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Differential Diagnosis/Imaging > Imaging of the Pelvis, Hip, and Knee > Flashcards

Imaging of the Pelvis, Hip, and Knee Flashcards

1
Q

Pathology of the hip and pelvis

A
  • Trauma
  • Metabolic disease: osteoporosis
  • Systemic disease
  • Nutritional deficiencies
  • Neoplasm
  • Infection: septic arthritis
  • Osteoarthritis
  • Operative studies: pre/post op
  • Congenital syndromes: developmental dysplasia (DDH)
  • Transient synovitis
  • Legg Calve Perthes
  • Slipped Capital Epiphysis
  • Snapping hip syndrome
  • Femoroacetabular impingement (FAI)
  • Vascular lesions
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2
Q

Imaging modalities

A
  • X-ray: fracture, dislocation, arthritides
  • CT: complex fractures, acetabular fractures, localization of fracture fragments
  • MRI: eval soft tissue injuries = labrum, articular cartilage, FAI, avascular necrosis
  • MSK US: DDH assessment in neonatal, snapping hip syndrome, effusion assessment, guide needle for aspiration
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3
Q

ACR guidelines for the hip and pelvis

A
  • Chronic hip pain
  • Avascular necrosis
  • Stress fractures
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4
Q

Diagnostic imaging pathway

A
  • Non traumatic hip pain
  • Suspected hip fracture
  • Avascular necrosis
  • Stress fracture
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5
Q

Guidelines for the hip and pelvis imaging

A
  • Trauma
  • Low energy: avulsions, individual bone fracture; AP view or oblique view
  • High energy: pelvic ring disruption; high speed CT scan for TAP series
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6
Q

Diagnostic pathway for non traumatic hip or knee pain

A
  • X-ray of affected joints
  • Cause of pain found or cause of pain uncertain
  • Further investigation or further investigation will depend on suspicion of a serious underlying disorder
  • Further investigation: Mild arthritis -> conservative management; Mod-severe arthritis -> referral to orthopedics
  • Suspicion of serious disorder: Fracture -> go to suspected hip fx or traumatic knee pain pathway; Bone metastases -> bone scan; Infection -> septic arthritis (joint aspiration & antibiotics) or osteomyelitis (go to suspected osteomyelitis pathway)
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7
Q

Diagnostic pathway for suspected hip fracture

A
  • X-ray = fracture seen or no fracture seen
  • Fx seen = treat; no fx seen = ongoing suspicion of fx?
  • No = stop; Yes = MRI
  • If yes other options include Bone scan and/or CT
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8
Q

Diagnostic pathway for suspected avascular necrosis (AVN) of hip

A
  • X-ray = normal/nonspecific changes or positive for AVN
  • Normal = further investigation based on level of suspicion; Pos. for AVN = appropriate treatment
  • Level of suspicion = low or higher suspicion
  • Low suspicion = stop; Higher suspicion = MRI (preferred) or Bone scan
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9
Q

Diagnostic pathway for suspected stress fracture

A
  • X-ray = Negative or Positive
  • Negative = Early imaging or Delayed imaging; Positive = Treat
  • Early imaging = 3 phase bone scan; Delayed imaging = repeat plain x-ray after 1 month
  • Bone scan = other options like MRI or CT; Repeat x-ray = appropriate management depending on imaging findings
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10
Q

Routine radiologic exam for the pelvis and hip

A
  • Pelvis: only one projection; AP view
  • Hip: requires 2 projections; AP, Lateral frog leg, and oblique (special)
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11
Q

Typical patient position for routine x-ray of the pelvis and hip

A
  • Central ray (CR) is perpendicular to the image receptor & directed midway b/w the levels of the anterosuperior iliac spine & symphysis pubis
  • LEs are internally rotated 15-20 degrees to place femoral neck plane parallel to the image receptor
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12
Q

When does the triradiate cartila and coxal epiphyses fuse

A
  • Triradiate Cartel fuse at about 17 years old
  • Coxal epiphyses may not fuse until our early 20s
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13
Q

Differences between adult male and female pelvis

A
  • Male: <90º pubic arch, narrower, less flared, oval or heart shaped inlet
  • Female: >90º pubic arch, adapted for childbirth, broader, round pelvic inlet
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14
Q

Describe Shenton’s hip line

A
  • It should be possible to draw a smooth curve along the medial & superior surface of the obturator foramen to the medial aspect of the femoral neck
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15
Q

Describe iliofemoral line

A
  • It should be possible to draw a smooth curve along the outer surface of the ilium that extends inferiorly along the femoral neck
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16
Q

Describe the femoral neck angle

A
  • Normal = 130º
  • Alteration of the femoral neck angle can indicate fracture
  • Angle is formed by the intersection of a line drawn through the center of the femoral shaft & a line drawn through the center of the femoral neck
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17
Q

What is the most common injury of the hip and most common cause of chronic hip pain

A
  • Injury: hip fracture
  • Chronic pain: hip OA
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18
Q

Differences between coxa vara and coxa valga

A
  • Coxa Vara = <130º (look like right angle); increased risk of femoral neck Fx & SCFE
  • Coxa Valga = >130º (looks like a line); increased risk of dislocation
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19
Q

Describe a false positive view and Dunn view

A
  • FP view: anterior coverage of the femoral head can be assessed; can diagnose CAM deformity
  • Dunn view: evaluates relationship of the femoral head & acetabulum
20
Q

Primar indicates for a CT scan of the hip/pelvis

A
  • Severe trauma
  • Assessment of alignment & displacement of fracture fragments
  • Identification of loose bodies in the joint
  • Evaluation of fractures of the acetabulum or sacrum
  • Evaluation of bony alignment or accurate measurements of bone geometry
  • Evaluation of any condition typically seen by MRI if MRI is contraindicated
21
Q

Describe a femoroacetabular impingement with labral tear

A
  • Signs & symptoms: snapping, clicking, limited hip ROM, & painful provocation tests
  • Imaging: pelvic/hip x-ray are assessed for osseous alignment & acetabular configuration; MRA is choice for visualizing labral tears
22
Q

Pathological conditions at the hip

A
  • DJD (degenerative joint disease)
  • RA (rheumatoid arthritis)
  • AVN (avascular necrosis)
  • Leg Calve Perthes Disease
  • Slipped capital femoral epiphysis (SCFE)
  • Developmental dysplasia (DDH)
  • Femoroacetabular impingement (FAI)
23
Q

X-ray hallmarks of DJD at the hip joint

A
  • Joint space narrowing
  • Sclerotic subchondral bone
  • Osteophyte formation at the joint margins
  • Cyst or pseudocyst formation
  • Migration of the femoral head
24
Q

Characteristics of RA at the hip

A
  • Osteoporosis of periarticular areas
  • Symmetrical & concentric joint space narrowing
  • Articular erosions, located either centrally or peripherally in the joint
  • Synovial cysts located within nearby bone
  • Periarticular swelling & joint effusions
  • Axial migration of the femoral head
  • Acetabular protrusion
25
Q

X-ray findings for AVN/aseptic necrosis

A
  • Initial stages of AVN may appear normal for several wks on x-ray
  • Sclerosis & cyst formation at the femoral head, signs of initial necrotic processes, & healing attempts taking place
  • Presence of a radiolucent present image, representing the collapse of the necrotic subchondral bone of the femoral head
  • In advanced stages the femoral head will collapse or appear flattened
26
Q

What are some causes of aseptic necrosis

A
  • Anemia
  • Steroids
  • Ethanol
  • Pancreatitis
  • Trauma
  • Idiopathic
  • Caisson’s disease
27
Q

Describe Caisson’s disease

A
  • Decompression sickness
  • Condition arising from dissolved nitrous gases coming out of solution into bubbles inside the body on depressurization
  • Results in impingement of the blood vessels
28
Q

Describe AVN of the femoral head

A
  • Interruption of blood supply to the femoral head resulting in bone tissue death
  • Signs & symptoms: nonspecific dull pain in joint or thigh, limited ROM, and progressive painful limp
  • Imaging: MRI is most sensitive for early diagnosis
29
Q

Describe Legg Calve Perthes disease

A
  • Necrosis of the epiphysis of the femoral head (7 y/o)
  • Most common between 4-8 yrs
  • Permanent deformity: osteoarthritis
  • Boys are 5x more likely than girls
  • Imaging: MRI is most sensitive for early diagnosis
30
Q

Symptoms of Legg Calve Perthes disease

A
  • Limping
  • Pain and stiffness in hip
  • Decreased ROM
  • Can lead to THA in adulthood
31
Q

Describe slipped capital femoral epiphysis (SCFE)

A
  • Most common adolescent hip disorder
  • Weakening of the epiphyseal plate allows for displacement
  • Decreased ROM & antalgic gait
  • Imaging: lateral frog x-ray best demos the amount of epiphyseal displacement
32
Q

Treatment of a slipped capital femoral epiphysis (SCFE)

A
  • Stable = closed fixation
  • Unstable = open fixation
33
Q

Describe developmental dysplasia (DDH)

A
  • A malformation of the hip in young children beginning to walk
  • Etiology: genetic, hormonal, & mechanical factors
  • Usually affects the left hip, more prominent in girls, & has a familial tendency
  • Risk factors include firstborn children & children born in a breech position
34
Q

Stable versus unstable pelvis fractures

A
  • Unstable = ≥2 articulation sites on the pelvic ring are disrupted
  • Stable ischiopublic ramus fractures comprise half of all pelvic fractures
35
Q

Describe acetabular fractures and proximal femoral fractures

A

Acetabular Fx: most common at the posterior column/rim of the cup; associated with femoral head impaction or posterior dislocation
- Proximal femoral Fx: intracapsular often complicated by vascular disruption = AVN; extracapsular = vascular complication is rare

36
Q

Describe the importance of clinical exam to detect fracture

A
  • In stable/alert trauma patient, a thorough clinical examination will detect pelvic fractures with nearly 100% sensitivity
37
Q

Clinical exam to detect fracture in the hip/pelvis

A
  • All must be present = initial radiograph unnecessary
  • Age >3 yrs
  • No impairment of consciousness
  • No other major distracting injuries
  • No complaint of pelvic pain
  • No signs of fracture on inspection
  • Painless compression of iliac or pubic symphysis
  • Pain free hip rotation & flexion
38
Q

Stable pelvic fractures include

A
  • Avulsion fractures of the ASIS, AIIS, or ischial tuberosity
  • Iliac wing fracture
  • Sacral fractures
  • Ischiopubic ramus fracture
39
Q

Widening of the pubic symphysis greater than _____ is considered abnormal

A
  • greater than 1 cm is considered abnormal
40
Q

Signs and symptoms of a pubic ramus stress fracture

A
  • History of overuse
  • Relief with non-weight bearing
  • Insidious in nature
  • Local pain, tenderness, swelling
  • Typical site in the pelvis is the pubic ramus
  • Bone scan is diagnostic early
41
Q

Describe an acetabulum fracture

A
  • Anterior column fractures
  • Posterior column fractures: most common, hip precautions
  • Protected weight bearing
42
Q

Describe a femoral neck stress fracture

A
  • Signs & symptoms: gradually worsening pain in back, hip, or groin related to weight bearing activities, pain at extremes of passive external & internal rotation
  • MOI: fatigue stress fractures may develop in runners & military trainees owing to increased duration, frequency, & intensity of weight bearing activities imposed on normal bone; Insufficiency stress fractures may develop in the osteoporotic elderly female or females with the female athlete triad (disordered eating, menstrual dysfunction, premature osteoporosis)
  • Imaging: MRI is most sensitive & performed if immediate diagnosis ir required
43
Q

Red flags for colon cancer

A
  • Age >50 yrs
  • Bowel disturbances
  • Unexplained weight loss
  • Hx of colon cancer in immediate family
  • Pain unchanged by positions or movement
  • Possible tenderness to palpation of abdomen in area of colon
44
Q

Red flags for pathologic fracture of the femoral neck

A
  • Older women (>70 yrs) with hip, groin, or thigh pain
  • Hx of a fall from standing position
  • Severe constant pain, worse with movement
  • Shortened & externally rotated LE
45
Q

Red flags for osteonecrosis of the femoral head (aka AVN)

A
  • Hx of long term corticosteroid use
  • Hx of osteonecrosis of the contralateral hip
  • Trauma
  • Gradual onset of pain, may refer to groin, thigh, or medial knee that is worse with weight bearing
  • Stiff hip joint, primarily limited in IR & flexion
46
Q

Red flags for Legg Calve Perthes disease

A
  • 5-8 yrs boys with grain/thigh pain
  • Antalgic gait
  • Pain complaints aggravated with hip movement especially hip ABD & IR
47
Q

Red flags for slipped capital femoral epiphysis (SCPE)

A
  • Overweight adolescent
  • Hx of a recent growth spurt or trauma
  • Aching in groin exacerbated with weight bearing
  • Involved leg held in ER
  • ROM limited in hip IR

Differential Diagnosis/Imaging (20 decks)

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