the hip joint - physical and radiological examination · the hip joint - physical and radiological...
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TheThe Hip Joint Hip Joint --
PhysicalPhysical and and RadiologicalRadiological ExaminationExamination
Michael Michael DienstDienst
OrthopaedicOrthopaedic SurgerySurgeryUniv. Hospital Homburg/Univ. Hospital Homburg/SaarSaar
GermanyGermany
www.orthopaediewww.orthopaedie--homburg.dehomburg.de
Hip Pain Hip Pain –– AssessmentAssessment
HISTORY
EXAM
ADDITIONAL FINDINGS / IMAGING
DIAGNOSIS
Garvin & Garvin & McKillipMcKillip, The Adult Hip, , The Adult Hip, LippincottLippincott--Raven 1998Raven 1998
Hip Pain Hip Pain –– AssessmentAssessment
nn criticalcritical partpartnn diagnosisdiagnosis oftenoften byby historyhistory !!
HISTORY
EXAM
ADDITIONAL FINDINGS / IMAGING
DIAGNOSIS
Garvin & Garvin & McKillipMcKillip, The Adult Hip, , The Adult Hip, LippincottLippincott--Raven 1998Raven 1998
Hip Pain Hip Pain –– HistoryHistory
Onset Onset -- TraumaTrauma
LigLig. . teresteres LabrumLabrum CartilageCartilage LooseLoose BodyBody
DislocationDislocation ++++++ ++++++ ++++++ ++
TwistingTwisting InjuryInjury ++++ (ERO)(ERO) ++ ++++ ++
ImpactImpact ++++++ ++++
Hip Pain Hip Pain –– HistoryHistory
Onset Onset -- TraumaTrauma
via via anterolateralanterolateral
posteriorposterior dislocationdislocation post. wall post. wall FxFx + + defectdefect + + osteochondralosteochondral fragmentfragment
Hip Pain Hip Pain –– HistoryHistory
Onset Onset -- ∅∅ TraumaTrauma
L. L. teresteres LabrumLabrum CartilageCartilage LooseLoose B.B. SynovitisSynovitis
DysplasiaDysplasia ++++ +++ +++ ((antant--supsup)) +++ +++ ((antant--supsup)) ++
SCE/SCE/CamCam--FAIFAI ++ +++ +++ ((rimrim)) ++
SynovialSynovial D.D. ++++ ++++++ ++++++
etcetc……
Hip Pain Hip Pain –– HistoryHistory
Onset Onset -- ∅∅ TraumaTrauma
CAMCAM--FAI FAI pathognomonicpathognomonic cartilagecartilage delaminationdelamination anteroantero--superiorsuperior lunatelunate cartilagecartilage
via via anterolateralanterolateral
Hip Pain Hip Pain –– AssessmentAssessment
HISTORY
EXAM
ADDITIONAL FINDINGS / IMAGING
DIAGNOSIS
Garvin & Garvin & McKillipMcKillip, The Adult Hip, , The Adult Hip, LippincottLippincott--Raven 1998Raven 1998
nn intraarticularintraarticularnn extraarticularextraarticular
nn gaitgaitnn spinespinenn pelvispelvisnn alignmentalignmentnn leg leg lengthlength
InspectionInspection
nn groingroin//capsulecapsulenn spinesspinesnn symphysissymphysisnn adductorsadductorsnn greatgreat trochtrochnn etc.etc.
PalpationPalpation
nn ROMROMnn impingementimpingementnn apprehensionapprehensionnn logrollinglogrollingnn DrehmannDrehmannnn PsoasPsoasnn AdductorsAdductorsnn piriformispiriformis
FunctionFunction
Impingement TestImpingement Test
Flexion – Adduction – Internal Rotation
LeunigLeunig & & GanzGanz, , OrthopädeOrthopäde 19981998
hip pathology & hip pathology & periarticularperiarticular pathologypathology
Adductors Stress TestAdductors Stress Test
AdductorAdductor Tendinitis Tendinitis -- ContractureContracture
normal, symmetric abnormal, asymmetric, tender
SLR 0SLR 0--2020°°
Tenderness lower abdomen – SLR 0-20°
PsoasPsoas Tendinitis + Tendinitis + WeaknessWeakness
Snapping Snapping PsoasPsoas TendonTendon
Allen & Cope, JAAOS 1995Allen & Cope, JAAOS 1995
flexionabductionexternal rotation
extensioninternal rotation
Snapping Snapping PsoasPsoas Tendon Tendon -- usually physiologic !usually physiologic !
palpable – audible pop
Hip Pain Hip Pain –– AssessmentAssessment
HISTORY
EXAM
ADDITIONAL FINDINGS IMAGING
DIAGNOSIS
nn XX--rayraynn LALA--testtestnn MRI / MRAMRI / MRA
XX--ray Examinationray Examination
nn Standard Standard ProjectionsProjections
apap pelvispelvis
lateral: Lauenstein/cross table/Rippstein IIlateral: Lauenstein/cross table/Rippstein II
nn Additional Additional ProjectionsProjections
falsefalse profileprofile viewview
Rippstein I / IIRippstein I / II
inletinlet / / outletoutlet
alaala / / oburatoroburator ((JudetJudet viewsviews))
XX--ray Examinationray Examination
Most Most pathologiespathologies cancan bebe detecteddetected on on xx--raysrays !!!!!!
RoentgenogramsRoentgenograms >>> MRI>>> MRI
ap pelvis lateral
XX--ray Examinationray Examination
apap pelvis evaluationpelvis evaluation
XX--ray Examinationray Examination
AcetabularAcetabular Lines Lines -- TorsionTorsion
XX--ray Examinationray Examination
RetrotorsionRetrotorsion of the of the AcetabulumAcetabulum
XX--ray Examinationray Examination
DysplasiaDysplasia
XX--ray Examinationray Examination
CoxaCoxa profundaprofunda + Ossification of Labrum+ Ossification of Labrum
>>40>>40°°
XX--ray Examinationray Examination
Lateral ViewLateral View
Lauenstein
XX--ray Examinationray Examination
LauensteinLauenstein ViewView
XX--ray Examinationray Examination
Cam Cam –– FAI + Rim CystsFAI + Rim Cysts
XX--ray Examinationray Examination
αα –– angle (angle (NNöötzlitzli 2002)2002)
αα
MRI/MRAMRI/MRA
The evolution of MR imaging The evolution of MR imaging ……
NMRNMR: no : no moremore radiologistsradiologists
MRIMRI: : moremore radiologicalradiological incomeincome
MRAMRA: : moremore radiologicalradiological accuracyaccuracy ☺☺
MRI/MRAMRI/MRA
Get high resolution MR imagesGet high resolution MR images
“standard?” MRI high resolution 1.5 T MRA
Do not accept:Do not accept: Get these:Get these:
radial cuts
MRAMRA
Injection TechniqueInjection Technique
nn at at headhead--neckneck--junctionjunction
nn 1515--25 ml: 1025 ml: 10--15 ml 15 ml GadGad 1:100 + 51:100 + 5--10 ml LA 2%10 ml LA 2%
nn do not do not combinecombine withwith radiopaqueradiopaque contrastcontrast
MRAMRA
Cave: Cave: PeriarticularPeriarticular InjectionInjection
ReferralReferral Diagnosis: Hip Joint GanglionDiagnosis: Hip Joint Ganglion
nn high high resolutionresolution MRI: no MRI: no openopen tomographstomographs, , ≥≥ 1.5 Tesla1.5 Tesla
nn bodybody surfacesurface coilcoil
nn specialspecial sequencessequences
nn no 3Dno 3D--datasetsdatasets
nn multiple planes: multiple planes: coronarcoronar, axial, , axial, sagittalsagittal, radial, radial
MRAMRA
TechniqueTechnique
transversetransverse ligamentligament
LigLig. . teresteres
coronarcoronar
Z. Z. orbicularisorbicularis
labrumlabrum
medial medial synovialsynovial foldfold
MRAMRA
MR AnatomyMR Anatomy
LigLig. . teresteres
axialaxial axialaxial
MRAMRA
MR AnatomyMR Anatomy
nn SynovialSynovial chondromatosischondromatosis c multiple c multiple chondromaschondromas
sagittalsagittal acetabularacetabular fossafossa SagittalSagittal anterioranterior neckneck
MRAMRA
MR PathologyMR Pathology
nn LabralLabral LesionsLesions -- II B II B LesionLesion
coronarcoronar
MRAMRA
MR PathologyMR Pathology
nn labrallabral cystscysts
sagittalsagittal
MRAMRA
MR PathologyMR Pathology
nn PVNS: PVNS: PigmentedPigmented VilloVillo--NodularNodular SynovitisSynovitis
coronarcoronarcoronarcoronar
MRAMRA
MR PathologyMR Pathology
nn osteochondralosteochondral fragmentfragment anterioranterior neck neck areaarea
sagittalsagittal axialaxial
MRAMRA
MR PathologyMR Pathology
nn avulsionavulsion of of LigLig. . teresteres withwith bonybony fragmentfragment acetabularacetabular fossafossa
axialaxial coronarcoronar
MRAMRA
MR PathologyMR Pathology
Hip Pain Hip Pain –– AssessmentAssessment
HISTORY
EXAM
ADDITIONAL FINDINGS / IMAGING
DIAGNOSIS
Garvin & Garvin & McKillipMcKillip, The Adult Hip, , The Adult Hip, LippincottLippincott--Raven 1998Raven 1998
TreatmentTreatment
ThankThank YouYou
[email protected][email protected]
www.orthopaediewww.orthopaedie--homburg.dehomburg.de
Homburg/Homburg/SaarSaarGermanyGermany
Orthopedic SurgeryOrthopedic SurgeryUniversity HospitalUniversity Hospital