Dr. H.T.

Narayana
Professor, Dept of Radiology
Sri Siddhartha Medical college Tumkur
Chief Radiologist, Navarang Diagnostic centre
Bangalore
Hip joint
Conventional radiography is the main stay
of diagnosis of all pathologies.
USG was mostly dedicated to detect DDH
of infant hip.
With development and advances in the
USG technology and the awareness of the
capabilities of USG in the assessment of
MSK disease indications have increased.
Role of USG in the Hip joint
Infant Hip
Pediatric hip joint diseases.
Adult hip.
Infant HIP
Devlopmental Dysplasia of the Hip is a
spectrum of disorders.
Hip can be
Dislocated
Subluxated
Dislocatable & Subluxatable Instability
Dysplastic

DDH
1-2/1000 Live births
Hip instability (phys) at birth: 1-2%
Barlow JBJS1962
1 in 60 born with instability
60% resolve in the 1st week
88% resolve in 1st 2 months
Remaining 12% are true dislocations
~1.5/1000
Imaging in DDH
Ultrasound of infant Hip
High Specificity and Sensitivity: >90%
Helps in diagnosis of not only Subluxated/
Dislocated hips but also Dysplastic hips
Helps in Monitoring the treatment
Reduces the need for Arthrograms / Xrays.

Natural History
Ultrasonographic examination
Normal proximal Femur of infant
Neck
Greater
trochanter
Neck cartilage
Head cartilaginous
Static coronal view Hip at Rest.
Transducer in coronal orientation over the
lateral aspect of the hip
Normal Graf measurements
Alpha angle of bony
acetabulum ( N >60)
Beta - angle of
cartilaginous femoral head
coverage (N <55)
Femoral head coverage by
acetabulum d/D = >50%
Graf IIa IIc
Critical Zone Hip Physiologic Immaturity
Graf Type III Eccentric Hip
Type III a
De-centered
femoral head
pressing against
cartilaginous roof
Bony rim is flat, roof is poor
Cartilage pressed upwards
Graf Type IV
Hip is decentred
and cartilage
pressed
downwards
Children > 2 weeks to < 6 months have
ultrasound with Graf classification system
Class Alpha angle Description
I >60 Normal
II 60-43 Immature/Dysplastic
III <43 Subluxed/Dislocated
IV Unmeasurable Dislocated

Children > 6 months have X-rays.
DDH - Evaluation
Indications for USG in adult HIP
Intra & extra articular fluid collection
including bursal and synovial pathology.
Guiding aspiration and biopsy.
Assessment of muscle and tendon
pathology.
Assessment of snapping, locking and
clicking hip.
Assessment of prosthetic hip.


Hip disorders age wise
Elderly - OA , Occult #
5
th
6
th
decade OA, Bursitis,
3
rd
to 5
th
decade AVN, transient bone
marrow edema, synovial proliferative
disorders.
2
nd
to 3
rd
decade snapping tendon,
labral tears, Osteoid osteoma.
Hip Bursae
Bursae are fluid filled sacs that are located
between tendons and muscles over bony
prominences.
Bursal inflammation - due to local friction,
infection, arthropathies, direct trauma,
gait abnormality, obesity, prior surgery.
Trochanteric, Ilio-psoas and Ischiogluteal
bursae are commonly involved.

Hip - Bursae
Greater trochanteric bursae three
bursae Gluteus medius and minimus
bursae lie anterior to greater trochanter
and Gluteus maximus (largest) lies
posterior.
Ilio-psoas bursa - Lies between the hip
capsule and the Iliacus & psoas major
muscles. 5-7cms in length & 2-4 cms in
width (largest bursa in the human body)
and 15% cases communicate with hip.
Ischiogluteal Bursa weavers bottom.

Hip - bursa
Bursae are normally collapsed and not
visualized unless enlarged pathologically.
USG seen as enlarged an-hypoechoic
fluid filled sacs with variable internal
echoes depending on the etiologies.
USG - Differentiates solid masses,
inguinal hernia, undescended testis,
lymphadenopathy.

Hip Bursa
Distended
bursa over
the greater
trochanter.
Prosthetic Hip assessment
To detect collections like haematoma /
seroma, joint effusions and guide
aspirations
Distension of pseudo capsule >3.2mms at
the native lateral femoral neck an
indicator of infection.
Detection of para-articular collections
which can not be seen on arthrography.
CT / MRI are not suitable to detect due to
metallic prosthesis.
NORMAL
POST OP
HIP
PERIPROSTHETIC SEPSIS
Staph Aureus Kochs Fungal
ASSESSMENT OF MUSCLE AND TENDON
PATHALOGY
Hamstring tendinopathy.
Avulsion of Ischial Apophysis.
Injury to adductor muscles, iliopsoas,
anterior superior and inferior iliac crest and
their associated tendinous insertions.
Instability at the site of an apophyseal
avulsion.
Snapping Hip
1.External causes
a. Ilio-tibial band syndrome USG & MRI
2. Internal causes
a. Intraarticular bodies USG & Arthrogram
b. Synovial osteochondromatosis X-Ray, CT, MRI
& USG
c. Labral Tears USG, MR Arthrography
d. Articular surface abnormality MR, X-Ray
e. Intermittent subluxation of the femoral head.
f. Snapping ilio-psoas Syndrome USG,
bursography

External Snapping Hip syndrome
Painful and audible snap during hip motion or
walking.
External snapping occurs when thickened area
at the posterior border of the iliotibial band or
anterior edge of the gluteus maximus muscle
snaps forward over the greater trochanter during
dynamic hip flexion or during passive
movement from adducted internally rotated hip
to flexion and external rotation.
Examiner can sense the snap during dynamic
examination.

HIP IN ADDUCTION &
EXTENSION

ILIOTIBIAL BAND
OVER THE GREATER
TROCHANTER
HIP IN FLEXION

ILIOTIBIAL BAND
JERKS ANTERIOR TO
THE GREATER
TROCHANTER
HIP IN ADDUCTION &
EXTENSION
Gluteus maximus is posterior
to greater trochanter and
partly inserted into the
iliotibial band
HIP IN FLEXION

GLUTEUS MAXIMUS
JERKS ANTERIOR TO
GREATER
TROCHANTER
External snapping Ilio-Psoas tendon
Ilio-psoas tendon snapping over the
ilio-pectineal eminence
Hip flexed, abducted
Externally rotated
IPT moves laterally
In relation to
Iliopectineal eminence
Hip in extension IPT
Impinges on
Iliopectineal eminence
And at some point
Moves abruptly medially
Femoral nerve impairment
Periniguinal region direct and indirect
trauma, Hemorrhage due to coagulopathy
Iatrogenic causes vessel cannulation,
transection or compression during internal
bone fragment fixation with compression
plates, during inguinal hernia repair,
chronic diseases.
Dx - Clinical / ENMG studies / CT or MR
imaging / High resolution sonography.
Normal femoral nerve
Two cases of
femoral nerve
Impairment
Joint effusions
Hypoanechoic collection with variable
echogenecity depending on nature of the
fluid serous / bloody / infection.
Best seen along the femoral neck
capsule and ilio-femoral ligament bulge
away from the neck due to fluid.
Difference in joint distension of >2mms
between the symptomatic and normal hip.
Anterior joint capsule thickening >7mms.
Hip effusion
Septic arthritis US guided aspiration
AVN correlate with MRI & Radiograms
Inflammatory and non-inflammatory
arthritis (Aseptic effusions) correlate
with history & X-rays
Hemorrhage H/o trauma / bleeding
diathesis
Tumors PVNS & Synovial
osteochondromatosis
correlate with MRI & X-Rays.

Hip effusion
Advantages of USG in Dx & Aspiration
Avoiding a painful dry tap.
Detection of extra articular collection
Aspiration under direct visualisation.
Solid masses like PVN & amyloid can be
recognized and biopsied.
Power Doppler distinguishes inflammatory
from non-inflammatory.
Transient
Synovitis
in the right
hip of a
child.
E=Epiphysis, M=Metaphysis, C= Joint Capsule
RIGHT RIGHT RIGHT LEFT NORMAL HIP
EFFUSION
Hip Effusion
Septic Arthritis
Complex collection
around the dislocated hip
Pseudo aneurysm.
US guided manual
compression is the first
line of treatment.
US guided injection of
thrombin
Imaging of Knee
Disorders of the knee are the common source of
referral for imaging.
Plain radiograms, MRI, CT & USG are the
modalities employed.
Plain X-ray and MRI are the modalities of choice
USG indications are - to assess tendon
disease, bursal inflammation, synovial
abnormality or capsular disease.
USG advantage are Dynamic imaging, HRSG
for internal tendon structure and ability to
differentiate fluid form solid masses.
Knee examination
I phase patient in supine, foot on the
examination table and knee flexed at 30-
anterior aspect of the knee in Trans &
Long planes with emphasis on Quadriceps
and patellar tendon and suprapatellar
recess.
II phase patient in supine, leg on the
table and knee fully extended. Medial and
lateral aspects of the knee are imaged.
III phase patient in prone, postero-
medial aspect of the knee is imaged.

Bony landmarks in the knee
Lateral knee
Gerdys Tubercle on Tibia.
Sulcus for popliteal tendon on the femur.

Medial knee
Femoral epicondyle.
Sulcus for semimembranosus tendon on
the posteromedial aspect of the tibia.

AJR : 178: 2002: 1437-1444
Sonographic
landmarks
A- Gerdys tubercle
and iliotibial band.
B sulcus for popliteal
tendon, LCL and
biceps tendon.
C & D MCL.
E pes ansorinius
F Semimembranous
tendon
Ist Phase - Anterior knee
Quadriceps Tendon
knee in flexion 20 -30
Ist Phase - Anterior knee
Ist Phase -
Anterior knee
Ist Phase - Anterior knee
Patellar Tendon
IInd Phase - Medial collateral ligament
and pes anserinus tendon
IInd Phase
Lateral collateral ligament
IIIrd Phase - Posterior knee
IIIrd Phase - Semimembranosus and
Gastrocnemius bursa
IIIrd Phase - Popliteal neurovascular bundle
IIIrd Phase - Posterolateral corner and
biceps femoris
IIIrd Phase - Peroneal nerve
Imaging of Knee
Common clinical subgroups :-
1. Acute injury.
2. Chronic dysfunction.
3. Focal masses.
4. Anterior knee pain.
5. Post operative knee.
USG IN Acute IDK
Ultrasound showed good sensitivity, ranging
from 76% for the ACL to 90% for the medial
meniscus, and excellent specificity, ranging from
92% for the medial meniscus to 100% for the
ACL. Accuracy ranged from 86% for the ACL to
98% for the lateral meniscus. These figures
were comparable to the MRI findings.

Ultrasound is a simple, accurate, inexpensive
and non-invasive way of assessing internal knee
disorders. There is a learning curve, but results
are similar to MRI.
Knee Trauma

Anterior cruciate ligament disruption seen
as a hypoechoic haematoma at its femoral
attachment
Posterior cruciate ligament injury can be
assesed through posterior approach in the
popliteal fossa.
Normal USG
appearance of
Posterior
Cruciate
Ligament
PCL Tear
Collateral Ligament Trauma
Medial collateral ligament trauma
USG reveals thickened and
heterogeneous ligament.
Partial tear involves
meniscofemoral ligament with
avulsed bony fragment.
Healed femoral insertion tear result
in painful calcification
Pellagrini-Steida lesion.
Collateral Ligament Trauma
Lateral collateral ligament tear
is rare and is usually
associated with severe
intra articular trauma.
MRI is usually preferred for
accurate evaluation of
associated ACL injury.
Quadriceps trauma
Second most common injury to extensor mechanism.
Spectrum ranges from tendinosis to partal thickness tear
to complete rupture.

Full thickness tear of the Quadriceps
Quadriceps trauma
Partial thickness tear of the Quadriceps
Menisci
Normal triangular, homogeneously
echogenic with no internal heterogeneous
echo changes or differences.
Meniscal rupture
linear or echogenic areas or clefts extending to the
articular margins, sudden cahnges in the contours,
blunting of the medial surfaces.
Meniscus degeneration
Loss of homogeneous echo structure, linear or
nodular hypoechoic / echogenic areas which do
not involve an articular surface.

Popliteal artery entrapment
It is an uncommon entity. Prevalence of 0.16%
Typically affects young athletic males who
present with symptoms of calf claudication.
Caused by an anomalous relationship of muscle
and artery in the popliteal fossa resulting in
extrinsic arterial compression.
Repetitive insult to the popliteal artery can cause
arterial damage and lead to aneurysm,
thromboembolism and arterial thrombosis.
Awareness of this entity and a high index of
suspicion are important as tailored imaging
studies are required to make the diagnosis and
plan surgical intervention.
Popliteal artery entrapment
Normal popliteal artery is
adjacent to and lateral to
medial head of
Gastrocnemius muscle,
which is normally attached
just superior to medial
femoral condyle.
Medial head of
gastrocnemius
muscle is attached
more laterally
Anomalous muscle
band is responsible for
abnormal attachment.
Popliteal artery may
take abnormal course
medially
Fibrous band is
responsible for
entrapment.
Leg in neutral position
shows normal
triphasic waveform
Plantar flexion of foot
shows compression
of popliteal artery with
absence of flow
Medial
angulation of
popliteal artery
course
Nonocclusive acute
thrombus of popliteal
artery
with embolization to
distal tibial vessels.


Occlusion of
popliteal artery
Chronic Localised Knee Pain
Anterior
1. Chrondromalacia Patella.
2. Pre & infra patellar bursal
disease.
3. Hoffas fat pad
inflammation.
4. Quadriceps tendinopathy.
5. Patellar tendinopathy.


Medial & Lateral
1. Meniscal tear / cyst.
2. Intra articular ganglion.
3. Iliotibial band friction
syndrome.
4. Pes anserinus bursitis.
5. Peroneal neuropathy.

Posterior
1. Bakers cyst.
2. Semimembranosus
bursitis.


Pre & Supra
patellar bursa
Patella fracture
with joint effusion
Iliotibial band friction syndrome
Fibrous flat band in the
lateral aspect of the
thigh extending from
anterolateral aspect of
iliac crest to
anterolateral aspect of
tibia (Gerdys tubercle)
Repetitive abrasion and
friction of the ITB
across lateral femoral
condyle.
Long distance runners,
cyclists, weight lifters.
Jumpers Knee chronic patellar
tendinosis
Activity related pain / soreness at the
patellar tendon insertion into the patella.
Overuse of patellar extensor mechanism.
Volley ball & Basket ball players.
USG widened tendon with hypoechoic
areas and neovascularisation.

Peroneal neuropathy
Entrapment of common
peroneal nerve in the restricted
space between the bone and
fascia as the nerve winds
around the back of the fibular
neck.
Peroneal entrapment
Pressure during sleep or cross leg position.
SOLs ganglion cysts, soft tissue tumors,
osseous masses, large fabella,
# dislocation, cast / tight bandage
Bakers cyst
Distended gastrocnemiosemimembranosus bursa.
Fluid originates from the knee joint.
Communication between knee joint & bursa
- increasing age.
- thinning of the joint capsule.
- synovial effusion.
- increased intra-articular pressure.
- internal derangements.
Composite of Two bursae
Bakers cyst
Ruptured cyst
Cyst with septation
Bakers cyst D/D
Myxoid
liposarcoma
Meniscal cyst
Rheumatoid arthritis
Synovial thickening.
Joint effusion.
Alteration in the articular cartilage
blurred margins and thinning.
Bakers cyst.

USG very helpful to identify the joint
involvement and to monitor the response
to therapy
Rheumatoid arthritis
Normal articular
cartilage
Eroded and
thinned out
irregular cartilage
Post-op knee
Screening for infection.
Rupture of extensor tendon.
Detection of intra articular particles of
bone, cement, metal, loosening of
hardware & staples.
Wear& delamination of the polyethylene
liners in the TKR arthroplasty prosthesis.
Evaluation of arthrofibrosis

Knee imaging
The main strength of knee ultrasound is the
assessment of para-articular disease.
The specific structures best suited for ultrasound
assessment include tendons, muscles and
ligaments, as well as periarticular soft tissue
masses.
Joint effusions, synovial thickening, bursal fluid
collections, intra-articular loose bodies, ganglion
cysts, ligament and tendons tears, tendonitis and
occult fractures can be diagnosed.
With experience, ultrasound is a time-efficient,
economical imaging tool for assessment of the
knee.