Hip sonography according Graf
Tips, Tricks, common mistakes
The base for the trainig course is the Manual:
Essentials of infant hip sonography according to GRAF
Edition Stolzalpe ,Sonocenter,2016
Introduction: The contempt of this paper gives only additional comments and tricks for the trainers.It is recommended to go ahead in the courses chapter for chapter from the Manual.
1. Start with the 3 Pillars of hip sonography: A/B/C
*Explain why the anatomical idendificatio(A) is so important: German quality comission: In 48% wrong diagnosis because of wrong anat. identifcation! Tip: Ask now: "What anatomical structures are hyalin cart.preformed on the prox.fem.end"?---f.haed,trochanter,but the prox. part of the fem.neck is forgotten normally. (This question "keeps down" med. doctors,who know everything ?!?)
*Most important is the examination technique,--good technique solves the problem of A and B. (No experience and no skill is necessary for the ex.tech.,takes 1 minute (!) with a a special technique and equipment)
1.2 Fem.Haed. Point out:
* anular zone is not fluid
* because the fem.haed is not round,all measurement systems,which are working with " 50%, more or less haed covering" are not more than eye bowling.
1.4 Joint capsule.Point out the common mistakes:
* Capsule is mixed up with the intermuscular septum (mainly in decentred joints)
*ischiofemoral lig. shoud not be misinterpreted as a "ruptured labrum".
1.6. Bony rim definition.
* Explain,that the bony rim is the lateralst point of the sound shadow and how the sound shadow comes up.(see Fig in the Manual)
* Explain,that the sono must not be used,when even 1 of the structures of checklist I is not visible!! If all the stuctures are identified,you are always on the "safe side"! (Tilting effects and wrong anatomical identification are excluded)
2.Usability check,Checklist II.
2.1 Tip: *Demonstrate with a sheet as a plane on your hip joint,why it is important that the plane is in the middle of the acetabulum,marked by the lower limb.
* Make a drawing of the with a view in the acetabulum with the 3 bones and the lower limb and a sono with the l.limb also,to demonstrate the importance of the lower limb.
2.2 Tip: *Demonstrate on your body the rotation of the pelvis during the human evolution and where the good bony coverage is today because of the rotation,see Fig.
2.3 Tip: * Demonstrate with a sheet the tilting of the plane * point out the typical mistakes (1/2/3) of labral misinterpretion.
3.1 Point out: Never use the terms "healthy" or "normal"! Healthy or normal depends from the age.Use for Typ I "mature"!!!! (Type IIa is "normal " and "healthy" also!)
3.3/3.4 Point out,that the problem is not the labrum, it is the deformed hyalin.cartl.roof.The perichondrium is fixed on the cart.roof and shows indirectly wether the cartl. is pressed: up- or downwards. The difference,type III or IV is not made by the labrum! (common mistake by "experienced delegates").
Important now: Explain now the exception from the usability check and why in decentered joints the lower limb may be not visible.(Different planes! Typical wrong answers: 1. Nucleus is blocking the beam.2.Chondrooss.border is blocking!) Checklist I first(!),because if you see according the anatom.identification a decentred joint,---- it may be not in the plane,no measurement !!!!!!