Hip joint

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Hip joint

  1. 1. MRI OF THE HIP JOINTS. By .Dr/ABD ALLAH NAZEER. MD
  2. 2. Indication Hip joint complaint Pain Trauma Swelling Osteoarthritis. Tumours. Miscellaneous
  3. 3. Protocol of examination Axial scout Coronal T1, STIR Axial PD, T2 (gradient, T2*) , axial T1 ?! Sagittal T1 or T2 for the diseased hip If contrast is injected [ Axial, Sagittal ,coronal T1 WIs ]
  4. 4. MR anatomy  Ball and socket joint  Acetabulum covers 40% of the femoral head  A fibrocartilagenous labrium ↑ the depth of acetabulum  95% of the femoral neck is intraarticular
  5. 5. Axial anatomy
  6. 6. Coronal anatomy GMe GMi IOb EOb Ad.B Gr Ad. L
  7. 7. Items to be evaluated       Avascular necrosis Transient osteoporosis Perthes disease Slipped femoral epiphysis Trauma, muscle injury Miscellaneous     Labral tears Bursitis Loose bodies & chondromatosis Femoral neck antiversion
  8. 8. Avascular necrosis The antrolateral aspect of the femoral head is the commonest site, but no specific area is protected MR sensitive 97% specific 98% Causes:  Trauma  Corticosteroids  Sickle cell disease  Alcoholism  Gusher's disease  Radiation  Collagen disease, pancreatitis
  9. 9. Avascular necrosis of the right hip grad1111
  10. 10. Avascular necrosis CT findings :  Contour irregularities and fissures  Areas of bone sclerosis and porosis  Structural collapse  Osteoartheritic changes
  11. 11. Avascular necrosis I Bone marrow edema II Normal marrow + line III VI Fluid signal Bone sclerosis
  12. 12. .Stage I versus transient osteoporosis
  13. 13. Stage 1 AVN
  14. 14. Stage Radiographs Magnetic resonance [ MRI ] Appearance Marrow edema T1 Low T2 I Normal II Osteoporosis Normal Osteosclerosis marrow + line High Intermediate III Sclerosis + Cortical irregularities Fluid signal Low High IV Collapse +OA Bone sclerosis Low Low High Image
  15. 15. Stage 11 :] The line is composed of two layers [ double line sign Inner layer of hyperemic granulation tissue and an outer layer of osteoblastic activity
  16. 16. :] Stage 11. The line is composed of two layers [ double line sign Inner layer of hyperemic granulation tissue and an outer layer of osteoblastic activity
  17. 17. Stage 11
  18. 18. Stage 11
  19. 19. Stage 11  The size and location of the lesion will affect the prognosis.  Lesions < 25% of the weight bearing area of the femoral head responds well to core decompression  Medially and centrally located lesions have better prognosis  Contrast injection may be used to assess bone viability ?!!
  20. 20. Stage 111
  21. 21. Stage 11
  22. 22. Stage 11
  23. 23. Stage 111
  24. 24. Stage III
  25. 25. Stage III
  26. 26. Stage IV
  27. 27. Stage III Stage I
  28. 28. Osteoarthritis Stage IV
  29. 29. Transient osteoporosis Unknown etiology Middle aged over weight males Male : female= 3:1 Usually unilateral [left hip in females] Resolves spontaneously in 6-8 months Pain & limp with no history of trauma
  30. 30. Transient osteoporosis X ray Normal or ↓ bone density Bone scan ↑ uptake in the femoral head and neck MRI Bone marrow edema in the head and neck DD AVN, bone infarct, stress fracture Septic arthritis, primary and metastatic tumors
  31. 31. Transient osteoporosis
  32. 32. Transient osteoporosis  Some cases may demonstrate a line after clearance of edema suggesting that TOH as a precursor of AVN
  33. 33. Transient osteoporosis
  34. 34. Transient osteoporosis
  35. 35. Bilateral Transient osteoporosis
  36. 36. Transient osteoporosis 7/9/99 , 9/12/99
  37. 37. Transient osteoporosis with follow up
  38. 38. Subchondral fracture    In young may be a stress fracture In elderly may be the squeal of osteoporosis Leads to extensive marrow edema which may progress to femoral head collapse and secondary OA  DD include AVN , TOH , Rapidly destructive OA  MR shows a hypo intense line
  39. 39. Subchondral fracture
  40. 40. Legg- Calve- Perthes diseases  Avascular necrosis of the bony femoral epiphysis  Unknown etiology  Children 4-9 years old boys: girls= 4:1  Children with knee pain must be examined for hip pathology
  41. 41. Legg- Calve- Perthes diseases Stages I Anterior aspect of the epiphysis II Anterior aspect of the epiphysis + metaphyseal reaction III All of the epiphysis+ metaphyseal reaction IV Flattening and collapse
  42. 42. Early stage I : Fracture with gas
  43. 43. Stage 11:
  44. 44. 8m 18m 56m Healed epiphyseal changes + residual metaphyseal changes
  45. 45. Legg- Calve- Perthes diseases MR value  Morphology and signal characteristics of femoral epiphysis  Normal epiphysis shows bright signal in T1 (Fat marrow)  Intra articular effusion
  46. 46. Legg- Calve- Perthes diseases stage 111
  47. 47. I Anterior aspect of the epiphysis IV Flattening and collapse Spectrum of Perthes disease
  48. 48. Slipped capital femoral epiphysis  SCFE is a childhood disorder of the hip characterized by Posterior inferior displacement of the proximal femoral capital epiphysis  Unknown etiology and the current theory is (trauma, obesity, hormonal disorder)  Bilateral in 20-25% of cases.  Associated avascular necrosis of the in 15%. Classified into mild, moderate and severe according to the degree of slippage or acute and chronic according to the duration of symptoms (acute less than 3 weeks and chronic more than 3 weeks).
  49. 49. Slipped capital femoral epiphysis
  50. 50. Slipped capital femoral epiphysis
  51. 51. Slipped femoral epiphysis with normal marrow signal
  52. 52. Muscle sprains I II III Muscle edema with preserved morphology Disruption of up to 50% of muscle fibers with Subacute blood at the site of tear Complete muscle tear ± retraction and atrophy [ best seen in axial images with comparison to normal side ] Grade I muscle sprain of the obturator externus and adductor longus
  53. 53. Coronal STIR images show tear at the hamstring muscles at ischial tuberosity.
  54. 54. Complete rupture of the quadrates femoris tendon
  55. 55. Head rectus femoris head muscle and deep tendon injury.
  56. 56. Grade II tear of semitendinosis muscle
  57. 57. MR hip arthrogram  Normal saline or Gd -DTPA  Mixing 0.1 ml of Gd with 20 ml saline + 5ml of iodinated contrast + Lidocaine  The joint capacity is 8-20 ml  Surface coil  FOV = 14 -16 CM  Slice thickness 3-5 mm  T1 weighted images without and with fat suppression  Sagittal , coronal and axial oblique should be obtained  STIR images for the whole pelvis should be included  Labral abnormalities  Loose bodies  Osteo – chondral lesions
  58. 58. Labral tears  Normal labrum is a triangular low signal structure at the superior and inferior acetabular margins.  Surface coil  MR arthrogram. Labral tears are part of femoroacetabular impingement and can occur  due to trauma or secondary to degeneration.
  59. 59. MR arthrogram of the left hip showing an anterior paralabral cyst(arrow) and a complex degenerative tear of the anterior labrum
  60. 60. Brusitis  Bursae are sacs of synovial tissue  Prevent friction between bones and soft tissues.  15-20 Bursae around the hip joint  Trochnteric  Ischeo-gluteal  Iliopsoas : the largest in the body  10% - 15% communicate with the joint
  61. 61. Sagittal and coronal STIR images show ilioposas bursitis
  62. 62. AXIAL CT Scan and axial STIR MRI images show ilioposas bursitis
  63. 63. Coronal STIR images show left greater trochanter bursa.
  64. 64. Axial images show left greater trochanter bursa
  65. 65. Femro - acetabular impingement  Micro trauma from impingement of the femoral head against the acetabulum  Abnormal signal of the acetabular rim and femoral head  Labral tears and cartilage degeneration are seen  Clinically recurrent attacks of severe hip and groin pain  Pain increases by flexion and internal rotation and weight bearing
  66. 66. Femro - acetabular impingement
  67. 67. Femro - acetabular impingement with avascular head necrosis
  68. 68. Effusion, osteoarthritis  Narrowing of the superior joint space  Suprolateral migration of the femur  Osteophytic lipping  Subchondral sclerosis  Subarticular pseudo cysts  Effusion  Vacuum phenomena
  69. 69. Osteoarthritis, pseudo-cyst changes, bone marrow edema, synovial profilration , loose body and effusion
  70. 70. Loose bodies Etiology  Trauma  Osteoarthritis  PVNS  AVN  Synovial chondromatosis  Arthritis [ gout , septic , rheumatoid,…]
  71. 71. Loose bodies/ osteochondromatosis Clinical  Pain  Locking  Clicking  Snapping
  72. 72. Synovial osteochondromatosis Metaplasia of subsynovial soft tissues [Affects any joint [ knee , hip , elbow Age incidence 40 years M:F=2:1 Findings  Widening of the joint space  Bone erosions  Intra articular loose bodies  Secondary osteoarthritis changes cartilage formation
  73. 73. Synovial osteochondromatosis
  74. 74. Synovial osteochondromatosis
  75. 75. Types of acetabular of fracture
  76. 76. Stress fracture of the femoral neck
  77. 77. Femoral neck antiversion angle
  78. 78. Femoral neck antiversion angle 0-1 Y 2Y 3 -5 Y = 30 – 50º = 30º = 25º 6- 12 Y = 20º 12- 15 Y = 17º 16-20 Y = 11º 20 Y = 8º

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