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Reading & Evaluating Pelvis & Hip X-Rays

Nov 13 | 1:30 PM

X-ray examinations have been around for over a century and continue to play a vital role in diagnosing and monitoring current and potential disorders. Despite the availability of improved imaging technologies that aid physicians in diagnosing problems, X-Ray remains the most basic and widely used technique of imaging. A doctor should be able to evaluate an X-Ray and correlate it to clinical symptoms in order to treat the illness. Join us as Dr. Santosh Jeevannavar takes us through the process of evaluating pelvis and hip X-rays

[Music] good evening everyone i'm dr niveda and on behalf of team netflix i welcome you all to today's session uh so today's session takes us back to our basis of evaluating x-rays and though radiological imaging has uh made immense advancements uh one still needs to know the art of reading an x-ray and correlating it to the clinical findings and for this session we have with us um dr santosh given over he's a consultant orthopedic surgeon and professor and head of orthopedics sdm college of medical sciences and hospital. good evening everyone uh thank you dr navida for the kind introduction i would like to thank the netflix app people for giving me an opportunity to speak on this forum so i would like to begin my uh talk by in uh speaking a few words about why i chose this topic uh so my talk will be on evaluating hip x-rays the hip in the sense the pelvis with both hip joint evaluation how to go about it when you are faced with the hip x-ray now why i choose this topic for general uh orthopedic surgeon or the junior resident is the hip joint is basically a three-dimensional bony structure uh which has to be evaluated by a two dimensional investigative modality like an x-ray so i thought during my postgraduate days i had a tough time understanding the lot of x-ray points on the pelvis with both hips so i thought i'll just make it easy for the juniors or the consultants to read and hip x-ray so my talk will be majority on the non-chromatic pathologies of the pelvis and hip joints so so i'll go through these points during my talk i'll begin by telling you how what are the x reviews to be taken how to approach when you are going to read an hip x-ray what are the pelvis and astabular points what are the female points and what are the common hip diseases which present as a dilemma to the end orthopedic surgeon so the anatomy of the pelvis and hip it basically consists of the ileum the estrium the pubis and the sacrum so these are four bones which are in a three-dimensional anatomy three-dimensional anatomy means they are interconnected and it is complex so this has to be imaged and interpreted by a two-dimensional investigative modality like an x-ray so this is on the pelvis side on the femoral side you have got a proximal femur which consists of the head of the femur the neck of the femur and the proximal shaft these two these all bones together will form your pelvis and hip anatomy so during the last century there are various x-ray views that are the internal rotation view external rotation view the duty views a lot of views which were devised so that the average or the orthopedic surgeon can evaluate any hip pathology easily now what has happened is uh um the because of the advent of uh advanced investing modalities like the ct scan which can image the bony anatomy in a three-dimensional modality in a real time and mri which can image not only the bony anatomy the skin the subcutaneous tissue the muscles the intramedullary contents and everything can be uh evaluated in detail in mri the special views which was taken by the pelvis with both hips have been redundant or they have been almost of historical interest now with this background when we have got a advanced imaging modalities like the ct scan and the mri scan so what is the need of knowing about the pelvis with both effects right so so i'd like to tell from my experience of about 25 years working in orthopedic surgery the vast majority of indian population don't have access to this advanced modality like a ct scan and the mri that's the magnetic resonance imaging that this because of uh non-availability of these centers during at their home place or at their town or maybe even if they are available the cost is almost about 20 to 30 times of an x-ray so because of this one most of the patients in our country refuse to undergo this ct scan and mri so when the patients refuse to undergo ct and mri the young orthopedic surgeon is left only with an x-ray to image a hip pathology so the advantage of an x-ray is it is easily available the patient has no hesitation in getting an x-ray so it is easily available as a first contact between the primary treating orthopedic surgeon or the medical fraternity and the patient so that is the reason why we need to know about a little about the television x-ray so that we can catch any hip pathology in the earlier state so what are the views so everybody will just talk that he picks a hip x-ray or something like that so there's a lot of confusion but ideally when you are imaging the pelvis along with the hip joint the views which are supposed to be taken or which are essential to image the pelvic cavity and the hip joints are the first view is what is called as a pelvis with both hip apv that is the anterior posterior view so if you see in the left hand uh top top and left hand corner you can see that the legs have been put into internal rotation and the green tick mark has been applied so this implies that the pelvis with both x-rays have to be taken with the both the legs in internal rotation then you have got a what is called as a cross stable lateral so the cross stable lateral means this is the lateral view of the particular hip joint if you want to have a lateral x-ray of the right hip joint you take the cross step table lateral view if you want to have a lateral view of the left hip joint you can take this where you individually image the hip joint in a lateral view now the bottom uh image is of a frog like lateral view so what do you mean by frog like lateral view is this image at one exposure of the x-ray itself will give you both the hip joints in a lateral view so why this is essential the frog leg lateral view is most of the hip pathology is diagnosed when you compare it with the opposite side ninety percent of the cases it is assumed that the opposite side is extremity or the opposite side is normal so this imaging is done so that you can easily compare both the hip joints or both the pelvic bones in this one single film so this is the frog leg lateral view i have just taken out this picture to show that even if a junior orthopedic surgeon or a junior medical fraternity he can take this x-ray if he has got a x-ray machine so you have to just position the patient in this position this is similar to the frog that is the frog leg that is the both the hip joints are in abduction and flexion so that you get a proper image of the pelvis with both hip joints in the lateral view so you see in this view what is what you can see is you can see all the pelvic bones and you can also see the hip joint which has been imaged in the lateral view so the next one is the cross leg lateral view so what do you mean by cross leg lateral view is it is a view of a particular hip joint this is most essential when you are dealing with any hip pathology because you will try to know what is happening to the hip joint in the lateral view so this is how it is taken you can see that the patient is lying supine on the x-ray table the left side is which is being imaged so the left lower limb is completely internally rotated the patient himself will hold the x-ray uh cassette and the beam will come from the opposite side this is the proper technique to take a cross like lateral view so these are the techniques which you should adopt when you are when you have to be forced to take an x-ray if there is no other support to you so you can take this x reviews now what you will come to know by taking these views is uh the you can come to know both the hip joints you can come to uh know the pelvic bones that is the ileum is gem the pv spawns and you can come to know the both the sacroiliac joints and the sacrum and the symphysis pubis alignment so these are the bony structures of the pelvis and hip joint which you can interpret when you follow this views so the proximal femur side you can come to know the hip joint that is the femoral head you can come to know you can come to know the morphology of the femoral head you can come to know about the neck of the femur and the greater and the lesser trochanter so any pathology you are dealing with this areas you can easily come to know by just looking at these points so now before you proceed if you are not taking the x-ray by yourself if you are going to interpret interpreter x-ray which has been brought to you from outside or somebody has taken an x-ray and because he has come to you with your opinion how do you begin the first thing you have to begin is you have to see whether the ideal pelvis x-ray has been taken or not that is whether the patient whether the technician or the doctor who has taken the x-ray has followed the guidelines which have told you how to take a proper hip frog lateral and the cross stable lateral exercise so you have to know whether it is taken in a proper position so i will come to know about it is see the first thing is you can see the black markings which are there on the diagram the arrow which is there in the black uh it is the line which connects the pubic symphysis to coccyx bone so this has to be in a straight line and it has to be between one to three centimeters so this will tell you that the pelvis x-ray has been taken in a proper position and the black round dots which i have made in the obturator foramen they have to be symmetric that is the both the objective foramen have to be symmetric so this will tell you that the person who has taken the pelvis with both both hip x-ray has followed the guidelines which have been established and the x-ray has been taken in a proper way this is very important first to know and then you can proceed to then evaluate the x-ray if the x-ray itself has not been taken in an ideal way then your interpretation may sometimes give you a false uh impression or a false diagnosis so once you notice that the extra has been taken in a proper position and a proper technique then you can proceed so how you have to begin is you begin by seeing the bony texture and cortical outline so what i mean to say is uh it is very important to just see the bones first from one end to another end and just follow the bony texture and cortical outline this is to evaluate the integrity of the bone cortex and architecture so what will it tell you is it will tell you whether if there is any break in the continuity so what do you mean break in the continuity of any bone it is nothing but it is called as a fracture that is definition of the fracture so if you feel that there is any break in the continuity of the bone or the cortex then it straight away goes into a traumatic pathology or a fracture and the evaluation of rheumatic pathology and a fracture is a separate topic itself and you can stop here only and say that this patient has got a traumatic etology and then continue to see the other structure so first you have established that there is no fracture or break in the continuity then you follow if after take after seeing that there is no break in the continuity you follow a systemic approach so this systemic approach it begins by establishing the quality control of the x-rays to be used so the first point what i told you is the uh obturator forum and i have to be symmetric the pubic symphysis till the cockpit has to be in a straight line you see that both the hip joints are symmetrical that is the greater trochanter the lesser trochanter which i have marked here with green uh green marking that is the greater trochanter essential whether they both are visible clearly the contour of the femoral head which i have marked here in red are symmetrical so you just establish that the quality of the x-ray is good and then you if there is suppose at this point if the patient is still with you and if there is a symmetry in any one of the points which are told what you have to do is you have to go and correct the asymmetry which is there and if necessary you can repeat the x-ray if you are not satisfied that the points that is obturator phenomena are not circular the symphysis previous to existence is not correct then you can repeat the x-ray and again come back to evaluate it now first you begin by seeing the soft tissues that is the soft tissues and fat time so what i mean is the hip joint even though we are basically going to see the bony anatomy and the x-rays sometimes the soft tissue markings which are present along the hip joints will tell us if there is any abnormality which is going on around the hip joint so normally you've got three fat parts which are present around the hip joints so the white line which is which is pointing here in this diagram is pointing towards the gluteal line this white line is the gluteal shadow that is the gluteal musculature the gluteus medius and the minimus which attached to the greater trochanter it is the contour of this gluteus musculature the green arrow which is there it is a fat pad of the obturator this is called as a obturator pad pad and the yellow arrow which is showing is showing the ah shadow so these are the normal musculatures which are present around the hip joint that is the gluteus musculature the source musculature and the obturator musculature which produce these fat pads now what you have to see in this fat pad is whether they are symmetrical or whether they are in a straight line now if there is a bulge what you call it as a bulge fat parts so the left side x-ray shows you a normal fat pad of the gluteus musculature the right side you can see that the gluteus musculature is bulged bulge means there is some abnormality which is resulting in the bulk bulging of this normal gluteal fat pad this is most likely to be because of some collection of fluid or septic material besides the hip joint so it can be anything it can be a bursitis it can be a septic arthritis it can be just a synovitis or a fluid which has been collected beside the hip joint so this is the first sign it will tell you that the hip joint may be surrounded by a fission or a fluid so based on this suspicion you can subject the patient to a further industry modality like a ct scan or a mri now you come to the osseous anatomy and the lines so now what has happened is now till now you've just seen the pelvis bones that is the ileum ischemic the pubis that's impressive pubis the proximal um the femoral head and the greater and lesser trochanter now the biggest dilemma in imaging or to interpret the image of the pelvis of the both hips is the acetabulum so the acetabulum is a complex structure it has got a morphology in the sense that it has got the depth and it is circular in shape so that it is a three to four dimensional structure which can't be interpreted easily in a two dimensional way so these are lines which have been described which will tell you what is the anterior column of the astableum what is posterior column of the estrogen and how to interpret it so at the end of the lecture i will show you the animation of the video how these lines are drawn but i begin by first telling you about the elio pectinal line so if you see the the diagram in the right side you can see that there is a black line marking the black line marking is the iliopectinal line it tells you about the anterior column of the astableum it if this line which begins from the pelvic brim and continues to the pubic symphysis is is in correct alignment without any break it shows that the enter column of the establishment is intact or it is in shape this is the iliopectinal line now the second line which is there is the eleostial line so the ilion is the line which begins from the pelvic brim and ends at the ischial tuberosity so you can see in the right side diagram you can see the black line which are marked which begins from the pelvic brim and it goes to the ischial tuberosity this denotes that the posterior column of the acetabulum if there is any break in this line then it suggests that the posterior established wall may have been fractured or may have been injured so these two lines that is the ileopectinal line and the ilo ischial line will tell you about the anterior column and the posterior column of the acetabulum so after i leo pectinal and iloistial line we come to what is called as a teardrop so this is a radiological marking which is present in the pelvis in both hip ap projection of an x-ray lot of debate has been gone through this teardrop and what is its importance this is the common question which is asked in lot of mcq exams also so so the teardrop is a radiological finding made up of the in following points so i i'll show you the video at the end of the lecture where how you draw the teardrop so the teardrop the medial border is continuous with the ilo issue line and the lateral body border is continuous with the floor of esteban so this is like a inverted tear drop which is formed in the hip joint so it it is a summation of shadows in the middle aspect and it corresponds to the inner cortex of the pelvis so what it actually tells is this is the pelvis brim it is actually the sorry the established brim which is uh which is giving information through this teardrop so what is this importance of the stereo drop is due after any um surgical procedure on the hip joint like the most common surgical procedures which are done around the joint are the total hip replacement or the or the hemi hip replacement so when you are sometimes you are asked to evaluate a patient who has undergone a total hip replacement or a hemi hip replacement and he comes to you with an x-ray of the hip joint with the implant in c2 so what you're supposed to do is you are supposed to see whether the tear drop is intact or the teardrop can't be seen so there are a lot of studies which were done and these three diagrams which are showing shown in this figure that is a b and c will tell you the importance of the teardrop so in the figure a what is what has been done is there is a reamer which has been kept in the astableum and x-ray has been taken in this a when the x-ray has been taken with the remote just kept not reamed you can see that the teardrop is intact in the b section of the diagram when the reaming has been done you can still see that there is a part of the teardrop which is preserved so if the part of the teardrop is preserved that indicates that the stapler rim has not been violated however in the third diagram when the reaming is continued you can see that the teardrop disappears so when there is any teardrop which is not seen after the operative procedure on the hip joint it suggests that there may be some violation of the stabler brim and the violation of the established floor may have been undergone so if a patient with a hip pain if he comes to you after surgery and you notice that the trigger drop is violated you can just be saying that it can be because of the violation of the ring so this is one important uh radiological marker which is present that is the teardrop now the established floor now what do you mean by established flow is this is the uh bottom part of the establishm which you are trying to see in a pelvis with both hip x-ray so how do you come to see this is see there are three lines which are marked in this diagram the blue line the red line and the white line so the blue line is the ileoptilian line which i told you in the beginning of the lines uh part that is the ileopectic line is the blue line that starts from the pelvic brim and goes into the pubic symphysis the red line is the ileum line that is the represents the posterior column of the acetabulum the white line is the established force so it just starts around the superior lateral margin of the establishment and goes through the elevation line and goes back and ends near the tree top this is the true established probe after we have established these three lines that is the ileopectic line the ilo is chill line and the white line that is the sw4 now you should know about this various pathologies which can occur so the first diagram that is starting from the left side is the normal where you can see that the white line the red line and the blue line representing the established force the leo line and the ilo pectinal end all three are intact now in the second diagram that is the center diagram what you can see is the white line has crossed the red line that is the established floor is cross the ileo is chair line this is called as cross coxa profonda so this is not a pathology by itself but it is more commonly seen in women and a particular population where the established floor is deep so this is called as coxa profunda so you have to be careful and you have to think that this may because of a pain in a certain individual and you can further subject them to a further imaging modality now most important is the last diagram so in the last diagram what has happened is the white line which is representing the established floor has crossed both the green line and the red line that is the iliopectin line and the aloe ester line this is the proper protrusion established or the femoral head has itself driven deep into the established floor causing a stabler protrusion this is a true pathology of the hip joint which you can identify in a in a plane x-ray so these are the importance of the established floor and its relation to the iliopectinial line and the iliosteal line now morphology of the establishment so marshall physiology of the estermanes is basically what i told you now whether the quantity and the quality of the establishment has been maintained or not so we try to evaluate on an x-ray whether the quality and quantity both of the established are preserved or not so the established coverage and the established depth can be assessed by these two um lines that is the ce angle of v buck or what is called as the central edge angle of fiber and the femoral head extrusion index so what these two measurements will tell you is it will tell you what is the morphology that is the capacity of the stem whether it is normal or whether it is altered it is something like a cup now are you able to see if the cup can hold about 90 or 100 ml or will it hold only 10 or 20 ml so this coverage of the establishment or the morphology of the system can be known by these two uh measurements so the first one is center edge angle of v-buck so this also there is a video which will i'll play after the end of the talk so in this one what you do is you first draw a line that is the horizontal line which is drawn this is a line which is drawn to the tri-radiate cartilage also called as a transverse axis of the pelvis this is the transverse axis of the pelvis then you draw a line perpendicular to the transverse axis of the pelvis line that is the perpendicular to it from the center of the femoral head and another line from the center of femur head to the a lateral edge of the establishment so this is the center edge angle of v bug if the value is less than 20 then it indicates that the established capacity or the morphology of the stablem is decreased it is most commonly used in measuring the established volume in development displays of the hip now the second most important and simple thing which you can do is a what is called as a femoral extrusion index i want you all to look at the hip joint very carefully in this one what i have drawn is i have drawn a line called b with a black ink or a black shade there is a line drawn in the b so the b is the total uh width of the femoral head it starts from the medial aspect of the femoral hand and ends at the lateral aspect of the femoral head this is line b now the line a which i have drawn in white just be careful and see the line a so the line a is line measuring that part of the femoral head which is outside the established coverage so that part of the femoral head which is outside the established coverage is taken as a so what you do is a divided b by b into 100 this is the index what you get when you calculate it so normally it should be less than 25 okay so this a into ba divided by b into 100 you will get a value which is should be less than 25 if the value is more or less then you have got a certain abnormalities which can you can diagnose in most of the time in case of protruding the estrogen press through the swelling which i recently told you the value will be in minus it will be reversed though a will be coming inside so after this uh you got a stabler angle which uh is most commonly used in children which i'll be telling again in the next slide okay so now we we have done the measurements in the pelvis side that is we have done the measurements which will denote the anterior column the posterior column and the morphology of the establishment now will slightly focus to the femoral side measurement so in the femoral side measurements are relatively straightforward you have got what are what is called as the cox of alga and vara the cox of algae is the left side and coxavera is the right side so what exactly is this one is it will tell you about the angle which is formed by the femoral shaft with the head and neck so a line drawn from the femoral head to neck and another line drawn through the diaphysis of the femoral shaft extending upwards when these two lines meet there is an angle which is formed if the angle is more than 140 then it is called as coxa valga if the angle is less than 120 then it is called as coxal barra this after you go on seeing lot of pelvis and both hips x-ray you can just eyeball and diagnose it no need to do the measurements you will come exactly see the x-ray and you can tell hey this this patient has got foxavara or this patient has got oxavaga these are the two important measurements which you see on the femoral side now the other important thing you have to see is the femoral established joint space this is the true hip joint that is the joint space between the femur and the astableum so what you are supposed to see in the ap view that is the left side diagram is the uh weight bearing area that is the superior lateral weight bearing area you just see how much space is there whether the space has been completely obliterated which is suggestive of the arthritis or if the space is still maintained if the space is still maintained it suggests that the cartilage is good if the stage is if the space is obliterated which is suggestive of osteoarthritis in the cross table lateral view or a lateral view you have to see the posterior aspect of the femorostable joint in this one when you see the femoral established joint space which is reduced both in ap and lateral you can come to the conclusion that this patient may have a arthritic change or a reduced shift joint space so this is an x-ray now if i go back to the previous slide this is of a normal joint space if you go to this one you can see that the superior lateral weight bearing joint space is reduced both in ap and lateral now the coming to the sphericity and morphology of the femoral head see um this is the globular shape of the femoral head which you come to see by regular practice so the moment you go on seeing hundreds of x-rays normal x-rays you'll come to to a conclusion that this femoral head may not be looking ground or it is not spherical or it is a spherical so there are some moose meters which are available which i don't think which is available in local areas where you take an x-ray but if you are in a doubt that the sphericity is not there not maintained you can subject the patient to a further investigation or you can send the patient to a facility where this moves parasomatic or index are there where you can measure the specificity now these are three examples which are shown the left side you can see that the femoral head is just about round but in the center you can see that the shape of the femoral head is not particularly round it has been distorted and in the last one that is from the left the last x-ray it shows that the femoral spericity is round but you can see multiple lucent areas or lytic areas in the femoral head so what this suggests is it will tell you about the sphericity which is lost as it is shown in the middle diagram and it will also tell you about the morphology of the femoral head like in the last diagram where there are lactic areas so this may be a patient who has got an infection or you may have a arthritis so this after you practice seeing hundreds of x-rays normal x-rays you will come to know immediately that the spirit is lost now coming to a few lines and arcs on the femoral side okay so the first thing uh so the first thing you have to see is what is called as a sentence line or an arc so this sentence line or arc is a radiological line which is drawn uh just concentrated on the right side diagram where i have drawn the shenton's line or arc in the with a reading so it begins by the begins by starting at the inferior border of the superior pubic ramus it goes and meets the femoral head and curves beneath the inferior border of the femoral neck and ends at lesser tuberosity lesser trochanter sorry lesser proteinal so it starts by the inferior water of the superior peptic ramus goes to the hip joint goes to the inferior neck and ends at the lesser trochanter so this is like a in like a inverted c-shaped smooth line so any interrupt interpret interruption in this sentence line or arc is most likely because of fracture neck or because of dislocation of the uh hip joint so this is the center's line or arc i'll show the animation at the end of the lecture of this also so this break in sentence line as i've told you it indicates a fracture neck of femur or it can be because of a development displacement of the hip joint or it can be seconded to a dislocation of the hip joint also so in summary these are the pelvic rings and line summary so it looks confusion confusing but these are simple lines which you should be able to draw after a few uh practice x-rays so the elephant line the elevation line the teardrop the android positive wall of the established wall and the hosa now uh coming to a few pediatric x-rays so when i said that i will be covering uh hip x-rays i'll just tell you about a gist of what you have to look at a pediatric hep x-ray now the first thing to remember is that the pediatric apex rate is not constant so as the child is growing there are various neurological parameters which crop up during various ages so this is the pediatric capsule if picture is very according to different ages or the different age population of pediatrics which you see so you can see this x-rays which are put up you can the first x-ray on the left side is the x-ray of a six-month uh old uh child the eleven-month-old child and eight years so what you can see is in the six months old uh child x-ray you can't see the capital f spices of the femoral head that is the femoral head has not developed itself yet in the 11 month old child x-ray in the center you can see that you can see some amount of femoral head which has just come up and in the eight years you can see that the femoral head capital efficiency is completely formed so what i want to highlight here is the pediatric hip exercise to evaluate it is not fixed so it varies according to the edge and you should know what are the normal ossification centers and how a normal ah evolution of the pediatric bony parameters will go over now the most common um evaluation you are first you are forced to assess or you will necess is hip dysplasia so what do you mean by hip dysplasia is this is because of a development anomaly in the establishment itself so what i was telling earlier about the acetabulum depth or the esteban morphology or like a cup i was comparing it to so in some children because of some various causes the established cup is not deep that is instead of holding 100 ml of water the esteban will hardly hold 5 ml of water so what happens is in such conditions the femoral head can't fit into the astableum so the femoral head displaces or dislocates so this is as either congenital dislocation of hip or it is also called as hip dysplasia so most of the times this hip dysplasia is because of mild development of the establishment so how you identify it is as i've already told you you first draw the shenton's line so once you draw the shenton's line if you are sure that the normal c shape is there then it is very less likely that the patient may be having a hip dysplasia now next important thing are to draw these two lines okay so i just concentrate on the right side x-ray first and then you see the left side x-ray so the larger x-ray which is which have drawn on the right side is the normal x-ray so the red line the red line which is drawn is called as the hilgen rhinos line so this hilgian dryness line is a transverse line which is drawn through the tri-radiate cartilage so this line is drawn through the center just superior to the femoral head through the establim it is wrong that is the tri-rated cartilage so this is drawn as a transverse line then the green line this is called as the perkins line so this green line is drawn in a vertical manner and it begins at the lateral edge of the establishment it is drawn from the lateral edge of the establum and it is drawn perpendicular to the hilgine rhinos line so when you draw these two lines that is the elgin rhino line and the perkins line you you divide the hip joint into four quadrants that is superior lateral superior medial inferior lateral inferior middle so the hip or the capital femoral efficiency and the femoral head has to be in the inside the it should be in the inferior and middle aspect of this quadrant whereas if you now concentrate on the left side x-ray that is the smaller x-ray you can see that when you are drawn the elgin rhinos line in the perkins line the capital femoral epiphysis is not in the inferior and inferior and medial quadrant so this indicates that the acetabulum is not developed in its normal shape and is unable to contain the femoral head and it is a development dysplasia of the hip these are simple lines which you can draw you can just practice them on a paper and you can easily come to know about these two lines that is the elegant rhino line and the perkins line so this is another parameter which also can be done this is called as the establish index so the establish index is how you this is also a parameter which will measure the depth of this problem so you draw the hilgine minus line this in this case it is the white line that is the algae brightness line so you draw the elegant dryness line then from the elgin rhinos line you draw a line connecting the superior and lateral astable walls so when you draw this line you can see that if the established index is more than 25 then it's it is suggestive of a male developed established so these are three important parameters which you can draw or you should know to develop to diagnose the development displays of the hip that is the shenton's line the established index and the hilgine rhinos line and the perkins line so so i'll come to perthes disease this is another disease which is seen in pediatric population in india so what do you what is purpose disease i will not go into the depth of the pathology or physiology but it is a disease where there is a break in the blood supply to the femoral head that is what we call it as a capital femoral epiphysis because the head is not completely formed we just call it as a capital femoral epiphysis because of some unknown etiology or a known etiology there is a temporary interruption of the blood supply to the capital femoral epiphysis and the epiphysis doesn't develop so how you have to identify this is see you you have to make it a point to see the both hip joints and compare it now in the in this right side x-ray in the right x-ray what you can see is the white arrow will shows you the normal capital femoral efficiency so you have to see the length of the capital femoral epiphysis in the right side x-ray the white line shows a normal capital femoral epiphysis the black arrow will shows you that the chemical femoral epiphysis is reduced in size the moment you see that there is reduction in the length of the capital femoral epiphysis the red flag signs should be brought up you have to further image or further refer the patient as early as possible so that the destruction of the whole of the femoral head or the capillary femoral epiphysis is preserved if you don't identify that early stage you can see here now the left and the right diagram you can see that the capital femoral efficiency is destroyed destructed and it is completely resist in size in the right side x-ray you can easily appreciate the black and white arrows which shows the destruction of the capital femoral aquifices whereas in the opposite hip joint you can see that the length and the breath of the capital femur like a prices is preserved so this is a very important sign which you can see in in a child if you image the pelvis with both hip joint very self-explanatory so these are the various stages with through which the for this disease goes through and the various uh ways in which the capital femoral efficiency can be destroyed now coming to another pathology which is seen in pediatric population now very less very less cases we see maybe it is because of the increased awareness of this disease or the uh because of the changing environment of the patterns which has come down but still you should know about this this is called in short form as skiffy that is scfe but the long form is slipped capital femoral efficiency slipped capital femoral epiphysis so this is a pathology which is painful and deforming for the child when it occurs so how you identify this is it is a simple you draw a line which is called as a cleanse line uh so k l i e n s line or a tritone sign this also i'll show you an animation at the end of my presentation so you draw a line you can see the right side x-ray you draw draw a line from the superior aspect of the femoral neck so the left side is normal the right side is abnormal so once you draw the line and extend it to the capital femoral as it applies it it should cut some part of the capital femoral epiphysis or the femoral height at least 10 to 20 percent if it doesn't cut any part of the capital femoral epiphysis then it suggests that the femoral epiphysis is slipping and it is the first sign of skippy or a slipped capital femoral acceptance so this is about pediatrics and about the lines now i want to concentrate on osteoporosis and why it is important so what happens is a lot of camps are conducted lot of health camps are conducted where pelvis with both hips x-ray is also taken for the genetic population so the genetic population they are more prone for osteoporosis and in indirectly because they suffer from osteoporosis they are more prone for pathological fracture so what is osteoporosis and how to identify it is itself is a big topic but how to identify osteoporosis on x-ray i'll tell you in few points so before i tell you about the points this is how a proximal femur looks so if you see the proximal femur there are trabecular pattern or these are the dense thick hard bone which is present in the proximal femur so these are labeled as primary compression secondary compression primary tensile secondary or something like trabecular pattern you can see that it is thick and the trabecular easily seen so the left side is a specimen of a normal patient where you can see the trabecular pattern is evenly distributed the right side x-ray on your screen is of a patient who has got a osteoporosis now what you can appreciate here simply is that when you compare the left and right side the trabecular pattern is hardly there in the right side diagram so this is osteoporosis where the calcium content rather than the calcium content the trabecular pattern of the capacity of the bone to withhold the normal stresses and prevent from undergoing fracture is lost so what happens the it is just like an empty shell of bone which is present so it's a very uh it can it's also called as a silent killer or silent um [Music] silent disease in elderly population so this how you identify in x-rays you identify by the rebecca pattern so these are the normal trabecular pattern which are described which have already told you the primary compressor secondary compressor primary tensile or something like that but in the x-ray how to identify it is you just see the quality of the trabecular pattern in an x-ray the left side x-ray is of a normal trabecular pattern where you can see that in the proximal femur that is the head neck and the shaft of the femur you can see that the white uh coarse trabeculae which are present now if you look at the right side x-ray this course trabeculae pattern are not seen they even if they are seen they are few scattered here and there so this should always uh always um you should be always suspecting something is going wrong when you see such kind of x-rays so what is the simplest thing you can do is you can tell the patient that to me it looks like your bones are looking osteoporosis so it is better you just undergo a dexa scan or a further investing modality to confirm whether you got osteoporosis or not so this is a simple just all it needs is the consultant who is seeing the x-ray to open his eyes and see the x-ray and just tell the patient whether his bone quality and bone strength is normal or is it osteoporotic or osteopenic so these are the trabecular pattern which you should see when you are imaging the proximal femur now a vascular necrosis and osteoarthritis are very common now so they are very easily detected on x-ray but the only thing is by the time the features are seen on x-ray this disease would have advanced into a stage two or stage three that's why x-ray is not a useful tool to screen the patient for a vascular necrosis and osteoarthritis but still when the patient comes to you with these changes it is very important to refer him as soon as possible for a remedial measures so how do you identify our skill and necrosis and osteoarthritis the first thing which i've already covered in the sphericity and the morphology of the femoral head so when you see such an x-ray that is the left side is an x-ray where the femoral head sphericity is slightly disturbed and you've got a punched out legend or a lytic legends in the proximal femoral head you should always suspect that the patient may be having some osteoarthritis points so it is very important the globular shape of the femoral head be studied and the um and if there is any abnormality immediately it should be identified this is of a vascular necrosis and this is of a crescent sign what we call as a christian sign this is also a vascular necrosis where the subchondral bone has collapsed so more times what i want to send a message is it's not necessary to identify that the patient has got hyperscale analysis it is important for you to understand that this x-ray is not normal so what you can say is this x-ray is not normal because the sphericity of the femoral head is not maintained and there is a some abnormality going on either refer it to a specialist or subject into a further investigation so now coming to the last topic of my talk here is femara establish impingement so why have we included this topic here is during the last 10 to 15 years there has been a tremendous uh what you can say tremendous studies which have been done about this topic as a common source of pain in the young population most commonly in females so what i'll just try to explain what exactly it is and how you can identify it in the x-ray so the femoral establi impingement means because of the some alteration in the normal shape and structure of the femoral head or the establum there is some pathology which is being caused in the hip and this is resulting in the hip pain and the patient is not allowed to go through his normal day-to-day activities so what happens is you have to see it in a x-ray because what happens most of the times if you don't know about this one if a young person comes to you with a pain you do a imaging and if you don't know what premier establishment is and how to identify it on x-ray and if you tell them that the x-ray is normal most of the patients may go on doing their routine activities which may further worsen the disease and it can end up in osteoarthritis so first simple thing is you have to understand that there are two types of femural establi impingement the first one is the cam type and the second one is pincer type cam and pincer i'll just explain it in a few words so you can understand what is cam and what is pencil so if we take cam so the simple thing to understand is in a cam type of femoral stabler impingement the deformities always or the pathology is always in the femoral head so i just want you all people to see this diagram or any other line diagram which is which i put up here so what happens in cam type of femurous tabular impingement is the femoral head is not perfectly round now if you see this one the superior aspect where i have shaded the area or the diagram is shaded with black arrows which are lines which are drawn here that part of the femoral head instead of being global or round perfectly wrong it is not wrong so what happens is uh when this kind of hip joint this is the diagram which has been taken when the hip is in neutral position so now what happens when the hip goes into full rotation so you can see in the left side and the uh middle diagram so when such an hip is put into normal rotation that is internal rotation external rotation internal rotation external rotation this abnormal part of the femoral head will come and impinge against the establishment resulting in the hip pain disability and can lead to a osteoarthritis later life this can lead to destruction of the articular cartilage and it is called as a cam type of femoral acetabular impingement cam type of femoral establi impingement where the abnormality is in the femoral head shape it is not perfectly globular now how do you identify it so so simplest thing to identify this one is again i it goes back to the earlier point where i made where i told you about the globular shape of the femoral head which you have to practice by seeing a lot of normal x-rays then you'll come to know that this femoral head is normal so what happens is this is a there is a deformity of the femoral head you can see the first diagram on the left side where you can see that there is a bump which is seen this is what i was telling you that the femoral head is not normal it is not globular you can see the pump which is green this bump will result in impingement so it is there is a sign which is called it is called as a pistol grip deformity of proximal femur so the pistol group deformity of proximal femur means if you look at the right side hex renault it is a old flinstock pistol which was used in pirate movie so when you invert this um crystal the proximal femoral head neck and the shaft it will look like this pistol so the moment you see this extra you see that the femoral head is not ground and it is not in its normal shape so this is how you identify a femoral establi impingement to be more specific a cam type of femoral establi impingement so this is one [Music] formula which is there uh alpha angle this is specifically to be done by the specialist like uh orthopedic surgeon but still i would like to mention about this alpha angle so this is a simple measurement which is done in a cross leg uh lateral view of the hip joint where you draw a line through the femoral neck and another line from the center of the femoral head to that point where the head loses its globular shape so this angle if it is more than 45 is just your offset deformity i am not expecting all of you to be able to know this remember it android but if you just know that the fibonacci is not global or not wrong you can easily say that the patient is having some problem and it can be a femoral established impingement so this is about cam femoral establish impingement so again to summer summarize cam type of femoral establi impingement the problem is in the femoral head and the femoral head is not globular there is a loss of femoral velocity this results in impingement now the second is pincer so i think all of you know that pincer is a where the uh the some something like you can remember it as a pinch only so what happens in pincer type of deformities the female head is globular the femoral head shape is normal but the establi over coverage is there so if you look at the diagram on the right side carefully you can see that the external establishm will have to rotate completely in its full freedom so again i'm going to tell you cam type of femoral establishment the pathologies in the femoral side in pincer type of femorous stabler impingement the pathology is in the established side and this is because of overgrowth or over coverage of the astable so what happens is in every rotation the acetabulum will impinge against the femoral lead leading to pain and instead pain and disability and can end up in osteoarthritis so how you identify this is the simplest thing is the first measurement what i told you is the femoral extrusion index and the next one if you uh this most of the times the patient will have a protrusio so if you try to trace out the elo is gel line and the femoral establi wall you can see that the established wall is completely gone inside in a plane x-ray the moment you see that the femoral head is excessively covered by stubble you know that the patient has a femoral established impingement okay so another sign which is most commonly asked is what is called as a crossover sign so this crossover sign is a it it can be asked in mcqs and it is most commonly used to denote a pizza kind of fibroid in pigment so what is crossover sign simply is yeah the left side is the normal x-ray which is present of the hip joint normally the anterior and the posterior established walls they don't meet when you trace them so when in a pelvis x-ray when there is a ah when the two lines which you draw to denote the anterior and posterior wall when they meet or they cross over then it is most likely to be the establim is retroverted and there is a pincer kind of pimoros tabular impingement this is crossover sign and most uh 90 or 95 it denotes that the patient has got a pincer type of impingement so this finishes my talk on how to evaluate the hip x-rays non-traumatic so to summarize uh we should know what we are looking for what i want to say is that the hip joint x-rays are like a pandora's box so if you just go on looking for some things you may end up finding some things which are not important so what i mean to say is a proper clinical examination before you subject the patient to an x-ray is very important because the proper clinical examination will tell us what we are looking for so the normal radiological anatomy and measurements will help the clinician in not only diagnostic condition but also the plan the treatment and monitor it so this is the importance of pelvis with both hips x-ray how to evaluate it thank you for a patient hearing thank you sir do i play the videos now yeah yeah yeah just bear with me for a few more minutes i'll just try to explain the lines whichever i have told in my presentation i will i will explain the lines by drawing them and these are short videos which i'll explain them when she plays it yeah okay so this yeah so this is heliopectinial line so the line starts from the um from the pelvic brim and it goes to the superior pubic symphysis yeah next video please [Music] yeah so this is the illustration line it denotes the posterior column of the swamp so it starts from the pelvic brim and it goes towards the ischial tuberosity next video please [Music] [Music] okay okay so this is the teardrop the this is the marker which will tell you whether in after surgery or during surgery whether the established floor is violated or not next video yes [Music] this is the center edge angle of people the transverse line is the um transverse pelvis line and the two lines are the one from the center of the femoral head perpendicular to the transverse pelvic line and another one from the center of primordial head to the lateral edge of the stable which will tell you the amount of stable coverage next video please okay so this is the helgen trainers line and the perkins line to assess the development dysplasia of the hip joint so this will tell you whether the hip joint is normally developed and whether there is ddh or not next video please yes [Music] [Music] most of the times this sentence line there is a there is a break if there is a fraction neck of femur dislocation of the hip joint or developmental displacement [Music] [Music] just allow it to play i'll restart [Music] [Music] so now you can pause it yeah so the this is the cleanse line which is a simple line which is drawn from the superior neck and it is projected to bisect the hip joint in normal um hip anatomy it should bisector part of the capital femur life faces as you can see in this video the opposite side it is not bisecting any part which is suggestive of early stage of slip capital femoral efficiency yeah okay uh see what i what i'll do i think there are some questions in the comment section i'll try to address it from the beginning okay okay so the first question is so what is wondering so um i would like to tell you that wandering establim is a established destruction which is seen in case of tuberculosis of the hip joint where the acetabulum is destroyed so because the establishment is destroyed by the disease process the capital femoral epiphysis goes on following the establish so you can see that the establishment joint is uh formed at a different level than the where the initial position was so this is called as a wandering establishment okay so the next shiva raman ji so he has asked me about some points about bmd that is bond mental densitometry so this is in relation to osteoporosis so now what i told you was about the sings index of osteoporosis based on the trabecular pattern so this was disturbed this was described by an indian long long back so the disadvantage of this one is for the x-ray changes of osteoporosis to occur about 40 percent of the bone has to be removed so there is no fun in diagnosing osteoporosis when already the disease has occurred so this is not a good investment modality for diagnosing osteoporosis that is the disadvantage but still in india if a person comes to you for a normal x-ray you can still use it for diagnosing a osteoporosis so the bone bmd is what is called as a bone mineral densitometer so you got lot of bmd machines which are seen in camps that is the peripheral dexa so these are not specific or not gold standard so the gold standard to diagnose osteoporosis is what is called as a texas coin dexa scan d xa scan so dexa stands for dual energy x-ray absorptometry so that is the core standard to diagnose osteoporosis so the bmd what we use in a camp that is of the calcaneum of the finger is used basically for screening purpose if you find that the people have got altered bmd in this camps then you have to subject them from dexa for a definitive diagnosis okay so i think there is another question by makita he has asked me to explain about the mixed impingement so sir what i have tried to explain to you in very simple terms as easily as possible is about a femoral established impingement types that is the cam impingement and the pincer impingement so this is i just classified them into two types so that it will be easy to explain to the general population but in some people what happen is what happens is there may be a overlap of both there may be some developmental problem in the establishm which is resulting in a pincer deformity insert type of extra impingement and so also some trauma or some alteration the same of the femoral head during the development called cause a cam also so these are the patients who have got both cam and im insert kind of impingement and they are the ones with the severe symptoms which who need to undergo some kind of treatment either surgical at an early stage so another question is by rajet rani to explain the significance of teardrop sign i think rajat i have made it very clear in the slide itself i have explained the teardrop with the three diagrams so the teardrop is a the existence of create drop itself is questioned by many people so it is basically used to evaluate post-operative surgerical morphology of the hip joint during reaming of the establishment total hip replacement or when you are doing a partial hip replacement when the established cavity is deepened either androgenically by the surgeon or by the implant itself it will suggest that the femoral um rim has been violated so when the teardrop is not seen on the pelvic in both epics right you should say you should suspect that the pelvic establishment has been piloted so uh ventrachalam has asked me one one more question of limitation of x-ray evaluation or heat joint and to please clarify so the x-ray limitation is sir first and foremost it's a two-dimensional evaluation of a three-dimensional anatomical structures so it has got its limitation in not able to image the skins the soft tissue the muscles the intermediary tissues if you are interested or if you are so sure about your clinical examination and you know that there is no bone or bony abnormality you go ahead and go for a mri itself but if you are unsure of your clinical examination and if you feel that you need an x-ray to rule out bony pathology then please do x-rays rule out bony pathology and then further you can subject the patient to a further imaging modality like an mri so penetration ask me one more question of role of usg in hip joint evaluation so usg in hip joint evaluation is basically for the soft tissues so i would go and stick my neck out and say that if you are suspecting something in the skin soft tissue or the periodicals tissues please go ahead and do a mri we will get objective and subjective evidence of a skin and soft tissue pathology in ultrasound it is the radiologist who is going to interrupt interpret for you the skin and soft tissue so that is one disadvantage you are not going to interpret it it is the radiologist who is going to interpret it and the ultrasound is excellent modality for imaging the skin and soft tissues around the hip joint so transient osteoporosis again it is asked by him only so this is a osteoporosis which is seen in pregnancy and in some young woman it is because of temporary interpretation of the blood supply because of the pregnancy and the hormonal changes so most of the times it is important to identify it because uh the after the pregnancy the women will regain the bone mineral concentration back so the treatment of um vigneshware has asked me one more question about what is the treatment of femoral establishment and how we have to approach it so the most important thing is that we have to identify the type of impairment see many people still don't know that femurostable impingement exists so just when if patient comes to you with a hip pain and you're taking an x-ray it is very important to understand that there is a thing called as femoral stability impingement and just spend some time to see the morphology of a femoral head the globular shape the sphericity and if you are in doubt you also can do a further investigation and find out the impediment so the treatment depends upon the type of impingement [Music] say last question is about saya dhamma he's asking me is there a role of jude's brew in presence of cities can i agree with you there is no role for judah's view in presence of ct scan i began my lecture by telling you that the views internal rotation external rotation due to view if you feel they are necessary please don't do them you can subject the patient to a ct scan if the patient is willing for a ct scan and if you've got a ct scan in a nearby in extreme cases if you don't have a ct scan and if the patient is not willing for a citizen please go ahead and do the judicial i think uh last question yeah i think i may have answered that question from vancouver i'll answer this one also so the big room is so sir the peak bone mass is nothing but the bone mass which a person will attain it is something like a bank balance so the bone formation bone resorption this is a feminist process but the bone formation the amount of bone formation will end at the age of somewhere between 24 25 20 or 30 so this is the peak bone mass that is the maximum bone formation which has occurred after this then we slowly loss or reception of the bone mass this will lead to osteoporosis so the hypothesis is if you are have a healthy diet if you do exercise regularly and you are good in your discipline in your good in your exercises and you maintain a disciplined life you are supposed to have a good big bone mass that is debatable still but [Music] all right thank you so much sir for the presentation and for the whole q a um netflix thanks you and the audience that came in to uh for this session uh we hope to have you back on our platform again and we'll meet again thank you doctor and thanks the matrix team for giving me a super opportunity thank you very much

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Dr. Santosh Jeevannavar

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