1

Hofte - Lyske

Henrik Aagaard

ortopædkirurg, idrætsmediciner

Amager Hospital

Artroskopisk Center Amager

Gildhøj Privathospital

Kgl. Ballet

MS ultralydsscanning Faggruppen for UL-scanning

2

UL (US) bruger - kliniker

• 15 års UL

• daglig amb. brug

– ort. kir.

– idrætmedicin/ballet

• kliniker

– bedsite UL

• klinikerens forlængede arm

– ≠ radiologisk specialist

Hofte - UL teknik, udstyr

• udfordring

– pos./neg.

• udstyr

– standard MS UL

– transducere

• lineær

– lavere frekvens, dybere

• curved

– dybde > 4-6 cm

4

MRI or/and US - hip/groin

• MRI has become the workhorse in the imaging

evaluation of the painful or clinically abnormal hip. It

provides an excellent anatomic overview and

demonstration of the bony structures, articular surfaces,

and surrounding soft tissues.

• Conversely, US can also demonstrate superficial

intraarticular structures and the periarticular soft tissues,

is quickly performed, allows dynamic evaluation of

tendons and muscles, and can guide percutaneous

procedures.

• These two modalities are complementary

Friedman, Miller. MRI, HSS. Clin N Am 2013

5

Indikation - formål med billeddiagnostik

(rtg, CT. MT UL m.fl.)

• diagnose

– assistent

– NB! klinisk us.

• forløb

– behandlingsstrategi

• (behandlingseffekt)

• dokumentation

• pt. forståelse/tilfredshed/kompliance

6

UL-scanning • adskil

– beskrivelse

– fortolkning

• beskriv

– form, struktur

– afvigelser fra normal

– uregelmæssigheder

– normalt

• fortolk

– mulig patologi

– ‘tegn på’, ‘forenelig med’

• anatomisk atlas

• Uv.-mål

– scanning strukturer - genkende

– eksempler patologi - kendskab

7

1a. Hofteled

MS ultralydsscanning

• caput (collum)

• ledkapsel, recess = omslagsfold

• labrum

Hofte artrose - rtg. 52 år, tidl. elite fodbold

• caput

– form

– osteofytter

• ledspalte

– afsmalning

– >50%, >2 mm -> a-skopi

• acetabulum

– form

– labrum, forkalkning

• ledkapsel (omslagsfold)

– ansamling

– bløddelshævelse

– mus

9

Hofte artrose - UL scan • caput

– form

– uregelmæssigheder

• ledflader/-spalte

– brusk

• acetabulum

– form

– labrum

• ledkapsel

– ansamling

– bløddelshævelse

– mus

Normal

mus

osteofyt

Artrose

10

Hofte artrose - UL scan

• caput

– form

– brusk

• bløddele

– fortykkelse

– hypoeccocitet

– ansamling

Tilspidsning - osteofyt

Uregelmæssig overflade

mus

FAI - CAM

• Femuro Acetabular

Impingement (FAI)

• form

• evt. artrose

– grad

– 50% ledspalte

FAI - CAM

• standard

• systematisk udmåling

• MR/røntgen

• golden standard

Buck Eur Rad 2011

MR

UL

UL

MR

FAI - CAM

• variation

– ‘bump’

– hyppig

• artrose grad?

– røntgen

Buck, Eur Rad 2011

MR

UL

Bump: ostofyt/exostose?

Omslagsfold, ansamling

Case - hip FAI

• 29 y. female b. dancer

• hip/groin pain 2 y.

– intermittent

– progressing

• FAI: X-ray, MRI

– cortisone inj.

– rehab.

• surgery?

– return to ballet?

15

Hofteled - scan A • caput, collum

– lat -> med

– form, udbygning, mus, brusk

– med -> lat -> post

– dynamisk (rot, flex/ext)

Beskriv – fortolk

Hofteled - omslagsfold = recess

- ledkapsel

• ledkapsel

– fortykket

– fibrøse kapsel

– synovitis

– væske i recess

• diagnose?

– viderehenvis

– rtg., MR

– blodprøver

Case A:

59 år, ♂ murer

Hofteled

• led, knogle, sene/mm

– MR

– caput/collum

nekrose?

Case A:

59 år, ♂ murer

Hofteled - ledansamling

- i recess

• smerter, mobilitet

• UL: ansamling

– artritis

– synovitis

– årsag?

• diagnose?

– rtg., MR

– blodprøver

• UL vejledt blokade Case B:

66 år, ♀

hø.

coll. fem.

ve.

coll. fem.

Hofteled - ledansamling

- i recess

• diagnose

– MR

– AVasculær Nekrose (AVN)

Case B:

66 år, ♀

20

Doppler - hofteled

Artritis - infektion

Ansamling, synovitis – Ewing sarcom

Artritis – TB infektion

21

UL vejledt injektion - hofteled

US-guided hip injection. Needle (arrows) obliquely toward the femoral head neck

junction. (B) As the injection progresses, the capsule is distended by the hypoechoic

injectate (asterisk). A, acetabulum; H, femoral head; N, femoral neck.

• blokade: lokal anæsteticum (LA) + steroid

• diagnostisk/terapeutisk

• vs. MR

Curved transducer

22

Hofteled - scan B • ledkapsel, recess, omslagsfold

– følg lat -> med, dist -> prox

– dynamisk, adskil kapsel fra psoas

– hypoeccoicitet (væske)

– doppler v. basis

Beskriv – fortolk

FAI - pincer

(intro: labrum)

• Form

– form

– udbygning

– tag

• UL mindre egnet

osteofyt

pincer? normal

24

Labrum læsion

Acetabular labral tear. (A) MR image shows a high-signal-intensity tear (arrow)

through the low-signal-intensity labrum. (B) Longitudinal US image in the same patient

shows the hypoechoic tear (arrow) through the echogenic labrum.

25

Perilabral cyste

obs. labrum læsion

Perilabral cyst. (A) MR image shows a bilobed cyst (arrow). (B) Longitudinal US image of the

same patient shows the anechoic bilobed cyst (thin arrows). The labral tear (thick arrow) is

better appreciated on this image than the MR image. H, femoral head.

26

Perilabral cyste

Perilabrale cyster

27

Hip - labral tears: Diagnostic challenge Reiman MP BJSM 2013, review

28

Hofteled - scan C • (acetabulum)

– form, udbygning

– med -> lat -> post

• labrum

– identificér

– form, læsioner, cyster

Beskriv – fortolk

29

Hofteled - scan • caput, collum

– lat -> med

– form, udbygning, mus, brusk

– med -> lat -> post

– dynamisk (rot, flex/ext)

• ledkapsel, recess = omslagsfold

– følg lat -> med, dist -> prox

– dynamisk, adskil kapsel fra psoas

– hypoeccoicitet (væske)

– doppler v. basis

• (acetabulum)

• labrum

– form, læsioner, cyster

Beskriv – fortolk

30

1b. Hofte

MS ultralydsscanning

• iliopsoas

• cyster

• forkalkninger

• trochanter region

31

Iliopsoas

iliopsoas tendon (arrows)

32

Cyste/bursa • iliopectinea/iliopsoas

• diff. diagnose

• DVT

• aneurisme

longitudinel

transverse

m. doppler A=arterie V=vene

33

Iliopsoas cyste

Iliopsoas bursitis. (A) MR image in a patient with a total hip arthroplasty shows a mildly

distended iliopsoas bursa (asterisk) adjacent to the iliopsoas tendon (arrow). The tendon is

difficult to see because of the susceptibility artifact from the arthroplasty components. (B)

Transverse US image of the same patient shows the bursa (asterisk) adjacent to the tendon

(arrow). There is no artifact from the arthroplasty.

THA

34

Iliopsoas cyste

35

Iliopsoas - impingement

THA (total hip alloplastic). Iliopsoas impingement and tendinosis. (A) Longitudinal US image in a patient

with a total hip arthroplasty shows the acetabular component (A) contacting the overlying iliopsoas

tendon (arrow). Incidentally, notice the small effusion (asterisk) and the marked capsular thickening (C).

H (prosthetic femoral head), N (prosthetic femoral neck). (B) Transverse US image at the level of the

pelvic brim (P) in a different patient shows iliopsoas tendinosis (arrow) with thickening and a

heterogeneous appearance. The adjacent iliopsoas bursa is distended (asterisk). a, femoral artery.

THA

36

Iliopsoas - impingement

42 år, tidl. labrum repair. Smerter.

Prominerende acetabularkant. (A) Acetabulum, (Pile) psoas

37

Springhofte - intern

A. før klik - sene roteret

B. efter - normal, horizontalt

lateral medial

38

Iliopsoas

• 25 år ♂

• ikke motionsaktiv

• traume, nedspring, 1½-2 mdr.

• læsion

• intra-/peritendinøst flow

• doppler

39

Hofte - scan A • iliopsoas

– prox -> dist, langs/tværs

– struktur, fibre (sene mm.)

– relation til acetabulum, caput, kar

– dynamisk, adskil fra ledkapsel

Beskriv – fortolk

40

Rectus fem. - ruptur, forkalkning

• avusion

– posttraumatisk

– forkalkninger

– doppler

normal.

avulsion fra SIAI

41

Rectus fem. • læsion

– fiberstruktur

– omfang

– total/partiel ruptur

– dynamisk

– kontraktibilitet

22 år, fodbold, rectus fem.

42

Rectus fem. • mm. læsion

– ældre

– forkalkning

– væske

– (doppler, næppe)

43

Rectus fem.

• myositis ossificans

– post traumatisk

– hæmatom (ansamling)

– fiberlæsion

Vastus intermedius,

fluid + calcifications

44

Hofte - scan B • (rectus femoris)

– identificer, adskil fra andre mm.

– følg sartorius dist (tværs)

– prox -> dist på femur langs/tværs Beskriv – fortolk

45

Trochanter

• bursit

• trochanter major

– GT = Greater Trochanter

Bursitis trochanterica

Bursitis GMe

cranial

46

Bursa

• trochanter major (GT)

• UL vejledt blokade

• longitudinel

• langs

• fiberretning

• transversel

• tværs

Nål - blokade

Bursitis trochanterica

47

48

Glut. med. (GMed)

• GMed

• ruptur

• bursa

49

Glut. min. (GMin)

GMin tendinosis. (A) MR image shows a thickened and heterogeneous GMin tendon (white arrow)

with a focal insertional tear (black arrow) and highsignalintensity shallow tearing along its deep

surface. (B) Longitudinal US image in the same patient shows the thickened tendon (arrows) with

loss of the normal echogenic fibrillar appearance. G, greater trochanter.

GMi

50

Hofte - scan C • trochanter

– bursae

– fascie latae

– GMin, GMed Beskriv – fortolk

51

Hofte - scan • iliopsoas

– dist -> prox, langs/tværs

– struktur, fibre (sene mm.)

– relation til acetabulum, caput, kar

– dynamisk, adskil fra ledkapsel

• (rectus femoris)

– identificer, adskil fra andre mm.

– følg sartorius dist (tværs)

– prox -> dist på femur langs/tværs

• trochanter

– bursae

– fascie latae

– GMin, GMed

Beskriv – fortolk

52

2. Lyske - hofteregion

MS ultralydsscanning

• tendionopati,

calcificationer, rupturer

• adduktorer

• symfyse

• hasemm.

• tuber

• bursitter

• lyskebrok

53

54

Adduktor

• mm./sene - udspring

• conjoint tendons

Fortykkelse, fortætning

Normal

55

Adduktor

• mm. - udspring

– med lille partiel læsion

Adduktor 32 år, ♂

volleyball

elite

• mm. - udspring

– doppler

57

Adduktor - intramuskulær (add.)

Adductor hematoma. (A) MR image shows a large hematoma (asterisk)

in the left adductor muscles. (B) Transverse US image in the same

patient shows the hypoechoic hematoma (asterisk).

58

Adduktor - ældre læsion

Adductor ruptur, forkalkning

Adductor ruptur, forkalkning

Adductor ruptur, væske + forkalkning

59

Symfysitis

Athletic pubalgia. (A) MR image shows a thickened and hyperintense rectus abdominis

aponeurosis (thin arrow) and extensive cortical erosion (thick arrow) of the anterior aspect of the

right superior pubic ramus. (B) Transverse sonographic image in a different patient during a

cortisone injection shows a thickened rectus abdominis aponeurosis (black arrow) with a

horizontal tear (secondary cleft sign) (thin solid white arrows). Note the cortical erosion (thick solid

white arrow) of the anterior aspect of the right superior pubic ramus and the cortical irregularity of

the anterior aspect of the left superior pubic ramus. The reverberation artifact from the needle is

present (hollow white arrow).

60

Fremmedlegemer • muskel, underhud

– frit i væv

– indkapslede (granulom)

– vævsirritation

– evt. ansamling

– evt. bløddelslæsion

Glas - subcutant Glas - flere, intramuskulært

Træsplint – indkapslet, subcutant

61

Lyske - scan A • adduktorer

– udspring, conjoint tendons, symfyse

– prox -> dist, langs/tværs

– struktur, fibre (sene mm.)

Beskriv – fortolk

62

Hasemm.

• hasemm.

• biceps F

• semiM

• semiT

63

Hasemm. - læsion

64

Tendino-/myopati

CT 3-D: Hamstring calcifications,

stress/overload induced

Hamstring calcification,

post traumatic (partiel lesion)

65

Lyske - scan C • hasemm.

– tuber iscii (GMax inf.)

– semiT, biceps F, semiM

– prox. -> dist, langs/tværs Beskriv – fortolk

66

Hernie • lyskebrok

• femoralis

• inguinalis

• sportshernie?

Hernie

• symptomer

– pop ud

– smerter/ømhed

• intermitterende

– incarceration

• UL

– væske

– Lokalisation

– ligge/stå, bugpress

Hernie

• smerter

– intermitterende

– progression

• UL

– væske

– lokalisation

incarcereret hernie, væske, distenderet

69

Lymfeknuder – NB!

foreslå egen læge: henvisning til radiolog

metastase

blærecancer

Hodkin

lymfom

metastase

rectumcancer

metastase

blærecancer

lokal

infektion

lokal

infektion

De Gregorio Onc Gyn 2013

70

Lyske - scan C • (hernie)

– kar arterie/vene (doppler, bugpresse)

– inguinalkanal annulus int./ext.

– bugpresse, stående

Beskriv – fortolk

71

Lyske - scan • adduktorer

– udspring, conjoint tendons, symfyse

– prox -> dist, langs/tværs

– struktur, fibre (sene mm.)

• hasemm.

– tuber iscii (GMax inf.)

– semiT, biceps F, semiM

– prox. -> dist, langs/tværs

• (hernie)

– kar arterie/vene (doppler, bugpresse)

– inguinalkanal annulus int./ext.

– bugpresse, stående

Beskriv – fortolk

72

Litteratur • ESSR

– www.essr.org

• Textbook on Musculoskeletal US

– Bolvig L, Fredberg U, Rasmussen OS

– 2011

– ISBN: 9788762808249

• Cases

– www.ultrsoundcases.info

• Practical Musculoskeletal US

– McNally EG

– 2004

– ISBN-10: 0443073503

– ISBN-13: 978-0443073502