HIP X-RAY.pptx

Hip Xray with Pathologies

1. IMAGING OF HIP JOINT By Utkarsh Bhagat M.P.T Sem II

2. ANATOMY The hip joint is a ball and socket synovial joint, formed by an articulation between the pelvic acetabulum and the head of the femur. It forms a connection from the lower limb to the pelvic girdle, and thus is designed for stability and weight-bearing – rather than a large range of movement . <number>

3. NORMAL HIP X-RAY <number>

4. ANTEROPOSTERIOR VIEW If anteroposterior hip radiographs are taken in a supine position, one of the most common mistakes is image distortion as the hip is externally rotated1). Thus, either both patellae should be facing forward or lower extremities should be internally rotated by 15°-20° to accommodate femoral anteversion in anteroposterior hip radiographs <number> Callaghan JJ, Rosenberg AG, Rubash HE. The adult hip. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 349–391.

5. FROG-LEG LATERAL VIEW In the frog-leg lateral view, both sides are shown on one image and the knee joint is flexed 30°-40° in a supine position, while the hip is externally rotated by 45° so that the image is taken toward the middle of the line connecting the upper symphysis pubis and the anterior-superior iliac spine <number>

6. LÖWENSTEIN VIEW In the Löwenstein view, patient is turned onto the affected hip at least 45° with the hip flexion angle of 90° and internal rotation angle of 45° in a supine position and then images of each side are taken vertically from the groin region. <number>

7. CROSS-TABLE LATERAL VIEW In the cross-table lateral view, a lower extremity is internally rotated by 15°-20° in a supine position and then the hip and knee joints on the other side are flexed to prevent interference in radiographic projection; a cassette is positioned on the side of the hip at the right angle relative to the incidence angle, thereby projecting toward the groin region at 35°-45° of incidence parallel to the longitudinal axis of the femur <number>

8. FALSE-PROFILE VIEW False-profile view of the hip is obtained with the pelvis rotated 65° relative to the bucky wall stand, with the foot on the affected side parallel to the radiographic cassette. <number>

9. EVALUATION OF IMAGES <number> Lim, S. J., & Park, Y. S. (2015). Plain Radiography of the Hip: A Review of Radiographic Techniques and Image Features. Hip & pelvis, 27(3), 125–134. https://doi.org/10.5371/hp.2015.27.3.125

10. <number> Standard anteroposterior hip radiograph. The coccyx and symphysis pubis are in a straight line and are positioned in the middle line of the image; both sides of the iliac wings and obturator foramina are symmetric, while the distance between the superior border of the pubic symphysis and the tip of the coccyx is between 1 and 3 cm. The frog-leg lateral view can be taken multiple times in a similar position and makes is easy to evaluate the sphericity of the femoral head, joint congruency, and the shape and offset of the head-neck junction.

11. <number> Löwenstein view, it is easy to take radiographs of each side. In the cross-table lateral view, the greater trochanter is positioned posteriorly so that the femoral head-neck junction is well defined, but bony landmarks may not be clear in obese patients.

12. <number> In the false-profile view, the anterior coverage of the femoral head can be assessed. Leg length. Leg length difference is assessed by measuring the difference in distance between the most prominent part of the lesser trochanter and a parallel line connecting the teardrops.

13. <number> This is the angle formed by the longitudinal axis of the femoral shaft and the line drawn along the axis of the femoral neck, which passes through the center the femoral head. The normal range of the neck-shaft angle is between 125° and 140°. If the angle is either larger or smaller than this range, it is defined as coxa valga or coxa vara, respectively.

14. HIP JOINT PATHOLOGIES ON X-RAY <number>

15. HIP FRACTURES INTRACAPSULAR FRACTURES Femoral neck fractures can be described descriptively based the location of the fracture within the femoral neck or classified using the Garden or Pauwels classification. Thus, a femoral neck fracture located at the junction of the femoral head and neck is considered to be a subcapital fracture, while a transcervical fracture is located at the middle portion of the femoral neck. A basicervical fracture is located at the base of the femoral neck. The traditional Garden classification is divided into 4 types. Type 1 fractures are incomplete and valgus impacted, while type 2 fractures are complete. Type 3 fractures are partially displaced, and type 4 fractures are completely displaced. Type 1 : incomplete (so called abducted or impacted) – the femoral head in this case is in slight valgus. Type 2 : complete without displacement. Type 3 : complete with partial displacement – the fragments are still connected by the posterior retinacular attachment; the femoral head trabeculae are no longer in line with those of the innominate bone. Type 4 : complete with full displacement – the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned with those of the innominate <number> Lu, Y., & Uppal, H. S. (2019). Hip Fractures: Relevant Anatomy, Classification, and Biomechanics of Fracture and Fixation. Geriatric orthopaedic surgery & rehabilitation, 10, 2151459319859139. https://doi.org/10.1177/2151459319859139

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17. In Pauwels classification , type I fractures are less than 30°, type II fractures are between 30° and 50°, and type III fractures are greater than 50° <number>

18. AVASCULAR NECROSIS OF HIP Avascular necrosis of the femoral head is a type of osteonecrosis due to disruption of blood supply to the proximal femur. It can occur due to a variety of causes, either traumatic or atraumatic in origin. These causes include fractures, dislocations, chronic steroid use, chronic alcohol use, coagulopathy, congenital causes; among many others. This disease progresses through four stages: Initial/necrosis – when blood supply gets disrupted, and necrosis begins. Fragmentation – when the body resorbs the necrotic bone and replaces it with woven bone that is weak and prone to breaking and collapse. Reossification – when stronger bone develops. Healed/Remodeling – when bone regrowth is complete, and shape becomes finalized (whether normal or abnormal, depending on the damage done during the fragmentation phase). Stage I No changes are visible. Stage 2 Avascular areas are of normal or increased density, while immobile but vascular bone loses density. Stage 3 At large joints-hips, a subcortical necrotic zone of transradiancy and trabecular loss beneath a thin and sclerotic cortex. This results in structural failure in subarticular bone at areas of maximal stress with cortical microfractures followed by collapse and trabecular compression <number>

19. Stage 4 A flattened articular surface results with increased subarticular density as trabeculae are compressed. Stage 5 Osteoarthritis with joint space narrowing follows later. In the diametaphysis and subarticular regions, the infarcted area is surrounded by a serpiginous line of sclerosis. <number> Barney J, Piuzzi NS, Akhondi H. Femoral Head Avascular Necrosis. [Updated 2022 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

20. <number> Severe AVN of HIP Joint. Flattening of the femoral head and femoral head collapse (Involves greater than 30% of the femoral head).

21. TUBERCULOSIS OF HIP Tuberculous arthropathy is a type of musculoskeletal manifestation of tuberculosis (TB) and a common cause of infectious arthritis in developing countries. The primary causative organism is mycobacterium tuberculosis. The organism reaches the bone and remains dormant until recrudescence occurs. Any factor which modifies the state of local resistance and resultant activation of dormant tubercle bacilli, microtrauma has been proposed as a mechanism. The most common form of articular tuberculosis is spondylitis followed by arthritis of weight bearing joints (especially knee and hip 6). The spine is the most common site, followed by the hip joint, which constitutes approximately 15% of all cases. Tubercular arthropathy can be divided by radiological features into early and late stages: Early stages (stage of synovitis and arthritis) - radiographic features include Periarticular demineralization. Joint space widening (due to joint effusion). Mild subchondral erosion. <number> Mudgal, P., El-Feky, M. Tuberculous arthropathy. Reference article, Radiopaedia.org. (accessed on 25 Apr 2022) https://doi.org/10.53347/rID-27473

22. Late stages (stage of erosion and destruction) Gradual narrowing of joint space (there is involvement of articular cartilage). Severe subchondral erosion and destruction. Pathological subluxation and dislocation. Fibrous ankylosis - in contrast to pyogenic arthritis, the development of bone ankylosis is uncommon in tuberculous arthritis and, when present, is more likely to be secondary to prior surgical intervention. Atrophic changes in bones may occur and lead to atrophic arthropathy (seen in shoulder joint as carries sicca) <number>

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