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 PF 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 LF AF 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 Anterior Axial Axial Baker Cyst Evaluation: pitfall No Baker Cyst MG ST MG SM SM SM MG 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 13.