1. Ultrasound examination of the hip joint.
Dr/ ABD ALLAH NAZEER. MD.

2. ANTERIOR HIP
•sartorius and tensor fasciae latae muscles
•rectus femoris muscle
•iliopsoas muscle
•femoral neurovascular bundle
•coxo-femoral joint
MEDIAL HIP
• adductor tendons and muscles
LATERAL HIP
• gluteus tendons and muscles
POSTERIOR HIP
ischio crural tendons (hamstrings)
sciatic nerve.
The hip joint anatomy can be subdivided into four
compartments, each of those including a group of
structures that are extremely important for hip stability.

3. The ultrasound scan shows the tendinous insertions of sartorius (Sa) and
tensor fasciae latae (TFL) muscles on the antero-superior iliac spine (SIAS).

4. The axial scan shows the tendinous insertion of rectus femoris (arrowheads)
into the SIAI. Ps= iliopsoas muscle; SIAI= Anterior-Inferior Iliac Spine

5. The ultrasound scan shows the tendinous insertion of rectus
femoris (arrowheads) onto the AIIS. RF= muscle belly of rectus
femoris ; Ps= psoas muscle; SIAI= Anterior-Inferior Iliac Spine.

6. Axial evaluation of direct (arrowheads) and indirect (asterisk)
tendons of rectus femoris muscle. Sa= sartorius; F= femur.

7. The axial scan shows the distal tendinous aponeurosis (arrowhead) of rectus
femoris muscle (RF) shaped like a "C". Vi= vastus intermedius muscle; F= femur.

8. The axial scan shows the femoral neurovascular bundle: femoral artery
(Af), femoral vein (Vf) and femoral nerve (Nf). Pe= pectineus muscle

9. The scan shows the femoral head (F) covered by the articular
cartilage, the acetabulum (Ac), the acetabular labrum (asterisk), and
the anterior capsular profile (empty arrowheads). Ps= psoas muscle.

10. The longitudinal scan shows the tendon insertion (asterisk) of
adductor longus (AL), adductor brevis (AB) and adductor magnus
(GA) muscles in correspondence of the pubic symphysis.

11. The axial scan shows the tendinous insertion of gluteus
minimus (asterisk). medius @ and maximus # into the femoral
greater trochanter (GT). Arrowheads= tensor fasciae latae tendons.

12. Coronal Scan Plane. The gluteus minimus and medius
insert into the greater trochanter.

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

14. The longitudinal scan shows the tensor fasciae latae tendon
(arrowheads) superficial to the greater trochanter (GT).

15. The axial scan shows the tendinous insertion of long head of biceps femoris (1),
semitendinosus (2) and semimembranosus (3) muscles. Ti= ischiatic tuberosity.

16. The longitudinal scan shows the tendinous insertion (asterisk) of semitendinosus
(St) and semimembranosus (Sm) into the ischiatic tuberosity (Ti).

17. The axial scan shows the sciatic nerve, according to its short-axis.

28. Ultrasound is a valuable diagnostic tool in
assessing the following indications;
Developmental dysplasia of the hip
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 e.g solid, cystic, mixed
Post surgical complications e.g abscess, edema
Guidance of injection, aspiration or biopsy
Some boney pathology.

29. Developmental Dysplasia of the Hip (DDH).
Developmental dysplasia of the hip is an abnormal formation of the hip
joint in which the ball at the top of the thighbone (femoral head) is not
stable in the socket (acetabulum). The hip is a ball and socket joint, and
dysplasia can refer to a hip that is subluxatable (unstable if stressed),
dislocatable (can come out of socket under stress), or currently dislocated.
The severity of instability or looseness varies in each patient. Newborns
and infants with DDH may have the ball of his or her hip loosely in the
socket, or the hip may be completely dislocated at birth. Developmental
dysplasia of the hip (DDH) may occur during fetal development, at
delivery, or after birth.
Causes Hip Dysplasia/DDH? The exact cause of DDH is unknown, but
research has discovered several theories and risk factors for hip dysplasia.
The four F's of DDH:
First born
Female
Foot First (breech)
Family history

30. Hip ultrasounds are used to detect DDH in
newborns and young infants. The ultrasound can
accurately determine the stability of the hip joint,
and can be useful in the diagnoses and
management of DDH. By using high frequency
sound waves, there is no risk of radiation exposure
to the baby. Because many of the bones making up
the hip joint are made of soft cartilage, not hard
bone, plain x-rays are generally not helpful until
the baby is 5-6 months old. Ultrasound enables
direct imaging of the cartilaginous portions (bones
that are not yet ossified) of the hip that cannot be
seen on plain radiographs.

31. Morin index.
Schematic representation of Graf classification.

32. Graf classification

33. Anatomic schematic interpretation of the standard coronal plane.
S, superior planes; L, lateral(superficial)planes; FH, femoral head.

34. Coronal view. c- capsule; G- gluteus
muscles; H- cartilaginous femoral head; IL
– ilium: IS- Ischium; L- labrum; LT-
ligamentum teres; Tr-triradiate cartilage.
Morin Index - In this infant the Morin
index is normal (10/16.6 60%).

35. Measure of α and β angles – type I hip.
Schematic and ultrasound coronal scan
with alpha and beta angle calculation.

36. Coronal ultrasound image of the left hip. Normal type I hip (alpha angle > 60 degrees).

37. Normal mature hip. Type Ib according to Graf (α= 65°, β= 74°); angular bony promontory
(arrow); IL, ilium; TC, hypoechoic triradiate cartilage; 1, Baseline; 2, acetabular roof line; 3,
Labral line; (*), hyaline cartilage of the acetabular roof; (+), labrum.

38. A, B. Same hip.
Physiological immature
hip, appropriate for age.
Type IIa(+) according to
Graf (α= 55°, β= 77°);
rounded bony promontory
(arrow); FH, femoral head;
GT, great trochanters; IL,
ilium; TC, hypoechoic
triradiate cartilage; 1,
Baseline; 2, acetabular
roof line; 3, Labral line;
(*), hyaline cartilage of
the acetabular roof; (+),
labrum.

39. Coronal ultrasound image of the left hip. Type IIa hip (alpha angle of 50-59 degrees).

40. Critical hip. Type IIc according to Graf (α= 44°, β= 74°); Rounded or flattened bony
promontory; FH, femoral head; GT, great trochanters; TC, hypoechoic triradiate cartilage.

41. Coronal ultrasound image of the right hip. Type III with
decentering of the femoral head (alpha angle < 43 degrees).

42. Graf type IIIb (α= 34°, β= 123°).

43. Graf type IV

44. Type IV hip – the femoral head is totally out the
acetabular cup and is not aligned with the acetabulum

46. Joint Effusion:
Inflammatory joint diseases, such as rheumatoid arthritis and septic arthritis,
are often accompanied by joint effusion. In healthy adults on the other hand hip
joint effusion is very uncommon. The prevalence in less severe, or early stage
hip disorders is, however, not well documented. We neither know which
symptoms nor signs in early or less severe hip disorders relate to joint effusion.
Ventral Hip sonography: Depiction of the right and left hips in comparison:
obvious echo-free joint effusion on the left with distancing of the capsule

47. Coxitis with an
effusion in the
anterior recess
and slight
hypervascularity.

48. Irritable hip on the right side with effusion in the anterior recess of the hip.

49. Hip joint effusion and minimal synovial thickening.

50. Trochanteric bursitis is inflammation of the bursa (a small, cushioning sac
located where tendons pass over areas of bone around the joints), which lies
over the prominent bone on the side of your hip (femur).
The superficial trochanteric bursa is located over the greater trochanter. This
is the most commonly inflamed bursa. A deep trochanteric bursa lies deeper
and can become inflamed in more severe cases.
Causes Trochanteric Bursitis?
The trochanteric bursa may be inflamed by a group of muscles or tendons
rubbing over the bursa and causing friction against the thigh bone. This injury
can occur traumatically from a fall or a sport-related impact contusion.
It can also be a case of gradual onset via a repetitive trauma to the bursa
from such activities as running (with poor muscles control or technique),
walking into fatigue, or cycling, especially when the bicycle seat is too high.
It is also a secondary injury associated with chronic conditions such as:
Scoliosis - curvature of the spine
Unequal leg length
Weak hip muscles
Osteoarthritis (degenerative joint disease) of the hips or lower back
Calcium deposition in the gluteal tendons that run over the bursa
Rheumatoid arthritis.

51. Effusion in the anterior recess and filling of the iliopsoas bursa.

52. Iliopsoas bursa.

53. Iliopsoas bursitis with large fluid filled bursa.

54. Iliopsoas bursitis with increased vascularity of the bursal wall.

55. Iliopsoas bursitis with a large iliopsoas bursa with thickened synovium in a patient with a hip prosthesis.

56. Irritable hip – transient synovitis and reactive arthritis
Irritable hip or transient synovitis (TS) is the most common cause of hip pain in
the pediatric patient. TS . and reactive arthritis. are both benign, self limiting
conditions. The temperature is usually normal or slightly raised, white cell
count (WCC) and erythrocyte sedimentation rate (ESR) are normal or close to
normal. Treatment is rest and analgesia. The addition of an anti-
inflammatory may speed recovery. Usually these conditions follow a recent
viral illness in particular an upper respiratory tract infection (URTI).
Transient synovitis; hypoechoic effusion without hyperemia.

57. Patient with transient synovitis. Sagittal US image shows the superior articular
recess (SAR) effusion (A) with small particles floating in the effusion (B).

58. Reactive arthritis, often bilateral.

59. Infectious arthritis is a painful infection in the joint. It may also be referred to
as septic arthritis. It occurs when an infection, caused by a bacteria or virus,
spreads to a joint or the fluid surrounding the joint (synovial fluid). This
infection usually begins in another area of the body and spreads through the
bloodstream to the joint tissue. The infection may also enter the body through
surgery, open wounds, or injections. Infectious arthritis usually only occurs in
one joint. Most often, the joint affected is a large joint such as the knee, hip,
or shoulder. It occurs more often in children and older adults.
Symptoms of infectious arthritis can vary depending on the individual’s age,
as well as the medications the individual is taking. Symptoms may include:
severe pain that worsens with movement
swelling of the joint
warmth and redness around the joint
fever
chills
fatigue
weakness
decreased appetite
rapid heartbeat
irritability

60. Septic arthritis in the neonate
Premature infants are at risk of infection. Regular intervention, in
particular vascular access lines increases the risk of introduced
infection. Premature babies have an immature immune system
and do not exhibit obvious signs of sepsis. The prevalence of MRSA
is increasing in hospital intensive care units. Neonates in intensive
care units with septic arthritis are more likely to have MRSA
infection than non-MRSA. Bony destruction can occur quickly. with
a worse outcome than those with non-MRSA infection, due to the
limited range of antibiotics effective in treating an MRSA infection
and the relatively late presentation.
Disruption of the epiphysis leads to arrest of growth of the upper
femur with resultant leg length discrepancies Destruction of the
head of femur leads to life long joint deformity. Early identification
of joint sepsis aids early aggressive management, which increases
the chance of retaining the use of the joint and limb.

61. Septic Arthritis of the right hip joint. Septations are seen within the fluid.

62. Pyorthritis of left hip joint.

63. Destruction of head of femur of left hip due to MRSA septic arthritis.

64. Septic arthritis with destruction of the head of the right hip and femur.

65. Juvenile idiopathic arthritis
Hip involvement in juvenile idiopathic arthritis (JIA)
tends to be bilateral and develops in 30–50% of
children suffering from JIA. It is uncommon to have
hip monoarthritis. Clinical examination and history
usually suggest the diagnosis.
Ultrasound may show a joint effusion and
thickened synovium. These changes and other
findings of joint destruction are often better seen
on MRI or plain radiographs. Ultrasound can be
used for image-guided intra-articular steroid
injections.

66. Bilateral JIA with effusion.

67. Juvenile idiopathic arthritis with thickened synovium and joint effusion.

68. Hemoarthrosis of left hip joint.
Hemoarthrosis is bleeding into a joint. It often causes inflammation and pain.
Hemoarthrosis is more likely to occur in people with bleeding disorders, such
as hemophilia (a rare inherited condition), or in those who use blood-thinning
medication, such as warfarin. It also can develop after an injury to a joint
when blood vessels in the joint are also injured.

69. Hemoarthrosis of left hip joint.

70. Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the
adolescent hip. It is not rare. For reasons that are not well understood, the
ball at the upper end of the femur (thigh bone) slips off in a backward
direction. This is due to weakness of the growth plate. Most often, it
develops during periods of accelerated growth, shortly after the onset of
puberty.
The cause of SCFE is unknown. It occurs two to three times more often
in males than females. A large number of patients are overweight for their
height. In most cases, slipping of the epiphysis is a slow and gradual
process. However, it may occur suddenly and be associated with a minor
fall or trauma. Symptomatic SCFE, treated early and well, allows for good
long-term hip function.
Ultrasonography show in recent slipped epiphysis the ultrasound image
revealed a step at the anterior physeal line(mean 6.4 mm), diminished
distance between the anterior acetabular rim and the femoral
metaphysis(mean 4.3 mm), and an joint effusion. As metaphyseal
remodelling progressed the physeal step decreased. The femoral neck
appeared straighter in hips which has been symptomatic for longer than
three weeks.

71. Slipped capital epiphysis
with effusion in the
anterior recess

72. Slipped capital femoral epiphysis with joint effusion and posterior displaced epiphysis.

73. Slipped capital femoral epiphysis with joint effusion and posterior displaced left epiphysis.

74. Slipped capital femoral epiphysis with joint effusion and posterior displaced left epiphysis.

75. Legg-Calve Perthes’ disease
Legg-Calve Perthes’ disease is an idiopathic avascular necrosis
(AVN) of the hip joint. The peak incidence of LCP is between four
and eight years of age with boys being effected more than girls.
Recently LCP disease has been reported in children younger than
two years of age and must be a differential diagnosis in any hip
pain investigation of young children. Trauma to the hip joint can
cause increased intra-osseus pressure and compression of blood
vessels, this may lead to avascular necrosis. In advanced disease,
radiographs will display the classic picture of a reduced height
head of femur with fragmentation. In early LCP the radiograph
may be normal. A joint effusion may accompany LCP. An
underlying pathology should be suspected when a sustained
effusion is present.
In early LCP the head of femur may exhibit slight irregularity.
The treatment for LCP, especially when diagnosed early, is rest.

76. Hip effusion.
Comparison of both heads of femur
demonstrates irregularity of left head of
femur (LCP) as well as a joint effusion.

77. Hip effusion.
Appreciation of possible head of
femur irregularity more obvious
in comparison to normal hip.

78. Ganglion of the hip
is rare, or at least is rarely
recognized. Embedded in
muscles and covered by the
femoral vessels and nerve, its
hidden location accounts for
the diagnostic difficulties
which can cause varied clinical
presentations.
Ultrasonography, computed
tomography (CT), and
magnetic resonance imaging
(MRI) help to rule out more
frequent disorders of this
region, but in some cases it is
still detected only by surgery.

79. Right groin mass in a middle-aged woman with no recent history of trauma or instrumentation. (a, b)
Color (a) and spectral (b) Doppler US scans are suggestive of venous flow (solid arrow in a) within a
cystic right groin mass a provisional diagnosis of venous pseudoaneurysm was made

80. Thank You.