II. Images

III. Preparation: Ultrasound

  1. Low frequency (5 MHz) curved array probe
  2. Depth: Start at 9-10 cm

IV. Technique: Anterior Hip in Long Axis (LAX) and Hip Arthrocentesis

  1. Indications
    1. Differentiates hip effusion (intracapsular) from Iliopsoas Bursitis (extracapsular)
    2. Best image to guide Hip Injection or aspiration (broad femoral neck as target)
  2. Positioning
    1. Patient supine with hip in neutral position (hip exposed to inguinal ligament)
      1. Internal rotation of hip and knee flexion may aid visualization of small hip effusions
      2. Slight external rotation may help to visualize other structures
    2. Ultrasound linear probe in line with femoral neck (perpendicular to mid-inguinal ligament)
      1. Palpate femoral artery and probe is placed lateral to this position
    3. Ultrasound probe indicator toward Umbilicus
  3. Images
    1. usHip_antFemHeadNeckLax.png
  4. Components
    1. Iliopsoas Muscle (overlying hip)
      1. Overlies all deeper structures
    2. Acetabulum of hip (screen left)
      1. Bright, hyperechoic
    3. Femur with overlying capsule
      1. Extra-capsular space (Iliopsoas bursa)
      2. Joint capsule
        1. Linear band follows femoral head and concave over femoral neck
        2. Hyperechoic due to contained iliofemoral and pubofemoral ligaments
      3. Intracapsular space
        1. Increasing depth (and convex expansion of the space) suggests Hip Joint effusion
        2. Normal depth: 5 mm or within 1-2 mm of intracapsular space depth of opposite hip
        3. Abnormal depth >8-9 mm
      4. Bone
        1. Femoral head
          1. Rounded, convex
        2. Femoral neck
  5. Arthrocentesis
    1. Prepare skin
      1. Mark landmarks (but also performed under Ultrasound guidance)
      2. Antiseptic (e.g. Chlorhexidine)
      3. Local Skin Anesthesia (and along intended track) with Lidocaine 1% with Epinephrine
    2. Aspirate joint
      1. Spinal needle (3.5 inch, 20 gauge) advanced under Ultrasound guidance toward fluid pocket

V. Technique: Anterior Hip in Transverse or Short Axis (SAX)

  1. Indications
    1. Confirms hip effusion (intracapsular)
  2. Positioning
    1. Patient supine with hip in neutral position or slight external rotation (hip exposed to inguinal ligament)
    2. Probe in short axis with approximately 20 degrees angulation (probe indicator toward iliac crest)
      1. Probe rotated 90 degrees from the long axis view used above
  3. Images
    1. usHip_antFemHeadSax.png
  4. Components: Superficial
    1. Femoral artery
    2. Femoral vein
    3. Iliopsoas Muscle (position at mid-screen, over-lies femoral head)
    4. Rectus Femoris Muscle
  5. Components: Deep to Iliopsoas Muscle
    1. Joint capsule
    2. Intracapsular space
    3. Femoral head

VI. Technique: Lateral Hip at Trochanteric Bursa

  1. Indications
    1. Evaluates Trochanteric Bursitis (Gluteus Medius bursa)
    2. Directs trochanteric bursa region injection (typically tendonosis rather than the actually rare Bursitis)
  2. Positioning
    1. Patient lies on their side (decubitus)
  3. View 1: Long Axis (LAX)
    1. Positioning
      1. Ultrasound probe in long axis overlying greater trochanter
      2. Ultrasound beam tilted slightly anteriorly
        1. Better demonstrates IT Band interface
        2. Gluteus minimus attachment at anterior facet
      3. Ultrasound beam tilted slightly anteriorly
        1. Gluteus medius attachment at lateral facet
    2. Components
      1. Gluteus Maximus and Iliotibial Band (superficial)
      2. Joint capsule
      3. Femoral Greater Trochanter
  4. View 2: Short Axis (SAX, transverse)
    1. Positioning
      1. Ultrasound probe in short axis overlying greater trochanter (probe turned 90 degrees from above)
    2. Images
      1. usHip_latGreatTrochSax.png
    3. Components: Deep
      1. Anterior facet of Greater trochanter
        1. Appears similar to the front facing side of half dome (Yosemite)
        2. Gluteus minimus attaches at anterior facet
      2. Lateral facet of Greater trochanter
        1. Appears similar to the back side of half dome (Yosemite)
        2. Gluteus medius attaches at lateral facet

VII. Technique: Posterior Hip at Piriformis Muscle

  1. Indications
    1. Piriformis injection in Sciatica (or Piriformis Syndrome)
  2. Positioning
    1. Patient supine
    2. Ultrasound probe
      1. Start transverse (short axis) at posterior superior iliac spine (overlying SI Joint)
        1. Probe is oriented slightly oblique (higher on Sacrum than Pelvis)
      2. Slide probe inferiorly (caudal)
  3. Images
    1. usHip_postPiriformis.png
  4. Components
    1. Gluteus maximus Muscle
      1. Superficial, hypoechoic, large
    2. Piriformis Muscle
      1. Deeper, more hyperechoic, small
      2. Tapers laterally and inserts on greater trochanter
      3. Identify piriformis Muscle dynamically by rotating foot internally and externally while Ultrasounding
    3. Sciatic nerve
      1. Immediately deep to piriformis Muscle

VIII. References

  1. Moore (2010) Hip and Spine Ultrasound Video, GCUS
  2. Moore (2016) Musculoskeletal Ultrasound Course, Gulf Coast Ultrasound, St. Pete's Beach, FL

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