0:01

So in this next case, we have a person

0:03

with post-traumatic left hip pain.

0:05

In this case, a metallic shield was used

0:08

for radiation safety purposes,

0:11

although I will state that nowadays, uh,

0:14

there's a reluctance to use the shield

0:15

because it may cover particular pathology.

0:19

And in general, the doses are not considered injurious

0:23

unless it's a pediatric patient.

0:26

But nonetheless, we go through our typical checklist.

0:30

We can see our transverse processes are intact,

0:33

iliac wings are maintained, SI joints are not widened

0:38

ileal issue and ileal pectineal lines are maintained

0:41

bilaterally, nice teardrop seen

0:45

hip joint spaces preserved.

0:48

And so our pelvic lines are intact.

0:50

And then once we scrutinize comparing the left hip

0:54

to the right hip more closely, we can see that the femoral

0:58

head neck relationship is maintained.

1:02

If we look closely at the femoral head,

1:03

however, it appears that the left femoral head is not quite

1:07

as spherical as the right.

1:09

Remember we had mentioned in the anatomy discussion

1:12

that there is a small fovea.

1:13

That's a normal finding.

1:15

Uh, that's typically where the ligament and tes attaches.

1:19

However, looking more carefully on the left, there appears

1:22

to be some central flattening.

1:25

Additional images focused on the left hip confirm

1:30

that there is an abnormality of the contour

1:32

of the femoral head.

1:34

And so in this case here on the frog leg lateral, we can

1:39

see what looks like a little fracture fragment.

1:42

It has this lucency, it has the appearance of a

1:46

subcapital type of fracture.

1:49

And so in the setting of trauma as opposed to the setting

1:52

of chronic hip pain, you'd have to be suspicious

1:56

that this was a traumatic lesion.

1:58

And so with CT imaging, we confirm this fracture fragment.

2:04

And MRI shows a fracture line.

2:07

Here there is also a focal full thickness cartilage defect

2:11

representing a chondral shear injury in association

2:14

with this and the bone marrow edema pattern telling us

2:18

of its acuity.

2:20

And so this would be considered a osteochondral fracture

2:23

or osteochondral injury, inclusive

2:26

of a capital fracture meaning involving the head.

2:30

So a less common injury that occurs in the hip,

2:34

but something that's certainly possible

2:36

and should be distinguished from another common pathology

2:40

that could appear similar.

2:42

So in this next case here, we see that the femoral heads

2:47

appear abnormal in that there's this kind

2:49

of mixed radio density of sclerosis.

2:52

And lucency has the sclerotic margin.

2:56

That's almost a bit serpentine.

2:59

And again, the hip joint spaces are preserved.

3:01

The remainder of the pelvic lines are maintained.

3:04

And in this case, this is an example

3:06

of osteonecrosis of the femoral heads.

3:09

So osteonecrosis is a condition that occurs for a variety

3:13

of reasons related to diminished BLO supply.

3:17

And this is a case of non-traumatic osteonecrosis,

3:20

but it could look similar to that case

3:22

of trauma involving the femoral head.

3:25

The thing about osteonecrosis is

3:27

that typically you have the necrosis first,

3:29

and so you're gonna have some of these other changes,

3:31

whether it's some cystic like resorption

3:34

and marginal sclerosis

3:38

or more sclerosis

3:40

and opacity of the femoral head,

3:42

you can get subcapital fractures.

3:44

Uh, that's one of the characteristic findings

3:47

that can occur in osteonecrosis.

3:50

But again, that's in a context of somebody

3:51

with more chronic hip pain as opposed to somebody

3:54

who presents with acute traumatic hip pain.

3:58

And then MRI can help distinguish

4:01

where in this person here we see the MRI hallmarks

4:05

of osteonecrosis.

4:06

There is a well-defined

4:09

or geographic regions

4:10

that are separated from the normal bone

4:13

by this serpentine margin.

4:15

Here it appears hyperintense on the fluid sensitive

4:19

sequence, but it may have some low signal intensities on the

4:22

proton density or anatomic sequences.

4:26

And so in this case here,

4:27

there is bilateral femoral head osteonecrosis.

4:30

It has not gone on to collapse.

4:33

It does not have a prominent bone marrow DMA pattern.

4:36

So it may or may not be painful,

4:39

but this is different than those

4:40

osteochondral fracture lesions.

4:42

But they can appear quite similar.

4:44

So again, the radiographs may have some overlapping

4:46

findings, but I've showed you some of the discriminators.

4:49

And then as needed, uh, CT

4:51

or MRI could help further characterize it.