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Ultrasound of the Infant Hip and Spine

Sonography of the Pediatric Hip and Spine will familiarize the attendee with the normal and abnormal anatomy of the hip and spine, indications for scanning, and sonographic techniques used to visualize the anatomy, and imaging planes. Sonography of the Hip will cover the use of the hip angle measurement tool and define the classifications of developmental dysplasia of the hip.
Successful completion of this training is eligible for American Society of Radiology Technician (ASRT) Category A continuing education units (CEU).

Welcome to the Ultrasound of the Infant Hip and Spine Online Training course.   This presentation was written by: Jennifer Prewitt, BS, RDMS, RVT     Upon successful completion of this course, you will be able to: Identify normal vs. abnormal sonographic anatomy   Identify risk factors associated with DDH   Define the classifications of developmental dysplasia of the hip   Understand the use of hip angle measurement tools   Recognize the spinal anatomy by ultrasound   Explain the uses of spine sonography in infants   Define the indications of spine sonography   Developmental dysplasia of the hip ranges from mild acetabular dysplasia to irreducible dislocation of the femoral head Ultrasound is an excellent method in the diagnosis of DDH   Flex hip 90 degrees Apply maximum adduction Push the knee gently posteriorly Example of transverse view with stress Select play to begin the video. Female sex Family history (parental or sibling) Breech Presentation Multiple Gestations Certain neuromuscular disorders i.e. congenital torticollis Oligohydramnios Hip click (on clinical exam) Club foot deformity Asymmetric skin folds High birth weight In the 1980’s Dr. Graf developed a technique using ultrasound to replace radiography to diagnose DDH. Dr. Harke introduced dynamic imaging to hip sonography in 1984. Coronal View Baby in lateral decub or supine position Flex knee 90 degrees Transducer parallel and lateral to hip Image should show femoral head centered in joint space, ilium appears as straight line perpendicular to femoral head and parallel to transducer Includes: Ilium Acetabular Rim Femoral Head Ischium Labrum Greater Trochanter Ilium Labrum Greater Trochanter Femoral Head Acetabular Rim Transverse view Infant in oblique position Knee flexed 90 degrees Rotate transducer 90 degrees from coronal Femoral head should be centered on triradiate cartilage Stress the hip in this view Include: Femoral shaft Greater Trochanter Ischium Femoral Head Ischium Femoral Head Birth to 4 months of age High frequency linear transducer Multiple focal zones Output power at 100% Feed baby during exam!!! Decubitus position Place a small rolled up towel behind the back Hip is flexed 90 degrees Use both hands to stabilize the baby Foot pedal Baseline passes through plane of Ilium Alpha angle Most common Angle between baseline and roofline Measures acetabular concavity Beta Angle Angle between baseline and inclination line Indicates acetabular roof coverage Anything less than 55 degrees is normal SYNOPSIS OF SONOGRAPHIC HIP TYPES, RECOMMENDED DESCRIPTION, AND SUGGESTED MANAGEMENT OF GRAF SYSTEM Sonographic Hip Type Bony Modeling Bony Promontory Acetabular Roof Cartilage α β Suggested Therapy I Mature Hip Good Angular Narrow, extending far over the femoral head >60° - No therapy 2A Immature hip physiological, appropriate for age , 3 months Satisfactory Round buttons Broad, covering crown of the femoral head 50-59° - No therapy, follow-up US (8-12 weeks) 2B Delayed osseous development > 3 months of age Deficient Round buttons Broad, covering crown of the femoral head 50-59° - Abduction device 2C "Critical zone hip" Severely deficient Round buttons Broad, still covering the femoral head 43 -49° <77° Abduction device D Decentering hip (superior/posterior stress) Severely deficient Rounded-flattened Displaced 43 -49° <77° Like type 3 hips 3 (A or B) Eccentric (displaced) hip 3A = lucent roof cartilage 3B = echogenic roof cartilage A Poor B Poor Flattened Flattened 3A = Displaced, echolucent 3B = Displaced, echogenic < 43° <77° Reduction-abduction splint 4 Very eccentric (displaced) hip Poor Flattened Trapped between femoral head and ilium <43° <77° Various manufacturers   Note: Type 2A and 2B represent identical ultrasound appearances. However, most type 2A hips should naturally revert to type 1 by 8 weeks of age and therefore type 2 appearance at 3 months is abnormal. The A and B diagram in the type 3 category refers to the echogenicity of the acetabular roof cartilage NOT the age of the patient. Covers femoral head Acetabular rim is angular Labrum is in normal position Hip angle measurement is greater than 60 degrees Patients less than 3months of age Femoral head is not displaced Acetabular rim is rounded Labrum in normal position Hip angle measurement is between 50-59 degrees Repeat scan in 6-8 weeks Patients greater than 3 months of age Femoral head is not displaced Acetabular rim is rounded Labrum is in normal position Alpha angle is 50-59 degrees Orthopedic referral is suggested Femoral head less than 50% covered Acetabular is rounded Labrum is everted, more horizontally positioned Alpha angle is 43-49 degrees Treatment and follow up suggested Femoral head is almost completely displaced Acetabular rim is flattened Labrum trapped between femoral head and ilium Hip angle is less than 43 degrees Requires urgent referral and treatment Boney roof of acetabulum is poor Acetabular rim is flattened Acetabular roof is displaced Alpha angle < 43 degrees Treatment and follow up suggested Case #1: Is femoral head covered? How is Acetabulum? How is the Labrum? Answer: This hip is Graf  Type I Normal Case #2: Is Femoral Head covered? How is Labrum? How is Acetabular Rim? Answer: Graf Type IV Femoral Head is displaced Acetabular rim is flattened Labrum is trapped Neonatal Spine Sonography     Noninvasive procedure Does not require sedation or contrast material Does not use radiation Uses high-frequency transducers Evaluation of cutaneous lesions Screening for tethered cord Spinal deformities Neurological disturbances Syndromes with associated spinal cord compression Guidance for tapping spinal fluid Performed in infants up to 4 months High-frequency linear transducer Use multiple focal zones Place patient in prone position Obtain longitudinal and transverse images from mid-thorax to the coccyx region Higher level images are obtained if pathology is suggested Placing a small roll under the abdomen improves visualization in older infants Longitudinal Transverse Useful in determining level of conus Ability to visualize movement of spinal cord Scanning between vertebral spaces Ability to visualize each level of spinal cord anatomy Two methods to determine the level of spinal cord tip: Count each vertebral body from sacrum up Follow the last rib to its T12 origin and count down Longitudinal Imaging: Scanning length of spine View an example of a longitudinal image acquired by scanning along the length of the spine.   Select play to begin the video.  When complete, select the X in the upper-right corner to close the window and continue. Longitudinal Imaging: Panoramic Imaging View an example of panoramic imaging used during evaluation. Element HTMLWhen complete, select the X in the upper-right corner to close the window and continue. Sound File Audio ScriptPanoramic imaging is a useful technique to evaluate the entire length in one image and to demonstrate an accurate count of the vertebral bodies.  Notice in this longitudinal image of the spine that this has been acquired from the tip of the sacrum, all the way up into the L1- 2 area and possibility T12.  Notice how you can visualize each of vertebral body, the skin layer and the tip of the spinal cord.   Filum Terminale Conus Medullaris Spinal Cord Subarachnoid Space Nerve Roots Vertebral Bodies Anatomy Visible in Longitudinal Image of Spine View an example of the anatomy that is visualized in a longitudinal image of the spine. Element HTMLWhen complete, select the X in the upper-right corner to close the window and continue.Spinal CordConus MedullarisNerve RootsFilum TerminaleVertebral Body Sound File Audio ScriptThis is an example of the anatomy that should be visualized in a longitudinal image of the spine.  This is a panoramic image demonstrating the vertebral bodies from the sacrum up to the tip.  Notice the Filum Terminale, the conus Medullaris, the nerve roots, and the spinal cord itself in this view.   Spinal Cord Tip in Longitudinal Plane View a demonstration of the spinal cord tip in a longitudinal plane.   Select play to begin the video.  When complete, select the X in the upper-right corner to close the window and continue. T12 and L1 Tip Areas View an example showing the T12 and L1 tip areas are acquired using the Longitudinal Plane. Element HTMLWhen complete, select the X in the upper-right corner to close the window and continue. Sound File Audio ScriptHere is an example showing T12 and L1 tip areas and how they are acquired when scanning in the longitudinal plane.  Notice that the L2 area can be identified and the conus tip falling at the L1, L2 interspace.   Start at sacrum and work up First horizontal vertebral body is typically L5 Allows you to visualize: the spinal cord as hypoechoic center surrounded by anechoic subarachnoid space the nerve roots pulsating Anatomy Visible in Transverse Image of Spine View an example of the anatomy visible in a Transverse Image of the spine. Element HTMLWhen complete, select the X in the upper-right corner to close the window and continue.Filum Nerve RootsVertebral Arch Sound File Audio ScriptThis is an example of the anatomy used to visualize  the transverse image. Remember that the anatomy can vary depending on the level of visualization from the T spine down to the S spine.  In this image, we are visualizing the filum, the vertebral arch, and the nerve roots.   Transverse Imaging View an example of a transverse image of the spine.   Visualize nerve roots pulsating Scanning between vertebral bodies Echogenic center is filum terminale Select play to begin the video.  When complete, select the X in the upper-right corner to close the window and continue. Transverse Image: Thoracic Spine View an example of a transverse image of the thoracic spine. Element HTML Transverse image in thoracic spine Notice spinal cord with central echo When complete, select the X in the upper-right corner to close the window and continue. Sound File Audio ScriptHere the  transverse image is in the thoracic spine.  Notice the difference between this level and the previous one in the L region.  Look at the spinal cord with the central echo.  This image is taken prior to the end of the spinal cord within spinal canal.  Again, notice the nerve roots and the spinal cord with the central echo surrounded by the anechoic fluid.  Remember  that the anatomy varies between the levels scanned in the transverse image.   Transient dilatation of the central canal is an incidental finding in healthy newborns that disappears after the first week of life. Ventriculus Terminalis is a small oval, cystic structure that is located at the transition between the tip of the conus medullaris to the filum terminale that will regress in size during the first week after birth.   Select play to begin the video. Appearance of low-lying, blunt conus medullaris Spinal cord is abnormally fixated Movement is reduced or absent Dorsal fixation in prone position Is a common association of several spinal abnormalities   Select play to begin the video. Failure of neural folds to fuse Associated with tethered cord Clinical symptoms include neurologic disturbances, bladder or bowel dysfunction, and hydrocephalus Intraspinal mass of fat associated with hemangiomas Always associated with spina bifida Associated with tethered cord Epithelium lined tract from skin to spinal cord Lumbosacral region primarily Patients with a normal ultrasound will not require any further follow-up. If malformations are discovered, additional imaging such as MRI may be suggested.

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