hip injuries: imaging - towson sports medicinemay 01, 2015 · modalities of imaging • xr –...
TRANSCRIPT
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HIP INJURIES: Imaging Primary Care Approach To
Treating The Injured Athlete
Friday May 1, 2015 Manjiri M Didolkar MD, MS
Musculoskeletal Imaging
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Disclosures
• No disclosures
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Contents
I. Why Imaging? II. Imaging Modalities (brief general overview) - Radiographs (XR), Computed Tomography
(CT), Ultrasound (US), Magnetic Resonance Imaging (MRI)
III. The Hip A. Functions B. Anatomy on MRI (very brief overview!) C. Pathology on imaging
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Why Imaging?
• “In modern medical practice, the term Radiology encompasses the techniques used to investigate the architecture and physiological function of the human body.”
• To help identify the cause of pain, dysfunction, or disability
• If you know where is the ‘pain’ and what is causing the ‘pain’, you will be able to better treat the ‘pain’
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Modalities of Imaging
• XR – production of an x-ray beam to evaluate anatomy – portion of the x-ray beam, not absorbed by the
body, used to expose x-ray film, producing the diagnostic image
– bone and soft tissues require no special preparation for the evaluation
– 2 dimensional image – detail of the bones
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Hip XR
AP Frog-leg Lateral
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Modalities • CT
– production of an x-ray beam to evaluate anatomy – bone and soft tissues require no special
preparation for the evaluation – organ and circulatory systems, may require
contrast material to enhance the visualization of their shape, size, position, and functional status
– 3 dimensional images of a cross-section of a part of the body
– better detail of extra-articular and intra-articular bony architecture; also soft tissues
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Hip CT
Axial
Sagittal
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Modalities
• US – high-frequency sound beam used to visualize the
structures of interest – sound beam directed into the body – resulting densities of body tissue reflected back,
analyzed to produce the diagnostic image – Some detail of tendons, ligaments, organs, soft
tissues – NOT good for bones or lungs
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Hip Ultrasound
http://www.ultrasoundcases.info/files/Jpg/7678.jpg
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Modalities • MRI
– based on the magnetic behavior of H atoms in tissues when placed in a magnetic field and excited by radiofrequency pulses
– after excitation, H atoms return to normal state by emitting energy that is monitored
– this energy characterized by relaxation times, which reflect the chemical and physical properties of tissues, creating an image
– greatest for soft tissue detail and organ detail; including ligaments, tendons; also very good for bone
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MRI
• Depending on pulse sequence, tissues will show up as black, white, and everything in between (shades of gray) – T1, T2, Proton Density (PD)
• T1: fluid black, fat bright, muscle intermediate, tendons and ligaments dark, bone bright
• T2: fluid bright, fat bright or dark (FS), muscle intermediate or darker, tendons and ligaments dark, bone bright or dark (FS)
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MRI pelvis protocol
Coronal T1 Coronal FS T2
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Axial T1 Axial FS T2
MRI pelvis protocol
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Pain
Imaging
XR
Bony detail: fractures,
dislocations, foreign body
CT
Same as XR with intra-articular and
extra-articular detail, soft tissue
detail
US
Soft tissue detail: intra-articular and
extra-articular, other
MRI
Greater than US or CT for the soft
tissue detail, bone marrow changes
Upper extremity
Lower extremity Physical
Exam (Dx/Rx)
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Anatomy to evaluate/Indications for MRI of the hip
• Non-arthrogram – Everything!
• Bones, Joint, Tendons, Other (tumors)
– Bilateral hips or pelvis • Bilateral pain • Unknown pain source
– Unilateral • Unilateral pain • Specific symptoms
• Arthrogram – Labrum – Cartilage
• All else can be commented on if visualized
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The hip
• Most stable articulation in the body
• Ball and socket joint, 2nd greatest ROM
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The hip
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The hip
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Hip Functions
• Flexion • Extension • Abduction • Adduction • Internal/external rotation
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Hip anatomy
www.hwbf.org
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Hip anatomy
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Hip anatomy
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Hip anatomy
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The hip
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The hip
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Pain
Imaging
XR
Bony detail: fractures,
dislocations, foreign body
CT
Same as XR with intra-articular and
extra-articular detail, soft tissue
detail
US
Soft tissue detail: intra-articular and
extra-articular, other
MRI
Greater than US or CT for the soft
tissue detail, bone marrow changes
Upper extremity
Lower extremity Physical
Exam (Dx/Rx)
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Pathology
• Fracture spectrum • Tendon tear/Sports hernia • Rectus femoris tendon avulsion • Femoroacetabular Impingement • Labral tear
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Case A
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Stress reaction
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Stress reaction
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Case B
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Case B
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Stress fracture
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Case C
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Nondisplaced fracture
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Nondisplaced fracture
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Nondisplaced fracture
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Nondisplaced fracture
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Fracture spectrum
• MRI findings – T1 linear low signal with surrounding low
signal edema – T2 linear low signal with surrounding high
signal edema – +/- cortical break, osseous fragments – Stress reaction is edema
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Stress fracture
• Most commonly around pelvis and hip • Stress fractures in athletes F>M • 15% of runners sustain a stress fracture • 5-10% of all stress fractures involve the femoral
neck (usually basicervical) • MRI exquisitely sensitive for detection (the most
sensitive than all other modalities) • About 14% of femur and pelvic fractures are missed on CR • Kirby, AJR 2010;194:1054-1060.
• * Female Athlete Triad
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Case D
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Tendon tear
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Tendon tear
• MRI findings – T1 isointense to muscle (low) – T2 high signal in tendon (edema) – Disruption of fibers (waviness, discontinuity) – Edema (high T2 signal) in adjacent muscle and
bony attachment – For sports hernia also high T2 signal in the pubic
symphysis
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Sports hernia
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Case E
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AIIS avulsion
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Tendon avulsion
• Bony avulsion usually clear on radiographs • MRI findings
– Similar tendon findings – Edema (high T2 signal) in adjacent muscle and
bony attachment – Cortical break and adjacent bony fragment
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AIIS tendon avulsion
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AIIS tendon avulsion
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AIIS tendon avulsion
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Femoroacetabular Impingement Syndrome
• Major cause of early osteoarthritis of the hip, especially in young and active patients, including labral abnormalities
• Early pathologic contact during hip joint motion between skeletal prominences of the acetabulum and the femur
• Limits physiologic hip range of motion, typically flexion and internal rotation
• Pain in the groin; +/- pain in the trochanteric region extending to the lateral thigh
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Femoroacetabular Impingement Syndrome (FAI)
• 2 types of impingement – Pincer
• acetabular cause of FAI • focal or general over coverage of femoral head
– CAM • femoral cause of FAI • aspherical shape of femoral head, femoral head-neck
bony excrescence (CAM lesion), coxa magna
• Best evaluation is first by radiographs
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Copyright © 2007 by the American Roentgen Ray Society
Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552
Normal configuration of hip with sufficient joint clearance allows unrestricted range of motion
(top)
FAI
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Copyright © 2007 by the American Roentgen Ray Society
Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552
Schematic (left) and radiographic (right) appearances of normal hip (detailed view of
anteroposterior pelvic radiograph) in 35-year-old man FAI – Normal hip
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Copyright © 2007 by the American Roentgen Ray Society
Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552
Schematic (left) and radiographic (right) presentations of coxa profunda (detailed view of
anteroposterior pelvic radiograph) in 29-year-old woman FAI – Pincer type
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Copyright © 2007 by the American Roentgen Ray Society
Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552
Cam impingements
FAI – CAM type
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Labral tear
• MRI findings – Abnormal linear increased signal through
the dark signal triangular labrum – Deformity or irregularity of the labrum – Detachment of the labrum – Associated paralabral cysts
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Labral tear
• Acute injury, chronic stress (FAI), DDH • Pain and clicking • MRI arthrography the best to evaluate labrum
(and cartilage)
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Labral tear
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Labral tear
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Case F
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Labral tear
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Labral tear
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Labral tear
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Labral tear
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Conclusions
• Hip - complex joint with different anatomic structures causing pathology
• Imaging is the best way to evaluate pathology, including the hip joint
• In particular MRI is a great modality for all types of pathology
Thank you!
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References • * All images taken from various websites have their references listed under the
images . Other images with article references are from goldminer.arrs.org; under copyright laws. Some images also taken from the DUMC PACS.
• www. ptcentral.com • Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular Impingement:
Radiographic Diagnosis—What the Radiologist Should Know. Am J Roentgenol. 2007; 188: 1540 - 1552.
• Karjalainen PT, Soila K, Aronen HJ, Pihlajamäki HK, Tynninen O, Paavonen T, Tirman PFJ. MR Imaging of Overuse Injuries of the Achilles Tendon. Am J Roentgenol. 2000; 175: 251 - 260.
• Erkonen WE, Smith WL, editors. Radiology 101: the basics and fundamentals of imaging, 2nd ed. Lippincot Williams and Wilkins, Philadelphia, PA. 2005.
• Helms CA. Fundamentals of Skeletal Radiology, 3rd ed. Elsevier, Inc., Philadelphia, PA. 2005.
• Kaplan, Helms, Dussault, Anderson, Major. Musculoskeletal MRI, 1st ed. WB Saunders Company, Philadelphia, PA. 2001.
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References • Stoller DW. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine,
Volume 2, Upper Extremity. 3rd Ed. Lippincott Williams and Wilkins. Philadelphia. 2007.
• Sonin et al. Diagnostic Imaging Musculoskeletal: Trauma. 1st ed. Amirsys. Manitoba, Canada. 2010.
• Helms CA, et al. Musculoskeletal MRI. 2nd Ed. Saunders Elsevier. Philadelphia. 2009. • Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the
emergency department. AJR Am J of Roentgen. 2010;194:1054-1060.