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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5765_Библиотеки_им_академика_М_И_Перельмана.pdf
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8 Ultrasound ofNail Conditions
Keratoacanthoma
Denition
Rapidly growing subungual squamous proliferation that is
considered by some authors to be a simulator or a low-grade
squamous cell tumor. In contrast with the cutaneous presentation, the subungual variant tends not to present spontaneous regression.
a
Key Sonographic Signs
• Hypoechoic rim
• Anechoic or hypoechoic center (crater lled with
keratin)
• Posterior acoustic reinforcement artifact
• Eccentric
• Scalloping or erosion of the bony margin of the distal
phalanx (Fig.8.28)
• Hypovascular or intermediate degree of vascularity within
the tumor, with low-ow vessels [1, 2, 15, 19, 20]
b
Fig. 8.28 Keratoacanthoma. (a) Clinical image of the nail of the right
thumb. (b–d) Ultrasound images (b, greyscale; c, color Doppler; d, 3D
reconstruction; all longitudinal views) demonstrate 10.7-mm (longitudinal)×7.5-mm (thickness) subungual structure with a hypoechoic bor-
der (o) and a darker hypoechoic center (asterisk) that produces
scalloping of the bony margin of the distal phalanx. On color Doppler
(c), an intermediate degree of vascularity is detected in the periphery of
the tumor (in colors).
8.4 Benign Tumors andPseudotumors
c
d
253
Fig. 8.28 (continued)
254
8 Ultrasound ofNail Conditions
8.4.1.2 Solid Pseudotumors
Granuloma/Telangiectatic Granuloma
Denition
Proliferative scarring, brous, and inammatory reaction
that generates a mass-like tissue. It may involve the matrix
region and dystrophic changes in the nail plate. The telangiectatic (vascular) form of presentation presents prominent inammation and can show tenderness and easy
bleeding.
a
Key Sonographic Signs
• Ill-dened hypoechoic structure
• Thickening in the nail bed, or concomitant areas of
increased and decreased thickness
• Wavy or irregular nail plate due to involvement of the nail
matrix
• Lack of alteration of the bony margin of the distal
phalanx
• Vascularity varying from hypovascular to hypervascular
(telangiectatic variant) with low-ow vessels (Figs.8.29,
8.30, 8.31, and 8.32, Videos 8.15, 8.16, and 8.17) [1, 2].
Fig. 8.29 Granuloma.
(a)Clinical image of the nail of
the right thumb. (b and c)
Ultrasound images (b, greyscale;
c, power Doppler; longitudinal
views) show ill-dened
thickening and hypoechogenicity
of the nail bed with thinning of
the proximal part of the nail bed
(arrow in b), thickening of the
middle part, and thinning of the
distal part. On power Doppler
(c), a slight increase of
vascularity is detected in the
distal part of the nail bed (in
colors). Notice that the bony
margin of the distal phalanx is
unremarkable.
b
8.4 Benign Tumors andPseudotumors
Fig. 8.29 (continued)
255
c
a
Fig. 8.30 Granuloma. (a) Clinical image of the nail of the right middle
nger. (b, c) Ultrasound images (b, greyscale; c, power Doppler; both
longitudinal views) demonstrate ill-dened thickening and hypoechogenicity of the nail bed that involves the matrix region. The nail plate
has lost its bilaminar pattern and there is upward displacement of the
nail plate region. On power Doppler (c), an intermediate degree of
hypervascularity is observed in the proximal two-thirds of the nail bed.
No signs of abnormality are detected in the bony margin of the distal
phalanx.
256
Fig. 8.30 (continued)
8 Ultrasound ofNail Conditions
b
c
Fig. 8.31 Granuloma. (a) Clinical image of the nail of the right big
toe. (b–c) Ultrasound images (b, greyscale; c, color Doppler; longitudinal views) demonstrate ill-dened thickening and hypoechogenicity of
the nail bed that involves the matrix region and predominates in the
proximal part of the nail bed. Thickening, shortage, upward displacement, and loss of the bilaminar pattern of the nail plate are detected. On
color Doppler (c), prominent vascularity is observed in the distal part of
the nail bed. The bony margin of the distal phalanx remains unremarkable. Video 8.15.
a
8.4 Benign Tumors andPseudotumors
b
c
257
Fig. 8.31 (continued)
258
8 Ultrasound ofNail Conditions
Fig. 8.32 Telangiectatic
granuloma. (a) Clinical image
of the nail of the left big toe.
(b–d) Ultrasound images (b,
panoramic greyscale; c, power
Doppler; d,color Doppler,
side by side right-to-left
comparison; longitudinal
views) show ill-dened,
hypoechoic and heterogeneous
thickening of the nail bed that
involves the matrix region.
There is a loss of the
bilaminar pattern of the nail
plate and wavy shape of the
tissue on top of the nail.
Power Doppler (c)and color
Doppler (d) show diffuse and
prominent hypervascularity in
the nail bed of the left big toe.
The bony margin of the distal
phalanx show some
irregularities in the distal part,
but the rest is unremarkable.
Videos 8.16, and 8.17.
a
b
8.4 Benign Tumors andPseudotumors
c
d
259
Fig. 8.32 (continued)
260
8 Ultrasound ofNail Conditions
Subungual Wart
Denition
Viral infection of the nail bed by the human papillomavirus, which produces an inammatory broepithelial
reaction.
Key Sonographic Signs
• Frequently, they show as an ill-dened focal hypoechoic
thickening of the nail bed and sometimes with a fusiform
shape
a
• Eccentric
• Common involvement of the hyponychium and the adjacent nail bed. Occasionally, they can affect the lateral or
proximal periungual regions and nail bed, including the
matrix region
• Thickening and irregularities of the nail plate are detected
if the nail matrix region is involved.
• Bony margin of the distal phalanx unremarkable
• Vascularity varying from hypovascular to hypervascular
with low-ow vessels in the affected region (Fig. 8.33)
[1, 2].
Fig. 8.33 Subungual wart. (a) Clinical image of the nail of the right index
nger. (b, c) Ultrasound images (b, greyscale; c, color Doppler; transverse
views) demonstrates 3.8-mm (transverse)×2.1-mm (thickness), fusiformshaped, hypoechoic focal region (asterisk) in the nail bed, which also
involves the radial aspect of the periungual region, with focal loss of the
bilaminar pattern and irregularities and hyperechoic spot of the nail plate
in the affected region. Color Doppler (c) shows increased vascularity of
the nail bed and periungual nail fold in the vicinity of the wart (asterisk).
8.4 Benign Tumors andPseudotumors
b
261
Fig. 8.33 (continued)
c