Hip Anatomy and Ultrasound Disclosures: Scanning Technique • Consultant: Bioclinica • Advisory Board: Philips Jon A. Jacobson, M.D. • Book Royalties: Elsevier Professor of Radiology • Not relevant to this talk Director, Division of Musculoskeletal Radiology University of Michigan Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc.

Sonographic Technique: hip and thigh Technique • Hip: – Anterior: hip joint, musculature, iliopsoas bursa 1. Start with low frequency transducer: – Lateral: gluteal tendons, bursae global, complete examination – Posterior: external rotators 2. Familiarize with anatomy – Other: symphysis pubis, inguinal hernia 3. Compare to contralateral side • Thigh: 4. Consider dynamic imaging – Anterior: quadriceps femoris – Medial: abductors – Posterior: hamstring

Hip: anterior recess Sonographic Technique: Hip • Anterior and posterior layers • Anterior – Hip joint – Fibrous tissue + minute layer of synovium – Anterior musculature – Hyperechoic Radiology – Snapping iliopsoas – Each 2 - 4 mm thick 1999; 210:499 – Iliopsoas bursa – Lateral femoral cutaneous nerve • Transducers: – 10 – 12 MHz linear – <10 MHz curvilinear if needed

1 Hip: anterior recess Hip Joint

Anterior Posterior Femur

Femur

Transverse

Iliopsoas A Complex Sonographic Technique: Hip AIIS • Lateral – Greater trochanter A Ilium B – Gluteal tendons – Bursae – Snapping hip • Transducers:

Pubis – 10 – 12 MHz linear Femoral Head – <10 MHz curvilinear if needed From: Guillin R. et al. Eur Rad Short Axis 2009; 19:995

Greater Trochanter: gluteal tendons Greater Trochanter Lateral Anterior Posterior

FACETS: AF = anterior; LF = lateral; SPF = superoposterior; PF = posterior Gluteus medius (red) Gluteus minimus (blue) Pfirrmann et al. Radiology 2001; 221:469

2 Greater Greater Trochanter Trochanter

Yellow arrow = gluteus medius White arrow = Inferior 12 gluteus minimus

Anterior Posterior

Yellow arrow = gluteus medius Axial MRI White arrow = gluteus minimus 3 Superior 4

Greater Trochanter Gluteus Minimus and Medius: Long Axis Subgluteus Gluteus Medius Medius Gluteus Gluteus Gluteus Bursa Minimus TFL Medius Minimus Trochanteric Bursa

Glut Subgluteus Max Minimus Bursa LF AF PF PF

AF: anterior facet LF: lateral facet PF: posterior facet

Gluteus Minimus: Long Axis Gluteus Medius: Long Axis

Iliotibial Tract Gmed Gmed

LF

AF

Anterior Lateral Facet Facet

3 Posterior Thigh: anatomy Sonographic Technique: Thigh

• Posterior: – Semimembranosus – Semitendinosus – Biceps femoris • Long and short heads – Sciatic nerve • Transducers: – 10 – 12 MHz linear – <10 MHz curvilinear if needed From: Netter’s Atlas of Human Anatomy

Proximal Hamstring: gluteal fold Proximal Hamstring: gluteal fold to ischial tuberosity 1 2 3 Conjoint Medial Tendon

ST ST BF Gluteal fold Moving proximal

SM 4 Note: Long Axis Semimembranosus Adductor tendon (yellow Sciatic Magnus Nerve arrow) moving Transverse medial to lateral Note: Conjoined semitendinosus (ST) and biceps femoris long head (BF) tendon (yellow arrow), semimembranosus (SM blue arrow), and sciatic nerve in a triangle configuration *Conjoined ST-BF and SM tendons Ischial tuberosity only seen together in long axis when *Toggle transducer to eliminate anisotropy* they cross over distal to tuberosity

Posterior Thigh: A Conjoined ST-BF Proximal hamstring: at ischial tuberosity Tendon proximal hamstring Conjoined ST-BF Tendon A SM Ischium Sciatic Nerve B

B Semimembranosus SM Sacrotuberous Ischium Ligament

Ischium Lateral Medial Ischium Transverse Lateral Medial Transverse

4 Posterior Thigh: Semitendinosus Raphe Posterior Mid Thigh: moving distal

ST ST BF BF BF SM SM SM Sciatic Nerve

Lateral Medial

Lateral Medial BF SM Transverse BF SM Transverse Note: tapering of Note: hyperechoic raphe or veil that moves obliquely through semitendinosus semitendinosus muscle in proximal thigh over SM

Posterior Mid Thigh: moving distal ST ST Posterior Thigh: longitudinal SM SM

Lateral Medial Transverse SM SM Note: tapering of Sciatic Nerve Hamstring Origin semitendinosus over SM

Take-home points:

• Know bone landmarks • Hip evaluation: – Anterior: hip joint – Lateral: greater trochanter • Thigh: focused examination Syllabus on line and other educational material: www.jacobsonmskus.com Twitter handle: @jjacobsn

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