Infant hip ultrasound - all you wanted to know but were

afraid to ask

Poster No.: C-1469

Congress: ECR 2011
Type: Educational Exhibit
Authors: 1 1 2 3
R. H. Castro , M. Castro , T. C. Fernandes , A. Braga , A. J. B. S.
3 1 2 3
Madureira ; Espinho/PT, Vila Praia de âncora/PT, Porto/PT
Keywords: Dysplasias, Ultrasound, Pediatric, Musculoskeletal joint
DOI: 10.1594/ecr2011/C-1469

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Learning objectives

- To provide an overview of the basic technique and interpretation of neonatal hip

ultrasound;

- To describe the normal anatomic findings;

- To review typical ultrasound imaging features of developmental dysplasia of the hip.

Background

Definition

Developmental dysplasia of the hip (DDH) is a term used to describe disruption

of the normal relationship between femoral head and acetabulum. 'DDH' is thus a
somewhat general description encompassing a wide spectrum of disorders of the hip
including dislocation, subluxation, instability and inadequate acetabular development,
morphologically dysplastic hips, reducible subluxed or dislocated hips, irreducible hips
and dislocations resulting from teratologic causes. Congenital dislocation of the hip is
now felt to be less meaningful because it does not re#ect the true spectrum of disorders. It
is thought that hip instability is the primary disorder, and that secondary dysplasia occurs
as a result of compromised growth of the acetabulum.

Epidemiology

The incidence of the condition based upon symptomatic cases that require treatment
falls within the range 0.1-2/1000. Clinical screening using physical examination increases
the apparent incidence, with published data showing the incidence to be in the range
5-7/1000.

However, a signi#cant minority of adults who undergo hip replacement for osteoarthritis
have a background of previously undetected and asymptomatic hip dysplasia and the
true incidence must therefore be very much higher.

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It is a pathology more prevalent on Caucasian population. It is four to eight times more
common in females. It is also more common in patients with a family history of DDH, in
first born children, in large infants, and in infants of history of oligohydramnions.

Etiology

The origin and pathogenesis of DDH are multifactorial. Probable causes include abnormal
laxity of the ligaments and hip capsule, space and movement restriction in the setting of
oligohydramnios; and extreme hip flexion with knee extension, in the setting of breech
position.

Imaging findings OR Procedure details

Ultrasound, due to its ability to demonstrate abnormalities that are not detected clinically
or radiographically, as a result of its ability to image the cartilaginous components of the
infant hip, has emerged as the recommended imaging tool in the diagnosis of DDH.

Two methods of ultrasound evaluation are described:

• a static acetabular morphology method (proposed by Graf), that is based in

a single coronal image;

• a dynamic stress technique (proposed by Harcke), which applies

modifications of Barlow and Ortolani maneuvers, while scanning in the
coronal and transverse planes.

Ultrasound anatomy:

At birth, the proximal femur and the majority of acetabulum are composed of cartilage.
On ultrasound, cartilage is hypoechoic compared with soft tissue; it can also show some
scattered specular echoes.

The acetabulum is composed of both bone and cartilage. At birth the bony ossification
centers in the ilium, ischium, and pubis. These are separated by the Y-shaped triradiate
cartilage. The labrum is a cartilaginous rim that extends outwards from the acetabulum to
form the cup that contains the femoral head. The lateral margin of the labrum is composed
of fibrocartilage, showing increased echogenicity. As ossification begins, the femoral
head ossification center is demonstrated. As the normal infant approaches 1 year of age,

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the size of the ossification center precludes accurate determination of medial acetabular
landmarks, making sonography impracticable.

Fig.: 1 - Anatomic schematic interpretation of the standard coronal plane. S, superior

planes; L, lateral(superficial)planes; FH, femoral head.
References: R. H. Castro; Espinho, PORTUGAL

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Fig.: 2- Anatomical structures of the infant hip (as seen on coronal ultrasonography).
1, ossified external wall of ilium; 2, psoas muscle; 3, labrum; 4, lower limb of the os
ilium; 5, triradiate cartilage; 6, Synovial fold; 7, chondro-osseous junction at the femoral
neck, 8, greater trochanter.
References: R. H. Castro; Espinho, PORTUGAL

Technique:

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A linear, real-time, 5 or 7,5Mhz transducer is used. All scanning is performed from the
lateral or postero-lateral aspect of the hip. In each position of the hip, the transducer
is placed in coronal and transverse orientations. The neutral position is obtained in the
lateral decubitus position and the hip in 35 degrees of flexion and 10 degrees of internal
rotation (figure 3).

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Fig.: 3 - Coronal / neutral position of the right leg. To study the left hip it is more useful
to switch hands (holding the probe with the left hand, and the lower limb with the right
hand).
References: R. H. Castro; Espinho, PORTUGAL

Dynamic study is acquired by scanning the hip, while moving from the neutral position at
rest to one in which the hip is flexed. Then, posterior stress is applied to the knee with
the palm of the hand (the Barlow provocative test) (figure 4).

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Page 8 of 20
Fig.: 4 - Transverse / flexion view. Posterior stress is applied by gently pushing the
knee with the palm of the hand (the Barlow provocative test). Any resultant subluxation
is then noted.
References: R. H. Castro; Espinho, PORTUGAL

The normal hip is always seated at rest and during provocative stress. The lax hip
is normally positioned at rest, showing abnormal movement with stress, remaining,
however, within the confines of the acetabulum. The subluxable hip is displaced laterally
at rest and is loose, but is not dislocatable. A dislocated hip may be able to be returned
to the acetabulum with traction and abduction (Ortolani maneuver). This is distinguished
from the most severe form of DDH in which the femoral head is dislocated and cannot
be reduced.

Morphologic Graf classification:

Standard coronal plane:

The Graf classification relies on the morphologic appearance of the cartilaginous

acetabulum. In order to this evaluation be reproducible, the same ultrasound plane
through the hip must always be used. Three points must be depicted in a correct coronal
plane:

1. the lower limb of the bony ilium in the depth of the acetabular fossa.

2. The acetabular labrum;

3. The mid portion of the acetabular roof.

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Fig.: 5 - Coronal reference plane. Sonographic image of the infant hip in the coronal
plane has three landmarks: 1, lower limb of os ilium as rotating axis for the sectional
plane; 2, acetabular labrum; 3, mid part of the acetabular roof (standard sectional
plane).
References: R. H. Castro; Espinho, PORTUGAL

Small changes in probe orientation can provide inadequate images:

Fig.: 6- a - The posterior plane , the silhouette of the iliac bone bends away from
the probe. b - The anterior sectional plane. The silhouette of the iliac bone bends
superolaterally.
References: R. H. Castro; Espinho, PORTUGAL

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Fig.: 7 - Coronal hip image not usable for padronized acetabular morphologic
evaluation due to anterior angulation of ultrasound beam. Note that the iliac bone line
"bends" superolaterally.
References: R. H. Castro; Espinho, PORTUGAL

Alpha and Beta angles:

In the appropriate coronal plane three lines are drawn:

1. a horizontal line drawn parallel to the ossified lateral wall of the ilium;

2. A line drawn along the roof of the cartilaginous acetabulum, from the lateral osseous
edge of the acetabulum, from the lateral osseous edge of the acetabulum to the labrum;

3. A line drawn from the inferior edge of the osseous acetabulum, to the most superior
osseous rim.

The intersection of line 1 and 2 is called Beta angle. The intersection of line 1 and 3 is
called the Alpha angle.

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Fig.: 8 - Schematic and ultrasound coronal scan with alpha and beta angle calculation.
References: R. H. Castro; Espinho, PORTUGAL

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The lower limit of normal alpha angle is 60º degrees. Because this angle reflects osseous
coverage of the femoral head by the acetabulum, the smaller the angle the greater the
degree of dislocation. A beta angle superior to 77 degrees indicates labrum eversion and
subluxation of the hip.

Based on these measurements, the hip is then classified into one of four main types
according to Graf´s classification (table 1):

Fig.: Table 1: Ultrasonographic hip types according to Graf.

References: R. H. Castro; Espinho, PORTUGAL

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Fig.: 9 - Coronal ultrasonogram of a 7 week-old boy showing a Graf type I (normal)
hip. The alpha angle is 63º and beta angle is 40º. The acetabulum shows a good
osseous and cartilaginous roof. The femoral head has good acetabular coverage.
References: R. H. Castro; Espinho, PORTUGAL

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Fig.: 10 - Coronal ultrasonogram of a 4 week-old girl depicting a Graf type IIa hip. The
alpha angle is 54º and beta angle is 41º. The promontory of the osseous rim is slightly
rounded.
References: R. H. Castro; Espinho, PORTUGAL

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Fig.: 11 - Coronal ultrasonogram of a 5 week-old girl depicting a Graf type IIc hip.
The alpha angle is 46º and beta angle is 43º. The promontory of the osseous rim is
rounded.
References: R. H. Castro; Espinho, PORTUGAL

Other possible morphologic measure in the reference coronal plane is the classification
of acetabular morphology in terms of percentage of femoral head coverage.

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Fig.: 12 - Femoral head coverage measurement: The static method of Morin classi#es
acetabular morphology in terms of a percentage of femoral head coverage. A line is
drawn over the straight lateral wall of the acetabulum through the femoral head. In a
normal hip, more than 55% of the femoral head should be below this line.
References: R. H. Castro; Espinho, PORTUGAL

Dynamic method

The dynamic technique is performed with the infant in both the lateral and supine position,
and images are obtained in the coronal and transverse planes, both with and without
stress.

The coronal image is obtained with 90 degrees flexion of the hip, as posterior stress is
applied to the knee (figure 2). Any resultant subluxation is noted. It should be rememberd
that 4 to 6mm of subluxation is normal in the first few days of life. With subluxation
and dislocation, the femoral head migrates laterally and posteriorly, and there will be
echogenic soft tissue interposed betwenn the femoral head and the acetabulum.

The second stage of the dynamic method consists of performing the same maneuvers
while scanning in the transverse plane and visualization of the position of the femoral
head with respect to the triradiate cartilage of the acetabulum (figures 13 and 14).

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Fig.: 13 - Transverse neutral view: a,b,c - Schematic demonstration of transverse
neutral view of normal (a), subluxation (b) and severe subluxation (c) of the hip. d-
Subluxed hip sonogram shows femoral head displaced posterolaterally with gap
between pubis and femoral head (curved arrow). Arrow, triradiate cartilage; FH femoral
head; i, ischium; L lateral, P, posterior; p, pubis.
References: R. H. Castro; Espinho, PORTUGAL

Page 18 of 20
Fig.: 14 - a,b - Schematic demonstration of transverse flexion view of normal (a),
and dislocated (b) hips. With stress, dislocable hips will suffer lateral displacement
from medial acetabulum. c - a transverse flexion ultrasonographic view of a normal
hip shows the femoral head (FH) remaining in contact with the ischium (arrow) during
movement. A, anterior; L, lateral; P, posterior; m, femoral metaphysis; I, ischium.
References: R. H. Castro; Espinho, PORTUGAL

Conclusion

Disorders of hip maturation are the commonest musculoskeletal pediatric diseases.

These pathologies have strong individual and public health implications. Early detection is

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fundamental for adequate treatment. For this purpose, ultrasound is a safe, noninvasive
and reproducible method, with superior accuracy than isolated physical examination.

Personal Information

References

Wientroub S, Grill F; Ultrasonography in Developmental Dysplasia of the Hip, J Bone

Joint Surg Am. 2000;82:1004.

Fang C, Portess H, Wilson D; Application of ultrasound in the diagnosis and

management of paediatric hip conditions, Current Orthopaedics (2004) 18, 291-303

Harcke, HT: Screening newborns for developmental dysplasia of the hip: the role of
sonography. AJR, 162: 395-397,1994

Graf R; Hip Sonography, Diagnosis and Management of Infant Hip Displasia - 2nd edition,
Springer 2006.

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