Ultrasound of the musculoskeletal system bianchi pdf

These well chosen illustrations strongly enhance the didactic and educational value of this book. Leuven Albert L. Baert VII Contents Foreword Over the last 15 years, musculoskeletal ultrasonography has become an important imaging modality used in sports medicine, joint disorders, and rheumatology.

With the rapid development and sophistication of this modality, essential information for a better understanding of the pathophysiologic assessment of many disorders has been established. This, in turn, has aided both in making crucial decisions regarding surgical intervention and in monitoring the effects of therapy. Equally important is the ready availability, affordability, speed, and diagnostic accuracy of ultrasonography. The authors have designed unique schematic drawings which aid in better understanding the anatomy of the body part in terms of its sonographic characteristics discussed in each chapter.

Technical advances continue to improve the utility of ultrasonography as a diagnostic technique in musculoskeletal imaging. Many of the techniques described in the text have been pioneered or improved by Dr. Bianchi and Dr. This text should become a key library reference source for radiologists, orthopedists, and rheumatologists.

Ultrasound of the Musculoskeletal System is the most comprehensive work of its kind to date. It establishes a higher standard in musculoskeletal imaging and should remain a classic for years to come. Schematic drawings have also been extensively used throughout the chapters to emphasize depiction of anatomy, pathomechanisms and biomechanics underlying the disease processes. It was our deliberate intention to compile the book with a uniform style throughout. This is the reason why most of the chapters have been written by the two editors and by a relatively small numbers of authors who have worked or continue to work with the editors.

The book begins with an introductory section on the instrumentation and general aspects of musculoskeletal ultrasound, followed by a systematic overview of the applications of this technique in the different areas of the upper and lower extremities. With regard to certain clinical applications, there is still considerable difference of opinion on the role of musculoskeletal ultrasound as compared to that of other imaging modalities, such as magnetic resonance imaging.

However, every effort has been made to provide accurate accounts of present knowledge and experience, as well as to indicate the most advanced references of emerging applications. XI XII Preface A new textbook of this size inevitably contains errors and weaknesses -- we welcome corrections and suggestions for future editions. Meanwhile, happy reading! Seneca, Epist. These colleagues are listed below. Contents Contents Intrumentation.

Derchi and Giorgio Rizzatto. Derchi and Giorgio Rizzatto 1. This chapter will review the main advances in US technology and address the clinical impact they have had or are likely to have in the future in the field of the musculoskeletal system.

New developments in transducer technology and advances in the quality and presentation of US images will be discussed. It greatly influences spatial resolution, penetration and signal-to-noise ratio. In recent years, research in transducer technology has been focused on the development of piezoelectric crystals with lower acoustic impedances and greater electromechanical coupling coefficients, as well as on improving the characteristics of absorbing backing layers and quarter-wave impedance matching layers Claudon et al.

Currently, transducer arrays formed by ceramic polymer composite elements of variable shape and thickness and multilayered technology are used, leading to a more accurate shaping of US pulses in terms of frequency, amplitude, phase and length Whittingham a; Rizzatto These refinements led to the use of very short pulses and an increased bandwidth Fig.

This is related to the fact that the shorter transmission pulses used in a broadband emission generate shorter echo pulses which can be faithfully converted into electric signals Whittingham b. Because short pulses suffer attenuation to a greater extent and are characterized by less penetration than long pulses, some specific techniques have been introduced by different manufacturers to compensate for these drawbacks, including single-pulse and multi-pulse techniques Claudon et al. Among single-pulse techniques, the emission of a long, peculiarly shaped transmission pulse, which varies in frequency and 3 1 4 L.

Derchi and G. Rizzatto a c b d Fig. Relationship between spatial pulse length and frequency spectrum. The bandwidth is measured between the 6 dB points on each side of the spectrum. The longer pulse in a generates a narrower bandwidth 1 MHz than the shorter pulse 2 MHz in b amplitude within the duration of the pulse itself, has been used instead of a simple sinusoidal pulse Fig.

When the signal is received, a filter analyzes the signal frequencies as a short pulse, erasing the components introduced to make it long chirp : the result is increased image penetration with an improved signal-to-noise ratio, without compromising axial resolution. Other multi-pulse techniques make use of a coded-emission mode consisting of transmission of an integrated sequence of many short, high-frequency transmission pulses which vary in terms of phase and are modulated in a code sequence.

When the signal is received, the signal frequencies are compared with the transmission pulses by a matching decoding filter working at a high sampling rate. The subtraction process results in increased image penetration without loss of axial resolution or an increase in emission peak pulses Claudon et al. Apart from advances in emission pulse technology, broadband transducers use a spectrum of frequency distribution i.

In multiple-frequency imaging, the available broad bandwidth is subdivided into multiple frequency steps for transmission and reception of sound waves: these transducers enable selection of the optimal frequency range in a given scanning plane as though two or more independent transducers — each with a different center frequency — were available Fig.

Other systems use the total transducer bandwidth for the transmitted pulse and then adjust the receiver bandwidth to lower frequencies as deeper depths are Technical Requirements a b Fig. US pulse shaping.

This short-duration pulse is associated with a broad bandwidth but, when transmitted through tissues, it is rapidly attenuated and absorbed resulting in a poor penetration of the US beam. This pulse has a longer duration to increase the penetration of the US beam. Multiple-frequency transducers. In contrast, a strong attenuation affects the deep part of the US image, which loses intensity.

Rizzatto sampled. These systems give increased flexibility to the US examination, enabling the same transducer to change the image acquisition parameters during scanning based on the desired clinical information. In musculoskeletal imaging, this is particularly important when the study focuses on both superficial i. In modern linear-array transducers, focusing is currently not obtained by means of a fixed lens as in the old mechanical sector probes in which degrading of the image quality occurred at a short distance from the focal zone Fig.

Focusing is now produced electronically by activating a series of elements in the array with appropriate delays, so that the trigger pulses to the inner elements are delayed with respect to the pulses to the outer ones. In this way a curved wavefront results from constructive interference bringing the US beam toward a focus.

By adjusting the values of the delays applied to the trigger pulses, the curvature of the wavefront and, therefore, the focal depth can be changed dynamically. As the resulting wavefront has the characteristics of a short excitation pulse, the axial resolution is preserved.

When the pulses are received, the US machine continuously refocuses them according to the position from which the echoes come, thus giving real-time focal tracking along the depth axis: synchronization of the received signals is essential to minimize out-of-axis echo interference. An important factor influencing the lateral resolving power of the system is the dynamic aperture: this is achieved by activating variable numbers of elements dynamically to optimize focusing at many depths.

As a rule, the higher the number of channels electric pathways involved in this process to activate the elements in a combined mode and with appropriate delays, the higher the complexity and the cost of the equipment, but the more accurately the beam can be focused. Recently, the introduction and refinement of matrix 1. In these transducers, the single row of long piezoelectric elements found in a conventional probe is replaced by more layers three to seven incorporated into a single thin layer to produce parallel rows of short elements.

The slice thickness of the US image is improved by performing dynamic focusing in the elevation plane Fig. This leads to better spatial and contrast resolution and reduction of partial-volume averaging artifacts Rizzatto A less expensive alternative to 1. The Hanafy lens has non-uniform thickness and resonance properties: it produces a narrow and uniform image slice thickness and, simultaneously, a very broad bandwidth pulse. The inner portion of the lens is thinner, resonates at higher frequencies and focuses in the near field, whereas its outer portions resonate at lower frequency and are focused in both transmission and reception at the deepest part of the image providing better penetration Claudon et al.

In addition, US can reveal loculated abscesses in the fascial plane — allowing US-guided diagnostic aspiration — and gas formation in soft tissues in advanced disease Robben ; Wilson Gas gangrene, which is produced by organisms of bowel origin or by Clostridium, is an ominous sign Fig. US is a reliable means to confirm the presence of focal shrinkage of the subcutaneous fat by comparing the affected side with either the contralateral healthy side or an adjacent normal area.

In clinical practice, focal areas of subcutaneous atrophy may occur around the radial head following steroid injection for treatment of tennis elbow and at the buttock secondary to intramuscular injections. Although the US appearance of subcutaneous atrophy is rather specific, awareness of the clinical history is essential to correlate the US findings with a specific causative factor. Necrotizing fasciitis. Valle and M.

Zamorani anticoagulation therapy, steroids, etc. US reveals bloody fat infiltration as an increased echogenicity of fatty lobules that can make the separation from the hyperechoic skin and the connective tissue strands of the subcutaneous tissue undefined Fig. Hemorrhagic fat infiltration can be readily distinguished from simple edema because of the absence of anechoic fluid distending the connective septa. The differential diagnosis with a superficial hyperechoic lipoma is based on the clinical history and the oval, well-circumscribed appearance of the soft-tissue mass.

Following a contusion trauma, subcutaneous fat necrosis may arise with edema, hemorrhage and fibrosis with lack of a discrete soft-tissue mass and volume loss of the subcutaneous tissue Tsai et al. Fat necrosis appears as a hyperechoic focus containing hypoechoic spaces related to infarcted fat Fernando et al.

In hematomas, the US appearance of the bloody collection varies over time. Soon after the blood leakage, fresh fluid may appear highly reflective up to a pseudosolid appearance because of fibrin and erythrocytes forming multiple acoustic interfaces. With time, the hematoma tends to become completely anechoic as a result of liquefaction of the clot and increases in size Fig.

A network of thin strands may often be seen resulting from fibrin organization Fig. Over a period of months, the hematoma eventually resolves, but a residual fibrous scar and focal retraction of the overlying skin may persist Fig. This condition indicates a post-traumatic seroma which derives from local trauma usually located over the lateral aspect of the proximal thigh.

In cases of an abscess secondary to trauma, the examiner should attempt to recognize any possible foreign body within it as the causative factor Fig. This is valid even if the patient denies previous open wounds, because the presence of foreign bodies requires surgical removal. In an effort to exclude a more extensive spread of infection that may deserve different treatment, the examiner should check the status of underlying regional muscles, tendon sheaths and joint spaces.

Finally, a contusion trauma on the skin by a pointed, sharp object can be transmitted to the subcutaneous tissue causing laceration and focal discontinuity of fat lobules. Subcutaneous tissue contusion trauma and fat necrosis. T T, tibia. US can determine whether the discontinuity is limited to the subcutaneous fat or involves the deeper structures too Thomas et al. Subcutaneous scars are easily depicted with US as vertically -oriented thin linear stripes surrounded by hyperechoic halo that interrupt the normal tissue layers.

The abnormal tissue can extend deeply across the fascia into the muscles or the ligaments. Scars may eventually calcify see Fig. In a post-traumatic setting, foreign bodies derive from open or penetrating wounds. Most are composed of plant fragments wood splinters, thorns, etc. Foreign-body-related abscess. Surgery revealed an abscess containing a small wood splinter 28 M.

Subcutaneous fat fracture. Note the disrupted appearance of fatty lobules asterisks and the alignment of the fracture plane with the edge white arrow of the iliac bone a d b c e Fig. Foreign bodies: US appearance in two patients presenting with a—c wood and d,e glass fragments.

The fragment is surrounded by a hypoechoic rim arrowheads representing reactive edema and granulation tissue. Initially, physical exploration was negative for foreign bodies and the wound was sutured. Part of them may remain at the site and unrecognized even after apparent successful removal by the patient at the time of the injury Peterson et al. If missed, foreign bodies can results in granuloma formation, secondary soft-tissue infection with formation of an abscess, fistula, purulent tenosynovitis and septic arthritis.

Bone destructive changes and damage to adjacent nerves may also occur Choudhari et al. An early diagnosis and prompt removal of foreign bodies is required to prevent complications. Physical examination has intrinsic limitations for detecting and localizing small foreign bodies due to the associated local soft-tissue swelling and pain.

The deep position of a fragment makes palpation more difficult and less successful. Plain radiography is the initial imaging modality to identify and localize foreign bodies but it can only show radio-opaque fragments: even if very small, metallic fragments are readily detected on plain films. Detection of glass fragments depends on their size and, less importantly, on their lead content, as even if lead-free, almost all glass material is radio-opaque to some degree on radiographs Felman and Fisher Radiolucent fragments, such as wood splinters, plant thorns and plastic fragments, cannot be detected by X-rays.

In addition, local complications are not recognized. Xeroradiography and low-kilovoltage radiography have been proposed to increase the detection rate of foreign bodies, but these techniques are currently obsolete. US is an excellent means of detecting and evaluating post-traumatic foreign bodies Dean et al.

In cases of suspected foreign bodies, the examiner should extend the study to a larger area than that closely surrounding the skin wound, as fragments may migrate far away from the entrance point as a result of repeated muscle contraction Choudhari et al.

As an example, it is not unrealistic to hypothesize that a retained fragment entered the soft tissues on the volar aspect of the wrist may dislocate proximally to reach the anterior distal forearm. As assessed in cadaveric and in vivo studies, the US appearance of foreign bodies varies to a great extent depending on the composi- tion metal, glass, wood, etc.

Either radio-opaque or radiolucent fragments can be identified with US as reflective structures with posterior acoustic shadowing or reverberation artifact, depending on the surface characteristics and composition of the foreign body Boyse et al.

In general, wood fragments are characterized by posterior acoustic shadowing, whereas glass and metal exhibit reverberations and comet tail artifact Fig. Although these findings lack specificity, they can help to identify foreign bodies as such.

Detection of posterior acoustic artifact is particularly helpful for locating tiny fragments that, because of their small size, can go unnoticed. Similarly, a hypoechoic halo surrounding the fragments is of the utmost importance to distinguish them from adjacent soft-tissue structures, such as fat strands or muscles.

As assessed in a comparative US-pathologic study, the halo correlates with fibrin, granulation tissue and collagenous capsule formation, whereas the hypervascular pattern seen at color Doppler imaging reflects neovasculature Davae et al. On the other hand, the relationship of foreign bodies with adjacent vessels, tendons, muscles and nerves can be precisely assessed. US can recognize a variety of complications, including abscess, granuloma, infectious tenosynovitis and septic arthritis Fig.

Generally speaking, the main limitations of this technique occur in the acute phases of trauma, when open wounds or soft-tissue emphysema may make the examination difficult. In an acute setting, care should be taken to avoid contamination of the open wound with gel. In these circumstances, the use of sterile gel and a lateral approach to the skin wound can be recommended to image the fragment.

If the foreign body is retained in the distal arm or in the distal leg, US examination can be better performed by placing the affected extremity in a water bath Blaivas et al. As determined in an in vitro study, air bubbling can decrease the visibility of foreign bodies, leading to attenuation of the US beam deep to the gas Lyon et al.

In a preoperative setting, US can identify the foreign body, place a skin mark over it and measure the depth of the fragment relative to the skin. As described in Chapter 18, US can guide the removal of superficial foreign bodies during real-time scanning Shiels et al. In summary, when a foreign body is suspected on clinical grounds, the examiner should briefly 29 30 M.

Tenosynovial foreign body. A thin hypoechoic effusion asterisks in the tendon sheath allows the fragment to be precisely located in the synovial space. Radiographs should be always performed before US examination. Then, US scanning should cover a wide tissue area around the wound, as foreign bodies may migrate far away from the penetration site. The examiner should seek for bright echoes in the soft tissues but, even more, for structures with posterior acoustic attenuation. Once detected, the fragment should be measured as regards its size, orientation, distance from the skin, and relationships with adjacent tendons, nerves and vessels.

Signs of possible infectious complications, such as fluid collections and tenosynovitis, should be annotated as well. Instead of writing a long descriptive report, we prefer to mark the skin overlying the fragment reproducing its size and orientation and to measure the depth of the foreign body: these are important pieces of information for the surgeon before removal.

For foreign bodies in deep locations, we recommend appending a drawing to the written report in an effort to better explain the relationship of the foreign body with the adjacent structures.

Orthopaedic implants screws, pins, etc. Metallic devices appear as bright hyperechoic structures with posterior reverberation artifact Fig. Although they are easily detected on plain films, US allows an excellent analysis of the relationship of loosened implants with adjacent structures, thus helping to plan their removal Grechenig et al. Implantable subcutaneous devices are used as long-acting and effective methods of contraception. They consist of a single rod implanted in the subcutaneous tissue of the medial aspect of the arm to release levonorgestrol into the systemic circulation.

Based of physical findings, identification of the rod can be difficult if it has inadvertently been inserted too deep or it has migrated away from the insertion point. If removal is required, US is an efficient modality to precisely localize nonpalpable rods, thus allowing their easy removal Amman et al.

Rods appear as a small, elongated, hyperechoic structures with well-defined definite posterior acoustic shadowing, an appearance that correlate well with in vitro findings Fig. Tissue expanders are widely used in plastic and reconstructive surgery Neumann US can assess twisting of injection ports that are surgically inserted into the subcutaneous tissue Kohler et al. Twisting is associated with failure of the injection procedure and fluid accumulation in the subcutaneous tissue.

US easily demonstrates the upside-down position of the port by showing the linear hyperechoic appearance of the metallic base tilted toward the skin replacing the normal concave superior face of the soft silicone component Kohler et al. Suture granulomas may occur after a surgical intervention in which nonabsorbable stitches are used. These tumor-like lesions usually develop slowly and may cause only vague symptoms or remain asymptomatic for many years. US is an accurate way to identify and characterize them by depicting suture material within Fig.

As assessed in an in vitro study, the US appearance of surgical sutures is independent of their chemical composition. Monofilament sutures appear as straight bright double lines like railway 31 Skin and Subcutaneous Tissue a b Cor c Fig.

Loosened surgical screw. US allows accurate assessment of the relationship of the screw with the short head of the biceps and the coracobrachialis muscles open arrows arising from the coracoid Cor lines due to high-amplitude reflection of the US beam at the superficial and deep interface of the suture with the surrounding tissue; braided sutures most often produce a single echo Rettenbacher et al.

Both patterns show posterior reverberation artifacts. In general, the surrounding granuloma appears as an ill-defined hypoechoic mass, containing a liquefied center where the stitch lies. The main differential diagnoses are granulomas containing other foreign bodies and inflamed epidermoid cysts containing a hair. Scattered calcifications in the subcutaneous tissue are observed in scleroderma and systemic lupus erythematosus.

They appear as mottled hyperechoic lesions with posterior acoustic shadowing. US has little value in their assessment as they are manifest on plain films. Subcutaneous calcifications are often the result of drug injections. For the most part, they are encountered in the buttock and appear as well-delimited hyperechoic structures with strong posterior acoustic shadowing Fig.

In rheumatologic patients, subcutaneous nodules are mainly due to tophaceous gout or rheumatoid nodules Tiliakos et al. Tophi are softtissue agglomerates of uric acid crystals that can develop in different areas of the body: the hand, the foot and the elbow the most commonly involved. Zamorani a b c Fig. Subdermal contraceptive device Implanon. In selected cases, US can assist in the localization and minimally invasive removal of the implant. Suture granuloma. Within the hypoechoic granuloma arrows , the surgical suture appears as a hyperechoic rail-like line arrowheads when imaged in its long-axis.

On the short-axis image, the suture assumes the appearance of a double dot arrowhead At US examination, tophi appear as heterogeneous masses containing hypoechoic areas related to chalky liquid material surrounded by hyperechoic tissue Nalbant et al. Rarely, calcific deposits can be detected within the tophaceous mass in the form of hyperechoic spots with or without posterior acoustic attenuation Fig.

They seem to derive from an immune complex process between rheumatoid factor and immunoglobulin G initiating small vessel abnormalities and then progressing to necrosis and granulation tissue.

Non-neoplastic subcutaneous masses. Note the osteoarthritic changes white arrowheads in the underlying joint. Rheumatoid nodules are usually found at pressure sites, such as the extensor aspect of the elbow, the fingers and the calcaneus, and correlate with a bad prognosis.

US displays hypoechoic masses with a central sharply demarcated hypoechoic area reflecting necrosis Fig. Lipomas have a male and familial predominance and tend to grow in the back, shoulder and upper arms with a predilection for the extensor surface. They are more common in the fifth and sixth decades.

At US examination, lipomas have a wide range of appearances. Typically, they present as elliptical compressible masses containing short linear reflective striations that run parallel to the skin Fig. However, their internal echogenicity may vary from hyperechoic to hypoechoic or mixed relative to muscle depending on the degree of connective tissue and other reflective interfaces — such as cellularity, fat and water — within the mass Fornage and Tassin ; Ahuja et al.

At least theoretically, it has been postulated that lipomas composed of pure fat should be echofree lesions due to a low number of tissue acoustic interfaces Behan and Kazam In a recent retrospective review of 39 US-diagnosed superficial and 34 M.

Subcutaneous lipoma: spectrum of typical US appearances. Its echotexture consists of short thin linear striations that run parallel to the skin. Note the fascia dividing into two hyperechoic sheets arrowheads to envelop the lipoma. This indicates that the variable echotexture of lipomas may make their differentiation from other masses subjectively difficult.

This may lead to difficulties in identifying them with US even if the mass is apparent clinically. Nonencapsulated lipomas may require comparison with the contralateral side to detect significant asymmetry of fat tissue. In daily practice, the occurrence of a superficial palpable lump suggesting a lipoma in the absence of a definite nodule detectable with US is not uncommon.

Both maneuvers can increase the detection rate of the mass, which is less compressible than the adjacent subcutaneous tissue. Most superficial lipomas do not present substantial internal vasculature at color and power Doppler imaging, a finding that may enhance the confidence of the examiner that a benign mass is present Ahuja et al.

Some lipomas grow in the deep subcutaneous tissue, in close contact with the fascia. Care should be taken when reporting on these masses not to lead the surgeon to believe that the lesion can be easily excised, because deep subcutaneous lipomas may adhere to the fascia. A well-delimited mass does not always mean an easily Skin and Subcutaneous Tissue removable lesion.

Lipomas growing inside the deep fascia may also occur. The clinical diagnosis of these lesions may be difficult because they are firm and tethered to the deep plane and may mimic more aggressive tumors. At US examination, intrafascial lipomas appear as lenticular lesions growing into a split of the fascia, which retains a normal hyperechoic appearance Fig.

In these cases, US can rule out abnormalities of the underlying muscles and aggressive growth patterns suggestive of a malignant tumor. Lipomas containing other mesenchymal elements, such as fibrous tissue fibrous lipomas , cartilage chondroid lipomas , mucoid component myxolipoma and vessels angiolipoma , may be encountered.

In these cases, the presence of nonlipomatous elements may make the US appearance of the lesion less specific. They are well-defined hyperechoic subcutaneous masses containing small patchy hypoechoic areas and sparse internal vasculature Fig. Hibernomas fetal lipomas are rare benign tumors composed of brown fat. Brown fat is histologically distinct from white adipose tissue and plays a role in nonshivering thermogenesis of hibernating animals and newborn humans.

In humans, brown adipose tissue progressively decreases through adulthood. Usual locations of tumors arising from brown fat are the parascapular and interscapular spaces, the mediastinum, the upper thorax and the thighs. US demonstrates a solid well-marginated hyperechoic mass somewhat resembling a lipomatous tumor and Doppler imaging may show a hypervascular pattern reflecting the presence of vascular structures and the increased cellular metabolism of hibernomas.

Other rare forms of lipomas, including lipomatosis of nerves see Chap. Other space-occupying nonlipomatous masses containing fat may mimic the US appearance of lipomas. Among them, hemangiomas contain a variable amount of adipose tissue interspersed between abnormal vessels. However, in most cases their typical US appearance made of serpentine or tubular hypoechoic structures contained within the mass, scattered phleboliths and prominent blood flow at color and power Doppler imaging, allows the correct diagnosis to be made.

Lipomatosis represents a diffuse overgrowth of mature adipose tissue histologically similar to simple lipomas. The fatty tissue extensively infiltrates the subcutaneous and muscular tissue and is not associated with nerve involvement.

Many entities of superficial lipomatosis are described Murphey et al. In multiple symmetric lipomatosis, which is commonly referred to as Madelung or Launois-Bensaude lipomatosis, multiple symmetric lipomas are found in the neck and the shoulder in association with alcoholism, hepatic disease and metabolic disorders Uglesic et al.

Dercum disease, which is also referred to as lipomatosis dolorosa or adiposis dolorosa, is a rare disorder occurring in middle-aged women, often obese, in which multiple painful subcutaneous lipomas occur Wortham and Tomlinson Most lesions arise in children less of 10 years of age and appear as small masses 2 kHz are typically observed and help in distinguishing hemangiomas from other soft-tissue masses Fig.

High-flow malformations are typified by an abnormal network of vascular channels the nidus , interposed between a prominent feeding artery and a dilated draining Skin and Subcutaneous Tissue T b a c d Fig.

Epidermal inclusion cyst. Correlative c fat-suppressed T2-weighted and d gadolinium-enhanced fatsuppressed T1-weighted MR images show a homogeneous lesion arrow of high signal intensity on T2-weighted images, central non-enhancement and peripheral thin rim enhancement.

Surgery revealed an epidermal inclusion cyst d T T a b e c f Fig. The mass reveals several intratumoral vessels. Zamorani vein. Spectral Doppler analysis demonstrates high systolic arterial flow and arterialization of the veins Fig. Slow-flow venous malformations are characterized by abnormally dilated venous spaces and a normal arterial component.

Often, they may be suspected on the basis of a subcutaneous bluish or reddish stain. Due to slow blood flow, color Doppler imaging may detect only sparse monophasic flow or no blood flow signals at all Trop et al. Distinguishing between a slow-flow malformation and an involuted hemangioma may be problematic.

In general, vascular malformations are distinguished from hemangiomas owing to the absence of solid tissue Paltiel et al. In addition, hemangiomas have similar vessel density and peak systolic velocities but lower venous velocity Paltiel et al. Finally, there are capillary malformations limited to the dermis. For the most part, US is unable to display such superficial abnormalities that typically present with a port-wine like stain. In some instances, however, an increased thickness of the subcutaneous tissue and some prominent veins may be demonstrated.

They usually result from seeding of deep tumors during interventional i. In some cases, however, skin metastases can be the first manifestation of an occult cancer, therefore requiring an accurate and early diagnosis Giovagnorio et al.

Histopathologically, metastases of the skin and subcutaneous tissue can develop from almost any kind of malignancy, but nearly half of them derive from melanoma, lung cancer and breast carcinoma White In most cases, metastases appear as well-circumscribed solid hypoechoic masses Nazarian et al.

A lobulated shape and multiple peripheral vascular pedicles feeding internal irregular vessels seem the most important gray-scale and color Doppler US imaging findings for differentiating them from other benign soft-tissue masses Fig. In follow-up studies, color Doppler imaging has been proposed as a mean to assess the pharmacodynamic response to chemotherapy a b c Fig. Arteriovenous malformation. Venous malformation.

Subcutaneous tissue metastases. In both nodules, correlative color Doppler imaging shows a hypervascular pattern with peripheral and internal vessels. Postsurgical histologic examination revealed metastases from a,c gut carcinoma and b,d colon adenocarcinoma d 40 M. Zamorani by depicting reduction of intratumoral blood flow Fig.

Derchi [et al. Account Options Sign in. We can notify you when this item is back in stock. Shoulder chapter alone is worth the full price.

Table of contents Intrumentation: The Best Books of To assist jartinoli understanding, the ultrasound scans are correlated with drawings, photographs, images obtained using other modalities, and anatomic specimens. Selected pages Page Product details Format Hardback pages Dimensions x x Ultrasound scans biancbi correlated with drawings, photographs, images obtained using other modalities, and anatomic specimens.

The first is devoted to general aspects, while the second provides a systematic overview of the applications of musculoskeletal ultrasound in different areas of the body. Hard copy is quite heavy and weighs down your suitcase, so get the online version too.

This book will acquaint beginners with the basics of musculoskeletal ultrasound, while utlrasound advanced sonologists and sonographers will learn new skills, means of avoiding pitfalls, and ways of effectively relating the ultrasound study to the clinical background.

I have been doing MSUS for 6 years and have seen many texts on the subject. Everybody who is serious about MSUS must own this book and wear out their hard copy reading it cover-to-cover. Illustrations note XIV, p. Skin and Subcutaneous Tissue. Review Text From the book reviews: Other books in this series. This book is undeniably the best text on musculoskeletal ultrasound ever published, by a long shot.

It is organized into two main sections. Nerve and Blood Vessels. Looking for beautiful books? By using our website you agree to our use of cookies. It has the potential to be both an invaluable tutorial and a constantly used resource for subspecialist musculoskeletal radiologists.

Stefano BianchiCarlo Martinoli. Best of all, it is fascinating, readable, and extremely well illustrated Visit our Beautiful Books page and find lovely books for kids, photography lovers and more. Book ratings by Goodreads. There is a generous complement of high-quality illustrations based on high-end equipment.

Back cover copy This book is a comprehensive reference and practical guide on the technology and application of ultrasound to the musculoskeletal system. I found this book extremely useful with many little tips for improving my own skills.