Diagnostic Imaging of Pediatric Hip Lesions

1. Musculoskeletal
Pediatric Hip Lesions

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Pediatric Hip Lesions
-Three distinct conditions of the hip occur in
children, each of which affects a different age
group :
1-Neonates, infants : congenital dislocation of the
hip (CDH)
2-School age : Legg-Calve-Perthes (LCP) disease
3-Adolescents : Slipped capital femoral epiphysis
(SCFE)

7. 1-Congenital Dislocation of the Hip (CDH)
,Developmental Dysplasia of the Hip
(DDH) :
a) Incidence
b) Radiographic features

8. a) Incidence :
-Results from an abnormal relationship of
the femoral head to the acetabulum
-More in females
-More in the left hip, bilateral in 5 %

9. b) Radiographic features :
1-Ultrasound :
-The test of choice in the infant (< 6 months) as
the proximal femoral epiphysis hasn’t yet
significantly ossified
-Normal femoral head is covered at least 50% by
acetabulum
-In DDH, <50% of femoral head is covered by
acetabulum
-Normal alpha angle is >60
-In DDH , alpha angle is <60

10. Normal infant

11. Normal CHD

12. 2-Plain Radiography :
-Shallow acetabulum
-Acetabular angle greater than 30 degrees (same
as alpha angle less than 60 degrees)
-Small capital femoral epiphysis
-Delayed ossification of the femoral head
-Acetabular sclerosis
-Loss of Shenton's curve
-Femoral head lateral to Perkin's line
-Femoral head superior to Hilgenreiner's line

13. -Shenton's curve : smooth curved
line connecting medial border of
femoral metaphysis with the
superior border of the obturator
foramen
-Hilgenreiner's line : a horizontal line
through the triradiate cartilage of
the acetabulum
-Perkin's line : a vertical line
(perpendicular to Hilgenreiner's
line) from the lateral margin of the
ossified acetabular roof that is
normally tangential to the lateral
margin of the ossification center of
the femoral head
-Acetabular angle : angle that the
acetabular line makes with
Hilgenreiner's line

14. Hilgenreiner's line Perkin’s line

15. Hilgenreiner's line & Perkin’s line

16. Shenton’s line

17. Acetabular angle

18. There is a dysplastic left acetabulum (shallow left acetabulum) and a
small left femoral epiphysis when compared to the right , the left
proximal femoral metaphysis is displaced superiorly and laterally

25. Chronic hip dislocation

26. 2-Legg-Calve-Perthes (LCP) Disease :
a) Incidence
b) Radiographic Features

27. a) Incidence :
-Osteonecrosis of femoral head
-School age (5-8 years)

28. a) Incidence :
-Osteonecrosis of femoral head
-School age (5-8 years)

29. b) Radiographic Features :
-Plain film staging system (Ficat) :
*Stage I : clinical symptoms of AVN but no
radiographic findings
*Stage II : osteoporosis, cystic areas and
osteosclerosis
*Stage III : translucent subcortical fracture line
(crescent sign), flattening of femoral head
*Stage IV : loss of bone contour with secondary
osteoarthritis

30. Stage II

31. AP pelvic radiography showing flattening of the superolateral aspect
(the weightbearing portion) of the right femoral head, there is a zone
of decreased density representing the crescent sign, indicating
subchondral fracture (stage III)

32. AP radiographic view of the pelvis shows flattening of the outer portion
of the right femoral head from avascular necrosis, with adjacent joint
space narrowing, juxta-articular sclerosis, and osteophytes
representing degenerative joint disease (stage IV)

33. -Early signs :
1-Asymmetrical femoral epiphyseal size
(smaller on affected side)
2-Apparent increased density of the femoral
head epiphysis
3-Widening of the medial joint space
4-Blurring of the physeal plate

34. -Late signs :
1-The femoral head begins to fragment with
subchondral lucency (crescent sign)
2-Femoral head deformity with widening and
flattening
3-Osteoarthritis

35. Bilateral Perthes

36. Bilateral

45. 2-MRI :
-Earliest sign is bone marrow edema (nonspecific)
-Early AVN : focal subchondral abnormalities (very
specific):
Dark band on T1, bright band on T2
Double-line sign (T2) : bright inner band / dark
outer band occurs later in disease process after
the start of osseous repair (inner bright line
representing granulation tissue and an
outer dark line representing sclerotic bone)
-Late AVN : fibrosis of subchondral bone :
Dark on T1 and T2
Femoral head collapse

46. Bilateral AVN, (a) T1, (b) T2

47. T1 T2

48. -Mitchell classification :
*Class A (early disease) : signal intensity
analogous to fat (high on T1 and intermediate on
T2)
*Class B : signal intensity analogous to blood
(high on T1 and T2)
*Class C : signal intensity analogous to fluid (low
on T1 and high on T2)
*Class D (late disease) : signal intensity
analogous to fibrous tissue (low on T1 and T2)

49. Coronal T1 of the pelvis in a patient with bilateral avascular necrosis of the femoral head
shows increased signal within the superior aspect of the femoral head, representing
fat, surrounded by a line of decresed signal, representing sclerotic reactive margin,
this is an MRI class A (fatlike)

50. Patient 39 years old with use of high dose of corticosteroids, Cor T1
and T2 of the pelvis shows a stage B (blood-like) at the level of right
femoral head with increased signal on T1W and T2W; AVN stage C
(fluid-like) in left femoral head, with decreased signal intensity on
T1W and increased signal on T2

51. Cor T1 and T2 in a patient with AVN on the left femoral head with
decresed signal intensity on T1 and T2, representing a stage D
(fibrous-like)

52. 3-Slipped Capital Femoral Epiphysis
(SCFE):
a) Incidence
b) Radiographic Features

53. a) Incidence :
-Known as Slipped Upper Femoral
Epiphysis (SUFE)
-It is one of commonest hip abnormalities in
adolescence and is bilateral in 20% of
cases
-Type I Salter Harris growth plate injury
-Overweight teenagers

54. b) Radiographic Features :
-Osteoporosis of head and neck on AP view early
-A line drawn up the lateral edge of the femoral
neck (line of Klein) fails to intersect the
epiphysis during the acute phase
-Metaphysis displaced laterally so that it does not
overlap posterior lip of acetabulum as normal
-Widened growth plate