Ultrasound Trochanteric Region
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1 Ultrasound Trochanteric Region Jon A. Jacobson, M.D. Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Disclosures: Consultant: Bioclinica Book Royalties: Elsevier Grant: American Institute of Ultrasound in Medicine and Harvest Technologies Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Greater Trochanter: gluteal tendons Posterior Gluteus medius (red) Gluteus minimus (blue) Greater Trochanter: facets Greater Trochanter Yellow arrow = gluteus medius White arrow = gluteus minimus Inferior 1 2 Facets: anterior, lateral, posterior, superoposterior Pfirrmann et al. Radiology 2001; 221:469 Axial MRI 3 Superior 4 1
2 Greater Trochanter Greater Trochanter Posterior Yellow arrow = gluteus medius White arrow = gluteus minimus Pfirrmann et al. Radiology 2001; 221:469 Gluteus Minimus: Long Axis Gluteus Medius: Long Axis Gmed Gmed Iliotibial Tract Facet Facet Sonographic Technique: Hip Femoral Cutaneous Nerve Sartorius Femoral Cutaneous Nerve Rectus Femoris Inguinal Ligament Short Axis Long Axis 2
3 Femoral Cutaneous Nerve Sartorius Medial Trochanteric Pain Syndrome: Most commonly caused by gluteus minimus and medius tendon abnormalities 1 Trochanteric bursitis: rare Not actually inflamed 2 Not associated with pain 3 Trochanteric Bursal Fluid: Bursal fluid not normally seen Fluid distention: simple fluid: anechoic complicated fluid: mixed echogenicity 1 Eur Rad 2007; 17: J Clin Rheumatol 2008; 14:82 3 Skeletal Radiol 2008; 37:903 Trochanteric Bursitis Trochanteric Bursitis PF PF Coronal Coronal 3
4 Trochanteric Bursitis Trochanteric Bursitis Arthrogram Metal-on-Metal Arthroplasty: pseudotumor Cup Neck Cup Troch 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 Positive predictive value = 90% (xray)* SPF *Steinert et al. Radiology 2010; 257:754 4
5 Tendinosis: Gluteus Minimus Tear: Gluteus Medius >2 mm cortical irregularity (x-ray) = 90% positive predictive value for gluteus tendon tear Steinert et al. Radiology 2010; 257:754 Post-operative: Gluteus Medius Calcific Tendinosis: Gluteus Medius SPF Long Axis Short Axis Potential Treatment Algorithm: If bursa: aspirate, inject steroids If tendinosis: Tenotomy or fenestration Inject steroids superficial to tendon 72% of patients significantly improved 1 If tendon tear: platelet-rich plasma injection? Trochanteric Region Bursae Trochanteric: deep to gluteus maximus Subgluteus medius Subgluteus minimus Axial plane PF 1 Labrosse, et al AJR 2010; 194:202 5
6 Gluteus Medius Tenotomy Greater Trochanter Snapping Hip Syndrome Painful snap with hip motion Intraarticular Extraarticular: Medial: iliopsoas tendon : iliotibial tract or gluteus maximus Snapping Hip: iliotibial tract over greater trochanter Hip external rotation / flexion Abrupt motion of iliotibial tract over greater trochanter 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
7 Morel-Lavallee Lesion Take-home points: Muscle Muscle Sub-Q Fat Muscle Trochanteric anatomy Bursitis: rare Gluteal tendons abnormalities: frequent Snapping hip: dynamic Coronal Normal 7
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