Complex Fractures and Hip Dislocations
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- Howard Garrison
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1 IMAGING OF HIP PAIN Patients may present with acute (< 2 weeks) or chronic hip pain. Acute pain may be related or not related to an acute traumatic event such as fall or trauma from a motor vehicle accident. Chronic or acute hip pain may be related to several conditions including but not limited to traumatic or stress fractures, osteonecrosis, tendon pathology, acetabular labral tear, bursitis, arthritides (inflammatory, infectious, metabolic or degenerative), hip impingement syndromes, athletic pubalgia (referred pain), snapping hip syndromes (extraarticular external and internal, and intra articular), and bone and soft tissue tumors and tumor like conditions such as pigmented villonodular synovitis and synovial chondromatosis/osteochondromatosis. Utility of Radiography In all situations, acute or chronic, after the clinical exam, the first most appropriate imaging test is radiography. Radiography may detect fractures, dislocations, calcific tendinosis, findings related to various inflammatory, metabolic, infectious and degenerative arthritides and primary or secondary osseous tumors. With proximal femur and acetabular fractures, in addition to hip radiographs, pelvic radiographs should be obtained to evaluate for additional fractures. With hip dislocations and displaced fractures, radiographs should be repeated after closed reduction. Complex Fractures and Hip Dislocations CT is frequently utilized in the evaluation of acetabular and other pelvic fractures. Coronal, sagittal and 3D reformatted images are frequently helpful in the preoperative setting. With hip dislocations, CT examination should performed after the closed reduction to evaluate for the extent of injury and intra articular bone fragments. With complex proximal femur fractures, CT examination may be helpful in the preoperative setting.
2 Radiographically Occult Hip and Pelvic Fractures MRI is the most sensitive imaging modality in the evaluation of radiographically occult fractures. If occult fracture of the native hip is clinically suspected in the setting of negative radiographs, MRI of the affected hip or ideally of the entire pelvis including both hips should be performed on an urgent basis. The entire pelvis should be imaged on at least one fluid sensitive sequence to exclude concomitant injuries or injuries that may cause referred hip pain. In the setting of hip arthroplasty, dual energy CT examination with metal artifact reduction is the study of choice to evaluate for radiographically occult periprosthetic fratures. Likewise, dual energy CT examination with metal artifact reduction is the study of choice to evaluate for prosthesis loosening. Femoral Head Osteonecrosis MRI is the imaging modality of choice in the evaluation and staging of femoral head osteonecrosis. High incidence of bilateral femoral head osteonecrosis in systemic disease with the use of corticosteroids and in children often requires imaging of the contralateral hip. At least one fluid sensitive sequence of the entire pelvis should be obtained to evaluate for other possible areas of bone infarction and other pathologies. Septic Joint If septic joint in the native or prosthetic hip is suspected, joint aspiration may be performed under fluoroscopy or US guidance. If osteomyelitis is suspected, MRI without and with contrast should be performed after radiographs to evaluate for the extent of disease.
3 Tendon Pathologies MRI is the imaging study of choice in the evaluation of gluteal and other tendons about the hip and pelvis. Calcific tendinosis is usually readily visible on radiographs and sometimes is better depicted on CT studies. Calcific tendinosis lavage may be performed under US guidance. With available expertise, US is useful in the evaluation of hip tendons but may be of limited utility in very large patients. Acetabular Labral Tear In younger patients (< 35 years old) direct MR arthrography is the study of choice in the evaluation of acetabular labral tear. In older patients routine MRI without contrast is usually sufficient in evaluation of acetabular labral tear, preferentially on 3T MRI machine. If the patient cannot have an MRI study, CT arthrography may be performed. Greater Trochanteric Bursitis, Iliopsoas Bursitis or Ischial Bursitis MRI and US have similar diagnostic accuracy in evaluation of greater trochanteric and iliopsoas bursitis. Aspirations and therapeutic injections of the greater trochanter and iliopsoas bursae are frequently performed under US guidance. Alternatively, if US expertise is not available, fluoroscopy guided injection may be performed. Ischial bursa may be injected under US, fluoroscopy or CT guidance. Athletic Pubalgia and Femoroacetabular Impingement Syndromes MRI is the imaging study of choice in the evaluation of athletic pubalgia and various femoroacetabular impingement syndromes (CAM, Pincer, ischofemoral, iliopsoas) in the native hip. Iliopsoas impingement syndrome in the prosthetic hip may be evaluated with US if local expertise is available.
4 Snapping Hip syndromes (Coca Saltans) External impingement syndrome which is caused by iliotibial tract sliding over greater trochanter and the more common internal impingement syndrome which is caused by the iliopsoas tendon snapping (over the femoral head, prominent iliopectineal eminence/ridge, lesser trochanter bony protuberance or iliopsoas bursa) are best evaluated by dynamic ultrasound. Intra articular causes of snapping hip syndrome such as joint bodies or acetabular labral tear are best evaluated by direct MR arthrography. If MR arthrography is contraindicated, CT arthrography may be performed. Primary and Secondary Bone Tumors and Soft Tissue Tumors Patients may present with hip pain with primary or metastatic bone or soft tissue tumors. Sometimes patients present with pathologic fractures of the proximal femur or acetabulum. In the setting of pathologic fractures, CT and/or MRI examinations may be needed in preoperative planning. Otherwise, advanced imaging of the musculoskeletal bone and soft tissue tumors (MRI, CT, PET/CT, Bone scan), may be performed on an outpatient basis. (Please see the ACR Appropriateness Criteria on soft tissue masses and the ACR Appropriateness Criteria on primary bone tumors). Disclaimer There is a consensus to avoid all gadolinium based contrast agents in dialysisdependent patients unless the possible benefits clearly outweigh the risk and to limit the type and amount in patients with estimated glomerular filtration rates <30 ml/min/1.73 m2. (For more information, please see the ACR s Manual on Contrast Media).
5 REFERENCES American College of Radiology. Acute Hip Pain Suspected Fracture. Available at American College of Radiology. ACR Appropriateness Criteria Chronic Hip Pain. Available at: American College of Radiology. ACR Appropriateness Criteria : Osteonecrosis of the Hip. Available at:
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