45-year old female with pain in the fingertip of the middle finger.
The patient did not want an MRI due to claustrophobia, thus an ultrasound was requested.
Gamekeeper's thumb (or skier's thumb) describes a UCL avulsion fracture or rupture, usually off the base of the first proximal phalanx.
These injuries at the ulnar aspect of the 1st MCP joint may lead to significant instability, at times requiring surgical intervention.
As the structures about the 1st MCP joint are superficial, ultrasound is a useful and efficient modality to assess for the integrity of ligamentous structures following trauma to the thumb.
Plantar fibromatosis, also known as Ledderhose disease, is the development of fibrous nodules, often multiple, in the plantar fascia. It can co-exist with palmar fibromatosis (Dupuytren’s contracture).
Pseudoaneurysm is an uncommon complication after total knee arthroplasty, with a reported incidence of 0.03% to 0.2%.
Symptoms of a pseudoaneurysm include pain, gait disability, cold foot, pulsatile mass and recurrent hemarthrosis.
Ultrasound is a cheap, sensitive modality for patients suspected of a pseudoaneurysm.
If a pseudoaneurysm is detected by ultrasound, MRA may be indicated to more accurately delineate the parent artery for possible embolization.
Trauma is the most common cause of acquired peripheral neuropathy, occurring as either direct injury to the nerve (e.g. laceration, contusion) or indirect injury (e.g. scar encasement, entrapment).
Peripheral nerves have a characteristic appearance on US which helps in their identification.
Scar tissue usually appears as hypoechoic/dark tissue on US, and can cause encasement or entrapment of adjacent nerves.
US is useful in the evaluation of peripheral nerves, particularly when there is adjacent metallic hardware that can limit MRI evaluation.
The clavicle is the most common site of birth-related fracture, reported to occur in up to 1% of vaginal deliveries.
Risk factors for fracture of the clavicle include large size of the baby, forceps delivery, and shoulder dystocia.
Although easily diagnosed by radiographs, ultrasound is an ideal alternative as it is fast, accessible, and most importantly, lacks ionizing radiation.
Additional value of ultrasound is that it can evaluate the soft tissues surrounding the clavicle should the patient’s palpable abnormality be caused by an entity other than a clavicle fracture.
Painful inflammation of the abductor pollicis longus and extensor pollicis brevis tendons. Most common in women and often in the 30-50 year age group Tendon tears are relatively uncommon. Associated with repetitive activities such as racquet sports, golf, manual labor and frequently lifting and holding a newborn child (as in the case presented). May also be associated with conditions such as rheumatoid arthritis. Treatment options include NSAIDs, physical therapy, reduction in the activities causing pain, and cortisone injections. Cortisone injections should be done with ultrasound guidance to confirm accuracy. Severe cases without response to more conservative measures may require surgery.
Involves inflammation of the synovial-lined bursa between the skin and the patella or the patellar tendon. Common condition, often related to repetitive kneeling (carpenters, maids, gardeners, etc.) Also associated with gout, rheumatoid arthritis, diabetes, uremia, etc. With any clinical suspicion for infection, ultrasound-guided aspiration should be performed.
Radiographs remain the initial diagnostic study of choice in evaluating for a metatarsal fracture. If radiographs are normal but the diagnosis is still suspected, MRI is the gold standard. In patients who cannot have an MRI and in other selected circumstances, an ultrasound of the area may confirm the presence of a fracture. However, if the ultrasound imaging is normal, fracture cannot be excluded and further imaging and follow-up is necessary.
Primary Synovial Chondromatosis.
The core biopsy samples obtained demonstrated findings compatible with Primary Synovial Chondromatosis. This is a relatively rare condition with proliferation of islands of irregularly hypercellular cartilage seen microscopically.
Most commonly seen in the knee, this process may arise from joint synovium or less likely a tendon sheath. The condition is twice as common in men and in the primary form has no known precipitating factors.
Bicipitoradial bursitis is a relatively uncommon condition resulting in inflammation and distention of the bicipitoradial bursa. This enlarged bursa may impinge upon the adjacent radial nerve bifurcation and posterior interosseous nerve.
Bicipitoradial bursitis is most commonly secondary to repetitive activity and may be associated with biceps tendon tears or tendinosis. In rare cases, the bursa may be infected and require antibiotic therapy and possible surgical intervention.
As demonstrated in this case, ultrasound is valuable in evaluating the distal biceps tendon for tear/tendinosis and in confirming the presence of an enlarged and inflamed bursa. Also, ultrasound allows safe needle aspiration and injection of the bursa as indicated.
Intramuscular lipoma of the vastus lateralis muscle.
Microscopic pathologic review of the core specimens obtained demonstrated Adipose tissue containing small bands of bland fibrous tissue and numerous skeletal muscle fibers. No evidence of mineralization.
Plantar foot abscess following puncture injury
Costal cartilage fractures may be a difficult clinical diagnosis.
Gram stain with culture and sensitivity of the fluid obtained from aspiration yielded gram-positive cocci (Staph Aureus).
Costochondral junction fracture
Costal cartilage fractures may be a difficult clinical diagnosis.
Radiographs are generally normal in the absence of an associated rib fracture.
While, as demonstrated, the diagnosis may be made by either CT or ultrasound imaging (as well as MRI), ultrasound is less expensive, faster, and like MRI avoids the use of radiation.
Ganglion cyst extending from the tibial tunnel into the adjacent soft tissues in the setting of prior ACL reconstruction.
MRI is the examination of choice in evaluating the integrity of the ACL in the setting of prior reconstruction and easily demonstrates the presence of ganglion cysts
Ultrasound may be used to confirm the diagnosis and more importantly to guide the safe and complete aspiration of these ganglion cysts
Ganglion cyst fluid is often extremely thick, requiring the use of larger (16-18 gauge) needles for complete aspiration
As clinically indicated, the fluid may be sent for laboratory analysis to exclude the possibility of infection.
Complete tear of the ulnar collateral ligament of the thumb with avulsion
While MRI has historically been the imaging study of choice for evaluating the ulnar collateral ligament, ultrasound will often quickly make the diagnosis and should be considered when this diagnosis is suspected.
It is important that complete tears are detected early so that prompt surgical correction may be performed.
Temporal (giant cell) arteritis.
Full-thickness tear of the anchilles tendon.
Lateral Ankle Sprain.
The interval elevation of the patella and increased patella-tibial tubercle distance as consistant with patellar tendon rupture.
Giant Cell Tumor of Tendon Sheath involving the extensor tendon of the 2nd digit of the hand, also referred to as localized nodular tenosynovitis. Pathologically, the tissue is identical to PVNS. Lesions contain histiocyte-like multinucleated cells and fibroblastic cells. Frequently, they contain hemosiderin deposits.
Calcium hydroxyapatite deposition disease.
Sciatic nerve stump neuroma.
Paralabral cyst extending posteriorly and impinging the sciatic nerve.
Post-traumatic seroma interposed between the medial gastrocnemius and soleus muscles following partial medial gastrocnemius tear. Ultrasound-guided seroma aspiration may allow prompt resolution of symptoms and rapid improvement in patient mobility. The use of ultrasound during these procedures allows safe and accurate needle placement and ensures complete evacuation of the fluid collection.
Immediately following aspiration of the ganglion cyst, the patient was able to painlessly perform the ballet maneuvers and great toe flexion that had previously elicited discomfort. As clinically indicated, cortisone injection into the ganglion could also be performed at the time of the initial cyst aspiration. Due to the relatively high recurrence rate of ganglion cysts, the patient will be monitored clinically for evidence of symptom recurrence.
Moderately differentiated mucin-secreting adenocarcinoma, consistent with a pulmonary origin. This matched the previous pathology of the patient's primary lung tumor.
Peripheral nerve sheath tumor of the ulnar nerve.
Congenital Muscular Torticollis.
Based on the clinical presentation, the diagnosis of meralgia paresthetica was considered most likely. Ultrasound evaluation of the lateral femoral cutaneous nerve was requested with peri-neural anesthetic injection to confirm the diagnosis.
Calcific tendinosis of the proximal hamstring tendons.
Infected Olecranon Bursitis.
Tarsal tunnel syndrome secondary to tibial nerve compression from a perineural ganglion cyst.
Treatment of choice is ultrasound-guided aspiration of the cyst with resulting nerve decompression.
Spinoglenoid notch cyst causing denervation atrophy and fatty replacement of the infraspinatus muscle.
Partial thickness ear of the proximal patellar tendon.
Nodular Pigmented Villonodular Synovitis arising from the lateral tibiotalar joint.
Myxomatous tumors of the soft tissues are a heterogeneous group of lesions, both benign and malignant, that show an overproduction of mucopolysaccharide substances. Characterized by a mixture of primitive mesenchymal cells and myxomatous stroma.
Following the ultrasound-guided aspiration of the paralabral cyst compressing the femoral nerve, the patient experienced symptomatic relief of her femoral nerve symptoms.
Calcific tendinosis of the long head of the rectus femoris tendon at the Anterior Inferior Iliac Spine
Epidermoid inclusion cyst.
Giant cell tumor with ABC formation.
Right rectus abdominus hypertrophy with strain common in tennis players.
Traumatic peroneus brevis tear status post ultrasound guided PRP injection with healing response.
Glomus tumor of the terminal tuft.
Lateral epicondylitis with deep surface tear of extensor tendon origin/lateral collateral ligament with seroma formation.Ultrasound guided seroma aspiration and platlet rich plasma injection.
Early Osteoarthritis with Lateral Hip Impingement.
Scar encasement/neuroma formation about ulnar nerve.
Initial imaging shows hypoechoic scarring surrounding the nerve near the Iliac crest and Sartorius origin. Ultrasound guided perineural injection was Performed resulting in symptomatic relief.
Linear calcification in anterior joint capsule producing anterior impingement and pain.
Large foreign body granuloma containing multiple foreign bodies.
De Quervain’s tendinitis/tenosynovitis.
Large tendon sheath effusion, inhomogeneity of the first dorsal compartment tendons with marked hyperemia on power Doppler imaging.
Isolated teres minor atrophy.
Peroneal tenosynovitis. Ultrasound shows fluid and nodular soft tissue surrounding the peroneal tendons giving rise to the soft tissue swelling seen on radiographs.
Sonographic appearances suggestive of gout. Confirmed on ultrasound guided aspiration.