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Diagnostic Imaging of Pediatric Hip Lesions

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Diagnostic Imaging of Pediatric Hip Lesions

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Diagnostic Imaging of Pediatric Hip Lesions

  1. 1. Musculoskeletal Pediatric Hip Lesions
  2. 2. Mohamed Zaitoun Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals Egypt FINR (Fellowship of Interventional Neuroradiology)-Switzerland zaitoun82@gmail.com
  3. 3. Knowing as much as possible about your enemy precedes successful battle and learning about the disease process precedes successful management
  4. 4. Pediatric Hip Lesions -Three distinct conditions of the hip occur in children, each of which affects a different age group : 1-Neonates, infants : congenital dislocation of the hip (CDH) 2-School age : Legg-Calve-Perthes (LCP) disease 3-Adolescents : Slipped capital femoral epiphysis (SCFE)
  5. 5. 1-Congenital Dislocation of the Hip (CDH) ,Developmental Dysplasia of the Hip (DDH) : a) Incidence b) Radiographic features
  6. 6. a) Incidence : -Results from an abnormal relationship of the femoral head to the acetabulum -More in females -More in the left hip, bilateral in 5 %
  7. 7. b) Radiographic features : 1-Ultrasound : -The test of choice in the infant (< 6 months) as the proximal femoral epiphysis hasn’t yet significantly ossified -Normal femoral head is covered at least 50% by acetabulum -In DDH, <50% of femoral head is covered by acetabulum -Normal alpha angle is >60 -In DDH , alpha angle is <60
  8. 8. Normal infant
  9. 9. Normal CHD
  10. 10. 2-Plain Radiography : -Shallow acetabulum -Acetabular angle greater than 30 degrees (same as alpha angle less than 60 degrees) -Small capital femoral epiphysis -Delayed ossification of the femoral head -Acetabular sclerosis -Loss of Shenton's curve -Femoral head lateral to Perkin's line -Femoral head superior to Hilgenreiner's line
  11. 11. -Shenton's curve : smooth curved line connecting medial border of femoral metaphysis with the superior border of the obturator foramen -Hilgenreiner's line : a horizontal line through the triradiate cartilage of the acetabulum -Perkin's line : a vertical line (perpendicular to Hilgenreiner's line) from the lateral margin of the ossified acetabular roof that is normally tangential to the lateral margin of the ossification center of the femoral head -Acetabular angle : angle that the acetabular line makes with Hilgenreiner's line
  12. 12. Hilgenreiner's line Perkin’s line
  13. 13. Hilgenreiner's line & Perkin’s line
  14. 14. Shenton’s line
  15. 15. Acetabular angle
  16. 16. There is a dysplastic left acetabulum (shallow left acetabulum) and a small left femoral epiphysis when compared to the right , the left proximal femoral metaphysis is displaced superiorly and laterally
  17. 17. Chronic hip dislocation
  18. 18. 2-Legg-Calve-Perthes (LCP) Disease : a) Incidence b) Radiographic Features
  19. 19. a) Incidence : -Osteonecrosis of femoral head -School age (5-8 years)
  20. 20. a) Incidence : -Osteonecrosis of femoral head -School age (5-8 years)
  21. 21. b) Radiographic Features : -Plain film staging system (Ficat) : *Stage I : clinical symptoms of AVN but no radiographic findings *Stage II : osteoporosis, cystic areas and osteosclerosis *Stage III : translucent subcortical fracture line (crescent sign), flattening of femoral head *Stage IV : loss of bone contour with secondary osteoarthritis
  22. 22. Stage II
  23. 23. AP pelvic radiography showing flattening of the superolateral aspect (the weightbearing portion) of the right femoral head, there is a zone of decreased density representing the crescent sign, indicating subchondral fracture (stage III)
  24. 24. AP radiographic view of the pelvis shows flattening of the outer portion of the right femoral head from avascular necrosis, with adjacent joint space narrowing, juxta-articular sclerosis, and osteophytes representing degenerative joint disease (stage IV)
  25. 25. -Early signs : 1-Asymmetrical femoral epiphyseal size (smaller on affected side) 2-Apparent increased density of the femoral head epiphysis 3-Widening of the medial joint space 4-Blurring of the physeal plate
  26. 26. -Late signs : 1-The femoral head begins to fragment with subchondral lucency (crescent sign) 2-Femoral head deformity with widening and flattening 3-Osteoarthritis
  27. 27. Bilateral Perthes
  28. 28. Bilateral
  29. 29. 2-MRI : -Earliest sign is bone marrow edema (nonspecific) -Early AVN : focal subchondral abnormalities (very specific): Dark band on T1, bright band on T2 Double-line sign (T2) : bright inner band / dark outer band occurs later in disease process after the start of osseous repair (inner bright line representing granulation tissue and an outer dark line representing sclerotic bone) -Late AVN : fibrosis of subchondral bone : Dark on T1 and T2 Femoral head collapse
  30. 30. Bilateral AVN, (a) T1, (b) T2
  31. 31. T1 T2
  32. 32. -Mitchell classification : *Class A (early disease) : signal intensity analogous to fat (high on T1 and intermediate on T2) *Class B : signal intensity analogous to blood (high on T1 and T2) *Class C : signal intensity analogous to fluid (low on T1 and high on T2) *Class D (late disease) : signal intensity analogous to fibrous tissue (low on T1 and T2)
  33. 33. Coronal T1 of the pelvis in a patient with bilateral avascular necrosis of the femoral head shows increased signal within the superior aspect of the femoral head, representing fat, surrounded by a line of decresed signal, representing sclerotic reactive margin, this is an MRI class A (fatlike)
  34. 34. Patient 39 years old with use of high dose of corticosteroids, Cor T1 and T2 of the pelvis shows a stage B (blood-like) at the level of right femoral head with increased signal on T1W and T2W; AVN stage C (fluid-like) in left femoral head, with decreased signal intensity on T1W and increased signal on T2
  35. 35. Cor T1 and T2 in a patient with AVN on the left femoral head with decresed signal intensity on T1 and T2, representing a stage D (fibrous-like)
  36. 36. 3-Slipped Capital Femoral Epiphysis (SCFE): a) Incidence b) Radiographic Features
  37. 37. a) Incidence : -Known as Slipped Upper Femoral Epiphysis (SUFE) -It is one of commonest hip abnormalities in adolescence and is bilateral in 20% of cases -Type I Salter Harris growth plate injury -Overweight teenagers
  38. 38. b) Radiographic Features : -Osteoporosis of head and neck on AP view early -A line drawn up the lateral edge of the femoral neck (line of Klein) fails to intersect the epiphysis during the acute phase -Metaphysis displaced laterally so that it does not overlap posterior lip of acetabulum as normal -Widened growth plate

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