MS ultralydsscanning Faggruppen for UL-scanning Hofte - Lyske Henrik Aagaard ortopædkirurg, idrætsmediciner Amager Hospital Artroskopisk Center Amager Gildhøj Privathospital Kgl. Ballet 1
UL (US) bruger - kliniker 15 års UL daglig amb. brug ort. kir. idrætmedicin/ballet kliniker bedsite UL klinikerens forlængede arm radiologisk specialist 2
Hofte - UL teknik, udstyr udfordring pos./neg. udstyr standard MS UL transducere lineær lavere frekvens, dybere curved dybde > 4-6 cm
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 2013 4
Indikation - formål med billeddiagnostik (rtg, CT. MT UL m.fl.) diagnose assistent NB! klinisk us. forløb behandlingsstrategi (behandlingseffekt) dokumentation pt. forståelse/tilfredshed/kompliance 5
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
MS ultralydsscanning 1a. Hofteled caput (collum) ledkapsel, recess = omslagsfold labrum 7
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
Hofte artrose - UL scan caput Normal form uregelmæssigheder ledflader/-spalte brusk acetabulum form labrum ledkapsel ansamling bløddelshævelse mus Artrose mus osteofyt 9
Hofte artrose - UL scan Tilspidsning - osteofyt caput form brusk bløddele fortykkelse hypoeccocitet ansamling mus Uregelmæssig overflade 10
FAI - CAM Femuro Acetabular Impingement (FAI) form evt. artrose grad 50% ledspalte
FAI - CAM MR standard systematisk udmåling MR/røntgen golden standard MR UL UL Buck Eur Rad 2011
FAI - CAM variation bump hyppig artrose grad? røntgen Bump: ostofyt/exostose? MR UL Omslagsfold, ansamling Buck, Eur Rad 2011
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?
caput, collum lat -> med form, udbygning, mus, brusk med -> lat -> post dynamisk (rot, flex/ext) Hofteled - scan A Beskriv fortolk 15
Hofteled - omslagsfold = recess - ledkapsel ledkapsel fortykket fibrøse kapsel synovitis væske i recess diagnose? viderehenvis rtg., MR blodprøver Case A: 59 år, murer
Hofteled led, knogle, sene/mm MR caput/collum nekrose? Case A: 59 år, murer
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.
Hofteled - ledansamling - i recess diagnose MR AVasculær Nekrose (AVN) Case B: 66 år,
Doppler - hofteled Artritis - infektion Artritis TB infektion Ansamling, synovitis Ewing sarcom 20
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
ledkapsel, recess, omslagsfold følg lat -> med, dist -> prox dynamisk, adskil kapsel fra psoas hypoeccoicitet (væske) doppler v. basis Hofteled - scan B Beskriv fortolk 22
pincer? normal FAI - pincer (intro: labrum) Form form udbygning tag UL mindre egnet osteofyt
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
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
Perilabral cyste Perilabrale cyster 26
Hip - labral tears: Diagnostic challenge Reiman MP BJSM 2013, review 27
(acetabulum) form, udbygning med -> lat -> post labrum identificér form, læsioner, cyster Hofteled - scan C Beskriv fortolk 28
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
MS ultralydsscanning 1b. Hofte iliopsoas cyster forkalkninger trochanter region 30
Iliopsoas iliopsoas tendon (arrows) 31
Cyste/bursa iliopectinea/iliopsoas diff. diagnose DVT aneurisme longitudinel transverse m. doppler A=arterie V=vene 32
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
Iliopsoas cyste 34
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
Iliopsoas - impingement 42 år, tidl. labrum repair. Smerter. Prominerende acetabularkant. (A) Acetabulum, (Pile) psoas 36
Springhofte - intern A. før klik - sene roteret B. efter - normal, horizontalt lateral medial 37
Iliopsoas 25 år ikke motionsaktiv traume, nedspring, 1½-2 mdr. læsion intra-/peritendinøst flow doppler 38
iliopsoas prox -> dist, langs/tværs struktur, fibre (sene mm.) relation til acetabulum, caput, kar dynamisk, adskil fra ledkapsel Hofte - scan A Beskriv fortolk 39
Rectus fem. - ruptur, forkalkning avusion posttraumatisk forkalkninger doppler avulsion fra SIAI normal. 40
Rectus fem. 22 år, fodbold, rectus fem. læsion fiberstruktur omfang total/partiel ruptur dynamisk kontraktibilitet 41
Rectus fem. mm. læsion ældre forkalkning væske (doppler, næppe) 42
Rectus fem. myositis ossificans post traumatisk hæmatom (ansamling) fiberlæsion Vastus intermedius, fluid + calcifications 43
(rectus femoris) identificer, adskil fra andre mm. følg sartorius dist (tværs) prox -> dist på femur langs/tværs Hofte - scan B Beskriv fortolk 44
Bursitis GMe Trochanter bursit trochanter major GT = Greater Trochanter cranial Bursitis trochanterica 45
Bursitis trochanterica Bursa trochanter major (GT) UL vejledt blokade longitudinel langs fiberretning transversel tværs Nål - blokade 46
47
Glut. med. (GMed) GMed ruptur bursa 48
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
trochanter bursae fascie latae Hofte - scan C GMin, GMed Beskriv fortolk 50
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
MS ultralydsscanning 2. Lyske - hofteregion tendionopati, calcificationer, rupturer adduktorer symfyse hasemm. tuber bursitter lyskebrok 52
53
Normal Adduktor mm./sene - udspring conjoint tendons Fortykkelse, fortætning 54
Adduktor mm. - udspring med lille partiel læsion 55
Adduktor 32 år, volleyball elite mm. - udspring doppler
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
Adduktor - ældre læsion Adductor ruptur, forkalkning Adductor ruptur, forkalkning Adductor ruptur, væske + forkalkning 58
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
Fremmedlegemer Træsplint indkapslet, subcutant muskel, underhud frit i væv indkapslede (granulom) vævsirritation evt. ansamling evt. bløddelslæsion Glas - subcutant Glas - flere, intramuskulært 60
adduktorer udspring, conjoint tendons, symfyse prox -> dist, langs/tværs struktur, fibre (sene mm.) Lyske - scan A Beskriv fortolk 61
Hasemm. hasemm. biceps F semim semit 62
Hasemm. - læsion 63
Tendino-/myopati Hamstring calcification, post traumatic (partiel lesion) CT 3-D: Hamstring calcifications, stress/overload induced 64
hasemm. tuber iscii (GMax inf.) semit, biceps F, semim prox. -> dist, langs/tværs Lyske - scan C Beskriv fortolk 65
Hernie lyskebrok femoralis inguinalis sportshernie? 66
Hernie symptomer pop ud smerter/ømhed intermitterende incarceration UL væske Lokalisation ligge/stå, bugpress
Hernie smerter intermitterende progression UL væske lokalisation incarcereret hernie, væske, distenderet
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
(hernie) kar arterie/vene (doppler, bugpresse) inguinalkanal annulus int./ext. bugpresse, stående Lyske - scan C Beskriv fortolk 70
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
Litteratur ESSR www.essr.org Textbook on Musculoskeletal US Bolvig L, Fredberg U, Rasmussen OS 2011 ISBN: 9788762808249 Cases www.ultrsoundcases.info Practical Musculoskeletal US McNally EG 2004 ISBN-10: 0443073503 ISBN-13: 978-0443073502 72