Hip, Thigh, and Knee: Anatomy and Scanning Techniques • Consultant: Bioclinica • Book Royalties: Elsevier

Disclosures: Hip, Thigh, and Knee: Anatomy and Scanning Techniques • Consultant: Bioclinica • Book Royalties: Elsevier

Jon A. Jacobson, M.D. Professor of Radiology 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: Anterior Hip: anterior recess • Hip joint and labrum • Anterior and posterior layers • Iliopsoas bursa – Fibrous tissue + minute layer of synovium

• Muscles: – Hyperechoic Radiology – Iliopsoas, rectus femoris, sartorius – Each 2 - 4 mm thick 1999; 210:499 • Other: – Adductors – Pubic symphysis – Inguinal hernias

Hip Joint Hip Joint

H Femur A Neck

Sagittal-oblique Transverse

1 Iliopsoas Anterior Hip Anatomy A Complex AIIS

A Ilium B

Pubis Femoral Head Short Axis From: Guillin R. et al. Eur Rad From: Netter’s Atlas of Human Anatomy 2009; 19:995

Rectus Femoris Origin: direct head Rectus Femoris Tendon Direct Origin

Anterior Inferior Indirect Iliac Spine Origin

Long Axis

Lateral Femoral Cutaneous Nerve Sonographic Technique: Hip Inguinal Ligament

• Anterior Sartorius

– Lateral Cutaneous Rectus Nerve of the Thigh Femoris

Short Axis Long Axis

2 Greater Trochanter: gluteal tendons Sonographic Technique: Hip Anterior Lateral Posterior • Lateral – Greater trochanter

Gluteus medius (red) Gluteus minimus (blue)

Greater Trochanter: facets Greater Trochanter Subgluteus Medius Gluteus Medius Gluteus Bursa Minimus TFL Trochanteric Bursa

Glut Subgluteus Max Minimus Bursa LF AF

AF: anterior facet LF: lateral facet Facets: anterior, lateral, posterior, superoposterior PF: posterior facet

Pfirrmann et al. Radiology 2001; 221:469

Gluteus Minimus: Long Axis Gluteus Medius: Long Axis

Iliotibial Tract Gmed Gmed

Anterior Lateral Facet Facet

3 Rectus Femoris Sonographic technique:

• Anterior – Rectus femoris – Vastus intermedius – Vastus lateralis – Vastus medialis

From: Netter’s Atlas of Human Anatomy

Quadriceps Muscles: central Quadriceps Muscles: medial

RF RF VM

VI VI

Femur Femur

Transverse Transverse

Quadriceps Muscles: lateral Quadriceps Muscles: longitudinal

VL RF RF P

VI VI Femur

Femur Distal

Transverse

4 Sonographic technique: • Medial – Adductors – Sartorius – Gracilis

From: Netter’s Atlas of Human Anatomy

Medial Thigh Muscles Sartorius Tendon

Sartorius Ad L Anterior Superior Iliac VM Ad B Spine

Ad M Femur Longitudinal Transverse

Gracilis Sartorius Saphenous Nerve Saphenous Nerve Sartorius • Largest cutaneous branch of the femoral nerve • Travels beneath sartorius: Adductor Vastus – Moves anterior to posterior Magnus Medialis – Over gracilis tendon Posterior Anterior Gracilis • Infrapatellar branch: thru sartorius Sartorius

• Subcutaneous: great Posterior Anterior saphenous vein Gr. Saphenous Vein Gracilis

5 Medial Thigh Muscles Sonographic technique: Gracilis • Posterior Ad B – Semimembranosus – Semitendinosus Ad M – Biceps femoris

Transverse

Anatomy Posterior Thigh: central Posterior ST

BF SM

Lateral Medial Transverse From: Netter’s Atlas of Human Anatomy

Posterior Thigh: medial Posterior Thigh: medial Posterior Posterior ST ST SM SM

Lateral Medial Lateral Medial Transverse Transverse

6 Posterior Thigh: proximal hamstring Posterior Thigh: Conjoint proximal hamstring Tendon Conjoint Tendon Conjoint Tendon Ischium Lateral Medial ST Sciatic BF Nerve Semimembranosus SM SM Ischium Sciatic Nerve Ischium Lateral Transverse Medial Transverse

Posterior Thigh: longitudinal Sonographic Technique: Knee • Focused examination • Complete assessment – Anterior – Medial – Lateral – Posterior Sciatic Nerve Hamstring Origin • Transducers: 5 - 17 MHz linear

Anatomy: anterior Technique: anterior • Quadriceps tendon • Patellar tendon • Suprapatellar recess: joint effusion • Bursa: – Prepatellar, superficial infrapatellar, deep infrapatellar

From: Netter’s Atlas of Human Anatomy

7 Suprapatellar Recess and Gutters Quadriceps Tendon & Suprapatellar Recess

Patella

Femur Long Axis

From: Miller PJ et al. Am J Sports Med 2001;29:822.

Quadriceps Tendon & Suprapatellar Recess Quadriceps Tendon

Patella

Femur

Short Axis Long Axis

Patellar Tendon Retinaculum Joint Effusion Patella • Knee flexion: Medial – Suprapatellar Femur recess Fat Pad – Sagittal plane • Knee extension: – Medial and lateral Pat Short Axis gutters – Axial plane Lateral Femur

8 Patellar Tendon Articular Cartilage: femur

Long Axis

Femoral Condyle Trochlea Axial Sagittal Patella Tibia

Anatomy: medial

Technique: medial • Medial collateral ligament • Medial meniscus – Body – Anterior horn • Pes anserinus

From: Netter’s Atlas of Human Anatomy

MCL and Medial Meniscus

Medial Collateral Ligament: 1 2 • MCL Complex: 3 layers* 3 1: deep fascia (not important) 2: tibial collateral ligament (thickest layer) Femur Tibia 3: capsular ligament (deep) • Second and third layers seen best – Hyperechoic and fibrillar

*Radiographics 2000; 20:S83 Long Axis

9 Semimembranosus Anisotropy: Pes Anserinus pseudo-mensical cyst

PHMM

Femur Tibia Longitudinal: distal MCL Longitudinal: Semitendinosus

Coronal Coronal

Anatomy: lateral Technique: lateral • Iliotibial tract • Lateral collateral ligament • Popliteus tendon • Biceps femoris tendon • Common peroneal nerve • Lateral meniscus: body & anterior horn

From: Netter’s Atlas of Human Anatomy

Iliotibial Tract Lateral Collateral Ligament

Tibia

Femur

Longitudinal Longitudinal

10 LCL, Popliteus, and Lateral Meniscus Bifurcating Distal Biceps Femoris: • Long axis of fibular collateral ligament • Biceps separates: superficial, deep layers • Surrounds fibular collateral ligament LM Tibia Fibula • May be mistaken as tendinosis or ligament Femur abnormality

Smith, J Ultrasound Med 2011; 30:1156

Longitudinal

Bifurcating Biceps Femoris Tendon Biceps Femoris Tendon

LCL Fibula

Fibula

Longitudinal Femur Fibular Collateral Ligament (long axis)

Common Peroneal Nerve

BF LCL Technique: posterior • Baker cyst

Fibula • Menisci: posterior horns • Cruciate ligaments Posterior Anterior Longitudinal Transverse

11 Anatomy: posterior Technique: Baker cyst • Begin: axial, mid-calf • Locate soleus, medial, and lateral gastrocnemius muscles • Follow medial border of medial gastrocnemius muscle • Visualize semimembranosus tendon

AJR 2001; 176:373 From: Netter’s Atlas of Human Anatomy

Posterior No Baker Cyst

Posterior MG LG

SM MG Medial Soleus Femur

Axial Axial

Baker Cyst Evaluation: pitfall No Baker Cyst MG ST MG SM SM SM

Sagittal

12 Medial Mensicus: posterior horn Lateral Meniscus: posterior horn

Femur Femur Tibia p Tibia

Sagittal Sagittal

Anterior Cruciate Ligament Posterior Cruciate Ligament

Medial Lateral

Tibia

Femur Axial Sagittal