Chapter 14 - MSK Imaging, Breast, and Superficial Structures

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Clinical findings of a superficial hemangioma

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

Sonographic findings of a pilonidal cyst

(1) Complex, subcutaneous mass (2) hyperemia, around the mass (3) Hypoechoic tract may be seen extending from the cyst to the skin surface

Clinical findings of a Pilonidal cyst

(1) Edema, warmth, and pain in the area of the cyst (2) Bloody drainage from the cyst may be present

Sonographic findings of a superficial hemangioma

(1) Hypoechoic (2) Blood flow may be detectable with color Doppler

Sonographic findings of gynecomastia

(1) Hypoechoic mass posterior to the areola (2) May have a triangular shape

Sonographic findings of cellulitis

(1) Hypoechoic, edematous strands within the soft tissue [cobblestone appearance]

Sonographic findings of mastitis

(1) Ill-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

Sonographic findings of a superficial lipoma

(1) Most likely an isoechoic mass as compared to the surrounding tissues (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 mastitis

(1) Pain (2) Swelling (3) Warmth and redness in the area (4) fever (5) leukocytosis

Clinical findings of a galactocele

(1) Palpable, periareolar mass (2) Possible pain

Sonographic findings of a breast abscess

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

Sonographic findings of galactocele

(1) Round, complex mass (2) May contain a fluid-fluid level

Sonographic findings of metastatic melanoma

(1) Solid, vascular hypoechoic mass

Clinical findings of gynecomastia

(1) Tender, palpable retro areolar breast mass that is firm to touch

Sonographic findings of a Baker cyst

(1) anechoic mass with posterior enhancement (2) complicated bakers cyst may contain echogenic fluid, debris, or sepatations (do not confuse w/ DVT)

Sonographic findings of a superficial epidermal cyst

(1) anechoic, hypoechoic, complex, or hyperechoing cyst or mass (2) Pseudotestis appearance

Clinical findings of a Baker cyst

(1) asymptomatic (2) focal tenderness in the popliteal fossa

clinical findings of achilles tendon rupture

(1) audible snap may be heard (2) posterior ankle and leg pain (3) positive Thompson test

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

sonographic findings of DDH of the infant hip

(1) femoral head located completely outside the acetabulum [complete dislocation] (2) partially coverage of the femoral head by the acetabulum [subluxation] (3) evidence of a shallow acetabulum [<50% coverage of femoral head] (4) small alpha angle [Graf technique] (5) large beta angle [Graf technique]

clinical findings of DDH of the infant hip

(1) history of breech birth (2) family history of DDH (3) asymmetric skinfolds on the legs (4) leg length discrepancy (5) limited limb abduction (6) positive barlow or ortolani test

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

clinical findings of a tendon rupture

(1) pain (2) edema (3) audible snap may be heard

clinical findings of tendonitis

(1) pain (2) painful region may be swollen (3) painful region may be warm to touch

Inflammation and infection of the skin and subcutaneous tissues

Cellulitis

—— can occur at any time, but is most commonly encountered just after birth, during puberty, and during mid to late adulthood between 50 and 80 years of age -can be bilateral -Can be associated with high levels of HCG

Gynecomastia

A benign tumor composed of blood vessels

Hemangioma

Buildup of fluid within the hip secondary to inflammation

Hip joint effusion

Characteristics of the subcutaneous layer of the breast

Hypoechoic Composed mostly of fat

The largest and most superiorly located pelvic bone

Ilium [pelvis]

How do you determine the epidermis from the dermis on ultrasound?

They are indistinguishable and appear collectively as a hyperechoic linear structure

A clinical test used to evaluate for a compete test of the Achilles' tendon

Thompson test

what test can be performed to see if there is a complete tear of the achilles tendon?

Thompson test - patient lies prone - the calf is squeezed and the foot should plantarflex in a patient who does not have a complete tear of the achilles tendon

Superficial lipomas are typically —— in shape

Oval

sonographic findings of achilles tendon rupture

(1) partial tears: appear as focal hypoehoic areas within the tendon (2) complete tears: seen as 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 WBC count [especially with abscess development]

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 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 superficial lipoma

(1.) asymptomatic (2.) obvious mass under the skin (3.) compressible

Clinical findings of hip joint effusion

(1.) leg and knee pain (2.) reluctance to walk (3.) irritability (4.) low grade fever (5.) mild leukocytosis

Sonographic Findings of hip joint effusion

-Anechoic or hypoechoic fluid that elevates the anterior capsule of the joint -Width of the abnormal hip joint capsule typically exceeds 5 mm

explain the ortolani test

-evaluates for the reduction or relocation of a dislocated hip -performed by abducting [moving outward/away from the body] and lifting the thigh, essentially relocating the hip back into the acetablum -during this test an audible click may be heard and a palpable clunk felt as the head of the femur passes over the acetablum

tendon tears can be partial or complete

-partial tears appear as focal hypoechoic areas within the tendon -complete tears appear 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

explain barlow test

-used to evaluate the hip for dislocation -the hip is flexed and adducted [inward], and the knee is pushed posteriorly [down] and superiorly [up]

Clinical test for developmental hip dysplasia that is used to evaluate the hit for dislocation

Barlow test

The bowl shaped surface of the pelvis were the head of the femur normally rests

Acetabulum

Tendon located along the posterior ankle that connects the calf muscle to the posterior surface of the heel

Achilles tendon

A congenital disorder associated with severe joint contractures

Arthrogryposis

A synovial cyst located within the popliteal fossa

Baker cyst a.k.a. popliteal cyst

Large ganglion cysts in the wrist have been referred to as ——

Bible bumps, because individuals in the past have used large books, like the Bible, to reduce assessed by slamming the large book against it it

-a congenital anomaly that may be described as a shallow hip socket; -the ball of the hip - the femoral head - is prohibited from resting appropriately in the natural socket - the acetablum; -thought to be caused by abnormal fetal ligament development within the hip that is intensified by the excessive levels of circulating maternal estrogen

Developmental dysplasia of the hip [DDH]

Name the two layers of the skin

Epidermis and dermis

A common cyst found adjacent to a joint or tendon; most often found along the dorsal aspect of the hand, wrist, ankle, or foot

Ganglion cyst

What is the most common mass found along the dorsal aspect of the hand and wrist, although they can arise from any joint, and are those discovered in the foot and ankle as well?

Ganglion cyst

A technique used to measure the relationship of the femoral head and acetabulum by evaluating the alpha and beta angles created by the relationships of these structures

Graf technique

The benign enlargement of the mail breast; typically located posterior to the areola

Gynecomastia

Mastitis is most often associated with ——

Lactation/Breast-feeding

A benign, fatty tumor

Lipoma

Inflammation of the breast

Mastitis

Area located between the groove of the buttocks

Natal cleft

Clinical test for developmental hip dysplasia that is used to Evaluate the hip for the reduction or relocation of a dislocated hip

Ortolani test

These cysts are common and a result from the accumulation of synovial fluid from a weakening in the joint capsule of the knee, as seen in conditions such as rheumatoid arthritis or osteoarthritis - a channel may be seen connecting the cyst to the joint space

Popliteal cyst aka baker cyst

Acoustic shadowing caused by bending of a sound beam at the edge of a curved reflector; may be referred to as edge artifact or edge shadowing

Refractive shadowing

Superficial epidermal cysts are most likely found in the ——

Scalp, face, neck, trunk, or back

Name the three layers of breast tissue from superficial to deep

Subcutaneous layer Mammary layer Retro-mammory later

Cysts commonly found in the scalp, face, neck, trunk, or back; they can be congenital, the result of trauma, or the result of an obstructed hair follicle

Superficial epidermal cyst A.k.a. epidermal inclusion cyst aka epidermoid cyst, or possibly a sebaceous cyst

This is the most common cause of a painful hip and joint a fusion in children

Transient synovitis aka Toxic synovitis or irritable hip

Characteristics of the mammory layer of the breast

Typically hyperechoic Contains ducts and glandular tissue Is the functional layer of the breast **The sonographic appearance of this Lair can vary based on many factors, including the age of the patient in the distribution of the various functional elements

Characteristics of the retromammary layer of the breast

Typically hypoechoic Contains fat as well

Are lipomas usually compressible ?

Yes

When cellulitis is identified, the sonographer should look carefully for a complex focal fluid collection that may represent ——

abscess development

what is the most commonly injured ankle tendon?

achilles

what are the 2 clinical tests that can be performed to evaluate infant for DDH?

barlow test ortolani test

ligaments connect ---- to ----

bones - bones

sonographically, the infant hip is examined in which two planes?

coronal and transverse in either the supine or lateral decubitus position

2 types of tendonitits

diffuse - appears as a thickened and hypoechoic tendon focal - appears as a localized, enlarged hypoechoic area within the tendon

ligaments appear sonographically as ----

echogenic linear structures as well

tendons appear sonographically as ----

echogenic, fibrous structures connecting muscle to bone

is DDH more common in males or females?

females

the sonographic diagnosis of DDH can be definitive when the ----

femoral head rests clearly outside the acetabulum

A milk filled breast cyst

galactocele

Buildup of fluid within the hip secondary to inflammation

hip joint effusion

tendonitis may yield ---- flow with color Doppler

hyperemic

muscles appear sonographically as ----

hypoechoic tissue that contains linear, echogenic strands

Superficial lipomas are typically —— to the surrounding fat

isoechoic -but they kind of hear hypoechoic or hyperechoic

The ducts of the breast used to transport milk to the nipple

lactiferous ducts

what side is DDH more common?

left

tendons connect ---- to ----

muscle - bones

what causes tendonitis?

overuse or strain

A hanging flap of tissue

pannus

in most situations the transducer must be placed ---- to the tendon for it to be appropriately imaged with sonography

perpendicular [occasionally altering the angle of insonation can help differentiate the tendon from adjacent fat]

Cyst located along the natal cleft that is comprised of loose hairs and skin debris

pilonidal cyst

what is the best position to view the achilles tendon sonographically?

prone - with his or her feet hanging off the end of the bed

Inflammation of the breast that is related to pregnancy

puerperal mastitis

complete ruptures of a tendon may 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 - surrounding the area will most likely be edema with fluid accumulation

the ---- the alpha angle and the ---- the beta angle, the more likely the infant is suffering from DDH

smaller; larger

what has DDH been linked with?

spina bifida arthrogryposis and there is a familial link as well

partial dislocation of the hip

subluxation

this most likely results from some manner of recreational sport

tendon rupture aka tear

Inflammation of the tendon and synovial tendon sheath

tendosynovitis

inflammation of the tendon and synovial tendon sheath - fluid present within the synovial sheath

tendosynovitis

when looking at infant hip sonographically special attention should be given to the relationship of what?

the femoral head and its relationship to the acetabulum in both stress and relaxed states


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