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Ultrasound Trochanteric Region
Disclosures: Ultrasound Trochanteric Region • Consultant: Bioclinica • Book Royalties: Elsevier • Grant: American Institute of Ultrasound in Medicine and Harvest Technologies 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. Greater Trochanter: gluteal tendons • • • • Lateral Anterior Introduction: Posterior Anatomy and Scanning Technique Bursal Pathology Tendon Injury Miscellaneous Gluteus medius (red) Greater Trochanter: facets Gluteus minimus (blue) Greater Trochanter Yellow arrow = gluteus medius White arrow = gluteus minimus Inferior 1 2 Facets: anterior, lateral, posterior, superoposterior Axial MRI Pfirrmann et al. Radiology 2001; 221:469 3 1 Superior 4 Greater Trochanter Greater Trochanter Anterior Posterior Yellow arrow = gluteus medius White arrow = gluteus minimus Pfirrmann et al. Radiology 2001; 221:469 Gluteus Minimus: Long Axis Gluteus Medius: Long Axis Iliotibial Tract Gmed Gmed LF AF Anterior Facet Lateral Facet Lateral Femoral Cutaneous Nerve Sonographic Technique: Hip Inguinal Ligament • Lateral Femoral Cutaneous Nerve Sartorius Rectus Femoris Short Axis 2 Long Axis Lateral Femoral Cutaneous Nerve Introduction: Sartorius Lateral Medial • • • • Anatomy and Scanning Technique Bursal Pathology Tendon Injury Miscellaneous Transverse Trochanteric Pain Syndrome: Trochanteric Bursal Fluid: • Most commonly caused by gluteus minimus and medius tendon abnormalities1 • Trochanteric bursitis: rare – Not actually inflamed2 – Not associated with pain3 • Bursal fluid not normally seen • Fluid distention: – simple fluid: anechoic – complicated fluid: mixed echogenicity 1Eur Rad 2007; 17:1772. Clin Rheumatol 2008; 14:82 3Skeletal Radiol 2008; 37:903 2J Trochanteric Bursitis Trochanteric Bursitis PF PF Transverse Transverse Coronal 3 Coronal Trochanteric Bursitis Trochanteric Bursitis Transverse Arthrogram Metal-on-Metal Arthroplasty: pseudotumor Introduction: • • • • Troch Cup Neck Cup Anterior Anatomy and Scanning Technique Bursal Pathology Tendon Injury Miscellaneous Lateral Tendinosis: Gluteus Medius Gluteal Tendon Pathology: • • • • Tendinosis: hypoechoic, no defects Partial tear: anechoic clefts Complete tear: discontinuous tendon >2 mm cortical irregularity is associated with tendon tear AF – Positive predictive value = 90% (xray)* *Steinert et al. Radiology 2010; 257:754 4 LF SPF LF Tear: Gluteus Medius Tendinosis: Gluteus Minimus AF LF AF AF LF LF >2 mm cortical irregularity (x-ray) = 90% positive predictive value for gluteus tendon tear Steinert et al. Radiology 2010; 257:754 Calcific Tendinosis: Gluteus Medius Post-operative: Gluteus Medius AF LF SPF Long Axis Short Axis AF LF LF LF Trochanteric Region Bursae Potential Treatment Algorithm: • If bursa: aspirate, inject steroids • If tendinosis: – Tenotomy or fenestration – Inject steroids superficial to tendon • Trochanteric: deep to gluteus maximus • Subgluteus medius • Subgluteus minimus • Axial plane • 72% of patients significantly improved1 • If tendon tear: platelet-rich plasma injection? LF PF 1Labrosse, et al. 2010 AJR 2010; 194:202 5 Gluteus Medius Tenotomy Introduction: Greater Trochanter • • • • Anatomy and Scanning Technique Bursal Pathology Tendon Injury Miscellaneous Snapping Hip Syndrome Snapping Hip: iliotibial tract • Painful snap with hip motion • Intraarticular • Extraarticular: • Transverse over greater trochanter • Hip external rotation / flexion • Abrupt motion of iliotibial tract over greater trochanter – Medial: iliopsoas tendon – Lateral: iliotibial tract or gluteus maximus Snapping Hip Syndrome: iliotibial tract Morel-Lavallee Lesion: • Thigh and hip region • Fluid collection: – Between subcutaneous fat and fascia – Closed de-gloving injury • Trauma Mellado, AJR 2004; 182:1289 6 Morel-Lavallee Lesion Take-home points: Sub-Q Fat • • • • Muscle Muscle Coronal Muscle Transverse Normal 7 Trochanteric anatomy Bursitis: rare Gluteal tendons abnormalities: frequent Snapping hip: dynamic