Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Hip and Pelvis Imaging Outline Radiographs Routine MRI MR
Transcript
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 1 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 7 8 Femoral Head and Neck www.ESSR.org Labrum/Iliopsoas 9 www.ultrasoundcases.info Quadriceps Group 10 Femoral Nerve and Artery 11 www.ESSR.org 12 2 Structures of Interest – Hip Medial View Adductor Group Distal iliopsoas Adductor group Pubic symphysis Rectus abdominus insertion 13 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 16 Structures of Interest – Hip Posterior View Glut Med/Glut Min Garcia 2010 14 17 Glut max, med and min Hamstrings Sciatic nerve Piriformis 18 3 Hamstring Longitudinal Transverse HIP PATHOLOGY 19 Greater Trochanteric Bursitis www.ultrasoundcases.info 20 AIIS Avulsion 21 Gluteal Tendon Pathology www.ultrasoundcases.info Gluteal Tendon Tears MRI 23 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 22 Sensitivity of 79-100% Positive predictive value of 95-100% 24 4 Snapping Hip Snapping Hip Deslandes 2008 25 Labral Cysts www.ultrasoundcases.info 26 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% 27 28 Normal Hip Imaging Radiography HIP IMAGING ANATOMY Bilateral AP Hip/Pelvis AP Hip Frog MRI CT 5 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 6 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 7 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 8 Rectus abdominus Acetabular roof Rectus femoris Superior pubic rami Femoral head Sartorius Symphysis pubis Rectus femoris Greater trochanter Gemelli 9 Sciatic nerve Obturator internus Pectineus Tensor fascia lata Obturator externus Sartorius Iliopsoas Rectus femoris Tensor fascia lata Iliotibial band Quadratus femoris 10 Inferior pubic rami Semimembranosus Biceps Femoris Semitendinosus Iliopsoas Lesser trochanter Adductor longus Gracilis Vastus intermedius Vastus lateralis Adductor brevis Adductor magnus 11 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 12 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 13 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 14 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 15 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 16 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 17 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 18 Subcapital Fracture Manaster BJ. Radiographics. 2000 Nondisplaced Fracture Manaster BJ. Radiographics. 2000 Bilateral Acetabular Roof Fractures T1 T2 19
