Symposium J Korean Orthop Assoc 2017; 52: 476-483 https://doi.org/10.4055/jkoa.2017.52.6.476 www.jkoa.org Diagnosis and Joint Preserving Surgery in Disorders around Hip Joint 476 고관절초음파의임상적활용 이경재 최정훈 계명대학교의과대학정형외과학교실 pissn : 1226-2102, eissn : 2005-8918 Clinical Usage of Ultrasonography for the Hip Joint Kyung-Jae Lee, M.D. and Jung-Hoon Choi, M.D. Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea Thorough history taking and physical examination are highly important for the correct diagnosis of hip disease, and several diagnostic imaging tools are available depending on suspected diseases. Recently, the clinical use of ultrasonography has been increasing due to its relatively low cost, less invasiveness, and the possibility for dynamic evaluation. The purpose of this article was to review the basic technique and normal anatomic images for the clinical usage of ultrasonography around the hip joint and describe typical ultrasonographic findings of several hip diseases. Key words: hip joint, ultrasonography 서론 고관절질환의진단에있어서철저한병력청취및이학적검사 는무엇보다중요하며이후의심되는질환의특성에따라여러 가지영상의학적진단기기의도움을받을수있다. 각각의진단 기기들은나름의특징및장단점이있으나초음파검사는상대적 으로비용이저렴하고비침습적이며동적검사 (dynamic evaluation) 가가능하다는장점이있다. 또한초음파를이용한중재적시 술 (ultrasound-guided intervention) 은다른영상학적검사장비와 비교하여실시간 (real-time) 시술이가능하고, 추가적인방사선 노출없이병변부위에대한여러이미지를얻을수있으며, 정상 측과의비교가가능한장점등으로인해최근널리사용되고있 다. 1-3) 하지만고관절부위의초음파검사는여전히소아에서많이시 행되고있다. 성인의경우해부학적으로심부에위치하고주위 Received April 18, 2017 Revised June 17, 2017 Accepted June 20, 2017 Correspondence to: Kyung-Jae Lee, M.D. Department of Orthopedic Surgery, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea TEL: +82-53-250-8161 FAX: +82-53-250-7205 E-mail: oslee@dsmc.or.kr 근육및피하지방층이두꺼우며볼-소케트형 (ball and socket) 관절의특성상관절내부를정확히보기어려워자기공명영상검사등의추가검사가필요할수있다는점, 검사자의숙련도에따라그활용범위가달라질수있다는점, 중재적시술의경우드물지만감염및연골용해 (chondrolysis) 등의심각한합병증보고 4) 등으로인해실제임상에서의활용이다른관절에비하여제한되고있는실정이다. 5-8) 이에저자는고관절의초음파검사에필요한기본적인술기및초음파로볼수있는정상구조물의영상소견을기술하고, 임상에서흔히볼수있는대표적인질환들의초음파소견을살펴봄으로써고관절분야에서초음파의활용범위를알아보고자한다. 고관절초음파의기본술기및정상소견 1. 고관절초음파의준비고관절부위의초음파검사에앞서정확한병력청취와이학적검사가선행되어야하며, 이는초음파로진단할수있는질병인지를판단하고검사할위치를선정하며병변이의심되는구조물에집중할수있도록해주는데있어중요한과정이다. 고관절부위의초음파검사를위해서는관찰하고자하는부위 The Journal of the Korean Orthopaedic Association Volume 52 Number 6 2017 Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
477 linical Usage of Ultrasonography for the Hip Joint A FH B Figure 1. Anterior hip longitudinal axis. (A) Position of transducer (along the femoral neck). (B) Ultrasonography shows intact anterior capsule (block arrow) and collapsed synovial recess (arrows). FH, femoral head. IP ASIS IP Ac FH Figure 2. Sagittal plane ultrasonography of the anterior hip joint shows intact hyperechoic triangular labrum (arrow). IP, iliopsoas; Ac, acetabulum; FH, femoral head. 를충분히노출시켜환자를검사대위에눕히고다른관절과마 찬가지로전방, 내측, 외측, 후방의네개의구획으로나누어검 사를시행한다. 고관절주위는둥글고굴곡이있으므로변환기 (transducer) 에서나오는음파가수직으로투사되지않을경우관 절낭이저에코로보이게되어관절의삼출액으로혼동되는경우 가있으므로주의를요하며, 9) 비만한환자의경우관절의깊이가 깊어관찰이쉽지않으므로이러한경우저주파수 ( 중심주파수가 대략 5 MHz) 의변환기를사용하는것이도움이된다. 2. 고관절전방초음파검사의술기및정상소견 환자를검사대위에바로눕히고고관절을신전상태에서약간 외전시킨후시행한다. 10) 고관절자체를검사하기위해서는대퇴 경부의위치를가늠하여대퇴경부에대해변환기를종축 (longitudinal plane) 및횡사면축 (transverse oblique plane) 으로변환기를 위치시켜가면서검사하는것이좋다. 종축검사에서전방의활 막함입 (synovial recess) 을잘관찰할수있는데이구조물은장요 Iliac bone Figure 3. Transverse plane ultrasonography of the ASIS level. Tendon lies behind the IP muscle (arrows). Block arrow indicates iliopsoas tendon. IP, iliopsoas; ASIS, anterior-superior iliac spine. 근의심부근막과대퇴경부사이에있으며전방및후방의고에 코층 (hyperechoic layer) 으로보인다. 통상적으로전방관절막이 장대퇴인대에의해보강되므로더두꺼워보이며관절내삼출액 이없는경우두층은납작해지고고에코선 (hyperechoic line) 으 로분리되어보여이를 stripe sign 이라고한다 (Fig. 1). 11) 전방활막함입위쪽에서균일하게고에코로보이는삼각형 구조물인비구순 (acetabular labrum) 을확인할수있는데이는변 환기를시상면 (sagittal plane) 으로놓고고관절내 / 외측을오가면 서검사할때더잘관찰되며비구순에대해서초음파가수직으 로들어가야정상과비정상을구별할수있다 (Fig. 2). 고관절전방의근육은크게두개의층으로나눌수있으며표 층에는봉공근 (sartorius) 과대퇴근막장근 (tensor fascia lata) 이존 재하고심부층에는대퇴직근 (rectus femoris), 장요근 (iliopsoas), 치 골근 (pectineus) 이존재한다. 표층의근육을확인하기위해서는전
478 Kyung-Jae Lee and Jung-Hoon Choi TFL Sa AI Ab FH Am Figure 4. Transverse plane ultrasonography of the anterior-inferior iliac spine level. White arrows indicate acoustic shadowing due to the obliquity of indirect head of the rectus femoris compared with the direct head of the muscle (arrowhead). TFL, tensor fascia lata; Sa, sartorius; FH, femoral head. 상장골극 (anterior-superior iliac spine, ASIS) 에서시작하여횡축 으로변환기를놓으며, 내측으로봉공근, 외측으로대퇴근막장 근을확인할수있다. 특히이부위에서의횡축검사시에 ASIS 바 로내측에서외측대퇴표재신경 (lateral femoral cutaneous nerve) 이서혜인대 (inguinal ligament) 외측단의틈에의해형성된터널 을통과하는것을확인할수있다. 고관절주위에서의전방근육 들은외측에서부터내측으로대퇴근막장근, 대퇴직근, 봉공근, 장요근, 치골근이있으며특히장요근은종축검사시고관절전 방광절낭앞에위치하여확인이쉽다 (Fig. 2). ASIS 내측에서횡 축으로검사시장골익내측면에놓인장요근을확인할수있으 며장요근건역시관찰이가능하다 (Fig. 3). 정상적으로장요근 의심층과고관절막의표층사이에장요점액낭이존재하지만병 변이없을경우압착되어확인하기어렵다. 대퇴직근은전하장 골극 (anterior inferior iliac spine) 부위에서기시하는직두 (straight head) 와관절낭에서기시하는반전두 (reflected head) 의주행방향 이달라서횡축검사시에음향음영 (acoustic shadowing) 이발생 할수있으므로석회화병변과혼동할수있어주의하여야하며 (Fig. 4), 횡축으로검사시상부에서하부로내려오면서근육이 넓어지는것을확인할수있다. 3. 고관절내측초음파검사의술기및정상소견 고관절내측의내전근들을확인하기위해서는환자의무릎을굴 곡하고고관절을외전, 외회전하여검사하는것이좋다. 변환기를 종축으로위치시키면표층부터장내전근, 단내전근, 대내전근의 Figure 5. Medial hip longitudinal axis ultrasonography shows a three layer of the adductor muscle. These muscles are divided by hyperechoic fascial planes. Al, adductor longus; Ab, adductor brevis; Am, adductor magnus. 세개의근육층을확인할수있으며 (Fig. 5), 근건부착부를따라 치골까지검사를시행하여근육파열여부를확인할수있다. 치 골부착부위에서부터횡축으로검사를시행하면견열골절등에 서건의견인정도를확인하는데도움이된다. 4. 고관절외측초음파검사의술기및정상소견 고관절외측의초음파검사는환자를측와위로위치시켜시행하 며주로점액낭및근위대퇴부의외전근과대둔근에대한검사 를위해시행한다. 먼저대전자부위를손으로만져확인하고그 상방에서횡축및종축으로검사를시행하면표층에서는중둔근, 심층에서는소둔근을관찰할수있는데두근육을구분하기가쉽 지않으므로대둔근의전면혹은대퇴근막장근의후면을기준 점으로하여구분한다. 대전자부위에서의횡축검사에서소둔근 은대전자의전방에, 중둔근은대전자의후방에부착하는것을 확인할수있다 (Fig. 6). 종축초음파영상에서는외측부근육들의 근섬유방향이대전자를중심으로방사형으로주행하므로근육 의주행방향에맞추어변환기를기울여각근육을하나씩확인 하는것이필요하다. 정상적인경우점액낭의액체저류가거의 없어초음파로점액낭을관찰하기힘들다. 5. 고관절후방초음파검사의술기및정상소견 고관절의후방부위는병적인변화를보이는경우가적어드물게 검사하게된다. 환자를엎드리게한후확인하는데피하지방과 대둔근이두껍고엉덩이의굴곡이있어저주파수를이용하거나 굴곡형변환기를사용하는것이도움이된다 (Fig. 7). 그러나심부
479 linical Usage of Ultrasonography for the Hip Joint Anterior Posterior GMe GMi GMi GMe A B Figure 6. Lateral hip ultrasonography. (A) Longitudinal axis. (B) Transverse axis. GMe, gluteus medius; GMi, gluteus minimus;, greater trochanter. A IT B Figure 7. Posterior hip ultrasonography. (A) Convex transducer can be useful for posterior examination. (B) Transverse scan around the IT. Block arrow indicates conjoined tendon of the hamstring muscle, and arrow indicates sciatic nerve that is located just lateral to IT. IT, ischial tuberosity. 에위치한내전근, 이상근, 외회전근등은여전히관찰이힘들며 주로좌골조면 (ischial tuberosity) 에서기시하는대퇴근육에대한 검사나좌골점액낭을확인하기위해사용하는경우가많다. 고관절부위에서초음파로진단할수있는대표적질환 1. 장요점액낭염 (iliopsoas bursitis) 정상적으로장요점액낭은활막낭 (synovial cavity) 내에얇은액체막만존재하므로초음파로구분하기어렵다. 하지만관절과연결된경우가많아관절내압력이높아지는질병 ( 활액막염, 관절내유리체등 ) 에서점액낭이팽창될수있으며이경우초음파로쉽게진단이가능하다 (Fig. 8). 12) Figure 8. Anterior hip ultrasonography shows distended iliopsoas bursa (block arrow) and anterior synovial recess (arrow). 2. 발음성고관절 (snapping hip) 발음성고관절은크게관절내원인에의한것과관절외원인 에의한것으로나눌수있으며, 관절내원인의경우볼 - 소케트 형관절의특성상초음파만으로진단하기는어렵다. 그러나관 절외원인에의한경우는초음파검사를통해두꺼워진장경대 (iliotibial band) 를확인할수있으며기타영상의학적검사와달리
480 Kyung-Jae Lee and Jung-Hoon Choi 동적검사가가능하기때문에진단율을높일수있는장점이있다 (Fig. 9). 3. 비구순파열 (labral tear) 최근고관절분야에서많은관심을받고있는비구순파열은주로자기공명관절조영술 (magnetic resonance arthrography) 로진단적가치가더높으나다소마른체형의사람에서는초음파검사로도구별이가능하며 13) 고관절관절경과비교하여검사한다면추후비구순파열의진단에많은도움이될것으로생각된다 (Fig. 10). 5. 석회성건염 (calcific tendinitis) 고관절주위의석회성건염은주로대전자주위에서발생하며단순방사선영상으로확인가능한경우가많다. 하지만초음파검사와병행하여검사할경우동반된건병증 (tendinopathy) 소견의관찰이용이하며필요한경우초음파유도하에서주사등을시행할수있다 (Fig. 11). 6. 좌둔점액낭염 (ischial bursitis) 좌둔점액낭염은고관절후방초음파검사에서가장용이하게이 4. 비구주위낭종 (paralabral cyst) 비구순의퇴행성변화와함께비구주위에저에코의병변이관 찰될수있다 (Fig. 10). ITB AIIS Figure 9. Lateral hip ultrasonography shows hypertrophied ITB (arrows) over the. ITB, iliotibial band;, greater trochanter. Figure 11. Anterior hip ultrasonography shows calcification in the rectus femoris (block arrow). Acoustic shadowing is also shown beneath the calcification (arrow). AIIS, anterior inferior iliac spine. Ac FH IT Figure 10. Anterior hip ultrasonography shows detached anterolateral labrum from the bony Ac (arrow). Para-labral cyst is also shown along the tear (block arrows). Ac, acetabulum; FH, femoral head. Figure 12. Posterior hip ultrasonography shows large cystic mass (bursitis) around the IT (arrow). IT, ischial tuberosity.
481 linical Usage of Ultrasonography for the Hip Joint 용할수있다. 좌둔점액낭염이의심되나슬굴곡근을따라방사 통이있어추간판탈출증과감별이필요한경우초음파로낭성 병변을찾아도움을받을수있다 (Fig. 12). 7. 전자부점액낭염 (trochanteric bursitis) 대전자통증증후군 (greater trochanter pain syndrome) 의원인질 환중하나로대개중년의여성이외측혹은후위측고관절부위 에국한된통증을호소하고이환된부위로잘때통증이악화된 다. 14) 이학적검사상유동성종창 (fluctuant swelling) 이확인되는 경우도있으나이학적검사상에서확인이어려운경우초음파검 사로확인할수있다 (Fig. 13). 8. 외전근파열 (abductor tear) 인공고관절치환술등의수술후외전근부위의통증을호소하 는환자중외전근부착부위의국소압통및종창등이있는경우 의심해볼수있다. 외전근의주행방향을생각하며변환기를좌 우로움직이며관찰하면대전자부착부위에서근파열을확인할 수있다 (Fig. 14). 결론 Figure 13. Lateral hip ultrasonography shows distension of the bursa beneath gluteus maximus, around the greater trochanter. 고관절의초음파검사는해부학적으로고관절이심부에존재하며주위조직이두껍고술자의숙련도에따라결과가달라질수있다는등의문제점으로인해다른관절에비하여활용도가낮은실정이다. 하지만철저한병력청취및이학적검사를통하여검사할부위를결정하고해부학적인지식을바탕으로노력한다면외래진료시진단율을높이는데많은도움이되고특히비침습적이고빠르게결과를확인할수있으며고관절주위인공삽입물등으로인해자기공명영상검사등을시행하는데제한이있는환자들의이해도를높이는데큰도움이될것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Cardinal E, Beauregard CG, Chhem RK. Interventional musculoskeletal ultrasound. Semin Musculoskelet Radiol. 1997;1:311-8. 2. Dodd GD 3rd, Esola CC, Memel DS, et al. Sonography: the undiscovered jewel of interventional radiology. Radiographics. 1996;16:1271-88. 3. Rubens DJ, Fultz PJ, Gottlieb RH, Rubin SJ. Effective ultrasonographically guided intervention for diagnosis of musculoskeletal lesions. J Ultrasound Med. 1997;16:831-42. 4. Baffroy-Fayard N; Groupe de travail du CCLIN Paris-Nord. Infection control in interventional radiology: good practice guideline. J Radiol. 2002;83:351-9. 5. Nam WD, Nam SW, Han KY. Ultrasonographic findings of normal hip joint and painful hip due to soft tissue problem. J Korean Orthop US Soc. 2010;3:38-46. 6. Louis LJ. Musculoskeletal ultrasound intervention: principles and advances. Radiol Clin North Am. 2008;46:515-33, vi. 7. Rowbotham EL, Grainger AJ. Ultrasound-guided in- GMe GMi GMi A B Figure 14. Photographs showing an image of ultrasonography of the gluteal muscle detachment (A) and intraoperative findings (B). GMe, gluteus medius; GMi, gluteus minimus;, greater trochanter.
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483 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2017; 52: 476-483 https://doi.org/10.4055/jkoa.2017.52.6.476 www.jkoa.org 고관절주변질환의진단과관절보존술 고관절초음파의임상적활용 이경재 최정훈 계명대학교의과대학정형외과학교실 고관절질환의진단에있어서철저한병력청취및이학적검사는무엇보다중요하며이후의심되는질환의특성에따라여러가지영상의학적진단기기의도움을받을수있다. 초음파검사는다른영상진단기기에비하여상대적으로비용이저렴하고비침습적이며동적검사가가능하다는장점으로인해최근널리사용되고있다. 이에저자는고관절의초음파검사에필요한기본술기및정상구조물의영상소견을기술하고, 임상에서흔히볼수있는대표적인질환들의초음파소견을살펴보고자하였다. 색인단어 : 고관절, 초음파검사 접수일 2017 년 4 월 18 일수정일 2017 년 6 월 17 일게재확정일 2017 년 6 월 20 일책임저자이경재 41931, 대구시중구달성로 56, 계명대학교의과대학정형외과학교실 TEL 053-250-8161, FAX 053-250-7205, E-mail oslee@dsmc.or.kr 대한정형외과학회지 : 제 52 권제 6 호 2017 Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.