ULTRASOUND OF THE HIP & GROIN - Normal

For hip and buttock scanning protocol

For normal hernia scanning protocol

For Pathology

FEMORAL HERNIA

Scan Plane                                                                                           Image

Transverse View of a Femoral Hernia. Note that it descends The right femoral canal in transverse. The mouse over shows the expanding common femoral vein with the valsalva manouver. The femoral
medial to the common femoral vein. canal is medial to the vessels. The vein would be compressed by the hernia and no dilatation would happen.

INGUINAL HERNIAS

. Direct
2. Indirect

DIRECT HERNIA

 
  
Direct Hernia. A Direct Hernia is seen medial to the Inferior Epigastric Vessels

INDIRECT HERNIA

Indirect Hernia
Longitudinal Scan of the normal spermatic cord at the internal inguinal ring.
To Image an Indirect hernia start from down at the common femoral vessels and work your way in a transverse plane Prominent vessels are commonly seen.
superiorly until you reach the level above where the inferior epigastric vessels join the ext iliac vein and artery.

Ultrasound of the Hip and Groin - Protocol

Role of Ultrasound

To confirm the presence of a hernia

To distinguish between inguinal Vs femoral hernia
If inguinal, to subclassify direct Vs indirect
To identify the content of the hernia (omental fat +/- bowel)
Reducible V's non-reducible
Is it symptomatic (focally tender or not)
Identify alternative pathology
 

Limitations

Size of the patient

Ability to get the hernia to push through the weakened area

Equipment Selection

Use a linear transducer 7-12MHz

Use an abdominal preset rather than a MSK setting.

Patient position

Begin with the patient supine. If no hernia is detected, re-examine the patent erect.

Scanning Technique

FEMORAL HERNIAS

To find a femoral hernia: Scan transversely over common femoral vessels and look medial to the vessels when the patient strains.

The lump will present lateral and caudal to the pubic ramus.
With a hernia present, the common femoral vein will not expand as it normally should. As it pushes through the femoral canal, the hernia will compress the vein.
These are more common in older females.
It may take several attempts to actually see the neck of the hernia well and subsequently measure.
An entrapped/strangulated femoral hernia constitutes a medical emergency.

INGUINAL HERNIAS

To find the internal inguinal canal:Start from down at the common femoral vessels and work your way in a transverse plane superiorly until you reach the level above where the inferior epigastric vessels join
the ext iliac vein and artery.

Turn the probe to go along the plane of the spermatic cord/inguinal canal.
Get the patient to strain,situp/crunch or stand
Watch for movement of omentum/or bowel within the canal or medial to it.
If there is sliding down the canal this is usually an indirect hernia as it originates lateral to the epigastric vessels.
If there is medial movement to the IEV then this is a direct hernia and it does not usually communicate with the inguinal canal.
Check if the omentum/bowel is free to move back within the peritoneum (reducible hernia) or does it get stuck(strangulated).
Inguinal hernias are more common in males and can be from a very young age.

For  Hernia Pathology

Basic Hard Copy Imaging

A hernia series should include the following minimum images;

Inguinal canal at rest and straining

Femoral canal at rest and straining
Longitudinal and transverse measurements of the neck
Any alternative pathology
Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.

ULTRASOUND OF THE HIP AND BUTTOCK - Normal

 
 HIP EFFUSION

Readily seen in the anterior joint recess overlying the Femoral Neck

 
Scan Plane for Hip Effusion Normal Hip Recess.

 ILIOPSOAS TENDON

Probe position to assess the iliopsoas tendon.

A normal iliopsoas tendon in transverse
Transverse at pubis.

 
  

Iliopsoas Tendon scan plane.

Normal Iliopsoas Tendon
Longitudinal at pubis

 
Patient and probe position to assess the distal psoas
Normal psoas tendon insertion
insertion.

For iliopsoas pathology

GREATER  TROCHANTER and TENDON INSERTIONS

GLUTEUS MINIMUS                                                                   GLUTEUS MEDIUS

   
GLUTEUS MINIMUS is the most anterior of the gluteal tendons GLUTEUS MEDIUS inserts on the greater trochanter laterally and moves over the gluteus minimus.

BURSAE

   

GREATER TROCHANTER BURSAE

GLUTEUS MAXIMUS inserts further infero lateral and posteriorly.
There are a number of places that bursitis can arise and all areas must be scanned. 

trochanteric bursa movem…

movem…

Scan plane and leg movement to best identify the trochanteric bursal tissue plane.

The patient is on their side, knees together.

 Ask them to gently raise and lower the top foot off the bottom foot.

This example is a normal, assymptomatic patient.

The iliotibial band (ITB) is sliding over the gluteal insertions and greater trochanter.

GLUTEUS MINIMUS AND MEDIUS

 
 

The gluteus minimus and medius insert into the greater trochanter.The gluteus medius is commonly compared with the same appearance
Coronal Scan Plane.
as the supraspinatus tendon of the shoulder

GLUTEUS AND MINIMUS

SCAN PLANE                                                            IMAGE

 
Transverse Scan Plane Transverse view of the gluteus Minimus and gluteus Medius Tendons.

 
GLUTEUS MINIMUS AND MEDIUS MUSCLES

   
Gluteus Medius overlies the gluteus minimus muscle Gluteus Medius in pink and minimus in blue

ISCHIOGLUTEAL BURSA

SCAN PLANE                                                         IMAGE

 
Ischiogluteal Bursa Move the probe posterirly in a transverse plane till the ischium in visualised . The bursa is anterior to this and under the gluteus maximus.

TENSOR FASCIAE LATAE

SCAN PLANE                                                                                                                                           

   

Tensor fasciae Latae

Normal TFL coming off the ASIS.
The origin of the tensor fasciae latae is from the ASIS and it courses laterally and caudal to meet the anterior tensor fascia lata which is superficial to the vastus lateralis.

GROIN LYMPH NODES

   
Groin Lymph Node  

 
 Ultrasound of the Hip and Buttock -Protocol

Role of Ultrasound

Ultrasound is essentially used for .Ultrasound is a valuable diagnostic tool in assessing the following indications;

Muscular, tendinous and some ligamentous damage (chronic and acute)

Bursitis
Joint effusion
Vascular pathology
Haematomas
Soft tissue masses such as ganglia, lipomas
Classification of a mass eg solid, cystic, mixed
Post surgical complications eg abscess, oedema
Guidance of injection, aspiration or biopsy
Some boney pathology.

Limitations

The size of the patient can limit the visualisation of the normal anatomical landmarks.

Equipment Selection

Use of a high resolution probe (7-15MHZ) is essential

Careful scanning technique to avoid anisotropy (and possible misdiagnosis)

Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons.

Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure.

Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

INDICATIONS FOR TROCHANTERIC BURSITIS

Pain over greater trochanter

Pain in buttock
Pain down lateral thigh
Aggravation with lying on side , walking, abduction, internal rotation and external rotation
More common in females
More common over 50 yrs

 PREPARATION

Before scanning know the origins and insertion sites of the gluteus minimus, gluteus medius, gluteus maximus, piriformis tendons and the fascia latae position.
Know the 3 common sites of bursitis
Roll patient onto unaffected side initially then assess supine and compare
Start with a curved linear array probe approx 6-8Mhz to assess the muscles deep to the hip
To evaluate the bursae use a 7-12MHz linear probe
Use a multi focus
Narrow the dynamic range
Ask the patient where the pain is and scan there first
Run the probe up and down the lateral hip aligned to the long axis of the femoral shaft, and then move anterior and posterior.
Look in coronal and transverse
Compare sides.
Remember that fluid is mobile and gravity dependant so do not over compress and do look in supine .Also vary the patients leg position from extension to flexion and even abduction if this creates the
pain.Look at the patient erect.

Scanning Technique

There are 2 ways of approaching the lateral hip to start imaging.

. Start posteriorly and work towards anterior greater trochanter

2. Start anterior and work posteriorly

 The anterior-posterior technique (just adapt it in reverse if you prefer to work posterior to anterior).

i. Use a high frequency curved linear array probe to appreciate the entirety of the muscle bellies.
i. Start anteriorly to look at the linear hyperechoic band superficial to the gluteus minimus and gluteus medius muscles, this is the tensor fascia latae.
i. Change to a high frequency linear array probe 5-12MHz to scan in transverse and coronally.Check for tendinopathy at its origin or any fluid under it.
v. Now move posteriorly to visualize the anterior portion of the gluteus minimus and gluteus medius.The gluteus minimus is seen on the anterior surface of the greater trochanter.The muscle comes from deep
below the gluteus medius and is a hyperechoic tendon.
v. The gluteus medius inserts further posteriorly but can be seen in a transverse view of the greater trochanter with the gluteus minimus insertion.
i. Run up and down to check its insertion into the greater trochanter.
i. As you move posteriorly the gluteus maximus comes into focus.
i. Usually a curved linear array probe is the only way to see it because it runs deeply and attaches into the lateral femur.
x. The piriformis,oblique muscles and quadratus femoris are not seen well enough to reliably diagnose pathology.

Ultrasound Appearance

Beware of anisotropy at the insertion of the gluteus tendons onto the greater trochanter. It can mimic a partial of full thickness tear.

 PATHOLOGY
For Hernia Pathology

 
Trochanteric Bursitis
Tendinopathy
Tendinosis 
Enthesopathy
Tears
Snapping Hip
Tensor Fascia Latae Tendinopathy
Injections

For Pathology of the Hip and Buttock

Basic Hard Copy Imaging

A hip/buttock series should include the following minimum images:

Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.