6. HIP & KNEE RADIOLOGY
• The imaging modality used in a given patient
depends upon the differential diagnosis that
has been developed based upon the history
and physical examination
7. HIP & KNEE RADIOLOGY - XRAY
Plain film radiography of the is used in the
initial evaluation of
• any cause of pain.
• referred pain, such as sacroiliitis
8. HIP & KNEE RADIOLOGY - CT
• for preoperative planning,
• evaluation and guiding percutaneous biopsy
• septic joint
• soft tissue abscess
9. HIP & KNEE RADIOLOGY - MRI
MRI of the hip accurately evaluates
• bone marrow
• joint space
• neurovascular structures
• soft tissues
10. HIP & KNEE RADIOLOGY - MRI
MRI is the modality of choice for
• suspected femoral fracture not demonstrated
• osteochondral injuries
• muscle injuries
• joint effusion
• early diagnosis and staging of AVN
11. HIP & KNEE RADIOLOGY – Bone SCAN
• Radionuclide Tc-99m bone scan surveys
• Radionuclide bone scan is used for evaluation
of metastatic disease and infection.
12. HIP & KNEE RADIOLOGY - USG
• Readily available even at the bedside
• Allows dynamic evaluation of the tendons and
muscles( soft tissues )
• Does not involve ionizing radiation
13. HIP & KNEE RADIOLOGY - USG
• highly operator- and patient-dependent.
• Hip effusions
• bursal / periarticular fluid collections are
26. Hip pain in children
• Evaluation – The history and examination of
the child with hip pain is focused on
distinguishing between various causes
• This distinction helps to determine the
appropriate laboratory and radiographic
27. Hip Pain In Children
• Septic arthritis of the hip / the sacroiliac joint
• Osteomyelitis of femoral head
• Psoas abscess
• Spinal epidural abscess
• Appendicitis or abdominal/pelvic abscess
28. Hip Pain In Children
• Transient synovitis
• Systemic arthritis
• Infectious/post-infectious (eg, ARF,
• Rheumatologic conditions (eg SLE , vasculitis,
dermatomyositis , localized scleroderma )
• Arthritis associated with gastrointestinal
conditions (eg, IBD, celiac disease)
29. Hip Pain In Children
• Avascular necrosis
• Femoral stress fracture
• Muscular strain
• Trochanteric bursitis
• Acetabular labral tear
• Osteoid osteoma
• Solid tumor
• primary or metastatic
30. Hip Pain In Children - History
• Associated systemic symptoms
• Past medical history;
• Family history
38. Lateral Femoral Cutaneous Nerve Entrapment
• Also called Meralgia paresthetica
• Is the best known of the lower extremity nerve entrapment
Nerve irritation can be triggered by
• tight clothing belts
• car seat belts
• focal trauma
• INCLUDING SURGICAL INTERVENTIONS
a) such as appendectomy or
b) hysterectomy; and
39. • Symptoms include pain to the hip area, thigh,
or groin along the distribution of the nerve
(proximal anterior lateral aspect of the leg;
burning or tingling paresthesias may be
• Pain may be worsened or by tapping over the
area of the anterior superior iliac spine
40. Lateral Femoral Cutaneous Nerve Entrapment
• Those affected should limit the exacerbating
activity and eliminate the source of the
• local injections
• weight loss
• surgical excision of the nerve are other
41. Obturator Nerve Entrapment
• Obturator nerve entrapment is typically a sequela of pelvic
fractures or abdominal/ pelvic surgery.
• Obturator nerve inflammation is generally sensed in the groin and
down the inner thigh and aggravated by movement of the hip.
• Exercise-induced medial thigh pain may be the predominant
• Imaging studies are of limited value
• Surgery may be required for pain relief. Local injection of lidocaine
into the area of the nerve relieves the pain and associated reactive
weakness and may make the diagnosis
42. Ilioinguinal Nerve Entrapment
• The ilioinguinal nerve arises from the lumbar
plexus and passes through the psoas and then
travese near to anterior superior iliac spine, and
the abdominal oblique muscles
• Entrapment occurs due to hypertrophy of the
abdominal wall musculature or pregnancy.
• Hypoesthesia in the distribution of the nerve,
yielding groin pain
44. Piriformis Syndrome
• Irritation of the sciatic nerve from the piriformis muscle
• Pain in the area of the buttocks and hamstring muscles that
is worsened by sitting, climbing stairs, or squatting .
• The clinician may palpate a tender mass over the piriformis
muscle and elicit pain in the region of the sacroiliac joint or
• Hip flexion will exacerbate the symptoms.
• Imaging is useful only to rule out other conditions.
• Treatment is conservative.
46. BURSAL SYNDROMES OF THE HIP AREA
• New bursae may form at any area that is subject to repeat irritation.
• Causes of bursal pain include inflammation
• with repetitive minor trauma
• rheumatologic disorders
a) such as psoriatic arthritis
b) rheumatoid arthritis
c) ankylosing spondylitis
d) gout or pseudogout
• Arthrocentesis is required when a septic joint is suspected. The
development of a draining sinus tract favors septic bursitis
47. BURSAL SYNDROMES OF THE HIP AREA
• Trochanteric Bursitis (Posterolateral Hip Pain)
• Ischiogluteal Bursitis (Posterior/Gluteal Pain)
• Iliopectineal Bursitis (Anterior Hip,Groin Pain)
• Iliopsoas Bursitis (Groin Pain)
49. BURSAL SYNDROMES OF THE KNEE
• Pes Anserine Bursitis (Anterior Medial Knee
• Prepatellar Bursitis (Pain Anterior to the
50. TREATMENT OF BURSITIS
• Treatment is aimed at the suspected cause.
• For inflammatory conditions, NSAIDs, rest,
heat, and time are the basis of conservative
• Steroids with caution..
• Do not inject steroids into tendons, because
this may weaken the tendon and lead to
• Associated infection....antibiotics
51. TREATMENT OF BURSITIS
• Serial aspiration and surgical drainage or
removal of the afflicted bursa are indicated for
• If any patient presents with toxicity, admit for
IV antibiotics and consultation with
• When fibrosis or synovial thickening leads to
the development of painful nodules, surgical
excision of the bursa is indicated.
52. HIP MYOFASCIAL
• The diagnosis of these syndromes is clinical.
Overuse syndromes are simply the result of
repetitive stresses and microtrauma outpacing
the body’s ability to heal.
a) External Snapping Hip Syndrome
b) Fascia Lata Syndrome
53. External Snapping Hip Syndrome
• Also known as coxa saltans
• a snapping sound is heard and popping
sensation felt as the iliotibial band (an
extension of the fascia lata) slips over the
• In athletes, the syndrome is usually associated
with painful inflammation of the band and the
54. • The patient will be able to voluntarily cause the
snap with hip flexion and extension.
• Young women are predisposed to this syndrome,
which occurs with activities such as dancing or
• MRI may identify intra-articular causes or
demonstrate inflammation of the local bursa, the
iliotibial band, or the gluteal musculature.
Dynamic sonography is also an aid for the
diagnosis of extra-articular causes
55. Fascia Lata Syndrome
• The fascia lata syndrome is a potential cause of
pain in the lateral thigh region and is associated
with pain to palpation and trigger points.
• Unilateral enlargement of the tensor fascia lata
may occur with overuse
• Athletes develop pain in the anterior groin and
point tenderness over the anterior iliac crest.
• US is a useful aid to confirm the diagnosis.
• Treatment conservative
57. Patellofemoral Syndrome/Runner’s
• This syndrome is a major cause of anterior
knee pain, with three typical causes:
• focal trauma (least common),
• abnormal patellar movement in the patellar
• A major contributor is weakness of the
58. Patellofemoral Syndrome/Runner’s
• Typically unilateral & common in females
• Pain is exacerbated by prolonged flexion of
the knee, such as sitting & stair climbing.
• The patellar grind test is accomplished by
direct anterior to posterior pressure on the
patella or the quadriceps tendon while asking
the patient to contract the quadriceps muscles
59. • Radiographic studies are of limited value but
may detect arthritis.
• Treatment is usually conservative, with an
emphasis on physical therapy and
strengthening. Brace support of the knee will
• If severe arthroscopic management
60. Chondromalacia Patellae
• Chondromalacia patellae refers to a softening
of the cartilage on the posterior surface of the
• This diagnosis is made by direct arthroscopic
visualization of a ragged appearance of the
61. Iliotibial Band Syndrome
• Iliotibial band syndrome is most common in
distance runners or cyclists.
• The iliotibial band inserts onto the lateral
femoral and tibial condyles .
• The thickened fascia serves as a ligament and
stabilizes the joint in extension.
• With overuse, the bursa underlying the band
62. Iliotibial Band Syndrome
• Pain is reproduced consistently after reaching a
certain mileage during running or other physical
• Examination reveals localized tenderness to
palpation over the lateral epicondyles.
• Treatment involves rest, decreasing the training
distance, changing shoes to reduce stress on the
structures, stretching exercises, and steroid
64. Patellar Tendinitis/Jumper’s Knee
• The patella tendon is subject to significant wear,
with microtears and complete ruptures occurring
in athletes and nonathletes alike
• Any activity that involves jumping can result in
focal pain, typically at the inferior pole of the
patella or proximal portion of the tendon.
• Other activities that may exacerbate pain include
running (especially uphill), squatting, cutting
maneuvers, standing from a sitting position, or
even simple walking.
65. Patellar Tendinitis/Jumper’s Knee
• Treatment involves rest, NSAIDs, and
cryotherapy. Steroid injections are
• Most recently, US-guided intratendinous
injection of platelet-rich plasma has been
suggested to allow rapid healing in the
patellar tendon and other major tendons.
66. Quadriceps Tendinitis
• The quadriceps muscles and tendon are
subject to significant forces in athletes
• Resulting in microtears and inflammatory
changes, localized predominantly at the
insertion of the tendon into the proximal pole
of the patella.
• Chronic recurrent injury or acute explosive
trauma can result in complete tear of the
67. Semimembranosus Tendinitis
• Pain is elicited just distal to the joint line, where
the tendon is easily palpated in most patients.
• In younger patients, the pain is associated with
athletics and overuse.
• In older patients, it is seen secondary to
degenerative changes in the medial
• MRI will confirm the diagnosis if conservative
68. Snapping Knee Syndrome
• Similar to the same process in the hip, is a
result of the iliotibial band passing over the
lateral femoral condyle.
• The same effect may also result from the
semitendinosus muscle passing over the
medial condyle with the initiation of flexion
and termination of extension of the knee.
69. Snapping Knee Syndrome
• The snapping sensation and sound may be
accompanied by pain in the location of the
• Managed conservatively
70. POPLITEAL (BAKER) CYST
• Presents with posteroinferior knee pain
• Develops posteriorly and inferiorly to the knee
as a distention of a local bursa
• The cyst frequently communicates with the
knee (especially in adults), and associated
intra-articular pathology is common.
71. POPLITEAL (BAKER) CYST
• The cyst may develop as a herniation of the
synovial membrane through the posterior
• Popliteal venous thrombosis can be confused
with the pain and swelling produced by these
posterior cysts or may exist concomitantly.
• Other potential diagnoses include aneurysms,
vascular tumors, lipoma, and other tumors.
75. PSOAS ABSCESS
• The psoas muscle is susceptible to the
hematogenous spread of infection from distant
sites because of its rich blood supply and
proximity to overlying retroperitoneal lymphatic
• Mycobacterium tuberculosis & Staphylococcus
aureus is the most common pathogens
• Mycobacterium is more common in
76. PSOAS ABSCESS
• Symptoms include hip or flank pain (43%), abdominal pain (14%),
• To provoke pain, instruct the patient to perform forceful contraction
of the psoas. Place your hand just proximal to the patient’s
ipsilateral knee, and have the patient raise his or her thigh against
• . The overall sensitivity of contrasted CT imaging for the diagnosis is
• Treatment includes antibiotics & drainage.
• Consult surgery for percutaneous or open drainage
• Osteonecrosis Other terms used to describe
osteonecrosis include avascular necrosis,
aseptic necrosis, and ischemic necrosis.
• Osteonecrosis is the result of bone infarction
caused by a lack of blood supply.
• CAUSES :- Major / Minor Trauma
80. AVN ..
• Plain radiographs are helpful in establishing
• findings ranging from mottled densities and
lucencies to severe collapse of the femoral
• Joint replacement may be required.
• Osteomyelitis is an infection of the bone by bacteria or
fungus, resulting in bony changes and destruction .
• It develops by spread of infection from contiguous
structures (∼80%) or by hematogenous spread (∼20%).
• Hematogenous spread is more common to the long
bones in children and to the spine in adults.
• Spinal epidural abscess is an important differential
diagnosis to consider
• Pain at the site is a universal complaint and may be
accompanied by warmth, swelling, and erythema.
• Radiographs are normal early in the course,
but later will show periosteal elevation, and
• MRI is the preferred imaging modality, with
approximately 95% sensitivity
86. Risk Factors, Likely Infecting Organism, and
Recommended Initial Empiric Antibiotic Therapy
87. Risk Factors, Likely Infecting Organism, and
Recommended Initial Empiric Antibiotic Therapy
• Bone biopsy confirms the diagnosis with
certainty. S. aureus is the most common
causative agent overall.
• In acutely ill patients, begin presumptive
treatment based on the clinical findings, with
high-dose, broad-spectrum, parenteral
antibiotics ensuring coverage for S. aureus.
89. Osteochondritis Dissecans (Knee Pain)
• In osteochondritis dissecans, a portion of the
joint surface cartilage separates from the
• Seen most often in adolescents, and is of
• The medial femoral condyle is predominantly
involved, with unilateral occurrence.
91. Osteochondritis Dissecans (Knee Pain)
• The patient experiences pain and swelling.
• Plain radiographs may reveal a thin rim of
calcium separated from the underlying bone),
• MRI is sinvestigation of choice
• conservative therapy
• If fail go for Arthroscopic repair & removal of
associated loose bodies
92. Synovial Osteochondromatosis
• Synovial osteochondromatosis is characterized by
idiopathic, nodular synovial membrane
proliferation and subsequent calcification of the
• Eventually, multiple fragments of this growth (as
large as 2 cm) break off and occupy the joint
space or the area of the bursa and tendon
• With time, degenerative changes and secondary
93. Synovial Osteochondromatosis clinical
features & investigation
• The disease is more common in males
between the ages of 20 and 50 years old.
• Patients complain of pain and joint swelling.
• There is a limitation in range of motion, and
the joint may lock. The large joints are
commonly involved. Radiographs will show
the calcification and the intra-articular bodies
and later the changes of osteoarthritis.
95. Transient Osteoporosis of the Hip
• Transient osteoporosis of the hip occurs in
middle-aged men and in pregnant women in
the third trimester.
• The disease is uncommon, idiopathic, and
characterized by sudden onset of hip pain,
with the findings of osteoporosis on plain
• The disease spontaneously resolves within 6
to 12 months
96. Paget’s Disease (Osteitis deformans)
• Paget’s disease, is a chronic disorder resulting in
enlarged, deformed bones from breakdown and
• Most commonly affects hip joint (in 50% of
• The disease is familial and is suggested by an
elevated serum alkaline phosphate level. Patients
complain of pain, and radiographs reveal joint
space narrowing with minimal hypertrophic
98. Paget’s Disease (Osteitis deformans)
• Treatment is symptomatic, and medications
that slow the rate of bone turnover
(calcitonin, alendronate, others)
• Surgery is required for complications of the
disease, such as fracture and severe arthritis.
99. Osteitis Pubis (Midline Pelvis and Groin
Pain With Radiation to Hips)
• Osteitis pubis should be considered as a
possible diagnosis in athletes with pain in the
region of the pubis.
• It is an inflammatory process related to
overuse of the adductors and gracilis muscles.
• Bony changes with periostitis occur at the
sites of the origins of the involved muscles.
102. Osteitis Pubis - Treatment
• Symptoms start off gradually and progress to
severe pain with any movement of the legs.
• The symptoms may resolve completely over a
period of months with rest and NSAID use.
• Rarely, arthrodesis of the pubic symphysis is
103. Myositis ossificans or heterotrophic
• Diseases of Abnormal Calcification, is the
deposition of bone at a site where bone does not
• The process is related to direct trauma, with the
thigh and hip muscles frequently involved.
• Bleeding follows direct trauma to the muscle, and
calcium deposits form inside the hematoma.
• A firm, palpable, painful mass will develop within
2 weeks and may persist for up to 1 year.
105. • The appearance may be confused with a primary
neoplasm, such as osteosarcoma or periosteal
• Range of motion in the muscle or joint is limited
due to pain or physical presence of the mass.
• Operative removal of the deposition may be
107. HIP EXAMINATION
• INSPECTION (for asymmetry and position of
1. pain location
2. range of motion
3. assessment of ability to bear weight.
(The inability to bear weight is a sign of serious
pathology until proven otherwise. )
108. Hip Pain In Children - Laboratory
• complete blood count
• erythrocyte sedimentation rate(non specific)
• C-reactive protein
• blood cultures (if osteomyelitis or septic
arthritis is suspected).