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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5833_Библиотеки_им_академика_М_И_Перельмана.pdf
Anterior Hip
77
Fig. 6.2a Probe position to evaluate the sartorius
and tensor fasciae latae insertions
Fig. 6.2b US scan shows the tendinous insertions of sarto-
rius (Sa) and tensor fasciae latae (TFL) muscles on the
anterior-superior iliac spine (ASIS)
Fig. 6.2c Anatomical scheme: proximal insertion of sarto-
rius (Sa) and tensor fasciae latae (TFL) and respective mu-
scle bellies anterior-superior iliac spine (ASIS)
6 Hip
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Fig. 6.3b The axial scan shows the tendinous insertion of the rectus femoris
(arrowheads) into the AIIS. Ps, iliopsoas muscle; AIIS, anterior-inferior iliac
spine
Fig. 6.3c Anatomical scheme: proximal insertion of rec-
tus femoris (RF) and its connections with psoas muscle
(Ps). AIIS, anterior
-inferior iliac spine; F, femur
Fig. 6.3a Probe position to evaluate the rectus
femoris proximal insertion
Anterior Hip
79
Fig. 6.4a Probe position to evaluate the rectus femoris
tendon insertion onto the AIIS
Fig. 6.4b The ultrasound scan shows the tendinous insertion of rectus femoris
(arrowheads) onto the AIIS. RF, muscle belly of rectus femoris; Ps, psoas muscle;
AIIS, anterior-inferior iliac spine
Fig. 6.5Anatomical scheme: tendons of the rectus femo-
ris muscle. d, direct tendon; i, indirect tendon; r, reflec-
ted tendon; RF, rectus femoris muscle; F, femur
6 Hip
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Fig. 6.6a Probe position to evaluate the rectus femoris
tendon with longitudinal scans
Fig. 6.6b The longitudinal scan shows the direct (arrowheads) and indirect (*) tendons
of the rectus femoris muscle. Note the hypoechoic appearance of the indirect tendon
cranial portion, determined by the change in orientation of the tendon (anisotropy),
which courses externally and obliquely compared to the direct tendon
Anterior Hip
81
Fig. 6.7a Probe position for the axial evaluation of
the rectus femoris direct and indirect tendons
Fig. 6.7c Probe position to evaluate the rectus
femoris distal aponeurosis
Fig. 6.7b Axial evaluation of the direct (arrowheads) and indi-
rect (*) tendons of the rectus femoris muscle. Sa, sartorius; F,
femur
Fig. 6.7d The axial scan shows the distal tendinous aponeuro-
sis (arrowhead) of the rectus femoris muscle (RF) shaped like
a “C”. Vi, vastus intermedius muscle; F, femur
6.1.3 Iliopsoas
The iliopsoas muscle can be seen by means of
a series of axial scans, medial to the rectus
femoris. On these images, the hyperechoic ten-
don is located in an eccentric posterior-medial
position within the muscle belly (Figs. 6.8a, b).
The muscle can be followed using both axial
and longitudinal scans up to the insertion into
the lesser trochanter.
The iliopsoas muscle is often considered as
the only biarticular muscle, located in the
lumbo-iliac region and in the anterior region
of the thigh. Actually, it is formed by two
distinct portions: the psoas major muscle,
and the iliacus muscle. It arises from the
lateral side of the body of the last thoracic
vertebrae, from the first four lumbar verte-
brae and the interposed disc, and from the
base of the transverse processes of the first
four lumbar vertebrae. The muscle belly
runs obliquely down and outwards; it passes
under the inguinal ligament and ends on the
apex of the lesser trochanter on the thigh.
The femoral nerve runs between the iliacus
muscle and the psoas major.
The iliopsoas bursa is located anteriorly between
the joint capsule and the posterior surface of the
iliopsoas muscle. This is the largest synovial
bursa of the human body, which communicates
with the joint space in 15% of cases.
6.1.4 Femoral Neurovascular Bundle
Medial to the rectus femoris muscle, the neuro-
vascular bundle can be identified using axial
scans: lateral to medial, the femoral nerve, the
common femoral artery, and the common
femoral vein can be seen (Figs. 6.9a, b).
6.1.5 Hip Joint
Medially and distally to the ASIS, the hip joint
can be seen by an oblique sagittal scan to assess
the femoral acetabulum with the anterior por-
tion of the labrum, the anterior capsular profile
and the femoral head covered by the articular
cartilage (Figs. 6.10a, b). At the bottom of the
femoral there head is the anterior synovial
recess that is not detectable when normal.
Conversely, the anterior capsular profile is
almost always visualized as a hyperechoic
linear structure superficial to the joint space.
The joint capsule inserts proximally onto the
border of the acetabulum and the acetabular
labrum, distally onto the inter-trochanteric
line, and posteriorly onto a line located at
the border between the medium and lateral
third of the femoral neck. Therefore, the
anterior face of femoral anatomical neck is
intracapsular, whereas the posterior side is
only partially intracapsular.
6 Hip
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Anterior Hip
83
Fig. 6.8a Probe position to evaluate the psoas
muscle myotendinous junction
Fig. 6.9a Probe position to evaluate the femoral
neurovascular bundle
Fig. 6.8b The axial scan shows the myotendineous junction
(*) of the psoas muscle (Ps). F, femoral head
Fig. 6.9b The axial scan shows the femoral neurovascular
bundle: fA, femoral artery; fV, femoral vein and fN, femoral
nerve. Pe, pectineus muscle
Fig. 6.10a Probe position to evaluate the coxo-
femoral joint
Fig. 6.10b The scan shows the femoral head (F) covered by the
articular cartilage, the acetabulum (Ac), the acetabular labrum
(*), and the anterior capsular profile (arrowheads). Ps, psoas
muscle
6 Hip
84
6.2 Medial Hip
6.2.1 Adductor Tendons and Muscles
The patient is supine, with the lower limb
slightly externally rotated (Figs. 6.11 and 6.12).
With a sagittal scan, the bony landmark of
the anterior surface of the pubis can be seen to
detect the insertional components of the adduc-
tor muscles (Figs. 6.13a, b). Three muscle
layers can be seen: from the most superficial to
the deepest, the adductor longus muscle, the
adductor brevis muscle and the adductor
magnus muscle. Turn the probe over the cour-
se of a single muscle belly, according to the
axial and longitudinal planes.
Medial Hip
85
Fig. 6.11 Lower limb position for medial hip eva-
luation
Fig. 6.12 Anatomical scheme: adductor muscles. The
adductor longus (AL) is the most superficial and it is
represented in shadow. The adductor brevis (AB) and
magnus (AM) are shown deeply. F, femur; P, pubic
ramus
Fig. 6.13a Probe position to evaluate the adduc-
tor muscles’ proximal insertion
Fig. 6.13b The longitudinal scan shows the tendon insertion
(*) of the adductor longus (AL), adductor brevis (AB), and
adductor magnus (AM) muscles in correspondence with the
pubic symphisis
6.3 Lateral Hip
6.3.1 Gluteus Tendons and Muscles
With the patient lying on the contra-lateral hip
(Fig. 6.14), find the greater trochanter with an
axial scan and then slightly shift the probe cra-
nially (Fig. 6.16a). Similar to the shoulder rota-
tor cuff analysis, three muscles can be encoun-
6 Hip
86
Fig. 6.14 Patient in the lateral
position for the lateral hip
e
valuation
tered with their myotendinous junctions: from
the front to the back, the gluteus minimus
muscle (deep), the gluteus medius muscle,
and the gluteus maximus muscle (more super-
ficial) (Figs. 6.15 and 6.16b). Superficial to
these is the tendinous portion of the tensor
fasciae latae, which has a ribbon-like hypere-
choic appearance and is separated from the
cuff by a synovial bursa and adipose cleavage
planes (Figs. 6.17a, b).