Transcript
- This meeting is being recorded.
Welcome everyone to the webinar.
We're just gonna give it a minute
to let everyone in the room.
Okay, great. Welcome to our webinar on examining hip anatomy
and structure with point of care ultrasound
on the anterior hip.
Before we begin, please be advised
that all attendees are muted.
You may type your questions into the q
and a box in the toolbar located at the bottom
or side of your screen at any time.
We will conduct the q and a session at the
end of the presentation.
This webinar will be recorded
and archived for future reference.
Our present presenters today are Daniel Shelton
and Bill Medford.
Daniel Shelton is the director
of musculoskeletal market development
for Fujifilm Sono site.
Daniel spent 16 years
as a dedicated musculoskeletal sonographer
and 10 of those years here have been here at SonoSite.
He now leads musculoskeletal market development
where he works to spread the word about the benefits
of point-of-care ultrasound.
Bill Medford is the lead musculoskeletal specialist
for Fujifilm SonoSite with 40 years of experience
as a sonographer, including 22 specializing
musculoskeletal sonography.
Bill is an expert in using point
of care ultrasound across the breadth
of musculoskeletal specialties.
We'll now turn the time over to Daniel
and Bill to present on the anterior hip.
- Thank you Laura. Welcome everybody to this webinar.
We're excited to have you all here.
So when, when we discuss the hip, a lot
of my reference is going to be
to information gathered from the American Institute
of Ultrasound and Medicine Practice Parameters.
You see the website listed here
and you can go to just simply iu.org
and browse through to find these practice parameters.
Very useful information as you go about
performing ultrasound of the hip or any other joint
or musculoskeletal exam that you might perform.
Our objectives today will be we, well,
one thing we just discussed, the performance guidelines
where you can get those from a brief reminder
of the importance of Antio atropy and
and the importance of being familiar
with this physical principle as it relates to understanding
some of the appearances you might encounter.
We'll discuss today the anterior hip anatomy
with live demo from Daniel.
I will go through some,
a few anatomical components of the hip.
We'll then turn it over to Daniel
and come back to me for the remainder of the talk.
Future sessions on the hip will cover
lateral, medial
and posterior hip, so we'd like to encourage you
to participate in the dates that we're,
we've got scheduled.
I think the medial hip is actually scheduled now
for the 12th of December.
We'll review PA patient transducer position
and technique for image optimization
and anatomical presentation.
Some of the more common indications
for diagnostic ultrasound examination of the hip
included suspected tendon
or muscle injury tendinopathy,
hip effusion or
synovitis snapping hip.
And this is a dynamic exam.
Ultrasound obviously offers that feature
that no other imaging modality can offer.
Suspected labral abnormalities
where we might see a paralabral fluid collection,
or in fact occasionally we can recognize tears
of the acetabular labrum on in the anterior hip.
We can look at nerve pathologies and entrapment.
We'll talk a little bit
and Daniel will demonstrate how to look at
and the surrounding anatomy
of lateral femoral cutaneous nerve pseudo tumors.
In particular with regard to post-op hip replacement,
we can look at hernia with ultrasound.
This is a subject that we probably won't cover much today.
We'll cover a little bit more when we go to the medial hip
and a topic really unto itself for future webinars.
We can look for examples of bursitis in the
ilio SOAs bursa evaluation of soft tissue mass
and characterizing its solid or fluid filled nature
and where it might be coming from.
Is it muscle or is it tenderness or is it bone?
And also I, which I didn't include in here,
oftentimes it's just confirming the normal appearance of sus
of structures that may have suspect suspected abnormalities
of transducers
that we might use in assessing the hip would include the
curve transducer for greater depth of penetration,
a linear array transducer frequency of 15 megahertz
to four megahertz.
For our thinner patients, we might be able to reach all
of the anatomy that we need to see with this transducer.
And for very superficial imaging, the exquisite
image clarity that can be achieved when you advance
to frequencies as high as 19 megahertz.
The anatomy we'll cover today, first
and foremost, are the bony landmarks that are important
to be able to identify rectus fems,
both the direct head
and reflected head, the iliofemoral ligament
or the capsule, the acetabular labrum,
the anterior joint space
or the anterior hip recess, the ilio SOAs muscle
and tendon, the sartorious insertion
and tendon.
We'll also cover a little bit about the lateral femoral
cutaneous nerve.
While we're up discussing the sartorious insertion as that's
where you might want to direct your attention
and identification of the lateral femoral cutaneous nerve,
our key bony acoustic landmarks include the anterior
superior iliac spine,
the anterior inferior iliac spine, the acetabulum,
the greater trocanter, the femoral head
and neck, the lesser TRO candor,
and the superior pubic ramus.
Let's begin with look in terms of
describing our soft tissue anatomy with the rectus femes,
the direct head, and the reflected head,
when we're looking at the direct head,
our bony acoustic landmark is going
to be the anterior inferior iliac spine where it inserts.
At this level, we will see the direct head coming in
and inserting directly onto the A IIS.
We'll see this fibrillar pattern associated with tendons
and we'll follow it to the musculo tendinous junction.
The reflected head, conversely will be identified
where it splits from the direct head
by this characteristic acoustic shadow,
which reflects sound being reflected off this deep diving
tendon with careful tracking,
the indirect head can be followed
to its insertion onto the superior acetabular labrum
or onto the superior lateral acetabulum.
The ileal femoral ligament is the strongest ligament in the
body, plays an important role in joint stability
and serves to prevent hyperextension.
It attaches proximally
between the anterior inferior iliac spine
and the acetabular rim.
It then bifurcates to an inverted y shape
before inserting distally
at the interrater line of the femur.
It blends with the joint capsule
and is deep to the ileal femoral ligament
where we locate the anterior hip joint recess
for recognition of effusion and localization for injection.
Also to be mindful of are the neurovascular structures
and close proximity here, more anterior of course,
but always important to be aware
of the common femoral artery, common femoral vein and
or common femoral nerve and
and vein
visualization of the ileal femoral ligament requires first
that we line up our boning acoustic landmarks beginning
with the acetabulum in the femoral head.
So here we see the acetabulum, see the rounded femoral head.
We see the insertion of the ileal femoral ligament
and the capsule as it courses over the top
of the femoral head and proceeds distally.
After achieving this alignment, the distal end
of the transducer is fanned laterally
and this will align the femoral head
and neck where we will see the distal insertion at the
intertrochanteric line.
So this is where we will begin again in review
to line up the acetabulum in the femoral head.
And the second transducer placement will be
to fan the transducer out laterally
to line the femoral neck up.
And then it is deep at the femoral head neck junction
where we will deliver our corticosteroid injections.
To visualize the anterior labrum,
the transducer transducer is positioned in the longitudinal
or sagittal body plane.
As we see here, the fibro cartilaginous labrum will appear
as a brightly eCOA triangular shape structure, interposition
that between the underline femoral head
and the overline iliofemoral ligament.
At this point I want to remind everybody a little bit
of anti atropy.
We're going to be talking next about the ileal
SOAs tendon as it as it proceeds down
to its insertion on the lesser trocanter.
So anti atropy is a reminder as loss of reflectivity
to the transducer due to an off perpendicular sound beam.
The normal tendon appearance depends on that incident angle
of the beam being perpendicular to the tendon.
So it represents a potential pitfall
because it can mimic a focal area of tendon injury
and it can reduce or prevent visualization of intra
or peri tendonous pathology.
So here we see an example of an atrophy
as we look at the bicep tendon up in the bicipital groove,
and we notice that as the transducer becomes off angle,
off perpendicular to the tendon, that it becomes hypoechoic,
which can mimic the presence of fluid.
Daniel, I'll come back to the ilio soaz tendon
after you demonstrate the anatomy we've just talked about.
- Great, thank you Bill. There we're
Thank you everybody for joining.
Today we're going to be scanning
with the new sono site PX ultrasound system.
We'll begin on the anterior hip
with the L 15 four transducer.
As we progress through, we will switch back and forth.
You saw some curve linear images, depending on the size
of your patient, it is, it is necessary to drop
to a curve linear your patient to transducer.
Today we don't have that problem,
but I do wanna show you the difference in the images.
So I will be switching slightly back and forth.
And then as we get over
to the lateral femoral cutaneous nerve later in the
presentation, we'll also be talking about the L 19
transducers ability to,
to image the lateral femoral cutaneous nerve much easier.
So first things first, we'll go ahead
and get everything situated and exposed.
When you are ultrasounding the hip, it's very important
to be mindful of your patient's modesty.
Okay, so we've, we've discussed this on the learning
institute with another presentation with Dr.
Gary Chimes, and it is very important to know
that you disclosed to your patient
that we're gonna be exposing basically the swimsuit line
and, and we won't be going any further medial
unless we tell them that we're going to need to.
So clinically, I have found that to be relevant to go ahead
and, and disclose so that nobody gets embarrassed.
There is a palpation point, the A SIS
that was mentioned in the presentation here,
and I'm gonna, I'm gonna just place three
fingers right under the A SIS.
So here's a SIS here, three fingers,
and then our hip joint is left roughly right here.
So bottle of gel.
All right, so three, this is the kind
of a scanning pearl palpating, a SI S3 fingers down
and gonna be pointing slightly lateral
with the transducer orientation.
So little disclosure here, I am a lefty
and in the studio here for the camera setup, I've opted
for a left hip and I know that the presentation was,
was largely centered around the right hip.
So just know from the camera's perspective things are
gonna look a little bit different.
But screen left is distal screen right is proximal
and I'll, I'll try to keep that in
mind when we're scanning here.
So as as mentioned
before, a SIS is this very, very superficial structure here,
top of the screen, this first bony acoustic landmark here.
And I'm just gonna follow this shadow down to ileum
until I see another acoustic landmark, which is just,
it's not even the length of the transducer down,
that's a IIS the, the origin of our direct head
of the rectus femes, as Bill mentioned in his
slides, is right here.
So what I'm gonna do is just pan the transducer medially
and laterally across that origin.
Okay, so here's this nice smooth origin
and this is how it should look.
And then we're just gonna keep panning across
until we might see some little bony defects.
In this case, our, our patient today a former soccer player
and an avid runner.
We may see some small microcalcifications
at the, at the origin in the form of
what could be pull lesions
or tendinosis, early stages of tendinosis.
So what we're gonna do now is follow this broad tendon here,
pro more distally.
And you can see the myo tendinous junction starting to form
of the direct head of the rectus.
If I am to pull the transducer slightly more laterally,
what you're gonna notice is that that shadow formation
starts to occur that bill mentioned.
So more medially, you don't quite see it as as prominent,
but it's when you start panning the transducer laterally
that we start to see this vertically oriented shadow
of an isotropic artifact.
And that's not fluid. Don't put a needle in that.
That's not a bursitis or a joint effusion.
That is the, an isotropic artifact
of the reflected head of the rectus femoris.
And we can prove that if it is an isotropy,
it should also show up in long axis laterally.
So what I'm gonna do real quick is I'm just gonna turn the,
the transducer left side of the screen left here,
left side of the screen patient's, right, so here's lateral
and here's medial and here's that direct head.
And then here comes that reflected head also a shadow away
from the transducer laterally.
So what I'm going to do is bring my transducer over here
laterally and shine
that flashlight ultrasound beam right into this tendon,
this indirect head.
And so I'm just gonna do that, rolling the transducer
laterally, laterally, laterally.
There we go. And then I should start to see the,
the nice tendon fibers here as it wraps
around the acetabulum and the labrum.
So here's the origin of that indirect head.
You can see it really nice origin of the tendon as it wraps
around the labrum.
So we can follow that out, out, out, out back
to the anterior portion.
Keep rolling the transducer back
to the main direct head here.
So I'm just gonna rotate my transducer long axis
and continue with that exam.
Notice inferiorly here we have the acetabular labrum femoral
head as a landmark overlying, this is the sartorious
and if I were to go more medial, we'll start
to get into some of the anatomy that bill's about to cover.
So I'm just gonna use that as a a time to go ahead
and hand it off to Bill.
Bill. Have I missed anything on that? Rectus femoris
- Dis fous?
No. Dan, you might want to might review the capsule, capsule
or insertion and the distal insertion as well.
- Great point. I got ahead of myself there.
The most important part of why we're sitting here on the
front of the hip is that you may want
to access the hip joint one day, which is a great reason
to add ultrasound to your toolbox.
So here we've got the acetabulum and the labrum
and the most superficial portion of
that is the ileal femoral ligament right here.
So we're gonna follow that ileal femoral ligament
as it drapes down, up and over the femoral head.
So we can see the femoral head with its
articular lene cartilage here.
And we're just gonna keep tracing that down, down, down,
down distally and I'm, you notice the transducer pressure,
I'm actually digging in distally to level the ligament out
and make it easier to see if I were to let the curvature of
that ileo femoral ligament in the head neck junction
of the hip just naturally lie with the skin.
The structures are diving away from my
probe and make it harder to see.
So you may wanna apply some distal pressure here.
Here's that intra tr enteric line here.
That's the beginning of where we start seeing the
insertion of this ligament.
So the ligament comes here, here, here, here.
And as a capsule, it's kind of a redundant ligament
where it wraps and tucks itself back here.
So the joint capsule itself actually lies just
above this tuck area here.
And then there's the most distal insertion.
There we go. And if I were to go
to the more traditional keval linear transducer,
keep in mind this landmark here
and I'll just save that image and freeze
and I'm just gonna switch transducers over to the curve.
Linear, this will be the more traditional
of the ultrasound images that you see when your patient
population is larger than the patient we have here.
So just gonna bring my depth up a little bit
and go over that anatomy just briefly seeing
how it's projecting on zoom curve
- While you're lining up there, Daniel,
I think it's also really interesting to note
how thick this ligament is.
And so as you're advancing your needle
and you meet resistance
and it oftentimes some folks think they've,
they've hit bone, but that ligament is
that last thing you pop through
and you have to give a pretty good pop
with a needle to get through it.
It's, it's the strongest and thickest ligament in the body.
So, and it's displayed beautifully
there how thick it actually is.
- Absolutely right Bill,
the nice thing about ultrasound is if you are using it
to guide your needles, you can use smaller, thinner needles
and that pop might not be as bad
as if you were using an 18 gauge to access the hip joint.
So you can move to a 20 or a 22 gauge
and it will slip through the ligament much easier.
Another thing to be mindful is some of these other vessels
that might get in your area, if you throw color on,
you'll see the flow of that ascent, that circumflex femoral
laterally wrapping around beneath the sartorius
and wrapping around the rectus there.
So avoid that little neurovascular guy
and hopefully avoid an accidental hematoma.
But the trajectory would be something like this
inferior lateral to superior medial typically like. So
- Daniel, the other thing
that I would point out here is if you, if you look, go back
to where we want to leave the tip of the needle
and why we leave it at the head neck junction.
And it's because that there is actually a little more space,
there's a little more elasticity there between the,
the ileal femoral ligament and the bone
and there's a little redundancy to the iliofemoral ligament
that kind of wraps around.
There's a little bit of soft tissue that you see there
by your arrow and then you see a little bit
of hypo echogenicity
that you can leave your needle in, right?
You add it there earlier, sorry, there you go.
Right there. See that little bit of hypo echogenicity there?
That little hypo coic space right above that redundant fold
where you leave the needle
and then you'll see that expand with the inject there.
You see it nicely.
- Good point Bill. I will turn it back over to you.
- Okay Daniel, one other thing real quick.
Did you, I, I covered the labrum too.
Could you take a look at the anterior hip labrum
and show them that triangular?
There we go. Triangular
- Height. There
- We're, they're very nice.
So you see how it's just deep
to the iliofemoral ligament there
emanating right out from the acetabulum, much like
what you'd see up in the shoulder in the posterior shoulder,
- You can see that that hard line of fibers right here
where the arrow is from here, superficial is
that iliofemoral ligament margin here.
And then right here is where the labrum begins
and tapers off right here.
- Very good, thanks bud.
Let's go to the ilio SOAs muscle and tendon
and in evaluating the ilio SOAs, we're going to begin
with the transducer in the short axis in a true
transverse position.
At that level we're going to look at the ileal SOAs tendon
where it crosses the medial side of the femoral head
as we see here.
So this is the femoral head.
We see the superior pubic ramus here
and the brightly koic
ilio SOAs tendon.
Now this is where anti atropy can help
and that's why I wanted to remo review that
before we discussed this tendon.
Because much like the distal bicep tendon up in the elbow
or any tendon that you're looking at to identify it,
if you wag the tail of the transducer
and perhaps Daniel can demonstrate this when we go
to his live demo, it can be helpful to wag the tail
of the transducer to see it alternate
between being hypo coic and being hyper coic.
It's not at this level that we would want
to inject the ilio.
So as bursa,
because the, there is, there are reported instances
of communication between the bursa
and the hip joint space.
And if we move the transducer up ever
so slightly
to the myotendinous junction
and oblique the transducer,
so at the lateral side
of the transducer directs itself slightly more superior.
We will see the iliac wing
and the the pubic ramus, or not the pubic ramus,
but the superior, superior ramus.
And we'll see the ilio sos tendon sitting right on
that shelf of bone.
It's at this level that we would want to come up
to deliver a needle to the poster lateral aspect
of the tendon and leave our injection.
If we turn the transducer in long axis,
we, we will be able
to look at the ilio soaz tendon approximately by
sliding the transducer from the rounded view
of the femoral head to where medially to
where we begin seeing this fibrillar appearance just deep
to the muscle belly.
And this is the ilio, so s tendon over
that medial aspect of the femoral head.
To look at the distal insertion, we're going to want to use
the the Faber position, which stands, reflection, abduction
and external rotation to bring the lesser tro canor
out to where we can reach it
and where we can get to where the,
we see the ilio SOAs tendon come down and insert.
Moving on to the sartorius muscle, we're going
to come up more proximally now we're going
to identify the bony acoustic landmark
of the anterior superior iliac spine.
Once we place the superior end of the transducer on the
anterior superior iliac spine,
we'll see the tendonous fibers of the sartorius
and the myo tendinous junction.
It's in this region where we might turn,
turn the transducer in short axis
and look for the lateral femoral cutaneous nerve.
You can follow the sartorius all the way down as it courses
around medially
and ultimately inserts onto the
medial surface of the proximal tibia.
Daniel, I'll let you take it from there.
- Thank you Bill. So we're gonna go first to the ilio soaz
keeping the left side of the screen
to the patient's right again, here's
that A SIS which we'll come back to for the sartorious.
I'm just gonna plant my transducer slightly medial to
that again, right over the joint.
I'm still roughly two or three fingers down.
Here's our A IIS as a reference.
So we were there earlier
and you saw the A IIS in the cross section
of the rectus femes up north here.
We can see this sartorious already.
What I'm gonna do is keep following my bony acoustic
landmark down inferiorly and notice
that I can't see the rest of the joint.
So I'm gonna go down a little bit deeper
until I see at least that rounded shape of the femoral head.
And I can tell that's the femoral head
because of the cartilage on it.
If I take my transducer slightly more medial,
we'll actually see the acetabulum here.
So this is a good landmark as Bill said,
to practice the an artifact.
So what I'm gonna do is tilt the transducer,
distally the handle towards the feet and proximally
and this will help us with tendon identification.
So just up above
here we are the acetabulum.
I'm gonna, I'm gonna, I'm gonna leave the femoral head
and go just on top of the acetabulum at this point, that
that helps us kind of further just isolate IA SOAs.
So here we have the, the overlying iliacus
and then more medially and more rounded
and tapering down to this kind
of target shape looking circular formation is the SOAs.
So using an isotropic to our advantage,
just the tendons are gonna be isolated this way here.
So that is with a distal tilt of the transducer.
And what we're gonna do is follow that distally,
distally distally over the joint looking for a bursitis.
It's an incidental lymph node superficially here.
And then our great vessels here.
So we've got our vein collapsing
artery and nerve iliacs SOAs,
here's the SOAs tendon.
And as it goes more distally it will taper
and converge with the iliacs tendon
and they will become the IaaS tendon.
So I'm gonna go long axis.
Now I'm gonna turn the transducer left side
of the screen is proximal.
So here's that tendon in long axis right over the joint.
You can see the acetabular labrum here in a familiar
landmark where we were just moments ago.
But now that tendon is trying to dive medially
because we're in a neutral position on the hip.
So with that diving so much, I'm, I'm going
to use my patient positioning to my advantage now.
And we're gonna do that favor maneuver.
I'm gonna bend the knee up just a bit
and externally rotate like a frog leg.
Here we are. Now I should
be able to track that ilio soaz very nicely
to its distal enthesis on the, on the
inferior trocanter.
So here's the tendon, it's kind of shadowing.
We have some shadow artifact coming in from these vessels
here, but we're gonna follow that tendon distally.
Distally, distally gonna borrow some gel,
even more distally there it is.
Looks like a distal biceps tendon
of the elbow like Bill mentioned there.
So here we can see the enthesis very nicely
on the lesser tro canner.
We're gonna go right back up top.
And I'm gonna leave our patient the external
rotation position.
'cause I find that easier to find the sartorious.
It kind of elongates the sartorious instead
of having the sartorious jump more medially and inferiorly.
And we're gonna evaluate the origin of the sartorius
and then go look the lateral femoral cutaneous nerve.
So here's a IIS as a reference here,
and that just tells me
to keep following our cortical landmark further north,
further north to the as IS so
that we can find a few landmarks here.
Here is the cross-sectional tendon of the arius
and we're gonna follow it
and find its margins
because right here it's gonna jump over
that rectus femoral here
and here the, the tendon has kind of turned into this,
or the muscle has turned into this big oblong shaped muscle.
And why that's important is sitting on the lateral rim right
here of the sartorius.
I find it easier to come down here
and look for this group of you'll,
you'll see little septations in the fat little vertical
septations in the fat.
And then over here we'll see the TFL.
So between the sartorious and the TFL
and this triangular wedge of adipose tissue
is where the lateral femoral cutaneous nerve lives.
And we're not looking for one little nerve,
we're actually looking for a group like a flat ribbon.
I've described nerves to look like kind
of an extension cord cut in half
before this is more like one of those electrical ribbons
where all the wires are in a, in a flat row.
And what they're gonna do is they're gonna lay across the
sartorious after they come out from the A SIS region,
it can either be just lateral to the A SIS just medial
to the A SIS or even further medial over the iliac.
So we're gonna look for the nerve as we track
that more proximally,
beginning at this little fatty triangle here,
I can find an accompanying artery
that always runs right next to the nerve.
So here's the nerve, I'm gonna bring my depth up more
shallow and
as I'm panning back and forth, you can see a dot,
another dot, and then another dot and another dot.
And they're much easier to find when you're panning up
and down with your transducer.
And they stay somewhat centrally located in your image.
So they're, they're in this flat ribbon
in the subcutaneous fat area.
It's not really even a subcutaneous fat, it's that little
pouch between, like I said, TFL and Sartorious.
We're gonna switch to the 19 megahertz transducer
and we're gonna focus on this little guy here
and we're gonna follow it up until we look for that zone
of entrapment under the ileal inguinal ligament here.
So here's iliac. Now here's the ileal
inguinal ligament here.
And look how far away I am.
I'm not at that classic anatomy
that we see in the books of entrapment
where you would see the predominant nature of the,
of that nerve to be piercing
or getting trapped right at the corner here.
I was able to track hers to live just here
above the iliac is and below that, that ligament here.
So what we're gonna do to get a better look at that
is we're gonna switch over to the 19 megahertz transducer
and really take a close look.
I'm gonna use the nerve exam type and hit the scan button.
Gonna add just a little bit of gel here
and start where we left off.
So medial to the A SIS right over
that iliacus.
So arrow back up, here's iliacus, it's a bit more blown up.
And we're gonna be focusing right here on this group,
this flat group of nerves.
And let's follow it laterally
to the lateral margin of the sartorius.
Okay, so you can see my transducers having
to twist and come this way.
And here we can follow this flat ribbon of nerves
and you can actually see them in their group.
I'm gonna go more shallow
and that's gonna make them really big on the screen.
So I don't want it to disorient anybody.
But we're, we're gonna leave this area
where we can see the rectus femoral trying to make its way
to the a IIS.
We're still over mostly, oh, here's sartorious.
So we are over the belly is sartorious now,
and I'm gonna go more shallow
and this is kind of like a macro lens of photography.
We're really getting a close eye on what might be
swelling in the nerve.
We might see neuromas in here,
just depends on what's causing the entrapment.
But really beautifully we're able to see and
and appreciate the flat ribbon shape of these nerves
as they sit horizontally here.
This is a blood vessel, this is a vessel little artery.
So if you're having a hard time finding it, look
for this little artery that sits
medial to the rest of the group.
And we can see it pulsate really nicely here.
But here's one of the branches,
here's another one of the branches.
In fact, I just skipped over one here.
And they make themselves more prominent when we scan
distally and proximally distally and proximally.
So this is a very frustrating little nerve
to trace for a lot of people.
And if you just kind of keep that scanning tip in mind
that hey, we can see these when we pan
distally and proximally.
That's a really, really nice way
to see a very subtle structure
as it traverses through the body.
But watch the nerve.
This this branch here is gonna go su
superficially up towards the skin.
So right there, it's, it's already making its way
to its zone of innervation.
Here we are going a little bit more distally following a
diff a, a different branch.
So pick a branch and follow it distally and proximally
and then pick another branch.
Let, we will come out here just a bit more lateral
and we're gonna follow it distally.
So you're not gonna get 'em all in one view diagnostically
or even procedurally.
You want to pick one and follow it
and then pan back up to the rest of the group
where it's easier to identify.
But the take home here is find your sartorious in, in my,
in my opinion, find the sartorious first
because you know that they're gonna be laying in a flat
ribboned group over the sartorious
as they make their their way down the lateral thigh.
Much easier to find here.
So here's that zone that, that kind of triangular fat wedge
between the TFL and the Sartorius.
So those are your landmarks, Sartorious, TFL,
little fatty wedge between the twos
where the nerves are clustered together in a flat ribbon
shape and you can follow them on up to the iliac.
I know we didn't have slides over that,
but really it's, it's easier to see in a, in a scan than
to look at the anatomy I have found looking at the
anatomy slides.
No matter what the reference to be kind of ambiguous,
you set the tr the transducer down
and you, you expect to find this little group of nerves
and you just, you just don't
where all the anatomy says that it should be.
So just find these landmarks, right?
Here's the iliacus, here's that ileal inguinal ligament
and then here's the lateral femoral cutaneous nerve sitting
in a flat ribbon shape just above the sartorious.
Now as I went distally bill,
should I circle back on anything
or should we take some questions in the chat portal?
I think have we reached the end of our anterior scan?
- Yes, we have bud. Great demonstration
of those superficial nerves
and how high frequency aids in, in being able
to identify those.
That lateral femoral cutaneous nerve, at least
for me is always been a little bit
of the struggle here we have a question from one
of the attendees, wondered if you could show the TFLA little
bit and maybe it's relationship show
that little triangular space between the TFL
and the sartorious?
- You bet. So here I'm using some anti atropy.
If you are cutting everything nice
and 90 degrees, this little zone starts
to look a little bit like the muscle
because there's a lot of septations in this fatty
adipose tissue here.
But here's that sartorious lateral border here
and then here's that T FFLs medial or anterior border here.
But look at this zone right here, this big triangular wedge.
Superficially in that wedge is
where we're gonna be finding these,
these nerves to be traveling.
But here's TFL, we can follow
that up approximately.
You can see my transducer, I'm all the way up
to the A SIS again
and then just slightly lateral than where I was
for Sartorius is the TFL origin here.
We can see it flattening out right here
and at a smaller footprint,
maybe from a perspective standpoint it may
be harder to visualize.
So I'm gonna switch over to that 15, the L 15
or linear 15 megahertz transducer, which has a 50
millimeter foot print
and we can maybe more easily put these
things into perspective.
So here's our A-A-S-I-S here
and we'll use it as a center point.
And medial to A SIS is our iliac iliac
lateral climbing up
and over that hill is the origin of our,
of our TFL right here.
There it is. And we could follow that out.
It's a very short muscle.
It's, it's not gonna be the longest one that we have before.
It turns into that larger tendon
that sits over the TRO canner,
which will be covered in the lateral hip.
So please, please catch us for that.
- Daniel. One other question. Sure.
Not many people have the good fortune
of having a 19 megahertz transducer quite yet.
And one of our attendees asked if you could go back
to the 15
and oh, that's what you're looking,
you're using the 15 right now, aren't you?
- I am, yep. I I am already. Oh beautiful.
- Okay, nevermind you Pretty good resolution of the 15.
I thought we were using the 19 right there. Thank you.
- True story. But here's that lateral femoral cutaneous.
And like I said earlier,
scanning nerve anatomy sometimes helps to reduce your gain.
In fact, I'm on the SK exam type, so we wanna switch over
to the nerve exam type to make these
fatty fales kind of pop with more contrast.
And again, bring our transducer a bit more superficial,
panning up and down.
You can see I'm on the body of the iliacus again.
So here's iliacus until we follow that group
of nerves more laterally
and they will lay over the sartorious here.
So here's our sartorious here
and you can see the TFL has already made its way into
the, into the shot.
So here's that triangle that we're looking for.
And the group
of nerves has not quite made it to the triangle yet.
It's still superficial to the sartorius,
but panning approximately to distally approximately
to distally will help you navigate these little nerves
and don't look for them as a group.
Look, pick one shot.
I'm gonna look at the medial side of this group of nerves
and I'm gonna follow it as far
as I think is diagnostically necessary
or procedurally necessary.
And remember there's a little artery medial to these
so I can go up in depth
and if you don't have the luxury
of a 19 megahertz transducer,
sometimes zoom will help, sometimes it won't.
It just depends on the perspective that you need to see.
But I could, I could certainly go
to Zoom and see what we see.
It's a fantastic transducer with a broad range of uses.
Here we are. So I don't know how it's coming across on
out in zoom land, but not bad
but not as good as the 19.
- Daniel, we had another question about what's deep
to the Sartorius.
- So right here you see that familiar a IS in short axis.
I'm gonna unzoom real quick
so we can get a bit of perspective.
So here's A IIS
and Sartorius is already laying across it here.
All of this is sartorious.
So A IIS is here, this is rectus fems.
So this is the tendon, the direct head of the rectus fems.
And this is the muscle, remember in the nerve exam type.
So things look a little bit darker
with a little bit more pop, but cross-sectionally here
what we're looking at is the rectus femoris direct tendon.
And then here's sartorious laying across it right here.
And then here's that lateral femoral cutaneous nerve.
Remember panning approximately distally approximately
distally will help you find these tiny subtle,
almost like angel hair pasta, traveling
between these muscle planes.
But here we are, so rectus femoris sartorious.
And then just superficial to
that is our lateral femoral cutaneous and nerve.
- Another question, Daniel, that we have is
wanted, wanted to know about injections delivered at the
acetabulum femoral head location.
Do you want to address that? Or
- We may lead that to a procedures talk, but is it a
'cause this was more of the sonographic appearance
of these landmarks, but are you talking
about a joint injection?
- Yeah, they're talk the, the question was
regarding joint injection.
I know that I've always been taught under ultrasound
guidance to deliver the injection at the femoral head neck
junction because there's more space there that everything's
- Relax. Your
- Leg awfully tight, plus you're dealing
with needles heading toward the labrum
and there are fewer structure problematic
structures up there.
And it's just a more successful injection if delivered down
further at the more distal end of the anterior recess.
Is that I
- Hope? Yeah.
- Are those your thoughts as well?
- That is definitely. And you're staying away from
cartilage, just like in the knee.
You know, we hear people saying, Hey, I do my injections in
for patellar, why should I go super patellar?
And it's all about just avoiding these things
because you can, and in this case, from
what I hear from the experts,
the physician experts out there is that, you know,
we're really trying to avoid scuffing cartilage if we can.
You're dealing with a corticosteroid that may lay on top
of an iatrogenic scratch across that,
just like an anterior scope portal.
We know that a lot of scuffs are
because of that first portal entry.
So people like to stay away from
that cartilage for a lot of reasons.
And if you're dusting the rest of the joint
with some corticosteroids, that's really bad.
If you've, if you've accidentally caused a scratch in the
cartilage, it will no doubt get worse.
That would be, that would be the most common response I've
heard about why
to state down here at the head and neck junction.
- Very good. Another question, what tendon
above rectus fems
- In this view here we've got, let's go back to A IIS here,
A IIS laying just
above rectus long axis right here is sartorious
the most superficial muscle in this picture?
Sartorious, remember that little artery?
There we go. But this is all sartorious laying above rectus.
So here's, here's
rectus and sartorius.
So we've got our acetabulum labrum, head, neck,
interra, enteric lines, actually way down here.
So we may have a future little bony
prominence here, mid neck,
more medially, ileal as,
let's confirm our rectus.
So here's our rectus femoris direct and reflected
and sartorious superficially.
- Very good. And then one other here that I'm going
to share my screen to answer the next one, the questions
regarding the ilio SOAs tendon, right,
our ilio SOAs bursa actually wanted
to outline the ilio SOAs bur,
and I think it's important here to, to re remember,
to remind ourselves of that the bursa is more
of a potential space and don't oftentimes see it
and until it's distended by fluid.
But if we look at, at this slide right here,
the bursa is going
to not be on the lateral side
or the anterior side.
It's going to be postal lateral deep
and then it wraps around medially, which is why we want
to deliver the injection to the posterior lateral,
posterior lateral aspect
of the ilio SOAs tendon at this level so
that infiltrate can diffuse and fill.
- Great explanation. Bill,
- Do we have any other questions? That
- There are a couple.
Hi Bill, this is Laura again.
There are a couple questions, but I think with, with respect
to time, we should probably get wrapped up
and we will follow up with those questions
after the fact if that's okay with you all.
- Very good. - Great.
So thank you so much for joining us today
and this slide shows the link to our future
and upcoming webinars.
There are also links to recorded webinars from
previous as well.
So if you have any questions
or would like to reach out to us, please go to this page.
Thank you so much for joining us.
Learn diagnostic ultrasound of the hip utilizing point-of-care ultrasound. In this expert-led webinar, you'll view techniques to visualize anterior hip structures, including the direct and reflective rectus femoris, acetabular labrum, iliopsoas muscle, sartorius muscle, and the lateral femoral cutaneous nerve.
This webinar is the first of a four-part series on the hip.
What You'll Learn
- Visualization techniques for hip structures
- Identify key structures on the ultrasound image
- Pearls for diagnostic assessments
Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.
Bill Medford joined Fujifilm Sonosite 10 years ago as the Lead Musculoskeletal Clinical Specialist. He is a certified sonographer, with credentials that include RDMS (abdomen and OB/GYN) and RMSKS (musculoskeletal). Bill brings 42 years of experience, with 22 years in musculoskeletal. Bill has held numerous invited faculty positions over the years. He is a member of the AIUM and has been an ARDMS MSK Subject Matter Expert since 2015.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.