ULTRASOUND OF THE HIP & GROIN - Normal

For hip and buttock scanning protocol

 

For normal hernia scanning protocol


For Pathology

 

FEMORAL HERNIA

Scan Plane                                                                                           Image

 Femoral Hernia  Femoral Canal
Transverse View of a Femoral Hernia. Note that it descends medial to the common femoral vein.
The right femoral canal in transverse. The mouse over shows the expanding common femoral vein with the valsalva manouver. The femoral canal is medial to the vessels. The vein would be compressed by the hernia and no dilatation would happen.

 


 

INGUINAL HERNIAS

  1. Direct
  2. Indirect

DIRECT HERNIA

 Direct Hernia  

To Identify the Direct Hernia look medial to the inferior epigastric vessels
Direct Hernia.
A Direct Hernia is seen medial to the Inferior Epigastric Vessels

 

 

 

INDIRECT HERNIA

 Indirect Hernia  Normal Internal Inguinal Ring

Indirect Hernia

To Image an Indirect hernia start from down at the common femoral vessels and work your way in a transverse plane superiorly until you reach the level above where the inferior epigastric vessels join the ext iliac vein and artery.
Longitudinal Scan of the normal spermatic cord at the internal inguinal ring. Prominent vessels are commonly seen.

 


Ultrasound of the Hip and Groin - Protocol

Role of Ultrasound

 

  • To confirm the presence of a hernia
  • To distinguish between inguinal Vs femoral hernia
  • If inguinal, to subclassify direct Vs indirect
  • To identify the content of the hernia (omental fat +/- bowel)
  • Reducible V's non-reducible
  • Is it symptomatic (focally tender or not)
  • Identify alternative pathology

 

Limitations

  • Size of the patient
  • Ability to get the hernia to push through the weakened area

 

Equipment Selection

  • Use a linear transducer 7-12MHz
  • Use an abdominal preset rather than a MSK setting.

 

Patient position

Begin with the patient supine. If no hernia is detected, re-examine the patent erect.

 

 

 

Scanning Technique

 

FEMORAL HERNIAS

 

To find a femoral hernia: Scan transversely over common femoral vessels and look medial to the vessels when the patient strains.

  • The lump will present lateral and caudal to the pubic ramus.
  • With a hernia present, the common femoral vein will not expand as it normally should. As it pushes through the femoral canal, the hernia will compress the vein.
  • These are more common in older females.
  • It may take several attempts to actually see the neck of the hernia well and subsequently measure.
  • An entrapped/strangulated femoral hernia constitutes a medical emergency.

 

 

INGUINAL HERNIAS

To find the internal inguinal canal:Start from down at the common femoral vessels and work your way in a transverse plane superiorly until you reach the level above where the inferior epigastric vessels join the ext iliac vein and artery.

 

  • Turn the probe to go along the plane of the spermatic cord/inguinal canal.
  • Get the patient to strain,situp/crunch or stand
  • Watch for movement of omentum/or bowel within the canal or medial to it.
  • If there is sliding down the canal this is usually an indirect hernia as it originates lateral to the epigastric vessels.
  • If there is medial movement to the IEV then this is a direct hernia and it does not usually communicate with the inguinal canal.
  • Check if the omentum/bowel is free to move back within the peritoneum (reducible hernia) or does it get stuck(strangulated).
  • Inguinal hernias are more common in males and can be from a very young age.

 

For  Hernia Pathology

 

Basic Hard Copy Imaging

A hernia series should include the following minimum images;

  • Inguinal canal at rest and straining
  • Femoral canal at rest and straining
  • Longitudinal and transverse measurements of the neck
  • Any alternative pathology
  • Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.

 

 

 

ULTRASOUND OF THE HIP AND BUTTOCK - Normal

 

 HIP EFFUSION

  • Readily seen in the anterior joint recess overlying the Femoral Neck
 Hip Effusion  Normal Hip Joint
Scan Plane for Hip Effusion
Normal Hip Recess.

 

 ILIOPSOAS TENDON

 scan plane for the ilio-psoas tendon and bursa.  Normal Iliopsoas Tendon
Iliopsoas Tendon scan plane.
Normal Iliopsoas Tendon

 

For iliopsoas pathology

 

GREATER  TROCHANTER and TENDON INSERTIONS

GLUTEUS MINIMUS                                                                   GLUTEUS MEDIUS

 GLUTEUS MINIMUS  GLUTEUS MEDIUS
GLUTEUS MINIMUS is the most anterior of the gluteal tendons
GLUTEUS MEDIUS inserts on the greater trochanter laterally and moves over the gluteus minimus.

 

BURSAE

 

 GLUTEUS MAXIMUS  BURSAE
GLUTEUS MAXIMUS inserts further infero lateral and posteriorly.

GREATER TROCHANTER BURSAE

There are a number of places that bursitis can arise and all areas must be scanned. 

 

 

GLUTEUS MINIMUS AND MEDIUS

 

 Gluteus Minimus and Medius  

Image of gluteus Minimus and gluteus medius in coronal
Coronal Scan Plane. The gluteus minimus and medius insert into the greater trochanter.The gluteus medius is commonly compared with the same appearance as the supraspinatus tendon of the shoulder

 

 

GLUTEUS AND MINIMUS

SCAN PLANE                                                            IMAGE

 Scan Plane Transverse Gluteus Minimus and Medius  

TRANSVERSE VIEW OF THE GLUTEUS MINIMUS AND MEDIUS
Transverse Scan Plane
Transverse view of the gluteus Minimus and gluteus Medius Tendons.

 

GLUTEUS MINIMUS AND MEDIUS MUSCLES

 

 Muscles of the gluteus minimus and medius  Muscles of Minimus and Medius
Gluteus Medius overlies the gluteus minimus muscle
Gluteus Medius in pink and minimus in blue

 

ISCHIOGLUTEAL BURSA

SCAN PLANE                                                         IMAGE

 Ischiogluteal Bursitis scan Plane  

Ischiogluteal  Bursa
Ischiogluteal Bursa
Move the probe posterirly in a transverse plane till the ischium in visualised . The bursa is anterior to this and under the gluteus maximus.

 

TENSOR FASCIAE LATAE

SCAN PLANE                                                                                                                                           

 Tensor Fasciae Latae  Tensor Fasciae Latae

Tensor fasciae Latae

The origin of the tensor fasciae latae is from the ASIS and it courses laterally and caudal to meet the anterior tensor fascia lata which is superficial to the vastus lateralis.
Normal TFL coming off the ASIS.

 

GROIN LYMPH NODES

 

 Enlarged Groin Lymph Node  
Groin Lymph Node
 

 


Ultrasound of the Hip and Buttock -Protocol

Role of Ultrasound

Ultrasound is essentially used for .Ultrasound is a valuable diagnostic tool in assessing the following indications;

  • Muscular, tendinous and some ligamentous damage (chronic and acute)
  • Bursitis
  • Joint effusion
  • Vascular pathology
  • Haematomas
  • Soft tissue masses such as ganglia, lipomas
  • Classification of a mass eg solid, cystic, mixed
  • Post surgical complications eg abscess, oedema
  • Guidance of injection, aspiration or biopsy
  • Some boney pathology.

 

Limitations

The size of the patient can limit the visualisation of the normal anatomical landmarks.

 

Equipment Selection

Use of a high resolution probe (7-15MHZ) is essential

Careful scanning technique to avoid anisotropy (and possible misdiagnosis)

Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons.

Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure.

Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

 

INDICATIONS FOR TROCHANTERIC BURSITIS


  • Pain over greater trochanter
  • Pain in buttock
  • Pain down lateral thigh
  • Aggravation with lying on side , walking, abduction, internal rotation and external rotation
  • More common in females
  • More common over 50 yrs

 

 PREPARATION

  • Before scanning know the origins and insertion sites of the gluteus minimus, gluteus medius, gluteus maximus, piriformis tendons and the fascia latae position.
  • Know the 3 common sites of bursitis
  • Roll patient onto unaffected side initially then assess supine and compare
  • Start with a curved linear array probe approx 6-8Mhz to assess the muscles deep to the hip
  • To evaluate the bursae use a 7-12MHz linear probe
  • Use a multi focus
  • Narrow the dynamic range
  • Ask the patient where the pain is and scan there first
  • Run the probe up and down the lateral hip aligned to the long axis of the femoral shaft, and then move anterior and posterior.
  • Look in coronal and transverse
  • Compare sides.
  • Remember that fluid is mobile and gravity dependant so do not over compress and do look in supine .Also vary the patients leg position from extension to flexion and even abduction if this creates the pain.Look at the patient erect.

 

Scanning Technique

 

There are 2 ways of approaching the lateral hip to start imaging.

  1. Start posteriorly and work towards anterior greater trochanter
  2. Start anterior and work posteriorly

 The anterior-posterior technique (just adapt it in reverse if you prefer to work posterior to anterior).

  1. Use a high frequency curved linear array probe to appreciate the entirety of the muscle bellies.
  2. Start anteriorly to look at the linear hyperechoic band superficial to the gluteus minimus and gluteus medius muscles, this is the tensor fascia latae.
  3. Change to a high frequency linear array probe 5-12MHz to scan in transverse and coronally.Check for tendinopathy at its origin or any fluid under it.
  4. Now move posteriorly to visualize the anterior portion of the gluteus minimus and gluteus medius.The gluteus minimus is seen on the anterior surface of the greater trochanter.The muscle comes from deep below the gluteus medius and is a hyperechoic tendon.
  5. The gluteus medius inserts further posteriorly but can be seen in a transverse view of the greater trochanter with the gluteus minimus insertion.
  6. Run up and down to check its insertion into the greater trochanter.
  7. As you move posteriorly the gluteus maximus comes into focus.
  8. Usually a curved linear array probe is the only way to see it because it runs deeply and attaches into the lateral femur.
  9. The piriformis,oblique muscles and quadratus femoris are not seen well enough to reliably diagnose pathology.

Ultrasound Appearance

  • Beware of anisotropy at the insertion of the gluteus tendons onto the greater trochanter. It can mimic a partial of full thickness tear.

 PATHOLOGY

For Hernia Pathology

 

  • Trochanteric Bursitis
  • Tendinopathy
  • Tendinosis 
  • Enthesopathy
  • Tears
  • Snapping Hip
  • Tensor Fascia Latae Tendinopathy
  • Injections
For Pathology of the Hip and Buttock

 

Basic Hard Copy Imaging

 

A hip/buttock series should include the following minimum images:

  • Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.

 
You dont know what you are missing......
 

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