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Hofte - Lyske
Henrik Aagaard
ortopædkirurg, idrætsmediciner
Amager Hospital
Artroskopisk Center Amager
Gildhøj Privathospital
Kgl. Ballet
MS ultralydsscanning Faggruppen for UL-scanning
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UL (US) bruger - kliniker
• 15 års UL
• daglig amb. brug
– ort. kir.
– idrætmedicin/ballet
• kliniker
– bedsite UL
• klinikerens forlængede arm
– ≠ radiologisk specialist
Hofte - UL teknik, udstyr
• udfordring
– pos./neg.
• udstyr
– standard MS UL
– transducere
• lineær
– lavere frekvens, dybere
• curved
– dybde > 4-6 cm
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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
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Indikation - formål med billeddiagnostik
(rtg, CT. MT UL m.fl.)
• diagnose
– assistent
– NB! klinisk us.
• forløb
– behandlingsstrategi
• (behandlingseffekt)
• dokumentation
• pt. forståelse/tilfredshed/kompliance
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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
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
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Hofte artrose - UL scan • caput
– form
– uregelmæssigheder
• ledflader/-spalte
– brusk
• acetabulum
– form
– labrum
• ledkapsel
– ansamling
– bløddelshævelse
– mus
Normal
mus
osteofyt
Artrose
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Hofte artrose - UL scan
• caput
– form
– brusk
• bløddele
– fortykkelse
– hypoeccocitet
– ansamling
Tilspidsning - osteofyt
Uregelmæssig overflade
mus
FAI - CAM
• standard
• systematisk udmåling
• MR/røntgen
• golden standard
Buck Eur Rad 2011
MR
UL
UL
MR
FAI - CAM
• variation
– ‘bump’
– hyppig
• artrose grad?
– røntgen
Buck, Eur Rad 2011
MR
UL
Bump: ostofyt/exostose?
Omslagsfold, ansamling
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?
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Hofteled - scan A • caput, collum
– lat -> med
– form, udbygning, mus, brusk
– med -> lat -> post
– dynamisk (rot, flex/ext)
Beskriv – fortolk
Hofteled - omslagsfold = recess
- ledkapsel
• ledkapsel
– fortykket
– fibrøse kapsel
– synovitis
– væske i recess
• diagnose?
– viderehenvis
– rtg., MR
– blodprøver
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.
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Doppler - hofteled
Artritis - infektion
Ansamling, synovitis – Ewing sarcom
Artritis – TB infektion
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UL vejledt injektion - hofteled
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
Curved transducer
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Hofteled - scan B • ledkapsel, recess, omslagsfold
– følg lat -> med, dist -> prox
– dynamisk, adskil kapsel fra psoas
– hypoeccoicitet (væske)
– doppler v. basis
Beskriv – fortolk
FAI - pincer
(intro: labrum)
• Form
– form
– udbygning
– tag
• UL mindre egnet
osteofyt
pincer? normal
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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.
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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.
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Hofteled - scan C • (acetabulum)
– form, udbygning
– med -> lat -> post
• labrum
– identificér
– form, læsioner, cyster
Beskriv – fortolk
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Hofteled - scan • 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
Beskriv – fortolk
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Cyste/bursa • iliopectinea/iliopsoas
• diff. diagnose
• DVT
• aneurisme
longitudinel
transverse
m. doppler A=arterie V=vene
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Iliopsoas cyste
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.
THA
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Iliopsoas - impingement
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.
THA
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Iliopsoas - impingement
42 år, tidl. labrum repair. Smerter.
Prominerende acetabularkant. (A) Acetabulum, (Pile) psoas
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Iliopsoas
• 25 år ♂
• ikke motionsaktiv
• traume, nedspring, 1½-2 mdr.
• læsion
• intra-/peritendinøst flow
• doppler
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Hofte - scan A • iliopsoas
– prox -> dist, langs/tværs
– struktur, fibre (sene mm.)
– relation til acetabulum, caput, kar
– dynamisk, adskil fra ledkapsel
Beskriv – fortolk
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Rectus fem. - ruptur, forkalkning
• avusion
– posttraumatisk
– forkalkninger
– doppler
normal.
avulsion fra SIAI
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Rectus fem. • læsion
– fiberstruktur
– omfang
– total/partiel ruptur
– dynamisk
– kontraktibilitet
22 år, fodbold, rectus fem.
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Rectus fem.
• myositis ossificans
– post traumatisk
– hæmatom (ansamling)
– fiberlæsion
Vastus intermedius,
fluid + calcifications
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Hofte - scan B • (rectus femoris)
– identificer, adskil fra andre mm.
– følg sartorius dist (tværs)
– prox -> dist på femur langs/tværs Beskriv – fortolk
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Trochanter
• bursit
• trochanter major
– GT = Greater Trochanter
Bursitis trochanterica
Bursitis GMe
cranial
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Bursa
• trochanter major (GT)
• UL vejledt blokade
• longitudinel
• langs
• fiberretning
• transversel
• tværs
Nål - blokade
Bursitis trochanterica
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Glut. min. (GMin)
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.
GMi
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Hofte - scan • 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
Beskriv – fortolk
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2. Lyske - hofteregion
MS ultralydsscanning
• tendionopati,
calcificationer, rupturer
• adduktorer
• symfyse
• hasemm.
• tuber
• bursitter
• lyskebrok
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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).
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Adduktor - ældre læsion
Adductor ruptur, forkalkning
Adductor ruptur, forkalkning
Adductor ruptur, væske + forkalkning
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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).
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Fremmedlegemer • muskel, underhud
– frit i væv
– indkapslede (granulom)
– vævsirritation
– evt. ansamling
– evt. bløddelslæsion
Glas - subcutant Glas - flere, intramuskulært
Træsplint – indkapslet, subcutant
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Lyske - scan A • adduktorer
– udspring, conjoint tendons, symfyse
– prox -> dist, langs/tværs
– struktur, fibre (sene mm.)
Beskriv – fortolk
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Tendino-/myopati
CT 3-D: Hamstring calcifications,
stress/overload induced
Hamstring calcification,
post traumatic (partiel lesion)
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Lyske - scan C • hasemm.
– tuber iscii (GMax inf.)
– semiT, biceps F, semiM
– prox. -> dist, langs/tværs Beskriv – fortolk
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
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Lymfeknuder – NB!
foreslå egen læge: henvisning til radiolog
metastase
blærecancer
Hodkin
lymfom
metastase
rectumcancer
metastase
blærecancer
lokal
infektion
lokal
infektion
De Gregorio Onc Gyn 2013
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Lyske - scan C • (hernie)
– kar arterie/vene (doppler, bugpresse)
– inguinalkanal annulus int./ext.
– bugpresse, stående
Beskriv – fortolk
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Lyske - scan • 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)
– kar arterie/vene (doppler, bugpresse)
– inguinalkanal annulus int./ext.
– bugpresse, stående
Beskriv – fortolk
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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