Transcript
- Hello everyone, welcome to the webinar.
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Okay, great. Welcome to our webinar on examining hip anatomy
and structure with point
of care ultrasound on the medial hip.
This is actually part two of 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
or side 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 for
and archived for future reference.
Our presenters today are Daniel Shelton and Bill Medford.
Daniel Shelton is the director
of MU 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
across a breadth of musculoskeletal specialties.
Bill, I'll turn it over to you to get us started.
- Alrighty, very good.
Thank you very much Laura
and welcome to all of you
for today's webinar on the medial hip.
The anatomy that we'll cover today include a conversation
about the adductor muscle complex.
We'll also touch on what anatomy is involved
with patients who have generalized or athletic pubal
and we'll look at the pectineus
and gracilis muscles
transducers that we might use anywhere in the hip
or pelvis would include the curved
five to one megahertz transducer
with a 60 millimeter footprint, the linear 15
to four megahertz transducer with a 50 millimeter footprint
and the small footprint 19 to five megahertz probe.
That said, most
of today's imaging will be done using the L 15
to four transducer.
Bony acoustic landmarks are always important to be able
to identify when we're looking for tendon insertions
and origins.
Boning acoustic landmarks that we will concern ourselves
with in assessing the medial hip anatomy
include the superior pubic ramus,
the inferior pubic ramus,
and the pubic tubercle.
- Let's begin with talking about the adductor muscles.
- The I vector longus originates from the anterior lateral
pubic tubercle
and inserts on the middle third of the linear aspera
of the femur.
The abductor brevis originates from the anterior surface
of the inferior pubic ramus
and inserts on the medial lip of linear aspera.
The adductor magnus originates from the inferior pubic
ramus, which we can't see here as it comes
underneath the brevis and the longest
and inserts in a few different locations along
the gluteal tuberosity of the femur, the medial tip
of the linear aspera, a medial supracondylar ridge
and most distally on the adductor tubercle.
To demonstrate the adductors with ultrasound we're going,
it's helpful to have the patient frog leg a bit
to bring the medial side of the hip out to
where we can easily access it with the transducer as well.
We also wanna be mindful of patient modesty
as we bring the transducer
near some sensitive areas on the patient.
The adductor longus is the more
superficial of the muscles.
We wanna perch our transducer, the superior end
of the transducer on the edge of the pubic tubercle
and oblique it down the leg
and we will then see the adductor longus.
Superficial deep to that will be the adductor brevis
and the deepest of the three muscles
is the adductor magnus.
We can remember these by remembering the great state
of Alabama here in Crimson tide red.
And we also wanna remember this fascial plane in
between the brevis
and the Magnus through which courses the obterator nerve.
Daniel, I'll let you go into a demonstration
of the adductor muscles.
- Thank you, bill. Today we'll be using the sono side PX
and we're gonna begin with the L 15 to four transducer.
It's kind of a general purpose transducer.
We're gonna expose the hip and groin area.
We've tucked in a cloth here in this case just
a extra pillow case.
But to maintain that patient dignity portion of the exam,
very important to just make sure everybody's comfortable
before you move forward into the growing area.
We're gonna go into a frog leg position
and just externally rotate.
And what that does is it really perches up
that adductor longest
and the gracilis too, really exposing just right there
where we're gonna set our transducer.
So get a little bit of ultrasound Joe and we'll get started.
I start with the adductor longest and short axis
and then I go long axis.
So the short axis approach is just right here.
My thumb will be screen left,
which will be the patient's right side.
So I'm just gonna set the transducer right down there
and that first very large circular structure that we see
as adductor adductor longus.
So I'm gonna adjust the depth, throw an arrow on there.
Here we go. So pointing out this whole circular structure
here, adductor longus, brevis.
And then even deeper we rely on that obterator nerve to kind
of define, hey, where is that fascial interface
that that we were looking for.
There we go. So there I can see
after my arrow pops back up the obterator nerve defining
that fascial plane here
between the adductor brevis and Magnus.
So I'm gonna go back up here to adductor longus
and I'm just gonna rotate the transducer
and place the proximal
screen left will be proximal,
which is the orientation marker you see on the upper left.
So I'm just gonna rotate that here. There we go.
And then in long axis kind of ramping up here shallow,
we can start to see that central tendon
of the adductor longus right here.
So here we have adductor longus
and then the beginning of adductor brevis just under it.
And then we remembered because we set our depth as as deep
as we needed to go where the obrador surface was
the fascial plane for the obrador,
defining the adductor magnus much deeper.
Here we go.
So what we're gonna do is follow this structure right up
here, even more medially up close to the synthesis here.
And we're gonna use Sano palpation while we scan.
So this is a great method to kind of evaluate pain locally.
So what I'm gonna be doing is just pressing down on the
transducer and just asking for patient feedback
as we climb up to the origin
of the adductor longest kind keep in mind to keep things.
- Daniel, I'm gonna interrupt you just for a second.
Suggest that because the image quality doesn't transfer
over to zoom.
Yes, quite as well please.
I might have you just turn the,
turn the gain up a little bit.
It's looking a little bit dark
and I'm sure that's not what you see there.
- Yeah, zoom really, zoom does kind of its own thing.
So the image quality you guys are seeing
is absolutely much better in person.
So if you are satisfied with what you're seeing, wait
until you see the PX in person.
So here we are. Is that, is that better Bill?
Is it a a bit more balanced?
- Yes it is. Thank you.
- Brought up a little near field there as well.
Okay, so tracing that adductor longest
proximally up until its origin there
and you can see the three kind of tapering up
and we can see the in that ramus at the bottom left
of the screen starting to kind of delineate itself.
So that gives you an idea of where we are.
So we have Magnus, brevis and longus here.
Bill, should I evaluate any further
or we ready to go to the next step?
- Maybe just come up and demonstrate the pubic tubercle
and the insertion of the longest there.
Although I know you'll cover that when we go
to the discussion of
- Yeah, - Athletic pubal.
- Exactly. That'll be covered a little bit more
comprehensively once we get up to the to the pubal.
- Let's go do that. I'll
share my screen.
We'll go back to the PowerPoint
often referred to as sports hernias.
Misnamed, according to many athletic pubal, often occurs
where the abdominals
and the adductors attach to the pubic bone
while traditional hernias occur further up in the
inguinal canal.
It most often occurs during sports
that require sudden changes of direction
or intense twisting movements such as kicking
or sprinting
to to see the both of these structures,
the rectus abdominis
and the adductor longus, the two muscles
that insert on the pubic tubercle
that are oftentimes involved as a cause for athletic
or generalized pub alga.
We'll see an ultrasound image that looks like this
where we see the hyper coic surface
of the pubic tubercle coming in from superiorly
rectus abdominis and coming from inferiorly
the adductor longus muscle.
So Daniel will a few more things in just this,
in his live demonstration of the insertions
onto the pubis.
Daniel.
- Thank you Bill. So I've changed how we've draped here.
Instead of coming from inferior, what I've done is I've,
I've draped and tucked the bedsheet here
into the underwear portion of the,
the strap on the pants right here.
And then I brought another blanket just right across kind
of mid, mid sagittal
and that gives me access to this little scanning window,
which I'll be just setting the transducer right up under.
And I like to start in a short axis
and evaluate that synthesis first.
And then I will pan up approximately
and see the rectus in short axis.
And at that point I should be able
to see if there's any issues in cross-section
because cross-section is really gonna show me the breadth
of the enthesis, of the rectus abdominus
and it's gonna show me a really nice origin
of the adductor longus.
And then I'm also gonna see a really nice cross section
of the synthesis pubis.
So if you're not seeing the entire scan head,
I'm just being sensitive to the situation here when we're
doing a live web demonstration.
I above anybody else right now don't want anything
to go wrong on a demo.
So here we go. I'm gonna go right up here.
And I mentioned scanning synthesis first.
So this is the edge of the synthesis
and I'm also ano palpating.
So this is the right side synthesis
and I'm just gonna bring the transducer a bit more midline
and there we can see the joint right
between those two synthesis.
So bringing our arrow back up, pointing a few things out.
Here's the very large ligament that spans that gap.
And then just superficial to that, I'm looking
for the musculature of the rectus abdominis.
So not focusing on the ligament to structures
or the joint themselves, but I am looking for symmetry.
I am looking for anything
that is asymmetric in terms of soft tissue.
Like up here we have a little
calcification on the table today.
We have a runner, avid runner,
a former soccer player, 15 years.
So there, there are gonna be calcifications
to look for older, more,
more chronic injuries, more than acute.
So we've got rectus origin here and and
or and thesis.
And I'm just gonna be scanning cross-sectionally across the
rectus first and then I'm gonna climb up
and over the rectus here.
And the of the origin
of longus is a little bit less storytelling than
just going long axis.
So I'm just gonna catch the rectus first
and I'm gonna spin the transducer long axis the same way
that I had told you before.
Find that bony landmark here of the synthesis.
So right side synthesis.
Again, here's the cross section of
that ligament, we can see it right here.
And then here's the tendon of the rectus abdominis here.
And here we can see the muscle.
So here's the distal most muscle
of the rectus abdominis here We can see
the tendon formation here on the lower edge
and linea alba structure right there above rectus there.
So all of that I'm just watching
and looking for any other asym asymmetrical views.
And then down here we've got the genital femoral
neurovascular complex.
And then we're gonna follow this just right up
and over the synthesis.
So synthesis here.
And then here's where we're gonna see the The rectus longest
rectus longest, the adductor longus origin.
So we're up and over, up and over
and we're just gonna scan right across.
So it kind of went pectineus there a little bit too lateral.
Here we are. So there we can see the common
tendon right here where they share structure.
So this is the adductor longus origin right here tapering up
to the synthesis and then you can see it's superficial most
fibers bridging up and over.
So you can see that soft tissue connection
and how an injury to the longest could affect the pole on
the rectus side and vice versa.
Bill, I'm gonna turn it back to you.
- Bill, is your mic turned on?
- It is. - Okay, now we can hear you. Great.
- Okay, sorry about that. Just checking.
Alrighty, very good.
Alright, moving on. Let's talk about the pectineus muscle.
So the pectineus origin is from the pectineal line
of the pubis on the superior pubic ramus.
It is the most superior originating muscle
of the thigh adductors.
Its insertion is on the posterior surface
of the femur along the proximal part of the linear aspera
pectus muscle functions to adduct, whoops, sorry,
serves to adduct and laterally rotate the thigh.
But its primary function is hip flexion.
It can be injured by overstretching out to the side
or in front of the body
and is a muscle that can also be injured
by rapid movements such as kicking or sprinting
- Daniel.
- All right, so we've repositioned again
to go back down inferior
and I don't know what's happened with that shot.
My auto focus is not, there we are. Okay, good.
Auto focus can be good, auto focus can be bad.
Back to the familiar adductor
longest right where we started.
So right across that, that larger muscular hump on the
inside thigh here.
And hopefully you're seeing that okay, zoom may have
knocked down my gain again.
Now this time instead of traveling more proximally,
I'm just gonna bring the transducer medially
and just on the medial edge of where we saw adductor,
longus, brevis
and even deeper Magnus,
I'm gonna follow this larger muscle here.
So this is our pectineus.
Lemme get that recentered here
and we're gonna follow it up more proximally
to the ileal pectineal imminence of the ileum
where it originates right up here.
And you see the abrupt angle I'm having to take.
And that's because that pectineus tendon is really sloping
upward to meet that the, the, the inside margin
of the synthesis as it meets the rest of the ileum.
So it takes a sharp, very, very sharp dive,
but we're able to follow it out
and really evaluate the muscle all the way to its origin.
So you see that the motion is very much a pivot
instead of a sweep.
So I'm not sweeping the transducer more than I am letting
the transducer fan across those fibers from a
central pivot.
So again, landmarks here, midline on the screen,
adductor longest, this tends to be the easiest one
'cause here's the central tendon
of adductor longest right here.
Here we have brevis
and then just lateral to that
we've got pectineus follow pectineus proximally.
And what we're gonna do is just aim, aim, aim up into its
origin there on the ileal pectineal
imminence Bill
- Daniel, the two hypoechoic look like nerve structures deep
to the pectineus in that fascial plane, right, right
where you were at there come over a little more.
Yeah, see those? There you go.
See those, those two that are deep in that bright, yes sir.
Right there. Can you elaborate on what those might be?
- Ator, - Are they branches of the ator?
- I believe these are branches of the saw.
I typically, I typically focus on radR when it's
down here. So we could,
- Right, - That's the beauty of ultrasound.
You know, we're not dealing with a
static imaging modality, right?
So let's follow this, this landmark back approximately,
approximately, approximately.
And then I do see an offshoot right there.
Shoot laterally, laterally, laterally,
whatever those individual branches are, if they're important
to a particular subspecialty.
Sorry for not elaborating on the individual branches here,
but it does put us right back into that landmark
underneath the belly of the pectineus. So
- That's, that's exactly what I hoped you'd do.
I wasn't sure that they were branches of the odd trader,
but they clearly are Beauty
of ultrasound, dynamic assessment,
- Beauty of ultrasound.
You bet this is an investigational tool more than anything.
- Very good. I'll take it from there
unless there's something else you wanted to look at there.
- No, that'll do it. Bill, I'm gonna let you go ahead and
- Okay, - Get to the next I think gracilis.
- Yes sir.
- So the last structure that we're gonna talk about today is
the gracilis muscle it's
named, describes its shape.
An interesting little factoid that I didn't know is
that the gracilis is the Latin word for slender.
And as we see here in this cadaver,
we see this slender little tendon
and muscle of the gracilis
as it proceeds distally down the medial thigh.
It is the most superficial and medial
and it originates on the inferior pubis of the ramus.
Its insertion is on the medial tibial shaft,
slightly posterior to the sartorius.
And as we all know, it is one of the tendons
of the pean serene because of its insertion.
It has a role to play in knee flexion as well
as thigh abduction and medial tibial rotation.
Daniel, I'll let you demonstrate the gracilis.
Obviously we're not gonna be able
to demonstrate the insertion of the
or I mean the origin of the gracilis.
But Daniel can demonstrate some
of the surrounding na anatomy
to help us identify the gracilis muscle.
- Thank you Bill. Again, kind of a lighthouse
for this medial hip is, is continuing to be
that adductor longus here.
So I'm just gonna set that down.
As we have before, observe that that much larger
prominence here, which is the
adductor longus brevis underneath ator.
But this time instead of going laterally, we're gonna go
and roll more medially.
When I'm doing this, I'm not just translating the transducer
just like the elbow
or other more cylindrical structures
that we, that we do scan.
As I go more medial, I need to aim the beam laterally
to stay perpendicular to the anatomy of interest.
So all I'm doing here is, is painting the probe medially
there and aiming it laterally
and that keeps it centered.
We have to stay as centered as we can.
So here we are gracilis
muscle and we could trace
that all the way down the thigh all the way to the knee.
But it's all about identifying this muscle belly First,
more branches of the obrador here.
Here Bill. We'll have to go back
and learn all the names of these branches now
that we can see 'em so nicely.
But here's the muscle of the gracilis.
I'm gonna go just like we do anything diagnostically, I need
to evaluate this in longitudinal orientation as well.
- There we're - Looks a lot like the adductor longest,
so you don't want to confuse the two.
See how you could confuse that view
and say, oh, that's the longest right here.
So it's very important in my opinion,
to start short axis when looking at a lot of these groups.
This could be on the, on the more distal thigh, on the calf
or the forearm or in the middle of the humerus.
Identifying these structures,
cross-sectionally first will be much more of a roadmap.
So here I can see that
that nice fascial plane separating the adductor
longest from the gracilis.
So what I'm gonna do is just pull the transducer over
and as I go more proximally, the angle that has
to be taken here is pretty abrupt to get towards the origin.
Even though we're not gonna go all the way
to the origin today, you can see
where these things are tapering extremely thin
on the uppermost portion of the screen.
So you basically end up laying the
transducer against the thigh
and pressing on the inferior aspect of the of the synthesis.
And I hope that projected,
well I hope everybody understands the sensitivity
of not getting all the way up
to the origin on a web conference.
So I'm gonna leave it at that Bill, is there anything
that I missed on this exam
that you didn't cover on your slide?
- It looks great, Daniel.
And so that concludes our webinar on the medial hip.
Laura, I'm gonna turn it over to you at this point.
Do we have any questions that we can address?
- Well thank you Daniel and Bill,
that was excellent presentation and demonstration.
I am looking for questions. I don't see anything right now.
Just a reminder, if you do have any questions, go ahead
and type 'em into the q
and a box at the bottom of your screen.
We'll just take a moment to see if there are any.
Okay, it doesn't look like there's any questions today guys,
but everyone who's attending you will be receiving a
survey after this webinar.
Please take a moment to answer those questions for us.
It does help us plan all the future webinars
and to view our upcoming webinars.
You can go to the link on the page that you see here.
It's secure sono.com/behind the
the scan webinar with dashes in between.
Recordings of our past webinars are also posted there.
Thank you so much for joining us today.
We will see you soon.
- Thanks everybody. Thanks everybody.
Learn diagnostic ultrasound of the hip utilizing point-of-care ultrasound during this expert-led, live webinar. View techniques to visualize medial hip structures, including the adductors, gracilis, and pectineus; and discuss diagnostic assessments using ultrasound.
This webinar is the second 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.