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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5765_Библиотеки_им_академика_М_И_Перельмана.pdf
262
8 Ultrasound ofNail Conditions
8.4.1.3 Cystic Subungual Conditions
Mucous Cyst
Denition
Cystic subungual structures produced by degeneration of
collagen.
Key Sonographic Signs
• Anechoic, round or oval (sometimes lobulated) structure
in the nail bed
a
• Occasionally, echoes representing debris may be seen
within the cyst.
• Posterior enhancement artifact is typically seen in uidlled entities.
• No vascularity within the cyst (Fig.8.34)
• If the cyst involves the matrix region, alterations such as
upward displacement, thickening, and irregularities of the
nail plate may be detected.
• Bony margin of the distal phalanx unremarkable, or slight
scalloping
• No connection to the distal interphalangeal joint [1, 2]
Fig. 8.34 Mucous cyst. (a) Clinical image of the nail of the right index
nger. (b, c) Ultrasound images (b, color Doppler; c, 3D reconstruction; longitudinal views) show an oval-shaped, anechoic structure that
produces posterior acoustic reinforcement and involves the matrix
region. Notice that there is no vascularity within the cyst. Upward displacement, thickening, and irregularities of the nail plate are observed.
On color Doppler (b), there is increased vascularity in the proximal nail
fold close to the cyst. Dip distal interphalangeal joint.
8.4 Benign Tumors andPseudotumors
b
c
263
Fig. 8.34 (continued)
264
8 Ultrasound ofNail Conditions
8.4.2 Periungual Origin
8.4.2.1 Solid Tumors andPseudotumors
Subungual Exostosis
Denition
Outgrowth of bone with or without cartilage from the distal
phalanx, which protrudes into the nail bed. The clinical
a
appearance of exostoses can easily mimic other nail conditions. Commonly, it affects the big toe.
b
Fig. 8.35 Subungual exostosis. (a) Clinical image of the nail of the
right big toe. (b–e) Ultrasound images of the right big toe (b, c,
greyscale; b, side-by-side comparative right-to-left longitudinal view;
c, transverse view; d, color Doppler, and e, 3D reconstruction, longitu-
dinal views) present an eccentric, hyperechoic irregular band (exostosis) that produces posterior acoustic shadowing and protrudes to the
medial aspect of the nail bed. This hyperechoic band is connected to the
bony margin of the distal phalanx and is accompanied by an upward
displacement of the nail plate as well as thickening and hypoechogenicity of the nail bed in its vicinity. On color Doppler (d), slight
hypervascularity in the nail bed is observed in the periphery of the
hyperechoic band. Video 8.18.
8.4 Benign Tumors andPseudotumors
c
d
265
f
Fig. 8.35 (continued)
266
8 Ultrasound ofNail Conditions
a
b
Fig. 8.36 Subungual exostosis. (a) Clinical image of the nail of the left
big toe. (b, c) Ultrasound images (b, color Doppler, and c, 3D reconstruction; longitudinal views) demonstrate a hyperechoic, irregular
band (exostosis) that produces posterior acoustic shadowing and pro-
trudes into the distal part of the nail bed. This hyperechoic band is connected to the bony margin of the distal phalanx. Color Doppler (b)
shows a slight increase of vascularity in the periphery of the hyperechoic band.
8.4 Benign Tumors andPseudotumors
c
Fig. 8.36 (continued)
267
268
8 Ultrasound ofNail Conditions
a
b
Fig. 8.37 Subungual exostosis. (a) Clinical image of the nail of the left
5th toe. (b, c) Ultrasound images (b, color Doppler, and c, 3D reconstruction; longitudinal views) show a hyperechoic band (exostosis) that
generates posterior acoustic shadowing and protrudes into the nail bed.
Hypoechogenicity of the nail bed and a slight increase of vascularity in
the periphery of the hyperechoic band are detected. These alterations
involve the matrix region. Thickening and loss of the bilaminar pattern
of the nail plate are detected. Color Doppler (b) shows a slight increase
of vascularity in the periphery of the hyperechoic band.
8.4 Benign Tumors andPseudotumors
c
Fig. 8.37 (continued)
269
Key Sonographic Signs
• Hyperechoic band (exostosis) in the nail bed that produces posterior acoustic shadowing (Figs.8.35, 8.36, and
8.37; Video 8.18)
• Commonly, eccentric in the nail bed
• Connection to the bony margin of the distal phalanx
• Hypoechoic cap on top of the hyperechoic band, in the
presence of cartilage
• Thickening and hypoechogenicity of the nail bed due to a
secondary inammatory and scarring reaction (Figs.8.35)
• Hypovascularity or hypervascularity in the periphery of
the hyperechoic band, depending on the degree of inammation of the nail bed [1, 2, 17]
270
8 Ultrasound ofNail Conditions
8.4.2.2 Cystic Tumors andPseudotumors
Synovial Cyst
Denition
Also called myxoid cysts, these are periungual cystic structures produced by the leakage of uid and/or synovial
proliferation that comes from the distal interphalangeal joint,
commonly associated with osteoarthrosis. These cysts usually affect the proximal nail fold.
a
Key Sonographic Signs
• One or more anechoic, round or oval-shaped cystic structures in the proximal nail bed
• Commonly eccentric in the proximal nail fold
• Connection to the distal interphalangeal joint through a
thin and tortuous anechoic duct
• Synovitis and osteophytes in the distal interphalangeal joint
• Extrinsic compression of the ungual matrix (Fig. 8.38
Video 8.19)
• Concavity and irregularities of the nail plate due to the
compression of the matrix region in the same axis of the
cyst [1, 2, 17, 21] (Fig.8.39).
Fig. 8.38 Synovial cyst. (a) Clinical image of the nail of the left index
nger. (b–d) Ultrasound images (b, c, greyscale transverse views; b, At
the proximal nail bed level and c, at the nail bed level; d, color Doppler,
longitudinal view) present an oval-shaped, anechoic structure at the
proximal nail fold, which produces extrinsic compression of the matrix
region (b). Notice the concavity (arrow) of the nail plate in (c, d) sec-
ondary to the extrinsic compression of the nail matrix. On color Doppler
(d), there is a slight increase of vascularity in the distal part of the nail
bed. See video 8.19.
8.4 Benign Tumors andPseudotumors
Fig. 8.38 (continued)
271
b
c
d