The Unknown CasesThe Unknown Cases
Texas Radiological SocietyTexas Radiological Society
9292ndnd
Annual Scientific Meeting...
55 year old man55 year old man with chronic hip pain.with chronic hip pain.
Pain worse when hip is "in the side kicking po...
FindingsFindings
 XR-loss of normal indentation at left superiorXR-loss of normal indentation at left superior
femoral he...
Diagnosis?Diagnosis?
Femoral AcetabularFemoral Acetabular
ImpingementImpingement
PISTOL GRIP DEFORMITY (loss of normal degree of
indentation @ superior head/neck-YELLOW ARROW)
WHICH IS LIKELY CONTRIBUTIN...
Coronal T2-weighted MR image of the hip joint shows cartilage damage
(chondral defects) in the superiolateral portion of t...
Femoral Acetabular ImpingementFemoral Acetabular Impingement
 Impingement of femoral head-neck jxn against adjacentImping...
FAIFAI
 IMAGING: “pisto grip” deformity,IMAGING: “pisto grip” deformity, anterosuperioranterosuperior
acetabular labral t...
REFERENCESREFERENCES
Ito K, Minka MA II, Leunig M, Werlen S, Ganz R. Femoracetabular impingement and the cam-effect: an MR...
Case 7
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Case 7
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  • Figure 1. Plainfilm evaluation of the left hip shows a prominent femoral head-neck junction superiorly (black arrows in figures A and B). The femoral neck cutback zone is less well defined in the superior portion of the head-neck junction than in the more inferior portions of this junction.
  • Figure 1. Plainfilm evaluation of the left hip shows a prominent femoral head-neck junction superiorly (black arrows in figures A and B). The femoral neck cutback zone is less well defined in the superior portion of the head-neck junction than in the more inferior portions of this junction.
  • Figure 12. Coronal T2-weighted MR image of the hip joint shows cartilage damage (chondral defects) in the superiolateral portion of the hip joint (small white arrows). There is also an associated acetabular labral tear (black arrow). These findings are typical of those seen in patients with FAI.
  • Two basic mechanisms of impingement
    Cam impingement
    Pincer impingement,
    are based on the type of anatomic anomaly contributing to the impingement process.
  • Figure 2. Prominence of the femoral head-neck junction in the anterior/anterosupeior portion of the proximal femur (white arrows) is known as the “pistol grip deformity” due to its similarities with the smooth hand grip appearance seen on many pistols.
  • Figure 9. Anteroposterior radiograph of the pelvis in a 16 year old patient with FAI will shows flattening of the left femoral head neck junction (arrows) consistent with a pistol grip deformity.
  • Figure 11.
    Coronal STIR MR image of the hips and pelvis shows a region of increased signal within the right acetabular labrum (white arrow) indicative of an acetabular labral tear. This may be contrasted with the normal left acetabular labrum (white arrowhead). Some evidence of impaction injury is visible in the superolateral femoral head (yellow arrow).
  • Figure 11.
    Anteroposterior radiograph of the right hip shows evidence of impaction injury to the superolateral portion of the femoral head-neck junction (arrow).
  • Case 7

    1. 1. The Unknown CasesThe Unknown Cases Texas Radiological SocietyTexas Radiological Society 9292ndnd Annual Scientific MeetingAnnual Scientific Meeting San Antonio, TX; April 1-3, 2005San Antonio, TX; April 1-3, 2005 Justin Q. Ly, MD*+ Douglas P. Beall, MD^ Ernesto Torres, MD+ Daniel H. Duffy* Department of Radiology and Nuclear MedicineDepartment of Radiology and Nuclear Medicine Wilford Hall Medical Center/SAUSHEC Radiology*Wilford Hall Medical Center/SAUSHEC Radiology* Oklahoma University Health Sciences Center^Oklahoma University Health Sciences Center^ Brooke Army Medical Center+Brooke Army Medical Center+
    2. 2. 55 year old man55 year old man with chronic hip pain.with chronic hip pain. Pain worse when hip is "in the side kicking position".Pain worse when hip is "in the side kicking position". On physical exam, pain exacerbated by flexion, adduction,On physical exam, pain exacerbated by flexion, adduction, and internal rotation.and internal rotation. CASE 7CASE 7
    3. 3. FindingsFindings  XR-loss of normal indentation at left superiorXR-loss of normal indentation at left superior femoral head/neck junction (“pistol grip”femoral head/neck junction (“pistol grip” appearance), focal calcification at theappearance), focal calcification at the anterosuperior aspect of left hip joint is likelyanterosuperior aspect of left hip joint is likely related to chronic microtraumarelated to chronic microtrauma  Fluid-sensitive sequence coronal MR image showsFluid-sensitive sequence coronal MR image shows focal chondral defect just medial to superior labralfocal chondral defect just medial to superior labral base, torn labrum, adjacent focal subchondralbase, torn labrum, adjacent focal subchondral marrow edema, and subtle evidence ofmarrow edema, and subtle evidence of impingement at left femoral head-neck junctionimpingement at left femoral head-neck junction
    4. 4. Diagnosis?Diagnosis? Femoral AcetabularFemoral Acetabular ImpingementImpingement
    5. 5. PISTOL GRIP DEFORMITY (loss of normal degree of indentation @ superior head/neck-YELLOW ARROW) WHICH IS LIKELY CONTRIBUTING TO FAI
    6. 6. Coronal T2-weighted MR image of the hip joint shows cartilage damage (chondral defects) in the superiolateral portion of the hip joint (small white arrows). There is also an associated acetabular labral tear (black arrow). These findings are typical of those seen in patients with FAI.
    7. 7. Femoral Acetabular ImpingementFemoral Acetabular Impingement  Impingement of femoral head-neck jxn against adjacentImpingement of femoral head-neck jxn against adjacent acetabulumacetabulum  Can result in tearing of labrum and progressive damage to articularCan result in tearing of labrum and progressive damage to articular cartilagecartilage  Repetitive microtraumaRepetitive microtrauma  Precursor to early onset OA.Precursor to early onset OA.  Two basic mechanismsTwo basic mechanisms – Cam impingement:Cam impingement: squeezing or jamming of a reduced concavity anterolateral femoral head-neck jxn into acetabulum during motion – Pincer impingement:Pincer impingement: direct linear contact between the femoral head-neck junction and a limited portion of the acetabular rim. – Post traumatic or dysplastic conditions may predispose to hip impingement  GROIN / POST HIP PAINGROIN / POST HIP PAIN
    8. 8. FAIFAI  IMAGING: “pisto grip” deformity,IMAGING: “pisto grip” deformity, anterosuperioranterosuperior acetabular labral tears, impaction injury to adjacetabular labral tears, impaction injury to adj anterolateral femoral head/neck junction, lateralanterolateral femoral head/neck junction, lateral acetabular cartilage damageacetabular cartilage damage, abnormal femoral head to, abnormal femoral head to neck ratio, convex appearing femoral head-neck jxn thatneck ratio, convex appearing femoral head-neck jxn that may be quantified w/may be quantified w/ αα angle measurement andangle measurement and DJDDJD – paralabral cysts and synovial herniation pitsparalabral cysts and synovial herniation pits  RECOGNIZE EARLY AS SURG TX AVAILABLE:RECOGNIZE EARLY AS SURG TX AVAILABLE: osteotomy, an osteoplasty, or a combination of bothosteotomy, an osteoplasty, or a combination of both
    9. 9. REFERENCESREFERENCES Ito K, Minka MA II, Leunig M, Werlen S, Ganz R. Femoracetabular impingement and the cam-effect: an MRI-based quantitative anatomicalIto K, Minka MA II, Leunig M, Werlen S, Ganz R. Femoracetabular impingement and the cam-effect: an MRI-based quantitative anatomical study of the femoral head-neck offset.study of the femoral head-neck offset. J Bone Joint Surg BrJ Bone Joint Surg Br 2001; 83:171-176.2001; 83:171-176. H.P. Notzli, T.F. Wyss, C.H. Stoecklin, M.R. Schmid, K Treiber, J. Hodler. The contour of the femoral head-neck junction as a predictor for theH.P. Notzli, T.F. Wyss, C.H. Stoecklin, M.R. Schmid, K Treiber, J. Hodler. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement.risk of anterior impingement. J Bone Joint Surg BrJ Bone Joint Surg Br 2002; 84:556-560.2002; 84:556-560. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular Impingement.Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular Impingement. Clin OrthopClin Orthop. 2003;417:112-120. 2003;417:112-120 Wagner S, Hofstetter W, Chiquet M, Mainil-Varlet P, Stauffer E, Ganz R, Siebenrock KA. Early osteoarthritic changes of human femoral headWagner S, Hofstetter W, Chiquet M, Mainil-Varlet P, Stauffer E, Ganz R, Siebenrock KA. Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement.cartilage subsequent to femoro-acetabular impingement. Osteoarthritis CartilageOsteoarthritis Cartilage. 2003;11(7):508-18.. 2003;11(7):508-18.
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