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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5779_Библиотеки_им_академика_М_И_Перельмана
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210 Chapter 7
Figure 7-12. (A) SX view of the sartorius
(white arrow). (TFL = tensor fascia lata.)
(B) LX view of the sartorius (white arrow).
A
B
Figure 7-13. Panoramic view of the anterolateral thigh showing the tensor fascia lata (TFL), superficial layer of the
iliotibial band (yellow arrow), deep layer of iliotibial band (blue arrow), and common iliotibial band distally (white
arrow). (VL = vastus lateralis.)
Hip 211
3. Relevant anatomy: The sartorius originates from the ASIS and runs anteromedially along the
thigh to attach to the proximal aspect of the medial tibial surface as the most proximal tendon
of the pes anserine tendons. The sartorius is a biarticular muscle, and the medial border of
the sartorius forms the lateral border of the femoral triangle. The iliotibial band has 3 layers:
superficial, intermediate, and deep. The superficial layer originates from the ilium superficial
to the origin of the tensor fascia lata muscle, the intermediate layer originates from the ilium
distal to the tensor fascia lata muscle, and the deep layer originates from the supra-acetabular
fossa between the hip joint capsule and the reflected head of the rectus femoris. Posteriorly,
the iliotibial band also receives tendinous fibers from the gluteal aponeurotic fascia and
gluteus maximus muscle. All the layers of iliotibial band merge together at the level of the
greater trochanter to continue distally along the entire length of the thigh and attach distally
at Gerdy’s tubercle of the tibia (see Figure 7-10).
4. Points to remember: The superficial layer of the iliotibial band is thicker posteriorly at the level
of the iliac tubercle compared with the anterior portion, which runs superficial to the tensor
fascia lata. The posterior contribution from the gluteal aponeurosis is much thinner. The tensor fascia lata muscle has a unique echotexture due to internal fat content.
7, 8
Tendons Originating From the Anterior Inferior Iliac Spine
1. Patient position: Supine
2. Probe/transducer position: The probe is placed in the LX orientation to the rectus femoris
direct head attachment at the anterior inferior iliac spine (AIIS; Figures 7-14 and 7-15). This
view can be obtained by first visualizing the femoral head-neck and then moving the probe
slightly proximal and lateral until the AIIS is visualized. To scan the indirect head of the
rectus femoris, the probe is moved slightly distal and lateral from the direct head with more
pressure on the proximal end of the probe to counter anisotropy because the indirect rectus
femoris fibers do not run parallel to the superficial structures (Figure 7-16).
A
Figure 7-14. LX view of the rector femoris. (A) Probe placement. (B) Hyperechoic rectus femoris direct head (white
arrow) attaching to the AIIS. The indirect head (yellow arrow) appears hypoechoic due to anisotropy as the tendon
attaches to the superolateral margin of the acetabulum.
B
212 Chapter 7
Figure 7-15. Relevant anatomy of the rectus femoris tendon origin. The direct tendon of the rectus femoris arises from
the AIIS as a short, strong tendon. The indirect tendon of the rectus femoris arises from the superolateral margin of
the acetabulum.
A B
Figure 7-16. Indirect head of the rectus
femoris. (A) Probe placement. (B) LX view
of the indirect head of the rectus femoris
(yellow arrow). The probe is moved slightly
distal and lateral from the direct head with
more pressure on the proximal end of the
probe to counter anisotropy.
Hip 213
3. Relevant anatomy: The direct tendon of the rectus femoris arises from the AIIS as a short,
strong tendon. The indirect tendon of the rectus femoris arises from the superolateral margin
of the acetabulum (see Figure 7-15). The indirect tendon travels with the central aponeurosis
of the rectus femoris, and the direct tendon travels with the superficial fascia.
4. Points to remember: In the LX view, the direct head appears as a hyperechoic fibrillar struc-
ture, whereas the indirect head appears as a hypoechoic structure due to anisotropy. Increase
the pressure on the proximal end of the probe in an attempt to counter anisotropy artifact to
visualize the indirect head better.
1,2
LATE RA L HIP
Greater Trochanter and Gluteal Tendon Attachments
1. Patient position: Side-lying with the hip neutral to slight flexion
2. Probe/transducer position: The probe is placed on the lateral aspect of the thigh at the level of
the greater trochanter in the SX orientation. The SX orientation helps identify the bony facets
of the greater trochanter as anterior, lateral, superoposterior, and posterior (Figures 7-17 and
7-18). After identifying the bony facets of the greater trochanter, imaging can be focused on a
specific structure (eg, gluteus medius anterior or posterior band, gluteus minimus, or trochanteric bursa; Figures 7-19 through 7-22).
2
Figure 7-17. The 4 facets of the greater trochanter: anterior, lateral, superoposterior, and posterior.
214 Chapter 7
Figure 7-18. SX view of the greater
trochanter (GT) showing 3 facets:
anterior (A), lateral (L), and posterior
(P). The bony apex (white arrow) of
the greater trochanter differentiates
the anterior from the lateral facet.
The posterior facet is more rounded,
whereas the anterior and lateral
facets are flat.
Figure 7-19. Footprints of the gluteal tendons on the greater trochanter. The gluteus minimus attaches to the anterior
facet, the gluteus medius anterior band attaches to the lateral facet, and the gluteus medius posterior band attaches
to the superoposterior facet. (G = gluteus.)
Hip 215
AB
Figure 7-20. LX view of the gluteus minimus. (A) Probe placement. The black star indicates the greater trochanter. (B)
LX view of the gluteus minimus (white arrow).
A
Figure 7-21. LX view of the gluteus medius anterior band. (A) Probe placement. The black star indicates the greater
trochanter. (B) LX view of the gluteus medius anterior band (white arrow).
B
216 Chapter 7
A
Figure 7-22. LX view of the gluteus medius posterior band. (A) Probe placement. The black star indicates the greater
trochanter. From the anterior band view, the probe is rotated slightly posterior, and pressure is increased on the
proximal end of the probe. (B) LX view of the gluteus medius posterior band (white arrow).
B
3. Relevant anatomy: The greater trochanter has 4 facets: anterior, lateral, superoposterior, and
posterior. The mean size of the facets is as follows: anterior = 2.6 × 3.0 cm; lateral = 2.0 × 3.7 cm;
superoposterior = 1.5 × 1.7 cm; po sterior = 2.5 × 2.8 cm .9 The gluteus minimus attaches to the
anterior facet, the gluteus medius attaches to the lateral and superoposterior facets, and there
is no attachment on the posterior facet. The trochanteric bursa overlies the posterior facet. The
gluteus medius has 2 bands: anterior and posterior. The anterior band attaches to the lateral
facet, and the posterior band attaches to the superoposterior facet.
9,10
Hip 217
4. Points to remember:
a. It is important to remember that probe orientation will change slightly if the patient adds
more hip flexion or assumes a more comfortable fetal position for gluteal tendon scanning.
Adding more flexion will result in more anterior rotation of the tendon fibers.
b. The posterior band of the gluteus medius plays an important role in gait biomechan-
ics; therefore, a tear of the posterior band is associated with greater discomfort and
impairment.
11
c. There are bursae under the gluteus medius tendon (subgluteus medius bursa) and gluteus
minimus tendon (subgluteus minimus bursa) as they insert on the greater trochanter.9
d. The trochanteric bursa is also called the subgluteus maximus bursa (Figure 7-23). This
bursa is present between the gluteus medius tendon and the gluteus maximus muscle,
overlying the posterior facet of the greater trochanter, to prevent friction between the
greater trochanter and the gluteus maximus as it sends fibrous extensions to the fascia lata.
Branches of the inferior gluteal nerve supply the trochanteric bursa.
Figure 7-23. The trochanteric bursa,
or subgluteus maximus bursa (white
arrows), is present between the
gluteus medius tendon (white star)
and gluteus maximus muscle (GMax),
overlying the posterior facet (P) of the
greater trochanter. (A = anterior facet;
L = lateral facet.)
12
218 Chapter 7
POSTERIOR HIP
Piriformis and Sciatic Nerve
1. Patient position: Prone
2. Probe/transducer position: The probe is placed over the posterior aspect of the greater tro-
chanter, transversely along the LX of the piriformis muscle. The probe is placed along the
imaginary line running between the sacrum and the greater trochanter. The sciatic nerve is
visualized in the SX, passing under the piriformis muscle to course distally toward the thigh
(Figure 7-24).
AB
Figure 7-24. Piriformis muscle. (A)
Probe placement. (B) Piriformis muscle
(white arrow), sciatic nerve (yellow
arrow), and greater trochanter (GT).
Hip 219
3. Relevant anatomy: The piriformis originates from the anterior surface of the sacrum at the
level of S2-S4 around the sacroiliac joint capsule and inserts as a short, round tendon on the
superomedial aspect of the greater trochanter (Figure 7-25). The sciatic nerve exits the greater
sciatic foramen, passing under the piriformis muscles. There are some variations in about
22% of the population where the sciatic nerve may pierce the piriformis, split the piriformis,
or both, in which one branch may pierce the piriformis muscle belly (usually the common
peroneal/fibular portion) and the other (the tibial portion) pass under or over the piriformis
muscle belly.
13
Figure 7-25. Relevant anatomy of the piriformis, sciatic nerve, and other posterior hip musculature.
4. Points to remember: External rotation may help differentiate the piriformis from the overlying
gluteus maximus muscle. The piriformis attachment is very close to the gluteus medius attachment. Other internal rotators of the hip attach very close, slightly distal to the piriformis.
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