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MUSCULOSKELETAL IMAGING
doi: 10.1259/img.20120023
2014 The British Institute of
Radiology
Cite this article as: Daghir A, Teh J. Imaging the hip. Imaging 2014;23:20120023.
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Anatomy
The hip is a ball and socket joint capable of transmitting
large forces. It allows a wide range of movement, while
maintaining strong stability such that dislocation occurs
much less frequently than in the shoulder. The cup-shaped
acetabulum is formed at the junction of the iliac, pubic and
ischial bones. The fibrocartilagenous labrum forms a ring
at the margin of the acetabulum, thereby increasing its
depth3,4 (Figure 1). The femoral head has a hemispherical
articular surface with a central fovea to which the ligamentum teres attaches. The capsule of the hip joint attaches
at the intertrochanteric line covering the anterior femoral
neck and most of the posterior femoral neck. The iliofemoral, ischiofemoral and pubofemoral ligaments reinforce the fibrous capsule. The transverse ligament and
ligamentum teres are intracapsular. The latter is a weak
ligament that transmits the foveal artery, which in adults
contributes little blood supply to the femoral head. The
femoral head receives most of its blood supply from the
medial and lateral femoral circumflex arteries, which form
a ring around the base of the femoral neck. These are at
risk when there is an intracapsular femoral neck fracture.
The lesser trochanter is the site of attachment of the iliopsoas tendon. Several muscles insert onto the greater trochanter, including gluteus medius, gluteus minimus and
piriformis.
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Condition
Occult fracture
Osteoarthritis
Trochanteric bursitis and gluteus
medius enthesopathy
Avascular necrosis
Transient bone marrow oedema
Synovial proliferative disorders
Femoroacetabular impingement
Snapping hip
Osteoid osteoma
Third to fifth
decade
Second to fourth
decade
high-signal bone marrow oedema and also allow assessment of soft-tissue injury (Figure 2a). Radiographs may
initially appear normal and later show periosteal thickening and a sclerotic fracture line (Figure 2b). Bone scintigraphy provides another means of diagnosis although the
sensitivity and specificity is lower than with MRI.8,13
Avascular necrosis
AVN, also called osteonecrosis, is common in the
femoral head and has a number of causes, the commonest
being chronic steroid use, chronic excessive alcohol use
and trauma. With interruption of the blood supply, myeloid cell death follows in 612 h. After 48 h, osteocyte
death occurs, and lipocytes die within 26 days.15 This is
followed by an inflammatory response increasing vascularity, leading to the formation of granulation tissue
and fibrosis. Collapse of the subchondral bone predisposes to OA. The condition is bilateral in up to 40% of
cases, so it is important to image both hips together.
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Figure 4. Avascular necrosis (AVN) of the femoral head. (a) Radiograph demonstrates subchondral collapse (arrow), a late feature
of AVN. (b, c) In a different patient: (b) coronal T1 image demonstrating a subchondral region of low signal (arrow); (c) short tau
inversionrecovery sagittal oblique image demonstrating the classical double line sign (arrow) of AVN. The high-signal line
represents hypervascular tissue on the necrotic side adjacent to the low-signal fibrotic/sclerotic line on the healthy side.
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Features
II
III
IV
V
Osteoid osteoma
Osteoid osteomas are benign neoplasms that usually
involve the long bones, particularly the proximal femur
and tibial shaft. The typical presentation is of localized
bone pain that is worse at night and relieved by antiinflammatory drugs. The tumour consists of a small nidus of osteoid tissue (usually ,1 cm) that demonstrates
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Figure 5. Transient osteoporosis of the left hip in a middleaged male. Coronal short tau inversionrecovery image demonstrates high signal (arrow) indicating bone marrow oedema
in the femoral head and neck. The subchondral region is
involved, which is not always the case in this condition.
Femoroacetabular impingement
Femoroacetabular impingement is a recently described
cause of hip pain resulting from morphological abnormalities of the hip. Two types are described, cam and
pincer, although most patients have a combination of
both types.45 Cam- and pincer-type deformities are not
thought to be painful by themselves. Rather, they predispose to damage to the acetabular labrum and cartilage,
which is painful. Identifying these morphological abnormalities has important implications as surgical correction
may prevent the onset of OA.46,47 Arthroscopic management involving recontouring of the cam and/or pincer
deformity has been reported to have favourable early
outcomes in most patients although the long-term benefit
is not known.48 Accurate assessment of the extent of
cartilage disease is important because, in cases of advanced damage, joint-sparing arthroscopic treatment is
unlikely to be helpful.
Cam impingement
Cam-type deformity, typically occurring in athletic
males, describes loss of the normal sphericity of the femoral head owing to the presence of an osseous bump at the
head/neck junction, which is usually found anterolaterally49 (Figure 8). It is so-called because of the resemblance to a camshaft in motor engines. Although a cam
deformity is often idiopathic, similar morphology may
arise secondarily as a result of conditions including
trauma, chronic slipped upper femoral epiphysis, previous
osteotomy and Perthes disease. Repeated contact between
the osseous bump and the labrum causes labral tearing
and detachment. This process leads to cartilage damage
and OA. A triad of findings on MRA has been described
consisting of a femoral head/neck osseous bump, anterosuperior cartilage abnormality and anterosuperior labral
abnormality50 (Figure 9). The degree of loss of sphericity
may be quantified using the a angle (Figure 10). This angle
can be measured on an axial oblique MR image or on
a cross-table lateral radiograph of the hip. An a angle .50
may be considered abnormal.51
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Figure 9. Cam impingement. MR arthrogram coronal T1 fatsaturated image shows a cam deformity (arrowhead). There
is an associated labral tear (arrow) and thinning of the
articular cartilage.
Pincer impingement
Pincer-type impingement, more common in middleaged females, describes focal or diffuse enlargement of
the acetabulum resulting in overcoverage of the femoral
head.51 Cranial acetabular retroversion, coxa profunda
and protrusio acetabuli are types of morphology leading
to pincer impingement. On anteroposterior (AP) radiographs of the pelvis, cranial acetabular retroversion is
present when the cranial part of the anterior acetabular
wall is identified lateral to the posterior acetabular wall.
Coxa profunda describes the overlap of the acetabular
fossa with the ilioischial line, whereas protrusio acetabuli
describes the overlap of the femoral head with the
acetabuli in an 82-year-old female. Radiograph shows overlap of the femoral head (black arrow) with the ilioischial line
(white arrowheads). (b) In the same patient: the centreedge
angle in pincer deformity. A line is drawn connecting both
femoral head centres. The a angle (*) is then measured
between a perpendicular line through the femoral head
centre and a line from the femoral head centre to the lateral
edge of the acetabulum.
Ischiofemoral impingement
Ischiofemoral impingement is a newly recognized condition, which remains the subject of debate. The condition
is found predominantly in females of middle age.58
Patients typically present with posterior hip pain that
may radiate towards the lower extremity.59 The space between the ischial tuberosity and lesser trochanter is typically much narrower in patients with this condition than in
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Inflammatory arthropathy
Inflammatory arthropathies such as rheumatoid arthritis or ankylosing spondylitis commonly involve the
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hip joint. On plain radiographs, joint space loss is predominantly in the axial region, unlike the superior joint
space loss that is typical of OA. Longstanding inflammatory arthropathy leads to widespread cartilage
damage, resulting in circumferential loss of hip joint
space. Erosions are not a common finding. With ultrasound, an effusion and synovial hypertrophy are detected early in the course of disease (Figure 13). There are
non-specific findings on MRI, including effusion, synovial thickening and peri-articular bone marrow oedema.
Septic arthritis
Septic arthritis of the hip, although rare, is important to
exclude owing to the risk of long-term joint damage if left
untreated. Infection may result from haematogenous
spread, direct inoculation or by spreading along the iliopsoas muscle from the spine.61 Using imaging alone, septic
arthritis may be very difficult to distinguish from a noninfective inflammatory arthropathy. However, there are
findings that are more specific for infection, including
soft-tissue collections, sinus tract formation and osteomyelitis. Ultrasound may guide aspiration of an effusion
for laboratory testing.
Osteoarthritis
OA is certainly the commonest cause of hip pain and
stiffness in the elderly. The classical findings on radiographs of superior joint space loss, osteophyte formation,
femoral neck buttressing, subchondral sclerosis and cyst
formation are well described. In addition to superior joint
space loss, medial joint space loss is more common in
females than males. In early OA, radiographs may appear
relatively normal and, in these situations, MRI may be
useful to determine if there is significant hip pathology.
On MRI, the key features of hip OA include joint effusions, subchondral bone marrow oedema, labral abnormalities and cystic subchondral lesions.62,63 There may be
associated features of femoroacetabular impingement
(see section Femoroacetabular impingement).
Synovial osteochondromatosis
Primary synovial osteochondromatosis (SOC) is a benign monoarticular condition of uncertain aetiology. It
presents with pain, swelling and movement restriction
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Bursitis
Bursae are synovial-lined structures found between
tendons and muscles over bony prominences. Bursal inflammation, or bursitis, may arise as a result of friction
from repetitive activity, trauma, infection or the involvement by systemic inflammatory conditions such as
rheumatoid arthritis. Gait disturbances and previous hip
arthroplasty may contribute to bursitis around the hip.
The commonly encountered types of bursitis around
the hip involve the trochanteric, iliopsoas and ischiogluteal bursae. Around the greater trochanter, bursae are
present deep to each of the three gluteal muscles.76 The
iliopsoas bursa is the largest bursa in the body and
communicates with the hip joint in approximately 15% of
individuals. Patients with bursitis typically present with
point tenderness. Iliopsoas bursitis may also give rise to
pain in the anterior knee and thigh owing to irritation of
the femoral nerve (Figure 19).
Radiographs are usually unhelpful in demonstrating
bursitis, although, occasionally, calcific deposits may be
present.77 Nevertheless, radiographs are usually obtained
to exclude other causes of hip pain such as OA.
Ultrasound plays an important role in the diagnosis of
bursitis as it identifies fluid in the bursa and allows the
sonographer to relate findings to symptoms.78 Trochanteric bursitis appears as a compressible rim-like sac of low
echogenicity over the greater trochanter. Gluteus medius
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