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Transcript

- Welcome to our webinar on examining hip anatomy

and structure with point-of-care ultrasound lateral hip.

This is part three of a four part series on the hip.

Before we begin, please be advised all attendees are muted.

You may type your questions into the q

and a box in the toolbar located at the bottom

of your screen at any time.

We will conduct a q and a session at the end

of the presentation and demonstration.

This webinar will be recorded

and archived for future reference.

Our 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 have been here at Sono site.

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 Sono site with 40 years of experience

as a sonographer, including 22 years specializing in

musculoskeletal sonography.

Bill is an expert in using point-of-care ultrasound across

the breadth of musculoskeletal specialties.

Bill, I'll turn it over to you to get started.

- Thank you, Laura. As Laura mentioned, we're going

to be covering the lateral hip today.

We're gonna be utilizing images

obtained from the sono site PX ultrasound system

and the images that you'll see will be from the

L 15 to four megahertz transducers.

Other transducers

that might be utilized depending on target depth,

might be the curved five to one megahertz transducer.

Or if you're looking at very superficial structures,

you might utilize the linear 19

to five small footprint transducer for exception,

exceptional image clarity.

The anatomy that we will be covering today include

the muscle, the gluteal muscles, the maximus,

the medias, and the minimus.

We will discuss the tensor fascia

and the ITB as well

as trocanter versa bony landmarks.

We're going to want to be able

to identify when assist when assessing the lateral hip,

include the dorsal ileum as well

as iliac crest,

the anterior superior iliac spine,

the lateral margin of the sacrum

and coys, as well as the greater tro canor

- And its associated facets.

Let's start with the gluteus maximus. It is the

- Primary extensor muscle of the hip.

It also assists with external rotation and abduction.

It is the largest

and most superficial of the gluteal complex

and is innervated by the inferior gluteal nerve.

Proximal bony origins are from the posterior aspect

of the dorsal ileum

and the posterolateral margin

of the sacrum.

It will also blend with lumbar fascia

and the sacro tubus ligament along

with the tensor fascia.

Lata. Its connection with the ileo tibial band

stabilizes the femur along the surface

of the tibia while standing during relaxation

of the extensors.

Ultimately, it will insert on gurney's tubercle of the tibia

and the more proximal point

of insertion directly onto bone is achieved at the

gluteal tuberosity

- Of the femur.

The gluteus

- Medias abducts the femur.

It also serves to assist inflection

and internal rotation as well as extension

and external rotation.

It is innervated by the superior gluteal nerve.

Its origin is deep

and lateral to the gluteus maximus.

Again, along the dorsal aspect of the ileum,

its distal insertion is on the greater tuberosity

and as described by Doctors Hoffman and Smith.

It has two bands,

an anterior band which inserts on the lateral facet

of the greater tro cantor.

I have tuberosity here. That's a mistake.

That is the greater trocanter

and the posterior band,

which inserts along this green shaded area, which is the sal

- Posterior aspect of the greater trope.

The gluteus minimus

- Serves to assist in hip abduction

and in internal rotation.

It is also a stabilizer in the gait cycle.

It also is innervated by the superior gluteal nerve

and it is the deepest of the gluteal muscles.

Its origin is along the dors salinium between the anterior

and inferior gluteal lines.

It is entirely covered by the gluteus medias

and inserts on the anterior facet

of the greater tro cantor in this blue shaded area here.

So again, our distal bony landmarks along the greater

trocanter are the anterior facet, which chas the fibers

of the gluteus minimus,

the lateral facet which accommodates the fibers

of the anterior band of the gluteus medias

and the sup posterior facet, which houses the fibers

of the posterior band

- Of the gluteus medias.

To demonstrate this anatomy

- Sonographic, I prefer

to start out in the short axis plane.

We're utilizing a linear array, 15

to four megahertz transducer.

The patient is rolled up on her contralateral hip

and the transducer is placed across the hip

to demonstrate this, what I call a matter horn appearance

to the greater tro cantor anterior is on this side

of the image, posterior is on the left side

of the image on the anterior side.

On the anterior facet of the greater trocanter,

we see the insertion of the gluteus minimus

around on the other side of the tip of the matter horn.

On the posterior side, we see the insertion

of the gluteus medias most likely the anterior band here.

And when we go to the live model demonstration,

perhaps Daniel can show how with a slight tilt of

or rotation of the transducer

or the posterior side of the transducer superiorly,

you'll be able to see the anterior band as well

as the posterior band and the short axis.

Also, we want to be able

to recognize the T trochanteric bursa, which lies

between the tensor fascia

and the gmax insertion into

the tensor fascia.

The tensor fas, the the TFL,

or I'm sorry, the i tibial band,

the iliotibial band seen here

as a more hyper poetic structure can be followed

superiorly to where it will accommodate the fibers

of the tensor fascia.

In between the gmax

and the ITB, we'll see, we'll recognize

the potential space of the trocanter bursa

and there are some dynamic maneuvers

that will assist in recognizing that to guide tro

- Trocanter bursal injection.

The gluteus minimus and the long axis is seen

- By patient up on their side,

again transducer placed in more of a coronal body plane

and angled from anterior back to posterior.

When this is done, we will see it

come over and insert on the anterior facet

of the greater trocanter

with a transducer naturally placed on the hip.

We'll also notice that the more proximal tendon fibers

course deeper

and so a heel toe maneuver, which Daniel,

I'm sure will demonstrate, will help flatten the tendon out

to bring out the hyper coic

- Fibrillar pattern.

More proximally.

The gluteus medias as mentioned, has two

- Bands.

We're going to again play, have the patient up on her side,

chronically oriented in the

transducer oriented in the coronal body plane.

But we're gonna angle back from posterior to anterior,

demonstrate the gluteus medias in its long axis.

So the anterior band we're going to see as it comes

and inserts onto the lateral facet.

It'll have a more horizontal appearance

or course as opposed to what we saw with a minimus

where natural transducer placement on the hip will take

it deeper.

The minimus as the deepest

of the gluteal muscles is responsible for that

and the medias situated in

between the gmax

and the minimus will

result in more horizontal anatomical

course of

- The tendon to where it inserts

the posterior

- Band is demonstrated simply by bringing the transducer

around on the patient's slightly more posterior.

An anatomic dissection of the gluteus medias muscle tendon

unit shows the anterior band between

the white arrowheads and the dotted line.

It is derived from the anterior two thirds of the gluteus

medias muscle and tapers to insert on the lateral facet

of the greater tro cantor, which denoted by these asterisk.

Here the posterior band is located between the dotted line

and the black arrowheads

and is derived from the posterior third

of the glute mead muscle

and inserts onto the superior posterior facet.

The dotted line present here separates the anterior band

from the posterior band.

If we get a sonographic image of the posterior band

of the gluteus medias, oftentimes we will see a segment

of the piriformis as it's coming over to insert onto the

- Superior aspect.

Greater tro.

- Daniel, I'll turn it over to you at this point to review

a live demo of these structures.

- Thank you, bill. Great presentation.

So just a reminder a bit about

examination preparation here.

Positioning is very important here.

Just like in the shoulder we, we talk about the differences

between anatomical position in the shoulder and resting

and how that rolls the greater tuberosity in the shoulder

into a di a different plane.

Today I've got our patient in a lateral decubitus position.

Feet are this way, head is to my left and

and her knees are bent.

So she's in in a more comfortable position

and I can, I can evaluate all these structures just

fine in this position.

There's no need to straighten the legs out,

but there is a technical consideration that needs to be

thought of when doing that.

When I'm looking from the ileum to the greater trocanter,

these structures are no longer mid coronal.

So what you're gonna do when I change my camera angles,

you're gonna see my transducer becomes more anteriorly

angled relative to the anatomical position.

So just kind of keep that in mind

as an anatomical consideration.

We're not standing upright,

we are roughly in the same orientation,

but the fact that the knee is bent the way it is, it's,

it's throwing those gluteal insertions this way.

And for example,

the gluteus minimus from the ileum here is much more

anterior than if you were just looking at an anatomy book.

So if, if you're just working your way through hip scanning,

that can be a bit of frustration going from you're studying

anatomical positioning to how the patient is,

is clinically laying.

So another consideration is lots of cover.

Okay, when I was scanning back in the, the clinical days,

I got embarrassed really easily.

So I, I always made sure I covered things a lot even though

the patients were much less embarrassed at times.

But I made sure I had layers of blankets

and anytime you're exposing the hip

and we covered this on the anterior

and the medial hip, we're gonna reiterate that here today.

I've got a blanket here

and then I also have another,

I'm not saying everybody needs this many blankets,

but I'm gonna be using lots of cover today,

so I'm just exposing what's needed.

Palpating the trocanter first and I can feel that here.

And then what I'm doing is tucking a bed sheet

up proximally here.

And always just keeping in mind patient dignity when doing

anything around the hip or pelvis.

Nobody wants any surprises.

So that is just almost my number one

consideration when scanning the hip.

So now we're gonna go to the, to the live scan.

So I'm palpating the tro canner distal is this way

'cause I know that the cameras can,

can throw things off a little bit.

And then proximal is this way.

Here's our patient's knee in the wide shot.

That lower camera angle, it's tucked here just for reference

because I don't want anybody to be thrown off.

Alright, I like to start at the trocanter palpating again.

I'm gonna expose a little bit more trocanter here

if you can't palpate the tro canner.

And I know in the real clinical world that happens a lot,

you may want to consider dropping

to a lower frequency curve, a linear transducer.

But for the sake of today,

I'm gonna keep my orientation marker facing anterior here.

And I'm just gonna plop the probe down.

And if all I see is soft tissue like we see here,

I'm gonna pan distally

and proximally until I come across that bony peak here.

So now that we have cortex, I need

to make the cortex look good.

So I'm gonna pan anteriorly

and then go proximally and distally again.

And then I found a high spot.

When I find that high spot, I want to zero in on

that high spot because that's very likely to be the facets

that we're talking about in the PowerPoint.

So I'm gonna roll, remember

how our patient's knee is rolled.

I'm gonna roll the probe more anteriorly until we get

that little rooftop that matter horn appearance

that bill talked about.

So here we have, let's get a label up there and an arrow

and let's spin that thing around there.

So here we have this bony rooftop

and it's really delineating anterior V versus posterior.

So on the anterior side we have that most anterior facet.

The lateral facet begins here

in the superior posterior.

I probably said that backwards 'cause we're filming

and I'm nervous, right is way back here.

Okay, just for a reference.

And as a scanning tip, it's key

to keep the bony cortex nice and bright.

Okay? If your, if your cortex is fuzzy,

your underlying tissues

or sorry, your your overlying

tissues are gonna be fuzzy too.

So any over angulation, anything off

perpendicular to the cortex

of the greater trocanter is also gonna make your image

look really, really bad.

So focus on your bony landmarks first.

Don't get too excited about all the soft tissues

until the underlying bony

landmarks look really, really nice.

So I like to start almost all

of my tendons in cross section.

I can see the entire body of the tendon.

So here we have the gluteus minimus anteriorly

and I'm just gonna pan proximally

until it looks more like an oval.

You saw me rotate the probe.

I know that I'm headed up towards the anterior A SIS region

inferiorly and I am starting, I'm starting anterior

and working my way posterior.

That's how I clinically scan.

And in the PowerPoint it's really nice

to understand the anatomy working your way down

as if it were a dissection.

So covering gluteus maximus first, then medias

and minimus in that, in that layering will help you

get ready for the layers that we're about to scan here.

So here we have the gluteus minimus here,

scanning it proximally proximally.

I'm taking a really sharp angle to,

to maintain perpendicularity

and you can see how sharp it dives when it dives this deep

and I can't lay my probe down anymore

and I've left that zone where there would be any

pathology anyways, which is right up here at the insertion.

After I leave the insertion, after panning that proximally

and distally leaving the insertion, I'm gonna rotate the

transducer now and go long axis on that particular tendon.

So gluteus minimus first

and we're just gonna spin the transducer here.

So I've, I've done this a couple of times,

especially pre scanning here.

So I just, I went straight to that,

that really nice picture.

Clinically what's gonna happen is this is all gonna be one

big black shadow.

And if you're just following the skin contour

and you're not, you're not trying to level out your tendon

and make up for the anisotropic artifact it, it's very prone

to just see this very jet black

tendon right here diving away from your probe.

Here's the overlying what's anterior most would be our

TFL fibers up here going

to the iliotibial tract.

And we, we don't have glute max in the shot yet

'cause we're not posterior enough.

But I do want to cover the, an isotropic artifact in case

that has been a, a source of frustration

for anybody that's attempted this scan.

You end up with this really, really dark sharp

dive here away from the probe.

And all I'm gonna do is apply distal pressure

to the proximal side of the probe

and you're gonna see me level that tendon out so

that these fibers are parallel with the surface

of my transducer.

And if I can achieve this angle of perpendicularity, look

how nice and bright we get these tendon fibers.

Not to mention 15 megahertz

large linear footprint transducer is allowing me

to see the enthesis all the way

to the myo tendus junction here approximately here.

So here's the muscle belly gluteus minimus.

Above it we have gluteus medias. That's next.

I'm gonna go back to transverse.

So I'm gonna go right back up to my home base,

which is the facets.

I'm gonna spin the probe back

and if I get this oriented I need to go find that bony peak,

that apex right there, the greater trocanter.

So here's that bony apex again and then just up

and over it I see my anterior head

of gluteus medias.

Now I wanna you, you see my transducer,

I'm maintaining perpendicularity as I climb up

and over the greater trocanter here.

Now my angle of intonation is now perpendicular

to the gluteus medias

and that's just setting myself up for a nice 90 degree cut.

So what I'm gonna do here is just again spin the transducer

trying to keep that right there.

Screen center to gluteus medias.

And as Bill mentioned, I am gonna climb

to the posterior side to the of the greater TR

and aim back anterior slightly to get that really,

really nice tendon also while maintaining a

perpendicularity to the greater trocanter.

So keeping these two pinned together is really key.

If not, you're gonna be a little lost

and say, I don't know what tendon is inserting here.

So you have to have that underlying bony landmark

and you have to have it looking really, really good.

So gluteus medias here

and we're just gonna follow its muscle.

It it lays more superficial this bi penate structure here.

It lays more superficial to the gluteus minimus.

If I were to scan further anterior, let's follow this.

I'm gonna go back to the anterior side

and we're gonna see an underlying gluteus

minimus come back into the shot.

Okay? Just to get oriented.

So minimus medias panning posteriorly

further, keep the enthesis on the greater trocanter in

view, that way we don't get lost.

And let's climb back to

that posterior two thirds when you lose your greater

TRO canner right there.

It's a good time to angle back in right there.

And we're gonna catch that posterior head really,

really nicely right there.

And as Bill mentioned in the PowerPoint slide,

we have a really, really nice piriformis which will be

covered in the posterior hip.

We'll cover that in depth along with its dynamic rotations.

So gluteus minimus medias

and then the overlying gluteus maximus has already started

to come into play and it does not insert

until the more lateral part of the the upper femur

and distal to the trocanter.

So this is all glute max here.

I'm gonna go back to transverse here.

Let's go back to somewhere that's familiar.

Let's go back to our apex there, that greater trocanter.

And let's point out what's glute max and what's TFL.

So in this view,

and you saw in the anatomy diagram how broad of a structure

that TFL in the glute max junction is.

So glute max is coming in from the ileum,

from the sacrum all the way down

to the sacro tubus ligament.

And it's wrapping over the trope headed

to the lateral aspect of the femur.

TFL is beginning.

I can palpate as IS right up here

where we were on the anterior hip.

Remember when we scan the lateral femoral cutaneous nerve on

the lateral, or sorry on the anterior hip webinar,

it bordered the FL and the sartorious.

So you're gonna come up here and find one big muscle belly.

And if it's not trying to jump extremely anterior

or head down to the kneecap,

you're on the TFL in this body position.

The TFL is not as coronal as you study in the book.

It's extremely anterior relative to

if the patient were just standing.

So that's important because I'm gonna

give you a little scanning tip.

So here we have the glute max

all the way back here and there's no need

to go entirely proximal

because we're gonna cover that in the posterior hip.

But we're gonna follow these fibers

of the glute max anteriorly anteriorly

until they hit this zone of connective tissue up here

right at the apex of that greater tuberosity.

Again, trocanter. I did, I did the same thing.

Bill, I'm gonna, I'm

gonna bring my depth more shallow.

Okay? And let's focus on this interface

'cause we read a lot about greater trochanteric bursitis

and this is a great place to look for that.

If I saw a fluid collection, it would be right in here,

right underneath that, that it band connective tissue TFL

kind of junction here and

and it may teardrop posteriorly under the glute max.

And there's many, many more bursa here that,

that we could cover, such as the glu sub gluteus medias

and sub gluteus minimus bursa.

You're don't get frustrated if you don't see the bursa

because I know in the shoulder you can see the sub

subacromial subdeltoid bursa fairly well even on a normal

patient, that's not the case in the hip.

So if I don't see a fluid collection,

check your transducer pressure.

Remember those fluid collections are

very easily compressible.

So what I'm gonna do is I'm just gonna,

I'm gonna push down a little bit

and let up my transducer pressure.

And what that does is leave a spot in the skin

to put a gel heap, ideally without as many bubbles

as I just got in the frame, I'm gonna use my fingers

underneath the transducer like stilts here.

And I'm gonna slowly float

through the gel shooting down ensuring

that I'm not collapsing this bursal interface right here.

So the fact that I can see the gel in the skin

and all the subcutaneous tissue not compressed shows anybody

else that might be looking at the image

that you're not compressing too much.

So now that I haven't collapsed a bursal interface,

I'm gonna go back to my normal scanning pressure.

And this is a time when you can at least see if there's any

adhesions or any scar tissue or,

or any, anything that might be loose in this interface here.

And all I'm gonna do is reach down with my opposite hand

and grab the patient's ankle.

I'm gonna have them bend their knee a little bit

and what we're gonna do is just rotate, see if I can grab

through this blanket and we're just gonna rotate the knee

up and down, almost like a frog leg.

There we go. And then back to the front. There we go.

And then out a little further, there we go. And then back.

And actually I'm gonna reach under

and we'll do this more passively

because if the muscles are tense it's gonna

mess up your scanning.

So I'm just gonna kind of expose the foot a little bit more

where I can reach it and I'm gonna passively do the motion.

There we go. So right here is the interface I'm looking for,

right under the gluten max.

Well when I move it, the arrow is no longer

where I want it to be there.

And that teeny tiny little tissue interface is much like

that subdeltoid bursa.

Okay, I'm gonna bring my depth up a little bit

more so we can see that.

And it's a teeny tiny interface.

So those greater trochanteric bursa injections

where people are hitting the, hitting the cortex

and trying to back out just to touch and then inject.

You're looking for loss of resistance,

you're hoping you're in one of these tissue planes,

but you could be intramuscular,

you could be doing a glute max injection and not know it.

And, and that's the benefit of adding ultrasound is finding

that fluid interface right in here, making sure

that you're gonna be in the, the tissue plane

that you're intending and and being able to delineate that.

I, I just felt like we should cover that really quick

in the live scan because there is a nice

dynamic component to it.

So let's leave the glute max. So this is glute max.

Let's go anterior still anterior.

Here's that TFL IT band junction.

And look at this thin ribbon of tissue up here.

That thin ribbon of tissue will then eventually connect

to the TFL here. So this is

- The muscle belly of the TFL, this is glute mead,

TFL.

- I'm gonna have our patient just,

let's get the same shot that I just had.

We followed this tissue plane all the way up,

all the way up here to the round TFL.

I'm gonna have our patient straighten our leg. There we go.

And what that does is hopefully bring us more

to an anatomic position.

Okay, so TFL is here and let's follow it and check our work.

Let's see if this goes all the way to A SIS

proximally and it does good.

So this is a SIS and it stays more lateral.

If I were to go more anterior at this point there

is sartorious, so sartorious, TFL

and that would be our, our little plane that we look

for the lateral femoral cutaneous nerve.

But we're gonna stay lateral

and we're gonna follow this out.

Another way to make sure this isn't rectus femes,

which is down here, is this will taper off to nothing there.

So this muscle disappears completely

with the rectus femoral underneath.

So that muscle tapers down to

what is now the iliotibial band or ileal tibial tract.

So all of this huge umbrella over the hip

to this muscle belly, you should be looking

for it band.

And the scanning tip I told you I was gonna let you know

about I've never been able to get

a snapping it band

with the patient laying in lateral decubitus.

You gotta stand them up.

So when they stand up and they go weight bearing,

ask the patient to make it click and they usually can.

And what you're gonna see is a separation

of the glute max side.

Typically glute max will separate completely from this

tract, usually right here at this interface.

And this tract is

what is hitting the trocanter harder than it normally would

and it snaps from anterior to posterior

or I've not seen it from posterior to anterior.

It's usually anterior to posterior as it tries

to meet back up with the glute max,

I usually see a big separation right here and that

and that snapping occurs

with this dense band right over the trocanter.

So we've covered, we went from deep anterior

- Minimus medias,

another medias maximus

- Following the superficial margin of the Maximus to the TFL

or the ileo tibial band at this point.

And then following that ribbon as anterior

until you hit this big oval muscle here,

which is the TFL muscle.

And then we went approximately to make sure

that it originated on the lateral aspect

of the A SIS, which it does.

While we're up here, we'll go into the anatomy of the ileum.

So here's our ileum diving.

If I wanted to maintain perpendicularity, I have

to tilt the transducer this way.

And now we can see the LEMA little bit better.

The most deeper tissue right here, this layer is all

gluteus minimus.

The more superficial layer just above it

actually feel like I should track that to the medias.

So let's go. Medias here, proximally.

Yes, all of this is medias, so minimus,

minimus medias and then the interface between medias

and maximus can be kind of thin and hard to discern,

but there it is right there.

So Maximus is here, so I hope we've combed

through all the layers of the hip that we normally would.

That covers everything in the PowerPoint.

There's more to scan here

and we can do that while we field questions.

But Bill, did I skim over anything that was,

that was in your PowerPoint did.

- I thought you demonstrated it all very nicely

Daniel. Well done.

- Okay. - Do we have any questions?

I don't see any in the chat box.

If you'd like to ask any questions, go ahead

and type them in and we'll give you a minute

or two to see what comes our way and

- Sure.

And just as a reminder, these are shorter webinars

that we're doing of segments about 30 minutes total.

So they're no longer an hour.

If you guys were on the MSK Power hour

before we merged it into the behind the scan series,

you've noticed that these have gotten more short

and sweet and to the point.

And that was also the point.

While I'm here, this is a really cool piece

of anatomy to cover.

While we're waiting on questions,

if we get a question interrupt me,

but very lateral trocanter, right?

I'm gonna pan proximally until the trocanter disappears

and we see a much, much deeper bony landmark here,

which is the neck of the femur.

And just above that we have ileal

femoral ligament laterally.

And then above that we should have a horizontal band

of tissue here, right there.

So that horizontal band of tissue,

we covered it in the anterior hip and I said we'd go back

and address that when we hit the lateral hip.

So this horizontal band

of tissue is the indirect reflected head

of the rectus femoris.

So here comes, it wraps over the, the acetabular labrum.

We're in long axis to it.

That's attaching on that posterior lateral margin

of the right there on the,

I just said the word acetabulum.

Not enough coffee today, bill.

And that is our reflected head of the rectus femes.

And you can check your work because it will meet right back

up with the rest of the rectus femes and a IIS.

So here's a IIS and here's the direct head

and then look at the reflected head.

Boom falls right off an isotropic first

until you level it out.

There it is. This internally rotated hip also stretches

that really nice when they're just laying on their back

and the leg feels relaxed

and it's slightly externally rotated.

This is much harder to see.

It kind of turns into a ribbon nice

and tight because she's relatively internally rotated

compared to the anatomical position she would have.

But really nice picture there

- And don't ever say we can't see the reflected head.

That's a beautiful demonstration of it, Daniel.

And a nice way to get to it.

I I tend to try to follow it when I look at the direct head,

then I go to the indirect head

and just try to follow the anisotropic artifact

and try to flatten it out to get that image there.

But going from the trope

and working superiorly

and anteriorly, that's a beautiful view.

Very nicely done. We have with question

Daniel, I was just gonna ask you to do that as well.

Could you just go over, I,

I think the person asking the question would like you

to start it from the tr again

and describe how you're getting to where the

head inserts on the ACE tablum.

- Sure. And I just went with my most easy

to palpate bony landmark.

You could just the same go from the ileum

and work your way south.

That's just fine. But this is, this is my most easy

to palpate lateral, bony landmark.

And I know that when I pan proximally,

I'm gonna fall off the trope into the neck.

I'm not perpendicular to the neck. It's down there a ways.

In fact, I'm not sure how zoom is treating my,

my gain settings, but we'll just,

we'll just hope it's there.

Let's get my arrow. Here we go.

So this is the neck of the femur down here.

Here's the acetabulum starting

- Daniel.

Maybe just a little more far game.

- A little far field game. - Yes. All right.

- So what I'm gonna

- Better, - That's great. Good.

- Good for zoom. All right.

So once I find that head neck acetabular junction,

there's the head and I could rotate the heel.

I'm just gonna grab the heel and rotate it this way.

And I can see the head roll.

Everybody recognize the head rolling

there where my arrow is.

So I'm not to the acetabulum yet and

therefore I'm not gonna see the indirect head

yet or the reflected head.

Here's acetabulum. So how do I make sure

that this is not simply the beginning

of the iliofemoral ligament?

Well, what I have to do is, is know that

that reflected head is gonna be headed anterior

and I'm gonna windshield wiper the

more anterior part of the probe.

So we're gonna plant the posterior lateral side

of the probe and follow.

We're gonna keep this bony la landmark, this acetabulum

'cause we're so far lateral, we're gonna keep that in view

while elongating the rest of it there,

it falls off the acetabulum at that point.

It's still a linear longitudinally striated structure

level with my transducer.

We've left the labrum,

the labrum fibers are gonna be more anterior than here.

We'd have to roll the patient

to get a more comfortable view of the labrum.

So this, this jumps up

and over the ile femoral ligament at this point

and comes up here and this is all cross-section

of the rectus femoris direct and indirect.

And just to check your work, Boni landmark, a IIS, so a IIS

fall off that anteriorly.

And these movements are less than an inch.

I'm probably taking centimeters at a time,

if not millimeters at a time.

- Excellent. Very good.

I don't see any other questions if you have one

and can get it in real quick.

Otherwise I think we'll wrap this up for today. Laura,

- We just, - Oh, here's, lemme, lemme take a look here.

Yep. Oh, we have somebody who

came in just a little bit late to the webinar

and she's having trouble seeing how the patient's oriented.

Can you describe that Daniel real quick to

- Them?

Yeah. And it, and it's also better

to show it in this wide shot here.

So if you were just late to the, to the webinar,

I went over some patient positioning considerations in

that we're no longer in an anatomical position.

We don't have the patient laying flat on their back.

These structures are rolled anteriorly

and relatively internally rotated to the anatomical position

and her knee is bent.

So here's, here's the lie of the leg here, almost 45

and here's the greater tro canner here.

And then just as a positioning consideration

where the patient is, we always wanna make sure

that they're nice and covered.

So anytime we're scanning the hip

or pelvis, we don't want any surprises.

The patient doesn't want any surprises.

Me as the sonographer, I don't want any surprises

and I tend

to keep everything very covered.

It's gonna be like this before the exam starts.

We're gonna, we're gonna inform the patient

that we are peeling back a layer

and then we're gonna try to tuck things here

to keep their clothes protected in their

underwear not exposed.

And even anteriorly let them know they can hold the blanket

on the front 'cause we're not going to the front.

And sometimes that that also helps them feel like they're

not gonna be disrobed accidentally in front

of anybody. But I

- Understand.

So real quickly now Daniel, go to your overhead camera.

So the person

who is asking the question can see Now describe in those two

shots what orient us.

- Yep. So lateral decubitus,

the patient is facing the screen and not me.

This is proximal. The, the femur is headed this way.

And then here's our knee bent to the, to the lower leg here.

So we're in a lateral decubitus.

Patient's legs are bent just comfortably

'cause we're gonna look for the bony reference point

of the greater trocanter here.

- And which way was anterior, which way is anterior

and which directions posterior.

- So anterior is this way and posterior is this way.

- Perfect. Thank - Youor.

- I hope that answers the question.

- Yeah, very important

because structures like this, when we're trying

to keep everybody covered up

and modest, it's hard to see hey, which way are they facing?

So do, do stop us at any point when it, when it's time

and we will absolutely reiterate the patient positioning.

- Very good. An important thing

- Laura, how are we doing?

- I think we're doing great.

I love watching you guys present. I always learn so much.

We did have a question just pop up.

- Okay, let me take it.

Were you keeping the probe consistent with medial

or anterior to the left?

- I kept it anterior to the left for my scanning purposes.

You could keep the patient's right side

or the patient's left on the right side.

Other way around patient's, right side on the left side

of the screen, I would've had to turn the probe so

that the left side of the screen was posterior.

And for me, I hand coordination wise, I think

that would've thrown me off for today.

There is no standard for for doing this.

Especially when you wrap around posteriorly,

the same question always pops up in the shoulder.

At what point do you flip the probe to maintain

that left side of the screen?

Patient's right side of the body.

Nobody has an, nobody has an answer for that really.

- And I will say, I will say

that I did notice a little inconsistency

between my presentation on PowerPoint

and your presentation in that I had anterior to the, I think

to the right and you had posterior to the left.

But the way you had our model oriented.

So there was a little bit of inconsistency from PowerPoint

to the, the

- Live model scanning.

Oh

- What same, same questioner

or were you keeping things consistent

or were you switching when you went

to look at the direct head?

- It was the same. So left side was still anterior.

So let's go over that real quick and button.

So exposing the hip again, keeping my little scanning window

going to the tro canner.

Easiest thing to palpate. Hopefully it's still imaging.

Well we can see our, our gluteus

- Maybe a little over gain bud.

- I don't wanna blind anymore. - There. That's better.

- There we go. So here's our facets. Anterior this way.

Lateral and posterior.

You can really nicely see

that posterior head of the medias there.

- So posterior to the right of the screen.

- Correct. So posterior, so maximus medias,

medias little

apex minimus.

And then what I'm gonna do is follow this bony landmark off.

I'm gonna scan proximally there

until I see this is probably the femoral head

and I wanna see ace tablum.

So here's the acetabulum here.

So this is the femoral head

and I could, I could show that by rotating the,

the hip internally and externally

- Or just notice how rounded it is.

- Yeah, well some of 'em are gonna be not around.

You're not gonna be able to tell with the arthritis,

you know, what landmark you're on.

- Good point. - It may be out of out of tread on the tires

by then by the time they're getting an ultrasound.

Right. And so here's the, the femoral head.

It's nice and round as Bill mentioned.

I'm gonna go proximally and we're gonna see a step up.

And now that we're on that step up, I should be able

to fan my probe off that ileoanal.

Okay, ECTs

- Here.

And there's that reflected head right there.

- It's jumping ile femoral ligament again,

but left side of the screen, patient's anterior side.

And I hope the upper camera is showing that. Okay.

- Okay. Very good. - That's such a cool picture.

- Yeah it is.

- Alright. Oh, let's, can we take one more, Laura?

- Yeah, we have time for one more.

- Okay, very good.

Can you show glut mead min

and max in longitudinal again please?

- You bet. So let's go back

to our skeletal reference point greater trucker here

and we'll go in the, in the order

of the minimus on the most anterior margin.

Okay, so here we have minimus

and we're gonna flip on this and spin it.

So now my transducer orientation

looks like it's aiming anteriorly,

but remember we've internally rotated the knee slightly

so these structures are hanging to the front of the hip.

And now if, if you're just following the surface anatomy,

this will be a big black shadow here.

So what you wanna do is dig in the

proximal side of the probe.

And once you level that out,

that tendon shows up really, really nice.

And you get this really, really classic shape here.

Almost a bird's beak like we talk about in the rotator cuff.

The greater troian is often described

as the rotator cuff of the hip.

So you can scan it very similarly with your tropic artifact

- And it's very easy to heel toe maneuver on that minimus.

And it's essential that you do so you're,

you're digging the superior end

of the transducer into the more fleshy part.

You're not against bone.

So it's an easy maneuver to do

and it it levels out the tendon so

that the fibers brighten up.

- Alright, so let's climb up

and over this little apex to the medias.

Purely the medias here.

And let's take that into long axis here.

So we're gonna just pivot the transducer again

until I see longitudinal fibers.

I'm not looking for a skin reference point

to determine long or short axis.

I'm looking at the orientation of the fibers

and here I can see the fibers very nicely in this bi pin

eight muscle, very characteristic shape

that you're gonna get very familiar with

as you scan more medias this nice bi pin eight look, follow

that central tendon on up to here.

And it,

- The other thing I, the other thing I would mention is

remember as you're looking at the, at the minimus,

you're angling the transducer from anterior to posterior.

And when you're looking at the medias,

you are angling the transducer from posterior to anterior.

- Very true bill. Very true.

So here's that bony peak

and it's long axis relatively speaking.

And I'm gonna fall off the back of that until I see

that anterior head on the lateral

superior lateral, no, no post. Help me out bill.

- What's that? The - Posterior superior facet or superior

- Posters.

Posterior facet. Yeah.

- Superior posterior. I'm, I'm mixed up today.

'cause obviously we're, we're scanning on camera

and those are, those are things that I often get backwards.

We all do scanning live.

So that's that, that the first head.

And let's go back to the posterior head as Bill mentioned,

you wanna fall off the tro canner

and aim back into it, fall off the tro canner,

aim back into it, go down in depth, just a touch,

bring my arrow back up, follow trocanter until it dives away

and aim back into it until you can't do that anymore.

I can't reasonably do that anymore. And this is it.

This is the posterior band of

that gluteus medias here.

If I fall off any further, I'm gonna see piriformis wrapping

around that uppermost part of the trocanter right there.

So down here is piriformis.

- Yep. And one more question just popped up, Daniel,

where does the bursa sit?

- That's a great question. There are many bursa here.

The most common bursa that we're looking for is the,

the greater TRO enteric bursa sitting underneath

that gluteus maximus and TFL interface.

I'm gonna go back to short axis on that bony peak.

Okay, so now that we see that bony peak,

get my arrow back up here.

So bony peak medias

or minimus medias maximus back here.

So here's Maximus, this huge difference in echo texture

because it's all muscle.

So here we have tendon wrapping around the greater trocanter

and here we have

wrapping around the, this muscle that glute max

until it's got that little, almost a little point to it.

And right there where it ends begins

that myo tenus junction on the TFL.

What we need to look for is the interface underneath

that TFL junction all the way underneath the glute max.

So glute max to TFL.

This whole white interface is your sub gluteus

maximus bursal interface here.

Greater tear right there.

And what we're gonna do is just like we did in the rotator

cuff, we're gonna zero in on that.

We're gonna zoom in on that, we're gonna watch it move.

So we're gonna go blow this thing

up there.

And what I'm gonna do is grab the patient's heel

with no surprises and passively move the tissue.

And what we're looking at is this interface specifically

this interface here,

let me raise my arrow just a touch.

There we go. That

interface will be your greater TR enteric versus

- Interface.

So now right there, Daniel, point out the ITB

and the myo tenus junction with the gmax

because it's right on the undersurface of that

- Right here.

- Yep. - So this, this is your glute max.

This is your IT band.

And this is where, this is where

that fascial plane merges to go share

with our TFL anteriorly.

You have to follow that band, follow that band, follow

that band, follow that band.

And then there's TFL, follow the band back, back, back,

back over the medias, over the medias muscle.

And then here, use an isotropic too to your advantage.

Let's go back over the trope here.

And if all these tissues are kind of looking the same,

remember they're going different directions.

So they're going to respond

to the an isotropic artifact differently from one another.

So what I'm gonna, I'm gonna do,

since I know I'm cutting my TFL

IT band in cross section

and I know it's headed to the knee,

what I'm gonna do is use the an isotropic artifact in

that direction to help me out.

And I, I know by using that an isotropic artifact,

I should see the interface underneath this specific

structure right there.

- Very good. - So use and dynamic.

So it's ultrasound, make it move,

and it's musculoskeletal ultrasound.

Use angle artifact to delineate

where certain structures begin and end.

- See how the ITB gets dark and then bright.

That's the anisotropy to help you identify that.

Very good. Excellent. Any other questions?

Looks like we're we're good Laura, how are we doing? Good?

- Yeah, we're getting great.

I'm just gonna share this one thing.

So if you guys want

to see any more information about upcoming webinars

and recorded webinars, including the others on the hip,

you can go to this website here,

secure dot sono site.com/behind the scan webinar.

And also posterior hip is coming up on December 17th.

So look out for that. And

after the webinar today, you will receive a survey.

So please fill out the answers to those surveys

that really helps us PR plan for our future programs.

And I think that all for today.

I do see one more question, but we will save that question

and reach out to that person directly.

So thank you so much for joining us today

and have a good afternoon,

- Laura, real quick, we'll do the piriformis when we go

to the posterior hip in a couple of weeks.

- Oh, okay. - That was the other question.

- That was the question. Okay, great.

- Yeah, very - Good. Thank you so much.

- Thank you everybody.

Learn diagnostic ultrasound of the hip utilizing point-of-care ultrasound during this expert-led, live webinar. View techniques to visualize lateral hip structures, including the gluteus minimus, gluteus medius, gluteus maximus, tensor fascia lata, and trochanteric bursa.

This webinar is the third 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
Presenter: Daniel Shelton, RT(R)
Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

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
Presenter: Bill Medford, RMSKS, RDMS
Position: Lead, Musculoskeletal Clinical Specialist, Fujifilm Sonosite

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.

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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.