Musculoskeletal & Superficial Structures

Causes of Baker's Cyst

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Describe the appearance of a Hemangioma?

- They are Asymptomatic. - They appear as a raised, red or reddish purple mass on the skin. - Blood flow may be detected on color doppler

Ganglion cyst were referred to as "Bible Cyst" why was it called that way?

Individuals in the past used to slam big books (like the bible) to reduce the cyst.

How would an inflammation of a Foreign body appear?

Inflammation around a foreign body will appear as a hypoechoic area adjacent to the structure

What is Tendonitis?

Inflammation of the tendon. It can be diffuse or focal.

Pilonidal Cyst may also be referred to as

Intergluteal cleft Gluteal cleft Pilonidal sinus

Sonographic Findings of Tendonitis

1. Diffuse: Enlarged, hypoechoic tendon 2. Focal: Localized, enlarged hypoechoic area within the tendon 3. Fluid may be noted 4. Hyperemic flow may be noted (excessive blood flow vessels)

Sonographic Findings of Developmental Dysplasia of the infant hip

1. Femoral head located completely outside the acetabulum (complete dislocation) 2. Partially Converage of the femoral head by the acetabulum (subluxation) 3. Evidence of a shallow acetabulum (<50% converage of femoral head) 4. Small Alpha angle (Graf Technique) 5. Large beta angle (Graf Technique)

Clinical findings of developmental dysplasia of the infant hip

1. History of breech birth 2. Family history of DDH 3. Asymmetric skinfolds on the legs 4. Limited limb abduction 5. Leg length discrepancy 6. Positive Barlow or Ortolani Test

Sonographic finding of a Superficial Hemangioma

1. Hypoechoic 2. Blood flow may be detectable with color doppler

Sonographic findings of a Superficial Abscess

1. Hypoechoic, edematous strands within the soft tissue (cobblestone appearance) 2. Focal fluid collection that is often complex, denoting the abscess. 3. A peripheral rim of hyperemia may be detectable with color Doppler

Sonographic Findings of Cellulitis

1. Hypoechoic, edematous strands within the soft tissue, also known as Cobblestone Appearance

Sonographic Findings of a Mastitis and abscess

1. I'll defined areas of echogenicity 2. Diffuse edema 3. Hypoechoic fluid within the subcutaneous tissue that outlines the fat lobules. 4. Breast skin thickening greater than 2 mm 5. Enlarged lymph nodes may be present.

Clinical Findings of Hip Joint Effusion

1. Leg and Knee Pain 2. Reluctance to walk 3. Irritability 4. Low Grade Fever 5. Mild Leukocytosis

Hemangioma

Is a benign mass that is comprised of vascular channels (blood vessels)

Baker's Cyst

Is a collection of synovial fluid in the popliteal fossa. It is commonly located in the medial aspect of the popliteal fossa, it may also extend downward into the calf muscles.

Melanoma

Is also the most likely primary tumor to metastasize to the subcutaneous fat.

Cellulitis

Is an infection and subsequent inflammation of the skin and subcutaneous tissue.

Transient Synovitis

Is the most common cause of a painful hip and joint effusion in children. It's also referred to as Toxic Synovitis or Irritable hip.

Sonographic Findings of a Superficial Lipoma

1. Most likely an isoechoic mass as compared to the surrounding tissue. 2. Typically have an oval shape

Sonographic Findings of a Ganglion Cyst

1. Noncompressible, anechoic mass with acoustic enhancement 2. May contain debris or septations

Clinical Findings of Tendon Rupture

1. Pain 2. Edema 3. Audible Snap may be heard

Clinical Findings of Mastitis

1. Pain 2. Swelling 3. Warmth and Redness in the area 4. Fever 5. Leukocytosis

Clinical Findings of Tendonitis

1. Pain 2. Painful region may be swollen 3. Painful region may be warm to touch

Clinical findings of a Ganglion Cyst

1. Palpable mass most often located along the dorsal aspect of the hand or wrist. 2. Can be painful

Clinical Findings of a Galatocele

1. Palpable, periareolar mass. 2. Possible Pain

Sonographic findings of breast abscess

1. Palpable, tender lump 2. Complex, focal mass that contains debris

What are the four pattern of muscle fiber organization?

1. Parallell (Fusiform) 2. Convergent (Triangular) 3. Pennate 4. Circular

Sonographic Findings of a Tendon Rupture

1. Partial tears: appear as focal hypoechoic areas within the tendon 2. Complete tears: seen as an anechoic or heterogeneous area within the tendon, often indicative of a hematoma; may also be sonographically identified as refractive shadowing in the area of the separated tendon, with fat, a hematoma, or granulomatous material filling in the gap created by the tear

Sonographic Findings of Achilles Tendon Rupture

1. Partial tears: appear as focal hypoechoic areas within the tendon. 2. Complete tears: seen as an anechoic or heterogeneous area within the tendon, often indicative of a hematoma; may also be sonographically identified as refractive shadowing in the area of the separated tendon, with fat, a hematoma, or granulomatous material filling in the gap created by the tear.

Clinical Findings of Cellulitis

1. Red, Tender warm area of the skin 2. Possible elevated white blood cell count (especially w abscess development)

Sonographic findings of Galatocele

1. Round complex mass 2. May contain a fluid fluid level

Sonographic findings of Metastatic Melanoma

1. Solid, vascular hypoechoic mass.

What are the 3 layers of breast? List them from Superficial to Deep.

1. Subcutaneous layer (Premammary) 2. Mammary Layer (Glandular) 3. Retromammary layer

Clinical findings of Gynecomastia

1. Tender, palpable retroareolar breast mass that is firm to touch.

Clinical Findings of a Superficial Epidermal Cyst

1. Visible, palpable mass just under the skin 2. Pain and redness in the area

Clinical Findings of a Pilonidal Cyst

1.Some are Asymptomatic. 2. Edema, warmth and pain in the area of the cyst 3. Bloody drainage from the cyst may be presented.

How is a galactocele caused?

It Develops after an abrupt termination to breast feeding or result from an obstruction to the lactiferous ducts.

Is gynecomastia bilateral ?

It is Bilateral and associated with high levels of Human Chronic Gonadotropin, which may be produced by some testicular tumors, high level of estrogen, adrenal tumor, hepatoblastoma.

How is the subcutaneous layer seen on ultrasound?

It will appear hypoechoic with interspersed hypoechoic linear echoes representing connective tissue septa.

When does gynecomastia occur?

It's can occur anytime but is most commonly encountered just after birth, during puberty and mid to late adulthood between 50-80 years of age

When hip dysplasia most commonly found?

It's seen at birth. Most common on the left side. It's 3 times more common in the left hip than right and in Female patients

What kind of patients present with a Galactocele?

Lactating patients, they may present to the emergency room with a palpable mass that may be painful.

What are ligaments and How are they seen sonography?

Ligaments connects bones to other bones and appear echogenic as well.

How are lipomas seen physically?

Lipomas are usually compressible and may be asymptomatic. Some may complain of unsightly bulging of the skin in the area of the lipoma.

Parallell (Fusiform)

Long axis of muscle fibers runs with longitudinal axis of muscle. ex: Biceps * Muscles that run longitudinal

What is the functional layer of the breast?

Mammary Layer

What is Galatocele?

Milk filled cyst

How would foreign bodies appear on ultrasound?

Most foreign bodies appear as hyperechoic structures with some degree of posterior shadowing.

How is cellulitis caused?

Most often caused by Staphylococcus aureus (germs spread skin to skin) and Streptococcus pyogenes.

Circular

Muscle fibers are arranged in concentric rings. Example: Orbicularis oris

Pennate

Muscle fibers branch from central tendon diagonally (Feather like) example: Rectus Femoris, Deltoid

Convergent (Triangular)

Muscle fibers converge toward a single tendon ex: Pectoralis muscle

How do muscles appear on ultrasound?

Muscles appear as Hypoechoic tissue that contains linear, echogenic strands.

Where is the mass galactocele located?

Near the areola - This type of cyst can be painful and cause infection.

What is a Hidden abscess called?

Occult abscess

When does Hip Joint Effusion occur?

Occurs in Children between 5 & 10 years of age.

How is tendonitis cause?

Overuse or strain

There are two types of Tendon Tears

Partial and Complete

How do you evaluate the Achilles tendon?

Patient lies prone with their feet hanging off the end of the bed.

Who are prone to Pilonidal Cyst

Patients who sit for an extended amount of time or hairdressers.

Where is the Achilles Tendon located ?

Posterior ankle and connects the calf muscle to the posterior surface of the heel or calcaneus.

How would affective breast skin measure?

The affective skin may measure greater than 2mm in thickness. Reactive, enlarged lymph nodes may be seen as well.

How would you know if the patient is suffering from DDH by using the Graf technique?

The smaller the Alpha Angle and the larger the Beta Angle, the more likely the infant is suffering from DDH

How is the Subcutaneous layer seen on ultrasound?

The subcutaneous layer is typically Hypoechoic and is composed mostly of fat

How is a ganglion cyst treated?

With an Injection of Corticosteroids or it may be surgically removed.

Fibroadenoma

a round, firm, rubbery mass that arises from excess growth of glandular and connective tissue in the breast

Where else might a Pilonidal Cyst be found?

in between the fingers and toes

Fibroadenoma Clinical signs and symptoms

-Painless. Palpable lump - Farm and rubbery - Mobile - Young woman ages 20 and 40 - more common an African-American woman Girls rapidly during pregnancy

True Sebaceous cyst

-True sebaceous cyst are uncommon. - implies that the cyst is sebaceous in origin).

Sonographic findings of gynecomastia

1, Hypoechoic mass posterior to the areola. 2. May have a triangular shape.

Sonographic Findings of a Baker's Cyst

1. Anechoic mass with posterior enhancement 2. Complicated baker cyst may contain echogenic fluid, debris or septations

Sonographic Findings of Hip Joint Effusion

1. Anechoic or Hypoechoic fluid that elevates the anterior capsule of the joint. 2. Width of the abnormal hip joint capsule typically exceeds 5mm

Sonographic findings of a Superficial Epidermal Cyst

1. Anechoic, hypoechoic, complex, or hyperechoic cyst or mass. 2. Pseudoptosis appearance

Clinical Findings of a Baker Cyst

1. Asymptomatic 2. Focal Tenderness in the popliteal Fossa

Clinical Findings of a Lipoma

1. Asymptomatic 2. Obvious mass under skin 3. Compressible

Clinical Findings of a Superficial Hemangioma

1. Asymptomatic 2. Red or reddish-purple, raised mass on the skin

Clinical Findings of Achilles Tendon.

1. Audible snap may be heard 2. Posterior Ankle and Leg Pain. 3. Positive Thompson Test

Sonographic finding of a Pilonidal Cyst

1. Complex, subcutaneous mass 2. Hyperemia around the mass 3. Hypoechoic tract may be seen extending from the cyst of the skin surface.

What is the normal percentage measured of the acetabulum converage?

55% is said to be normal, whereas 50% or less is said to be shallow, and less than 45% is considered very shallow.

Popliteal Cyst (Baker's Cyst)

A baker cyst or popliteal cyst is located in the popliteal fossa, behind the knee.

Lipoma

A benign, fatty tumor.

Describe a breast abscess

A breast abscess is a focal area of pus. Where diffuse pain may be seen more with mastitis, with an abscess the patient may have a palpable, painful lump.

What is a Ganglion Cyst?

A common mass found along the dorsal aspect of the hand, and wrist. Although they can arise from any joint, they may also appear in the Foot and Ankle.

Explain what Developmental Dysplasia of the hip is

A congenital anomaly that may be described as a shallow hip socket. The ball of the hip (femoral head) is not resting appropriately in the socket (acetabulum) *not resting in the correct location*

What is a Pilonidal Cyst?

A cyst comprised of loose hairs and Skin debris. Pilonidal means Nest of Hairs.

What is a foreign body?

A foreign body is something that is stuck inside you but isn't supposed to be there.

Superficial Epidermal Cyst

A superficial epidermal cyst may also be referred to as Epidermal Inclusion, an Epidermoid Cyst or possibly Sebaceous cyst.

What causes as Tendon Rupture?

A tendon Rupture may also be referred to as a Tear, and it's most likely caused by physical sports.

What is a Thompson Test?

A test that is performed on a patient to see if there is a complete tear of the tendon.

Malignant melanoma

Accounts for up to 11% of skin cancers. Primary melanoma appears hypoechoic with vascular flow noted w color doppler.

What is the most common injured ankle tendon?

Achilles tendon is the most commonly injured ankle tendon.

What might be seen on a ultrasound of a Foreign body?

Air at the site of a foreign body may produce bright echoes and therefore cause some ambiguity about the correct orientation of the object.

How are Baker's cyst seen sonographically?

Anechoic with posterior enhancement in the popliteal fossa.

Focal

Appears as a Localized enlarged hypoechoic area within the tendon.

Diffuse Tendonitis

Appears thickened and hypoechoic tendon

Complete Tendon Tear

Are seen as anechoic or heterogeneous area within the tendon, hematoma may be seen.

What are the two clinical test that can be performed to evaluate DDH?

Barlow and Ortolani test

What is Gynecomastia?

Benign enlargement of the Male breast.

What is puerperal Mastitis?

Breast infection most often associated with lactation.

What is Mastitis?

Breast infection, most often associated with lactation.

What is mastitis most often associated with?

Breastfeeding

Hip Joint Effusion

Buildup Fluid within the hip secondary to inflammation. It's most likely the result of Transient Synovitis.

What are some examples of Foreign bodies seen on ultrasound?

Bullets, shrapnel, and other metallic objects may cause ring-down or comet-tail artifact as well

Tendosynovitis

Fluid within the synovial shealth

Ortolani test

Evaluates for the reduction or relocation of a dislocated hip. Its performed by abducting and lifting the thigh, essentially relocating the hip back into the acetabulum. * Relocation of the dislocated hip, by abducting the leg. A palpable and audible "clunk" is noted as the femoral head slips back into the socket.

Partial Tendon Tear

Can appear as focal hypoechoic areas within the tendon.

What might also be seen on a complete tendon tear?

Complete ruptures may also be sonographically identified as refractive shadowing in the area of the separated tendon, with fat, a hematoma, or granulomatous material filling in the gap created by the tear.

How are complicated Baker's cyst seen?

Complicated baker's cyst may contain echogenic fluid, debris, pannus or septations.

What is another way you could evaluate the patient for DDH?

Coverage of the femoral head by Obtaining a coronal image and drawing parallel lines along the ilium and the maximum depth and height of the femoral head.

Barlow test

Evaluates the hip for dislocation, the hip is flexed and adducted, the knee is pushed posteriorly and superiorly. * Dislocation of the hip by adducting and pushing the leg posteriorly.

Hip Dysplasia

Developmental Dysplasia of the hip (DDH) is a spectrum of disorders affecting the proximal femur and acetabulum that leads to hip subluxation (partial dislocation) and dislocation.

Back then, Why was it called the "Jeep Disease" ?

During World War II, pilonidal cysts were often called "Jeep driver's disease" because they're more common in people who sit often

What are the two layers of the skin?

Epidermis and Dermis

What are some risk factors for hip dysplasia

Female First-born Frank Breech position Family hx of DDH Oligohydramnios (abnormally low amniotic fluid)

Describe Fascia appearance

Hyperechoic layer of varying thickness

How are the two layers of skin sonography?

Hyperechoic linear structure.

How is the Retromammary layer seen on ultrasound?

Hypoechoic and contains fat as well

Where are Superficial epidermal cyst located?

Scalp Face Neck Trunk Back

What are the Symptoms of a Baker's cyst?

Some patients may be Asymptomatic. However they may present with focal tenderness secondary to hemorrhage rupture or impingement on adjacent structures.

What is the role for ultrasound with a patient with Foreign body?

Sonography can aid in the localization and removal of some objects, particularly wooden fragments, which may not be recognized with radiography.

When are infants recommended to be screened for Hip dysplasia?

Sonography is performed after 4 weeks of age, typically between 4-6 weeks. Hips are evaluated in coronal & transverse plane.

What has DDH been linked with?

Spinal Bifida and Arthrogryposis (joint contractions)

How is Puerperal Mastitis caused by?

Staphylococcus & Streptococcus organisms

How are lipomas seen sonography?

Superficial lipomas are typically oval in shape, and isoechoic to the surrounding fat, but can also appear hypoechoic or hyperechoic

Symptoms of Baker's cyst pt. 2

Symptoms may be mistaken for deep venous thrombosis due to pain and swelling behind the knee and in the upper calf.

Why should the patient Achilles tendon be screened?

Tendonitis and Rupture

How are Tendons seen on ultrasound?

Tendons may be seen as echogenic fibrous structures connecting muscles to bone.

How is the Thompson test performed?

The calf is squeezed and the foot should plantarflex in a patient who does not have a complete tear of the Achilles tendon.

What is the Cause of Transient Synovitis?

The cause is unknown, although viral causes, trauma and an allergic reaction has been suspected.

How is the Mammary Layer seen on ultrasound?

The mammary layer is typically Hyperechoic and Contains the ducts and Glandular tissue. However, the u/s appearance of the mammary layer can vary due to age & distribution of the various junctional elements.

How are Superficial epidermal cyst caused?

They are Congenital or the result of trauma. They also result of an obstructed hair follicle.

How are musculoskeletal structures imaged?

They are imaged with a linear array transducer

How are Popliteal Cyst created?

They result from accumulation of synovial fluid from a weakening in the joint capsule of the knees. - A channel may be seen connecting the cyst to the joint space,

Graf Technique

This technique is used to measure the relationship of the femoral head and acetabulum by evaluating Alpha and Beta angles created by the relationships off these structures.

How can ultrasound help remove foreign bodies objects?

To aid in the removal of the object, a distance can be obtained from the surface of the skin to the foreign object by using electronic calipers

How does the Graf technique asses the acetabulum?

To assess the depth of the acetabulum from the coronal view, a line can be drawn along the ilium and through the femoral head, with 2 other lines drawn along the acetabulum and adjacent to the femoral head, to obtain the two pertinent angles.

What is the primary role of sonography in breast?

To determine the presence of a focal abscess within a breast that is affected with mastitis.

How must the transducer be placed in order to see the tendon?

Transducer must be placed Perpendicular to the tendon for it to be appropriately imaged sonography.

How would evaluate a Foreign body?

Using a High frequency linear array. Foreign bodies just below the skin surface may require the aid of a standoff pad for improved visualization.

Where is the Pilonidal cyst found?

within the Natal cleft