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SON5024 MSK > Topic 8 - Lumps and bump > Flashcards

Topic 8 - Lumps and bump Flashcards

1
Q

What is he role of ultrasound in imaging soft tissue masses?

A
  • to confirm the presence of a mass
  • to distinguish cystic from solid
  • to determine the relationship of the mass or cyst with surrounding anatomic structures and compartments
  • to assess the vascularity of the mass
  • to guide needle biopsy, aspiration, drainage, or the administration of certain drugs.
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2
Q

What is a fibroma?

A

• Hard, usually painful nodules are commonly found in the plantar tissues of the foot or palm of the hand.

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3
Q

What does a fibroma look like on ultrasound?

A
  • They result from the proliferation of fibrous tissue and appear as elongated fusiform hypoechoic nodules
  • often continuous with the surrounding fascial layers.
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4
Q

What is a granuloma and what does it look like?

A
  • hypoechoic rounded collection that forms around the site of inflammation or a foreign body.
  • The mass consists of transformed macrophages called epithelioid cells, and lymphocytes and fibroblasts.
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5
Q

What is a neuroma and what does it look like?

A
  • an oval or elongated hypoechoic fusiform swelling of a nerve.
  • Continuity with the nerve may be demonstrated.
  • It may have an associated bursal thickening, or central hyperechoic changes due to fibrosis and calcification.
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6
Q

What is a ganglion?

A
  • mucin-filled lesions most often found at the wrist
  • usually closely related to a joint or tendon sheath
  • 10% of ganglion cysts occur secondary to trauma.
  • The most common location is adjacent to the scapholunate articulation
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7
Q

How does a ganglion appear on ultrasound?

A
  • well-circumscribed, oval or lobulated anechoic cystic masses, with accompanying through transmission
  • may demonstrate low-level internal echoes and may be septated
  • typically noncompressible (as opposed to bursae, which are compressible)
  • do not usually demonstrate internal flow on color Doppler evaluation
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8
Q

What causes a ganglion?

A

• Acute trauma, repetitive chronic stress, and inflammation

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9
Q

What is a synovial cyst and how does it appear on ultradound?

A
  • This is a herniation of synovial membrane through the articular capsule of the joint.
  • Synovial cysts are secondary to arthropathies that result in joint effusion and elevated intra-articular pressure with capsular rupture and synovial protrusion.
  • US shows a well-circumscribed hypoechoic lesion that connects with the joint. It may contain echogenic debris or septations.
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10
Q

What can cause a bakers cyst?

A

• usually occurs in the setting of an underlying cause of joint effusion, including osteoarthritis, but also in the setting of posterior horn medial meniscal tear, inflammatory arthritis, and internal derangement.

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11
Q

How does a bakers cyst appear on ultrasound?

A
  • typically anechoic
  • may have a variable appearance, with complex fluid and hemorrhage, internal septations and debris, and thick, echogenic, hyperemic synovium lining the cyst.
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12
Q

What can happen when the neck of the bakers cyst acts as a valve?

A

fluid accumulation within the cyst can lead to rupture, resulting in acute pain, swelling, and erythema behind the knee and in the proximal calf

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13
Q

How does a ruptured bakers cyst appear on ultrasound?

A

• The margin of the cyst is often irregular caudally and there may be associated medial calf subcutaneous edema, with fluid tracking distally about the medial head of the gastrocnemius

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14
Q

Why is the diagnosis of a ruptured bakers cyst important?

A

The clinical presentation of this may mimic deep venous thrombosis or developing cellulitis

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15
Q

What is a muscle hernia and how does it appear on ultrasound?

A
  • This is a weakness or traumatic disruption to the fascial covering of a muscle
  • resulting in the protrusion of that muscle.
  • It may be reducible with compression, or the patient may create the hernia by straining or performing valsalva.
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16
Q

What is the role of ultrasound in imaging lymphnodes?

A
  • Often a solitary lump can cause extreme concern to the patient and doctor, particularly when it may have arisen suddenly and is tender.
  • Ultrasound can help to describe if the lump relates to a lymph node, and if so, what features it shows.
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17
Q

What is a glomus tumour and what is its ultrasound appearance?

A
  • This is an exquisitely painful, typically rounded, hypoechoic, and extremely vascular mass.
  • It is usually only a few millimetres in size, and often present in the pulp at the distal tip of a finger, or it may hide under the nail plate.
  • Sometimes a bluish discolouration in the nail bed is an associated finding.
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18
Q

How does a subcutaneous haemangioma appear on ultrasound?

A

• Subcutaneous haemangiomas present as multiple hypoechoic cyst-like structures with tubular vascular channels

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19
Q

How does an intramuscular haemangioma appear on ultrasound?

A
  • Intramuscular haemangiomas present as heterogeneous lesions with ill-defined margins.
  • Occasionally phleboliths within the lesion present as small hyperechoic foci with posterior shadowing.
  • They show very little colour flow with a static examination, but with compression there is a filling in of the lesion, and an increase in size of the lesion with pooling of blood in the vascular channels following exercise of the limb.
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20
Q

What is a myxoma and how does it appear on ultrasound?

A
  • This is an uncommon benign lesion that results from proliferation of altered fibroblast producing an excess of mucopolysaccharide.
  • On US, it appears as a hypoechoic well-defined lesion with posterior enhancement. It may be homogeneous or contain cystic areas.
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21
Q

How can bone surface changes be categorised sonographically?

A
  • thinning or thickening of the hyperechoic line
  • interruption of the bone continuity, including a step-off deformity, expansion, or excavation
  • periosteal reactions
  • cortical disruption, with visualization of intraosseous components.
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22
Q

What are the ultrasound findings of osteomyelitis?

A

o deep soft tissue swelling adjacent to the bone, with a hypoechoic layer representing pus collection beneath the periosteum
o increasing the periosteal thickness beyond the normal 2 mm.
o Serial scans show a progressive increase of focal bone resorption

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23
Q

What is an epidermal inclusion cyst?

A

a common lesion in patients who have had a trauma. The lesion is well-defined, hypoechoic with neither shadowing or through transmission.
aka implantation dermoid.
These are benign cysts that result from the cystic enclosure of epithelium within the dermis.
They are common in the finger region and are often associated with much milder trauma.

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24
Q

What is a lipoma?

A
  • Most common palpable soft tissue mass
  • mass of fatty tissue
  • fat cells have aggregated to form a lump
  • should be painless mobile and compressible
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25
Q

How does lipoma appear on ulrasound?

A
  • typically an oval shaped mass
  • orientated parallel to the skin
  • well defined borders lying within the subcutaneous fat layer
  • may also be intramuscular or intermuscular.
  • Echogenicity is usually increased compared to surrounding fat
  • but can present as hypoechoic, isoechoic, or of mixed echogenicity.
  • It is usually difficult to detect any capsular or internal colour Doppler flow.
26
Q

What ultrasound features should lead to concern in a suspected lipoma?

A 
o	deep acoustic shadowing
o	internal complexity or hypervascularity
o	size greater than 5 cm
o	deep or intramuscular location
o	pain
o	or history of enlargement
27
Q

What is often required when imaging a foreign body due to it’s superficial nature?

A

Stand off pad

28
Q

What should you always do to your probe before imaging a foreign body?

A

Cover it with a sterile bag

29
Q

Once located, why should you look around the foreign body?

A

• Look for surrounding structures to see if the foreign body has penetrated a tendon sheath, a joint, or a vessel. Use dynamic manoeuvres to see if the tendon or joint moves freely.

30
Q

What measurements are required when imaging a foreign body?

A

the foreign body should be measured in three dimensions, its depth from the skin measured at both ends, and the imaging angle noted to allow the clinician to excise the foreign body from the same angle and depth.

31
Q

generally, how do foreign bodies appear on ultrasound?

A

• All soft-tissue foreign bodies are initially hyperechoic on sonography. However, wooden foreign bodies may become less echogenic over time

32
Q

How do wood fragments appear on ultrasound?

A

initially echogenic
become progressively less echogenic as the surrounding inflammatory reaction evolves.
Eventually the fragment will decompose over a few weeks, but a residual post-inflammatory granuloma may persist.
Posterior shadowing present acutely, but as the organic material disappears, so too does the shadowing.

33
Q

How do plastic fragments appear on ultrasound?

A

slightly less echogenic than wood, but also demonstrate posterior shadowing. This material will not decompose in the surrounding inflammatory reaction.

34
Q

How to glass fragments appear on ultrasound?

A

appear echogenic, with comet-tail artifact produced by reverberation

35
Q

How do metal fragments appear on ultrasound?

A

appear brightly echogenic and are associated with a significant comet-tail artifact. Metal fragments may migrate through the soft tissues.

36
Q

What are the three steps to describing a foreign body lesion?

A

Step 1 Describe the FB… Size, shape, echogenicity, shadowing etc…
Step 2 Describe the immediate surround. Is there a track? Measure distance from the entry site.
Step 3 Describe the global surround.

37
Q

Describe the appearance of a thorn in the skin after 2 days

A

small echogenic, non shadowing focus in the distal volar aspect of the finger.
The entry site is not evident.
This FB is surrounded by a hypoechoic halo.
Beyond this halo, there is marked increase in the echogenicity of the soft tissue.
This reflects cellulitis/ inflammation.

38
Q

What measurements should be done on a foreign body?

A

This FB then should be marked to ensure, its location and orientation can be discerned by the clinician who will attempt to remove it.
The transducer can be oriented along the length of the FB and marking can be performed.

39
Q

What is the ultrasound appearance of Dupuytrens contracture?

A

Initial findings are of nodules seen superficial to the flexor tendons in the superficial fascia of the palm.
Early on these appear hypoechoic to tendons with hypervascularity
chronic nodules can appear hyperechoic without associated vascularity
These can progress to hypoechoic cords and bands adhering to the flexor tendon margins, eventually resulting in the characteristic clinically apparent contracture deformity.

40
Q

Where is the femoral canal?

A
  • The femoral canal lies immediately medial to the femoral vein within the femoral sheath, and contains fat, lymphatics, and often a deep inguinal lymph node.
  • Proximally the mouth of the canal is termed the femoral ring, which normally is closed by extraperitoneal fascia.
41
Q

How do you scan for a femoral hernia?

A
  • Scan just below the inguinal ligament in cross-section to the femoral vessels. Perform valsalva and straining techniques.
  • Tip: The femoral ring is prone to mild laxity which shouldn’t be mistaken for a true hernia.
42
Q

Where is the inguinal canal and what are its contents?

A
  • The inguinal canal runs between the internal and external rings, is approximately four centimetres long, and lies parallel and immediately superior to the inguinal ligament.
  • It contains the testicular vessels, vas deferens and the ilio-inguinal nerve in men, and the same nerve and the round ligament in women.
43
Q

Where is the deep ring?

A

• The internal or deep ring is an opening of the anterior fascia lining the peritoneum. It lies midway between ASIS and the pubic tubercle, with the inferior epigastric vessels immediately medial to it.

44
Q

Where is the superficial ring?

A

• The external or superficial ring lies just above and lateral to the pubic tubercle. It is a triangular shaped opening in the aponeurosis of the external oblique muscle, with the pubic crest forming the base.

45
Q

Where is the conjoint tendon and what is it?

A

• The conjoint tendon is formed by blending of internal oblique muscle and fascia transversalis fibres, at the attachment to the pubic tubercle.

46
Q

What is an indirect hernia?

A

hernia originates at the internal ring, travels along the inguinal canal, and exits at the external ring where it may also pass into the scrotum

47
Q

What is the cause of an indirect hernia?

A

usually congenital in origin due to a failure in closure of the processes vaginalis.
Herniation may not occur until well into adult life after a muscular strain or sudden increase in intra-abdominal pressure

48
Q

What is a direct hernia?

A

Direct hernia pushes directly through the posterior wall of the inguinal canal and appears to come up towards the transducer.
The herniated contents may be bowel mesentery and fat, or may also contain loops of bowel.

49
Q

What is the most common site for congenital hernias?

A

Umbilical

50
Q

Where does a Spigelian hernia occur?

A

between the layers of internal abdominal oblique and transverse abdominus.

51
Q

How do you assess for inguinal hernia with ultrasound?

A
  • Scan the length of the canal from the external ring and laterally to the internal ring, checking for any mass (lipoma, hernia) within the canal at rest.
  • Do not press hard as you may unintentionally reduce a hernia.
  • At the level of the internal ring you should be able to see the inferior epigastric vessels immediately medial.
  • Ask the patient to perform valsalva and straining manoeuvres.
  • Turn your probe to long-axis on the canal and repeat the straining.
52
Q

How does an indirect hernia appear on ultrasound?

A

on abdominal straining there is ‘ballooning’ of the AP canal diameters, and simultaneous protrusion of fat or hernia contents through the deep inguinal ring.
Abnormal ‘longitudinal glide’ within the canal is appreciated on real-time scanning, where you see a finger of tissue arise from the superficial ring and travel along the canal, causing a marked increase in its diameter.

53
Q

How does a direct hernia appear on ultrasound?

A

pushes through the posterior wall of the inguinal canal and can occur anywhere along the canal.
It will always arise just medial to the canal and appears as an ‘eruption’ of tissue coming up toward you, hence the term ‘the volcano sign’.
Check very carefully around the superficial ring for a direct inguinal hernia.

54
Q

What is a common false positive in scanning hernias?

A

mistaking of a lipoma for a hernia.
These can be mobile within the canal and thus appear as moving canal contents.
They will be well-defined, however, and in most settings, hyperechoic, although this is variable.

55
Q

What are two ways of telling the difference between a direct and indirect hernia?

A

A hernia which arises medially to the epigastric vessels will be a direct hernia while the indirect hernia will arise laterally.
My own preference is to observe the canal. Movement along the canal and/or filling of the canal with hypoechoic echoes are strongs markers of a hernia

56
Q

What are some tricks for scanning hernias?

A
  • Use the transducer in tranverse to reduce the hernia and then slowly release the pressure and watch the contents refill the potential space.
  • Use a distended abdomen. (Push your tummy out)
  • Use gradated straining. This is just enough straining to begin the mechnism which causes the hernia to fill.
  • Use a lower frequency transducer. There is often moderate amount of attenuative fat which can mislead the sonographer into using a the highest frequency transducer.
  • Reduce the dynamic range: This is the sonographer’s friend when delineation of the inguinal canal is very difficult.
  • Get the patient to move into the position which produces the ‘lump’. This will be important in visualising a spigelion hernia where the standing position many be the only position that shows the herniation.
57
Q

What are some benign features of a soft tissue mass?

A

small size
superficial location
homogeneous echo pattern
hypovascularity

58
Q

What are some malignant features of a superficial mass?

A 
Fascial edema
skin thickening
skin contact
hemorrhage,
necrosis
lobulation
peritumoral edema  are
highly significant factors indicative of malignancy
59
Q

What are some subtle signs of malignancy in soft tissue masses?

A
  • deep location of the mass
    an intramuscular or deep mass would raise concerns of a sarcoma
  • large masses (according to the articles, typically bigger than 5cm)
    at the very least, I would suggest follow-up of these lesions
  • any skin changes such as thickening or dimpling would also be a visual observation
  • hypervascularity, heterogeneity, internal haemorrhage or necrosis, lobulations, invasion through tissue layers, taller than wide etc. would all warrant follow-up if not biopsy

If in doubt, follow-up ultrasound!

60
Q

What is desmoplastic reaction or desmoplasia?

A

Some malignant masses show changes in the surrounding tissues with increased echogenicity and vascularity

SON5024 MSK (15 decks)

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