEAR WITH PARALABRAL CYST AND<br />
ARTICULAR CARTILAGE DEFECT
DETACHED ANTERIOR LABRUM
LARGE LABRAL TEAR AND O.A. CHANGES
LABRAL TEAR AND COMMUNICATION OF HIP<br />
JOINT WITH PSOAS BURSA
HIP DYSPLASIA WITH SUBCHONDRAL<br />
CYSTS
HIP DYSPLASIA WITH FOCAL LOSS OF<br />
ARTICULAR CARTILAGE
LABRAL TEAR AND LOSS OF ARTICULAR<br />
CARTILAGE
LABRAL TEAR, FOCAL ATTRITION OF<br />
ARTICULAR CARTILAGE AND LOOSE BODY
LABRAL ALTERATIONS AND FIBROCYSTIC<br />
CHANGE
CARTIGRAM<br />
When collagen breaks down, there is increased<br />
mobility of water in the cartilage and therefore a<br />
prolongation in T2 relaxation times.<br />
These values are represented by colour maps and<br />
allow visualisation of cartilage composition before<br />
changes in thickness can be seen on routine MR
T2 MAPPING WITH CARTIGRAM SHOWS<br />
EARLY DEGENERATIVE DISEASE
HIP IMPINGEMENT SYNDROMES<br />
• CAM IMPINGMENT<br />
• PINCER IMPINGEMENT<br />
• COMBINED CAM AND PINCER IMPINGEMENT<br />
• PIRIFORMIS SYNDROME<br />
• ISCHIOFEMORAL IMPINGEMENT
CAM AND PINCER IMPINGEMENT
A: NORMAL; B: CAM IMPINGEMENT<br />
C:PINCER IMPINGEMENT; D: COMBINATION
THE ALPHA ANGLE<br />
NORMAL IS 55 DEGREES
FAI<br />
CAM AND TEAR
CAM IMPINGEMENT AND OSTEOARTHRITIS<br />
anterosuperior osseous bump and decreased<br />
anterior offset on an oblique axial view (normally<br />
12 mm, less than 8 in cam impingement).
CAM LESION
ACETABULAR DEPTH<br />
CAM<br />
PINCER
PIRIFORMIS IMPINGEMENT
ACCESSORY PIRIFORMIS IMPINGING ON<br />
SCIATIC NERVE
ISCHIOFEMORAL INTERVAL IMPINGEMENT
ISCHIOFEMORAL IMPINGEMENT ON<br />
QUADRATUS FEMORIS
HIP DYSPLASIA
Hip dysplasia: a significant risk factor for the<br />
development of hip osteoarthritis. A cross-sectional<br />
survey<br />
S. Jacobsen and S. Sonne-Holm<br />
Rheumatology Vol. 44 No. 2 © British Society for Rheumatology 2004
HIP DYSPLASIA
HIP REPLACEMENT PROBLEMS
VR OF SURFACE REPLACEMENT<br />
NORMAL BONE/CEMENT<br />
DIE BACK<br />
OSTEOLYSIS FROM PARTICLE DISEASE
SEVERE METALLOSIS WITH OSTEOLYSIS
PSOAS MASS FROM METALLOSIS
RETRIEVAL CONFIRMS SEVERE DIE BACK<br />
AND METALLOSIS
TRAUMA
FEMORAL NECK FRACTURE
SUBTLE ACETABULAR FRACTURE
POSTERIOR COLUMN FRACTURE
CORONAL MPR AND VR ANGIOGRAM OF<br />
DISLOCATED PROSTHESIS
STRETCH INJURY OF ILIOPSOAS AND<br />
NORMAL
MR AND CT OF ATROPHIED AND<br />
RETRACTED TORN ILIOPSOAS
THE FOUR FACETS OF THE GREATER<br />
TROCHANTER<br />
anterior (A), lateral (L),<br />
posterior (P), and<br />
superoposterior (SP). The<br />
gluteus minimus tendon<br />
(Gmn) inserts on the<br />
anterior (A) facet and the<br />
gluteus medius (Gme)<br />
inserts on the<br />
superoposterior (SP) and<br />
lateral (L) facets. Three<br />
commonly encountered<br />
bursae are: trochanteric<br />
(TB), subgluteus minimus<br />
(SGmn), and subgluteus<br />
medius (SGMe).
GLUTEUS MEDIUS TENDON<br />
INSERTED ON SUPERIOR-POSTERIOR<br />
FACET
GLUTEUS MEDIUS TEAR<br />
lax and elongated
TORN AND ATTENUATED GLUTEUS MINIMUS<br />
displaced from insertion at anterior facet (arrowhead)<br />
with fluid in bursa
RECTUS FEMORIS AVULSION
DISRUPTION OF ILIOFEMORAL LIGAMENT<br />
FOLLOWING TRAUMATIC POSTERIOR<br />
DISLOCATION<br />
left: iliofem lig; right: capsule
RUPTURE OF POSTERIOR FIBRES OF<br />
ISCHIOFEMORAL LIGAMENT
THE COMMON ADDUCTOR-RECTUS ABDOMINIS<br />
APONEUROSIS<br />
The common adductor-rectus abdominis<br />
aponeurosis (CA-RA) is of critical biomechanical<br />
and pathophysiologic importance.<br />
This aponeurosis is composed of the tendons of<br />
the adductor longus and rectus abdominis<br />
muscles, which blend and insert on the anterior<br />
pubis
NORMAL AND TORN CONJOINED TENDON
SECONDARY CLEFT AT TEAR OF CONJOINED<br />
TENDON
RECTUS AND CONJOINED TENDON<br />
IN SAGITTAL PLANE
STRAIN AND TEAR OF RECTUS ABDOMINIS<br />
INTACT CONJOINT TENDON
STRAIN OF OBTURATOR EXTERNUS
TEAR OF ADDUCTOR LONGUS
COMMON ADDUCTOR-RECTUS ABDOMINIS<br />
CONJOINED TENDON (CA-RA) TEAR
HERNIAS AND OTHER<br />
MISCELLANEOUS LESIONS
AVN
AVN<br />
GEOGRAPHICAL SUBCHONDRAL LESION WIH DOUBLE LINE<br />
THE HIGH SIGNAL LINE AND INCREASED UPTAKE<br />
REPRESENT HYPERVASCULAR TISSUE
BILATERAL TRANSIENT REGIONAL<br />
OSTEOPOROSIS<br />
ON STIR AND T1
SEPTIC ARTHRITIS VS TRO<br />
NOTE MARROW AND SOFT TISSUE OEDEMA IN TRO
PERTHE’S DISEASE<br />
POST GADOLINIUM SEQUENCE SHOWS LIMITED<br />
INVOLVEMENT OF THE EPIPHSIS
SYNOVIAL CHONDROMATOSIS
STRANGUALTED INGUINAL HERNIA
CT PSOAS ABSCESS<br />
contrast and air from bowel fistula
PVNS
CHONDROSARCOMA
VARICOCOELE AND RENAL CELL<br />
CARCINOMA
PLEASE REMEMBER<br />
• Degenerative disease<br />
• Trauma<br />
• Bursitis<br />
• Tendonitis<br />
• Impingement syndromes<br />
• Labral and cartilage damage<br />
• TRO, AVN, Septic arthritis<br />
• Miscellaneous extrinsic to the hip eg.lumbar spine<br />
disease, hernias etc.