Urgent Cases and Foreign Bodies Catherine J. Brandon, MD, MS University of Michigan Ann Arbor, MI, USA
Introduction: Patients added on to the schedule from the emergency department or as urgent add-on from the clinics can be grouped into several categories: Suspected septic joint Acute pain with trauma, pre-operative evaluation Acute pain in post-operative setting New or suspicious mass For these patients and their referring physicians, the ultrasound study can be critical to appropriate clinical management.
Ultrasound evaluation for foreign bodies also can guide clinical and pre-operative evaluation. Not only should the foreign body be detected and described but any potential complication to its removal should also be communicated to the referring physicians. Marking the skin to show site of entry and size and direction of the foreign body can aid in its surgical removal.
Suspected Abscess/ Septic Joint History: Dorsal hand swelling and tenderness after human bite during fist fight. US: Dorsal hand abscess. Classic appearance of purulent material with multiple echogenic foci.
Suspected Septic Joint: History: Hemophilia arthropathy and AIDS US: Septic ankle effusion with US guided aspiration (arrows). Hyperemia seen with synovitis. Marnix von Holsbeeck
Suspected Septic Joint: History: Two patients with posterior knee pain and mass US: Leaking Bakers cyst, fluid plus synovium in cyst. US: Infected Baker s cyst in septic knee, gas in cyst (star)
Suspected Septic Joint: History: Swollen knee US: Pre-patellar bursa effusion, trace knee joint effusion History: Posterior elbow pain and swelling. US: Tendinosis of triceps with reparative hyperemia
Suspected Septic Joint: Olecranon longitudinal Olecranon longitudinal History: Left: diabetic with gout. Right: triceps tendon rupture with hematoma and swelling US: Left: Olecranon bursitis with hyperemia from soft tissue infection. Right: Soft tissue swelling as reaction to triceps rupture. TX: Conservative non-operative
Suspected septic joint/tendon sheath needle History: Painful swollen wrist in patient with rheumatoid arthritis. Question infection on MR US: Inflammatory response of extensor carpi ulnaris tendon. Fluid within sheath. TX: US guided aspiration to document no infection.
Acute Pain with trauma panoramic longitudinal History: Direct trauma US: Fractured patella longitudinal History: Severe pain during basketball US: Complete patellar tendon rupture panoramic transverse History : Traumatic patella dislocation with fracture US: Lipohemarthrosis
Acute pain with trauma History: Varsity athlete with sudden onset pain during game. US: Avulsion fracture of the ankle capsule with effusion and fracture fragment. Normal for comparison.
Acute pain with trauma History: 70 yo felt pop in lateral foot while lifting luggage out of the car. US: Rupture of the peroneus longus tendon with fracture of the peroneal ossicle (os peronaeum). TX: Conservative treatment.
Acute pain with trauma History: Thumb trauma skiing US: Torn UCL: loss of fibrillar structure, fluid, and retraction: Sterner lesion (balled up UCL) US: Torn UCL not retracted US: Normal UCL
Acute pain with trauma History: Severe pain catching falling box. US: Distal biceps tendon rupture with proximally retracted tiny bone avulsion fragment producing shadowing in the torn stump.
A panoramic longitudinal Normal longitudinal History: Severe pain catching falling box. US: Distal biceps tendon (arrows) after complete tendon tear from radial tuberosity (star). Typical fibrillar tendon pattern is absent. Tendon stump is retracted proximally (double headed arrow) 13 cm with shadowing from the torn fibers (arrowhead).
distal biceps, torn distal biceps, intact US: Since the distal biceps insertion on the radial tuberosity is difficult to see, scanning the elbow in 90 degree of flexion helps in ultrasound and MR.
Acute pain with trauma History: Pain in Achilles US: Achilles tendon thickening from tendinosis US: Achilles tendon proximal tear dorsiflexion plantar flexion US: Dynamic: gap between stumps decreases plantar flexion plantar flexion
Post-operative pain transverse longitudinal History: Lateral ankle pain, with dorsiflexion, after plate and screw fixation of distal fibular fracture. US: Plate and elevated screw (star). Peroneal longus tendon subluxes over screw with dorsiflexion (yellow arrow). TX: Hardware removed.
Post-operative pain peroneal longus tendon longitudinal transverse History: Post ORIF continued pain over peroneal tubercle of calcaneus. US : retained fracture fragment (yellow arrow) cutting into the peroneal longus tendon. TX: Operative removal
Post-operative pain History: Inguinal hernia repair with mesh. Patient now feels some pain and irritation in groin. US: Color flow demonstrates artifact associated with mesh and reassures the patient of intact repair.
Post-operative pain longitudinal History: Flexor tendon of the ring finger cut in industrial accident. Has undergone repair but sudden onset of pain after playing catch ball US: Intact flexor tendon without tear at the repair site.
Post-operative pain transverse longitudinal History: New pain and swelling at volar wrist distal radial plate operative site. US: Fluid collection (arrow) from incision to plate (star) with debris. US guided aspiration demonstrated infection. TX: Operative removal of plate and treatment.
Suspicious Mass History: New (?) mass on the ankle, decreased range of motion. US: Mass with blood flow within the anterior ankle joint. Focal PVNS on US guided biopsy.
Suspicious mass longitudinal transverse History: New palpable mass along the anterior abdominal wall in diabetic. US: Palpable mass is pump tubing connector for newly implanted pump and tubing placed deep in the subcutaneous tissues. Note posterior shadowing.
Foreign body History: Wooden toothpick stuck into hand during party. Fragments remain. US: Small hypoechoic halo of granulation tissue around the wooden fragment aids identification. TX: Removed surgically.
Foreign body longitudinal transverse History: Injuries while gardening US: Thorn adjacent to a flexor tendon ( ) (left). Wood fragment with granulation tissue entering transverse flexor tendon sheath (right)
Foreign body History: Hit in the mouth during car accident. Fragments of tooth seen on film. Laceration in lower lip. US: Tooth fragment as hyperechoic linear structure identified just within the laceration. TX: Surgical removal and repair of lip.
Foreign body History: Injury during metal work at factory US: (Clip) Metallic fragments adjacent to median nerve. Unsuspected partial cut of the nerve demonstrated TX: Damage to nerve confirmed and repaired surgically.
Summary: Ultrasound in the emergent, urgent and just need to know setting can provide a wide range of critical diagnoses for clinical management, pre- and postoperative evaluation and patient reassurance as the above cases have demonstrated.