0:00

It's coronal time in the hip, and we're assessing

0:04

different sequences starting with the basics.

0:09

We are looking at three orthogonal, non-angulated

0:13

coronal images, and in most cases, the coronal

0:17

projection is there to help you assess labra.

0:20

Oh, sure, we're going to assess avascular

0:23

necrosis and fractures, but those are easy

0:26

things that we'll discuss separately.

0:29

The coronal projections we have here include the

0:33

sensitive, labral-centric sequence, the PD SPUR.

0:40

Unfortunately, but with intention, this

0:43

patient moved a little bit, making this labral

0:46

friendly sequence a little bit tempered.

0:51

So you might say, "Well, now I

0:52

need to put contrast in the joint."

0:54

Well, no, you don't, because there are other

0:57

sequences that are going to give you the answer.

0:59

You're just nervous and scared.

1:02

And maybe you haven't seen enough.

1:03

Admittedly, it's a little hard to see the

1:05

labrum and decide whether this ill-defined

1:08

high signal intensity represents a tear or not.

1:11

In the meantime, the PD SPUR is

1:14

uber-sensitive for the bone marrow.

1:16

It is uber-sensitive for muscular and

1:19

musculotendinous injuries, including

1:22

the gluteus medius and minimus.

1:26

It's also uber-sensitive for

1:28

intra-articular pathology.

1:31

The T2 coronal.

1:34

It is very insensitive and is naturally

1:37

hampered in its assessment of labra and

1:40

menisci, for it makes them all dark.

1:44

But what it's very good for is assessing

1:46

the continuity, the presence or existence of

1:50

ligaments, like the ligamentum teres, like

1:53

the transverse ligament, and also like the

1:56

iliofemoral ligament and lateral capsule, which

1:59

may be stripped away from the acetabulum in

2:02

chronic pathology and in patients with increased

2:06

intra-articular pressure from arthritis.

2:08

That is not the case here.

2:11

The T2-weighted image can also be a very

2:14

useful sequence in the orthogonal projection

2:17

to help you decide when you have a fracture.

2:20

Not to find the fracture, that's done

2:22

on the T1 and the PD, but to see if the

2:25

fracture is intra or extra-articular, which

2:28

makes a massive difference in management.

2:31

So we take a line, drawn between the

2:34

two edges of a small amount of fluid

2:38

in the joint on the T2-weighted image.

2:40

So here's our line.

2:42

We can even draw it with our arrow.

2:43

Let's do it.

2:44

And that is going to tell you that

2:48

everything above that line is intra-

2:50

articular, subcapital, T2-weighted:

2:53

capital, neck, low neck,

2:55

and below it, trochanteric.

2:58

So fractures below this line have a better

3:01

prognosis, are managed differently, and

3:04

have a low incidence of avascular necrosis.

3:08

Fractures above this line, not so much.

3:11

They have a higher incidence

3:13

of avascular necrosis.

3:15

As stated previously, the conventional

3:17

T2-weighted image, even with some fat

3:20

suppression. Although very little

3:22

fat suppression is generated here.

3:25

Very insensitive to certain important

3:28

pathologies in the marrow and in the labrum.

3:32

It is a codifier.

3:35

It is a qualifier.

3:37

It gives you age and it dates.

3:40

Now, on the far right is your simple

3:43

T1 Spin-Echo image, which was discussed

3:47

in the first sequence vignette.

3:50

But you know what?

3:51

It's the salvage sequence in this case.

3:54

When you look at the T1-weighted image and

3:55

scroll it, and I'm sure many of you have

3:58

noticed teres, you might not have noticed that

4:02

there is a fissure in the superior labrum.

4:06

But it's not just any fissure.

4:07

Now, many of you are saying, well,

4:08

how do you know that's not a sulcus?

4:10

Well, first of all, sulci in the upper

4:13

quadrant of the hip are barely perceptible.

4:16

They're extremely shallow.

4:18

Ten percent.

4:19

If you're lucky, twenty;

4:21

twenty-five percent depth.

4:22

This line goes all the way through the labrum.

4:27

If you blow it up and look carefully,

4:29

there's no way that could be a sulcus.

4:32

That is a labral tear.

4:34

Now you might have also noticed that there's

4:36

not a lot of tapering here at the head

4:37

neck junction, but that will be a story

4:40

for another day and another projection.

4:42

And we've already covered the

4:44

orthogonal T1-weighted image in the

4:46

prior initiating sequence vignette.

4:50

But here, the T1-weighted image, even without an

4:54

injection of contrast into the joint, bailed us

4:56

out and told us that we have a pretty good size

4:59

through-and-through tear in the superior labrum.

5:01

There it is.

5:03

There it is again.

5:04

And there it is again.

5:05

And finally, it's difficult to

5:07

see on the far anterior sequence.

5:10

Let's move on to some

5:12

additional sequence analysis.