Hofte - Lyske. MS ultralydsscanning Faggruppen for UL-scanning. Henrik Aagaard. Amager Hospital. Gildhøj Privathospital Kgl.

Transkript

1 MS ultralydsscanning Faggruppen for UL-scanning Hofte - Lyske Henrik Aagaard ortopædkirurg, idrætsmediciner Amager Hospital Artroskopisk Center Amager Gildhøj Privathospital Kgl. Ballet 1

2 UL (US) bruger - kliniker 15 års UL daglig amb. brug ort. kir. idrætmedicin/ballet kliniker bedsite UL klinikerens forlængede arm radiologisk specialist 2

3 Hofte - UL teknik, udstyr udfordring pos./neg. udstyr standard MS UL transducere lineær lavere frekvens, dybere curved dybde > 4-6 cm

4 MRI or/and US - hip/groin MRI has become the workhorse in the imaging evaluation of the painful or clinically abnormal hip. It provides an excellent anatomic overview and demonstration of the bony structures, articular surfaces, and surrounding soft tissues. Conversely, US can also demonstrate superficial intraarticular structures and the periarticular soft tissues, is quickly performed, allows dynamic evaluation of tendons and muscles, and can guide percutaneous procedures. These two modalities are complementary Friedman, Miller. MRI, HSS. Clin N Am

5 Indikation - formål med billeddiagnostik (rtg, CT. MT UL m.fl.) diagnose assistent NB! klinisk us. forløb behandlingsstrategi (behandlingseffekt) dokumentation pt. forståelse/tilfredshed/kompliance 5

6 UL-scanning adskil beskrivelse fortolkning beskriv form, struktur afvigelser fra normal uregelmæssigheder normalt fortolk mulig patologi tegn på, forenelig med anatomisk atlas Uv.-mål scanning strukturer - genkende eksempler patologi - kendskab 6

7 MS ultralydsscanning 1a. Hofteled caput (collum) ledkapsel, recess = omslagsfold labrum 7

8 Hofte artrose - rtg. 52 år, tidl. elite fodbold caput form osteofytter ledspalte afsmalning >50%, >2 mm -> a-skopi acetabulum form labrum, forkalkning ledkapsel (omslagsfold) ansamling bløddelshævelse mus

9 Hofte artrose - UL scan caput Normal form uregelmæssigheder ledflader/-spalte brusk acetabulum form labrum ledkapsel ansamling bløddelshævelse mus Artrose mus osteofyt 9

10 Hofte artrose - UL scan Tilspidsning - osteofyt caput form brusk bløddele fortykkelse hypoeccocitet ansamling mus Uregelmæssig overflade 10

11 FAI - CAM Femuro Acetabular Impingement (FAI) form evt. artrose grad 50% ledspalte

12 FAI - CAM MR standard systematisk udmåling MR/røntgen golden standard MR UL UL Buck Eur Rad 2011

13 FAI - CAM variation bump hyppig artrose grad? røntgen Bump: ostofyt/exostose? MR UL Omslagsfold, ansamling Buck, Eur Rad 2011

14 Case - hip FAI 29 y. female b. dancer hip/groin pain 2 y. intermittent progressing FAI: X-ray, MRI cortisone inj. rehab. surgery? return to ballet?

15 caput, collum lat -> med form, udbygning, mus, brusk med -> lat -> post dynamisk (rot, flex/ext) Hofteled - scan A Beskriv fortolk 15

16 Hofteled - omslagsfold = recess - ledkapsel ledkapsel fortykket fibrøse kapsel synovitis væske i recess diagnose? viderehenvis rtg., MR blodprøver Case A: 59 år, murer

17 Hofteled led, knogle, sene/mm MR caput/collum nekrose? Case A: 59 år, murer

18 Hofteled - ledansamling - i recess smerter, mobilitet UL: ansamling artritis synovitis årsag? diagnose? rtg., MR blodprøver UL vejledt blokade Case B: 66 år, hø. coll. fem. ve. coll. fem.

19 Hofteled - ledansamling - i recess diagnose MR AVasculær Nekrose (AVN) Case B: 66 år,

20 Doppler - hofteled Artritis - infektion Artritis TB infektion Ansamling, synovitis Ewing sarcom 20

21 UL vejledt injektion - hofteled Curved transducer US-guided hip injection. Needle (arrows) obliquely toward the femoral head neck junction. (B) As the injection progresses, the capsule is distended by the hypoechoic injectate (asterisk). A, acetabulum; H, femoral head; N, femoral neck. blokade: lokal anæsteticum (LA) + steroid diagnostisk/terapeutisk vs. MR 21

22 ledkapsel, recess, omslagsfold følg lat -> med, dist -> prox dynamisk, adskil kapsel fra psoas hypoeccoicitet (væske) doppler v. basis Hofteled - scan B Beskriv fortolk 22

23 pincer? normal FAI - pincer (intro: labrum) Form form udbygning tag UL mindre egnet osteofyt

24 Labrum læsion Acetabular labral tear. (A) MR image shows a high-signal-intensity tear (arrow) through the low-signal-intensity labrum. (B) Longitudinal US image in the same patient shows the hypoechoic tear (arrow) through the echogenic labrum. 24

25 Perilabral cyste obs. labrum læsion Perilabral cyst. (A) MR image shows a bilobed cyst (arrow). (B) Longitudinal US image of the same patient shows the anechoic bilobed cyst (thin arrows). The labral tear (thick arrow) is better appreciated on this image than the MR image. H, femoral head. 25

26 Perilabral cyste Perilabrale cyster 26

27 Hip - labral tears: Diagnostic challenge Reiman MP BJSM 2013, review 27

28 (acetabulum) form, udbygning med -> lat -> post labrum identificér form, læsioner, cyster Hofteled - scan C Beskriv fortolk 28

29 caput, collum lat -> med form, udbygning, mus, brusk med -> lat -> post dynamisk (rot, flex/ext) ledkapsel, recess = omslagsfold følg lat -> med, dist -> prox dynamisk, adskil kapsel fra psoas hypoeccoicitet (væske) doppler v. basis (acetabulum) labrum form, læsioner, cyster Hofteled - scan Beskriv fortolk 29

30 MS ultralydsscanning 1b. Hofte iliopsoas cyster forkalkninger trochanter region 30

31 Iliopsoas iliopsoas tendon (arrows) 31

32 Cyste/bursa iliopectinea/iliopsoas diff. diagnose DVT aneurisme longitudinel transverse m. doppler A=arterie V=vene 32

33 Iliopsoas cyste THA Iliopsoas bursitis. (A) MR image in a patient with a total hip arthroplasty shows a mildly distended iliopsoas bursa (asterisk) adjacent to the iliopsoas tendon (arrow). The tendon is difficult to see because of the susceptibility artifact from the arthroplasty components. (B) Transverse US image of the same patient shows the bursa (asterisk) adjacent to the tendon (arrow). There is no artifact from the arthroplasty. 33

34 Iliopsoas cyste 34

35 Iliopsoas - impingement THA THA (total hip alloplastic). Iliopsoas impingement and tendinosis. (A) Longitudinal US image in a patient with a total hip arthroplasty shows the acetabular component (A) contacting the overlying iliopsoas tendon (arrow). Incidentally, notice the small effusion (asterisk) and the marked capsular thickening (C). H (prosthetic femoral head), N (prosthetic femoral neck). (B) Transverse US image at the level of the pelvic brim (P) in a different patient shows iliopsoas tendinosis (arrow) with thickening and a heterogeneous appearance. The adjacent iliopsoas bursa is distended (asterisk). a, femoral artery. 35

36 Iliopsoas - impingement 42 år, tidl. labrum repair. Smerter. Prominerende acetabularkant. (A) Acetabulum, (Pile) psoas 36

37 Springhofte - intern A. før klik - sene roteret B. efter - normal, horizontalt lateral medial 37

38 Iliopsoas 25 år ikke motionsaktiv traume, nedspring, 1½-2 mdr. læsion intra-/peritendinøst flow doppler 38

39 iliopsoas prox -> dist, langs/tværs struktur, fibre (sene mm.) relation til acetabulum, caput, kar dynamisk, adskil fra ledkapsel Hofte - scan A Beskriv fortolk 39

40 Rectus fem. - ruptur, forkalkning avusion posttraumatisk forkalkninger doppler avulsion fra SIAI normal. 40

41 Rectus fem. 22 år, fodbold, rectus fem. læsion fiberstruktur omfang total/partiel ruptur dynamisk kontraktibilitet 41

42 Rectus fem. mm. læsion ældre forkalkning væske (doppler, næppe) 42

43 Rectus fem. myositis ossificans post traumatisk hæmatom (ansamling) fiberlæsion Vastus intermedius, fluid + calcifications 43

44 (rectus femoris) identificer, adskil fra andre mm. følg sartorius dist (tværs) prox -> dist på femur langs/tværs Hofte - scan B Beskriv fortolk 44

45 Bursitis GMe Trochanter bursit trochanter major GT = Greater Trochanter cranial Bursitis trochanterica 45

46 Bursitis trochanterica Bursa trochanter major (GT) UL vejledt blokade longitudinel langs fiberretning transversel tværs Nål - blokade 46

47 47

48 Glut. med. (GMed) GMed ruptur bursa 48

49 Glut. min. (GMin) GMi GMin tendinosis. (A) MR image shows a thickened and heterogeneous GMin tendon (white arrow) with a focal insertional tear (black arrow) and highsignalintensity shallow tearing along its deep surface. (B) Longitudinal US image in the same patient shows the thickened tendon (arrows) with loss of the normal echogenic fibrillar appearance. G, greater trochanter. 49

50 trochanter bursae fascie latae Hofte - scan C GMin, GMed Beskriv fortolk 50

51 iliopsoas dist -> prox, langs/tværs struktur, fibre (sene mm.) relation til acetabulum, caput, kar dynamisk, adskil fra ledkapsel (rectus femoris) identificer, adskil fra andre mm. følg sartorius dist (tværs) prox -> dist på femur langs/tværs trochanter bursae fascie latae GMin, GMed Hofte - scan Beskriv fortolk 51

52 MS ultralydsscanning 2. Lyske - hofteregion tendionopati, calcificationer, rupturer adduktorer symfyse hasemm. tuber bursitter lyskebrok 52

53 53

54 Normal Adduktor mm./sene - udspring conjoint tendons Fortykkelse, fortætning 54

55 Adduktor mm. - udspring med lille partiel læsion 55

56 Adduktor 32 år, volleyball elite mm. - udspring doppler

57 Adduktor - intramuskulær (add.) Adductor hematoma. (A) MR image shows a large hematoma (asterisk) in the left adductor muscles. (B) Transverse US image in the same patient shows the hypoechoic hematoma (asterisk). 57

58 Adduktor - ældre læsion Adductor ruptur, forkalkning Adductor ruptur, forkalkning Adductor ruptur, væske + forkalkning 58

59 Symfysitis Athletic pubalgia. (A) MR image shows a thickened and hyperintense rectus abdominis aponeurosis (thin arrow) and extensive cortical erosion (thick arrow) of the anterior aspect of the right superior pubic ramus. (B) Transverse sonographic image in a different patient during a cortisone injection shows a thickened rectus abdominis aponeurosis (black arrow) with a horizontal tear (secondary cleft sign) (thin solid white arrows). Note the cortical erosion (thick solid white arrow) of the anterior aspect of the right superior pubic ramus and the cortical irregularity of the anterior aspect of the left superior pubic ramus. The reverberation artifact from the needle is present (hollow white arrow). 59

60 Fremmedlegemer Træsplint indkapslet, subcutant muskel, underhud frit i væv indkapslede (granulom) vævsirritation evt. ansamling evt. bløddelslæsion Glas - subcutant Glas - flere, intramuskulært 60

61 adduktorer udspring, conjoint tendons, symfyse prox -> dist, langs/tværs struktur, fibre (sene mm.) Lyske - scan A Beskriv fortolk 61

62 Hasemm. hasemm. biceps F semim semit 62

63 Hasemm. - læsion 63

64 Tendino-/myopati Hamstring calcification, post traumatic (partiel lesion) CT 3-D: Hamstring calcifications, stress/overload induced 64

65 hasemm. tuber iscii (GMax inf.) semit, biceps F, semim prox. -> dist, langs/tværs Lyske - scan C Beskriv fortolk 65

66 Hernie lyskebrok femoralis inguinalis sportshernie? 66

67 Hernie symptomer pop ud smerter/ømhed intermitterende incarceration UL væske Lokalisation ligge/stå, bugpress

68 Hernie smerter intermitterende progression UL væske lokalisation incarcereret hernie, væske, distenderet

69 Lymfeknuder NB! lokal infektion metastase blærecancer lokal infektion metastase blærecancer Hodkin lymfom metastase rectumcancer De Gregorio Onc Gyn 2013 foreslå egen læge: henvisning til radiolog 69

70 (hernie) kar arterie/vene (doppler, bugpresse) inguinalkanal annulus int./ext. bugpresse, stående Lyske - scan C Beskriv fortolk 70

71 adduktorer udspring, conjoint tendons, symfyse prox -> dist, langs/tværs struktur, fibre (sene mm.) hasemm. tuber iscii (GMax inf.) semit, biceps F, semim prox. -> dist, langs/tværs (hernie) Beskriv fortolk kar arterie/vene (doppler, bugpresse) inguinalkanal annulus int./ext. bugpresse, stående Lyske - scan 71

72 Litteratur ESSR Textbook on Musculoskeletal US Bolvig L, Fredberg U, Rasmussen OS 2011 ISBN: Cases Practical Musculoskeletal US McNally EG 2004 ISBN-10: ISBN-13: