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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5765_Библиотеки_им_академика_М_И_Перельмана.pdf
232
8 Ultrasound ofNail Conditions
8.3.2 Lupus
8.3.2.1 Denition
Autoimmune disease that can affect several parts of the body,
such as kidneys, skin, blood, heart, muscles, and bones. It
may affect the endothelium of the digital arteries, producing
chronic inammation and thrombosis.
a
b
8.3.2.2 Key Sonographic Signs
• Hypoechoic material lling the digital arteries (Fig.8.14)
• Lack of blood ow within one or more digital arteries
• Increased thickness of the nail bed
• Irregularities and loss of the bilaminar pattern of the nail plate
• Hypovascular nail bed that may be secondary to the vascular involvement [1, 2]
c
Fig. 8.14 Lupus nail. (a) Clinical photograph of the left index nger.
(b–d) Color Doppler ultrasound (b, side-by-side comparison right to left
index nger; c, longitudinal view; d, transverse view of the radial aspect
of the left index nger) showing increased thickness (vertical white line)
d
and hypovascularity of the nail bed of the left index nger (b). There is
hypoechoic inammatory and thrombotic material (asterisk and arrow)
lling the radial digital artery of the same nger. In (c, d) notice the lack
(asterisks) of blood ow (color) within the lumen of the artery.
8.3 Inammatory Conditions oftheNail
233
8.3.3 Fluid Collections
8.3.3.1 Denition
Subungual pocket of uid.
8.3.3.2 Key Sonographic Signs
• Well-dened anechoic or hypoechoic subungual uid collection located between the ventral plate and the nail bed
(Figs.8.15 and 8.16; Video 8.6)
a
• Hyperechoic laminar or bilaminar edge at the bottom of
the uid collection
• Hyperechoic echoes with posterior reverberance due to
free air can be detected within the collection [1, 2].
b
Fig. 8.15 Fluid collection. (a) Clinical photograph of the right thumb. (b–
d) Greyscale ultrasound (b, longitudinal; c, transverse; d, 3D reconstruction
longitudinal; right thumb) demonstrates 7.8-mm longitudinal × 1.1-mm
thickness×5.1-mm transverse well-dened, oval-shaped, anechoic subun-
gual uid collection (asterisk, between markers) in the middle third of the
nail bed. Increased thickness and decreased echogenicity of the proximal
part of the nail bed, as well as thickening and decreased echogenicity of the
dermis of the proximal nail fold, are also detected.
234
8 Ultrasound ofNail Conditions
c
d
Fig. 8.15 (continued)
8.3 Inammatory Conditions oftheNail
a
b
235
Fig. 8.16 Fluid collection. (a) Clinical photograph of the right thumb.
(b) Greyscale (longitudinal view), (c) Power Doppler (longitudinal
view), and (d) 3D reconstruction (transverse view) of the right thumb
show 5.5-mm longitudinal × 0.9-mm thickness well-dened, oval-
shaped, anechoic subungual uid collection (asterisk, between markers) at the proximal part of the nail bed. Notice the hyperechoic line at
the bottom of the uid collection. Part (c) Shows increased subungual
blood ow beneath the uid collection. Video 8.6.
236
8 Ultrasound ofNail Conditions
c
d
Fig. 8.16 (continued)
a
8.3 Inammatory Conditions oftheNail
237
8.3.4 Median Canaliform Dystrophy
8.3.4.2 Key Sonographic Signs
• Decreased echogenicity and alterations in the thickness of
8.3.4.1 Denition
Central abnormality of the nail, with longitudinal splitting or
groove usually related to trauma and starting at or close to
the proximal nail bed, such as thickening and/or thinning
• Concavity and irregularities of the nail plate in the central
part of the nail [1, 2] (Fig.8.17; Videos 8.7 and 8.8)
the proximal nail fold.
b
cd
Fig. 8.17 Median canaliform nail dystrophy. (a) Clinical photo-
graph of the thumbs. (b) Greyscale ultrasound (side-by-side comparison, longitudinal view). (c) Greyscale (transverse view, left
thumb) and (d)Color Doppler (longitudinal view; left thumb) demonstrate thinning of the proximal part of the nail bed and thickening
with decreased echogenicity of the proximal nail fold of the right
thumb. Notice the irregularities of the nail plate (arrows and arrow-
heads), with a concavity in the central part of the left thumb (c). No
signs of hypervascularity are shown on color Doppler at the right
thumb (d).
238
8 Ultrasound ofNail Conditions
8.4 Benign Tumors andPseudotumors
8.4.1 Ungual Origin
8.4.1.1 Solid Tumors
Glomus Tumor
Denition
Subungual tumor derived from the neuromyoarterial apparatus. These tumors commonly produce exquisite ungual pain
and sensitivity to cold. According to literature, 95% of glomus tumors occur in ngernails and only 5% in toenails. A
a
majority of them (64%) appear in the proximal third of the
nail bed, with 9% in the middle third and 27% in the distal
third [1, 2, 13, 14].
Key Sonographic Signs
• Well-dened, hypoechoic, oval-shaped nodule
• Scalloping of the bony margin. Erosion of the bone is less
common.
• Dystrophic changes in the nail plate that are secondary to
the involvement of the matrix region
• Hypervascular 80%; hypovascular 20% (Figs.8.18, 8.19,
8.20, 8.21, and 8.22; Videos 8.7–8.12) [1, 2, 13–17]
c
b
Fig. 8.18 Glomus tumor (proximal location). (a) Clinical photograph
of the right index nger. (b–d) Ultrasound (b, Greyscale, longitudinal;
c, Greyscale, transverse; d, 3D reconstruction, longitudinal view) demonstrates 5.9-mm (longitudinal) × 3.1-mm (depth) × 3.9-mm
d
( transverse) well-dened, hypoechoic nodule in the radial aspect of the
proximal part of the nail bed, which produces scalloping of the bony
margin. Notice the hypervascularity within the nodule in the 3D view.
Videos 8.7 and 8.8.
a
8.4 Benign Tumors andPseudotumors
239
a
c
d
b
Fig. 8.19 Glomus tumor (proximal location). (a) Clinical photograph.
(b, c) Greyscale ultrasound (b, longitudinal; c, transverse) demonstrates
5.0-mm (longitudinal) × 2.3-mm (thickness) × 5.5-mm (transverse)
well-dened, hypoechoic solid nodule at the proximal part of the nail
bed. Notice the scalloping of the bony margin. (d) Color Doppler ultrasound (longitudinal view) shows hypervascularity within the nodule.
Videos 8.9 and 8.10.
b
Fig. 8.20 Glomus tumor (proximal location). (a) Clinical image
shows longitudinal erythronychia in the left thumb. (b–d) Greyscale
ultrasound images (b, longitudinal; c, transverse; d, longitudinal comparison between radial and ulnar aspect) show 3.8-mm (longitudinal) × 2.1-mm (thickness) × 3.7-mm (transverse) well-dened
hypoechoic nodule in the proximal part of the ulnar aspect of the nail
bed, in the same axis as the erythronychia; it produces scalloping
(arrow) of the bony margin of the distal phalanx. (e) Color Doppler
ultrasound (longitudinal view) demonstrates increased vascularity
within the nodule. Videos 8.11.
240
c
8 Ultrasound ofNail Conditions
d
e
Fig. 8.20 (continued)
8.4 Benign Tumors andPseudotumors
241
a
b
c
Fig. 8.21 Glomus tumor (proximal location). (a) Clinical photograph.
(b, c) Greyscale ultrasound (b, longitudinal view; c, transverse view)
demonstrates 4.7-mm (longitudinal) × 3.2-mm (thickness) ×3.9 mm
(transverse) well-dened hypoechoic nodule at the proximal part of the
nail bed, with prominent scalloping of the bony margin of the distal
phalanx (arrows).