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418
Fig. 11.16 US in muscular dystrophy. Echogenic
fi brous remnants of affected muscle (leg) in
Duchenne muscular dystrophy. A standardised
device setting essential for comparison and
follow-up by US
11 Small Part and Hip Ultrasound
Myositis
US Findings:
Altered echogenicity of swollen and enlarged muscle, potentially accompanying
fascial effusion and adjacent soft tissue involvement, sometimes hypervascularity
(CDS).
US may depict necrosis or abscess formation, assess extent and defi ne muscles
involved.
NOTE : US used to recognise and differentiate muscular atrophy and changes in
degenerative disease and other muscle dystrophies:
• Helps differentiate thin but normal muscle from fi brodystrophic, fatty degener-
ated muscles (appear hyperechoic and less striated/structured, with increasing
distal sound attenuation).
• US can help selection of biopsy site and improve success.
• Muscular dystrophy – muscle size normal to thickened; spinal muscular atrophy
– muscles thin; affected muscle groups can be depicted helping to decide on site
of muscle biopsy (to avoid undiagnostic punctures), by defi ning affected muscle
groups, the entity can be better defi ned in early stages (Fig. 11.16 ).
• Standardised views and transducer position as well device settings are extremely
important; potentially a future application of quantitative US-Elastography
• Myositis ossifi cans: often posttraumatic, may mimic tumours (Fig. 11.17 ).
Cellulitis
Usually diagnosis made clinically; US used to assess extent of involvement, complications (abscess) and differentiate from fasciitis:
• US fi ndings: enlarged echogenic subcutaneous tissue with irregular ovoid fl uid
collections; reticular hypoechoic striations occur. Findings nonspecifi c, insect
bites appear similar.
• CDS: hypervascularity and hyperemia.
Fasciitis
Often induced by minor superfi cial skin lesion and in immunocompromised patients:
• US fi ndings: perifascial fl uid, swollen and echogenic subcutaneous layer, (phleg-
monous), poor fascial border, muscle usually spared (Fig . 11.18 ).
11.3 Investigation of Bones, Joints, Tendons
Fig. 11.17 Myositis
ossifi cans. ( a ) Calcifi ed
haematoma adjacent to
bone. ( b ) Complex
infl ammatory reactive
changes of muscle
structure with liquid
compartment (++) and
several calcifi cations
a
b
419
a b
Fig. 11.18 Subcutaneous tissue pathology. ( a ) Oedematous subcutis and thickened, multilayered
fascia that is accompanied by some fl uid. ( b ) Subcutaneous emphysema: echogenic gas layer in
subcutis, hinders sound penetration to deeper areas and causes reverberation artefacts: sometimes
it’s important to recognise what cannot be seen and why
• In necrotising fasciitis, air/gas seen – no further US access to deeper structures
achievable (as in subcutaneous emphysema).
Tendinitis – Tendovaginitis/Synovitis
Not so common in children, however increasingly observed with excessive sports
and training with non-physiological strain (“overuse injury”):
420
Fig. 11.19 Tenosynovitis. Echogenic swollen
tendon with fl uid within the tendon sheath; note
echogenic adjacent soft tissue as a sign for
oedematous-infl ammatory reaction. Plenty of US gel
used causing the superfi cial dark area in front of the
skin with some echoic spots
11 Small Part and Hip Ultrasound
• Characterised by swelling and thickening of tendon sheath with some effusion,
tendon inhomogeneous and thickened, surrounding soft tissues can be edema-
tous and swollen (Fig. 11.20 ).
• CDS: often hypervascularity and hyperemia.
Osteomyelitis, Soft Tissue Abscess
Specifi c pathophysiology in early childhood: predominantly starting at physis, thus
involving not only bone but also joint with septic arthritis. US very helpful in early
phase.
• US fi ndings (Fig. 11.19 ):
– Thickening of joint capsule.
– Periosteal thickening.
– Subperiosteal collections – subperiosteal abscess (Fig. 11.20 ).
– Osseous surface disruption (when extending into spongiosa in later phase),
increased sound penetration into bone when already demineralised.
– Adjacent infl ammatory reaction and soft tissue oedema, (secondary) soft tis-
sue/periosteal abscesses.
– CDS: hypervascularisation and hyperemia.
NOTE : US = fi rst-line exam, complementary plain fi lm (and often MRI)
mandatory.
11.3.3.7 Neoplasia
Bone Tumours : US fi ndings in all bone tumours with extraosseous components or
bone erosion are very sensitive but nonspecifi c.
Childhood-specifi c bone tumours: osteosarcoma and Ewing sarcoma:
• Added value to mandatory plain fi lm: assessment of soft tissue components,
periosteum, vascularisation.
Other Soft Tissue Tumours : US fi ndings nonspecifi c, show tumour and relation to
surrounding structures (osseous, joint and vascular), give information on components (solid, cystic, necrotic, vascular, etc.).
Typical Common Childhood Entities: Lipoma, haemangioma, neurofi broma,
rhabdomyosarcoma, lymphangioma, vascular malformations, fi bromatosis of sternocleidomastoid muscle (neonates – see neck chapter).
11.3 Investigation of Bones, Joints, Tendons
a
c
e
421
b
d
Fig. 11.20 Abscess and osteomyelitis. ( a ) Subcutaneous abscess after injection. ( b ) 3DUS of a
parosteal abscess after IV line-induced thrombophlebitis in a newborn. ( c ) Subperiosteal abscess
(axial section) with more complex appearance and enormous surrounding infl ammatory changes.
( d ) Subperiosteal abscess – longitudinal view (+ +). ( e ) Osteomyelitis (split/dual image technique):
normal knee of an infant on left image. The right image of left knee ( L ) shows the abscess forma-
tion with a more prominent sound penetration into the less ossifi ed distal femoral metaphysis. Note
irregularities of the cortical border close to the physis
US Appearance
All features known from other imaging modalities (Fig. 11.21 ):
• Codman triangle and spicules – echogenic disruption of more or less homoge-
neously anechoic tumour bursting from cartilaginous or bony surface.
• Periosteal infi ltration (Fig. 11.22b ).
• I n fi ltration of soft tissues.
• Relation to joint, physis or muscles, tendons and vessels.
• Depicts solid or cystic component of soft tissue tumours.
• CDS: demonstrates vascularity, particularly valuable for haemangioma/vascular
malformations.
Some typical features that may help suggesting specifi c entities:
422
11 Small Part and Hip Ultrasound
Cartilaginous tumours – anechoic structure:
• Particularly in cartilaginous exostosis, US ideal for depiction and assessing
extent as well as judging cartilaginous component of exostosis and DDx from
enchondroma; diffi cult without plain fi lm.
• US useless in chondroma and osteochondroma when positioned within bone.
Osteosarcoma – irregular structure with bony cortical defects.
Ewing sarcoma – dominant periosteal reaction with paralleled echogenic
structure.
Other bone tumours ( lymphoma ) and metastasis only seen by US if outer ossifi ed
cortex disrupted.
Muscular and cutaneous metastasis more easily detectable, diffi cult to classify –
same approach as in any other body region (see neck chapter).
Pilomatrixoma – hypoechoic, cyst-like, well-defi ned tumour with typical central
spot like echo.
Lymphangioma [= (veno-)lymphatic vascular malformation] multiple cystic com-
ponents with thin walls, may contain echoes from haemorrhage (with sedimentation), some vessels in septae depictable (see Fig. 11.15c , see also chapter neck/
chest/mesentery).
Haemangioma and vascular malformation – more or less echogenic and homoge-
nous tissue with varying sharpness of margins (“capillary haemangioma”); large
tubular-cystiform hypoechoic structures (vessels), which may dominate picture in
venous malformations; fl ow seen on aCDS – can be classifi ed by spectral analysis
(shunt fl ow? High-fl ow haemangioma? Low-fl ow angioma? Only venous fl ow) (see
also chapter neck).
NOTE : US = fi rst-line exam. Plain fi lm + MRI (and sometimes CT) mandatory
according to specifi c oncology protocols.
11.3.3.8 Foreign Bodies
US most effective in detecting superfi cial or tiny foreign bodies using US stand- off
pads, copious US gel and/or high-resolution transducers; helpful to compare
affected and unaffected side.
US Findings
Depends on physical characteristics:
• Metal, glass – produce reverberation echoes (comet-tail artefact)
(Fig. 11.22a ).
• Wood – acoustic shadowing (Fig. 11.22b ).
NOTE : US also used successfully to guide foreign body removal (Fig. 11.22c ) – see
Chap. 2 and below.
11.3.3.9 Peripheral Nerves
Many applications, increasing importance:
• Continuity of major nerves after trauma.
• Compression of nerves (rare query in childhood).
• Recognition of nerve tumours (in childhood mostly neurofi broma) (see
Fig. 11.21 ).
11.3 Investigation of Bones, Joints, Tendons
423
ab
c d
e
f
gh
ij
Fig. 11.21 Bone and soft tissue tumours. ( a ) Osteosarcoma: soft tissue component of a bone
tumour with destruction of the cortical layer. ( b , c ) Pathologic fracture with neurofi broma: longitu-
dinal ( b ) and ( c ) axial section of affected hand. ( d ) Eosinophilic granuloma of the skull: note bony
spiculae in the soft tissue bony defect. ( e ) (Cartilaginous) Exostosis (+ +) with only narrow cartilagi-
nous layer. ( f ) Inhomogeneous hypoechoic soft tissue tumour of deep gluteal muscle which proved
to be a soft tissue sarcoma. ( g , h ) Septated, relatively clearly demarked tumour ( g ), with vivid colour
signals on CDS ( h ), consistent with a high-fl ow haemangioma. ( i ) US appearance of osteochon-
droma – thick cartilaginous layer, irregular cortical margin. ( j ) Osteosarcoma with typical spiculae
in exophytic soft tissue part of bone tumour, Codman triangle, perifocal reaction
424
11 Small Part and Hip Ultrasound
a
b
c
Fig. 11.22 Foreign body. ( a ) Reverberation caused by a metallic foreign body (similar to needles
for punctures). ( b ) Echogenic foreign body (wooden splinter causing acoustic shadowing) in the
wrist. Note infl ammatory reaction of the oedematous and swollen surrounding soft tissue.
( c ) Subcutaneous echogenic foreign body (+ +) without shadowing, but reverberations, consistent
with glass splinter (foot)
US Findings :
Normal nerve – anechoic linear-tubular structure (more compressible than potentially adjacent vessels: for DDx – CDS, exhibit fl ow).
• Detailed anatomic-topographic knowledge indispensable for identifi cation.
11.4 US for Peripheral Vessels
Same rules apply for US of vascular pathology as in adults and in other body areas
(see chapters abdomen and neck).
Except for (syndromic) malformations and posttraumatic/postinterventional
fi ndings (e.g. aneurysm), vessel disease is much rarer than in adults (no arteriosclerosis, rare thrombosis) (Fig. 11.23 ).
11.5 US-Guided Interventions
Many applications, increasing importance – details see Chap. 2 .
US ideal for guiding and monitoring procedure:
11.5 US-Guided Interventions
425
• Particularly in superfi cial structures and in children (radiation protection
issues!)
Typical Interventions / Indications
• Biopsies (suspected tumours).
• Aspiration and drainage (abscess, fl uid collections).
• Foreign body removal.
• Vascular access.
ab
c
d
ef
Fig. 11.23 Vascular conditions. ( a ) Tortuous large iliac vessels in a newborn with Klippel
Trenaunay and large vascular malformations of the respective leg, with high shunt fl ow. ( b ) CDS
of the vessels reveals high velocity and turbulent fl ow (same patient as a ). ( c ) Numerous large
atypical vascular structures identifi ed by CDS in the thickened and oedematous soft tissues of the
respective leg (same patient as in a ). ( d , e ) Venous thrombosis: no fl ow on aCDS ( d , longitudinal
section) within stiff, incompressible vein that exhibits stationary echoes within lumen ( e , axial
section). ( f ) Femoral artery aneurysm after vessel puncture, with colour jet and high fl ow velocities
into the aneurysm
426
11 Small Part and Hip Ultrasound
• Sclerotherapy (venous and lymphatic malformations) US-guided reposition (e.g.
epiphysiolysis).
Preparation
• Proper preparation essential for success.
• Initial assessment, informed consent, discussion with clinician, laboratory
assessment, time out.
• Sterile handling, analgesia and sedation, patient positioning.
• Adequate transducers with sterile covers and potentially needle guide:
– Needle guides less frequently used/cumbersome in small and superfi cial
structures.
– Freehand technique is usually preferred.
• Proper instruments readily available (needles of various sizes and length, cathe-
ters, medications, fi xation devices, haemostat, etc.):
– For biopsies: specimen-handling needs, microscope in intervention room,
pathology support.
• Monitor and document procedure.
• Post-procedural check and follow-up.
Practical Tips
• Use highest-frequency transducer that allows visualisation of target lesion.
• Set focal zone at target.
• Reduce near-fi eld echoes to improve needle visualisation.
• Align transducer with long axis of needle to visualise entire needle path.
• Try to maintain fl at angle for needle path, as parallel as possible to transducer
surface – needle poorly/not depicted if passes parallel to US beam.
• Scan with nondominant hand; keep in contact with the patient.
Index
A
Abdominal/mesenteric abscess , 282
Abernethy malformation , 233
Abscess formation , 150–151
aCDS. See Amplitude-coded colour
Doppler sonography (aCDS)
Acoustic cavitation , 17
Acute (infective) endocarditis ,
184–185
Acute myocarditis , 184
Acute pyelonephritis (aPN)/interstitial
nephritis , 345
Adrenal glands
haemorrhage , 366–367
infl ammatory condition , 367
normal fi ndings , 365, 366
tumours
adrenal adenoma , 367
adrenal cysts , 367
carcinoma , 200, 369–370
ganglioneuroma , 367, 369
neuroblastoma , 368–369
phaeochromocytoma , 369
Aerobilia , 248
A-(amplitude) mode , 9–10
Amplitude-coded colour Doppler
sonography (aCDS) , 31–32
Anencephaly , 92
Angiomyolipoma , 242
Angiosarcoma , 244
Annular pancreas , 270
α1-Antitrypsin defi ciency , 229
Aortic aneurysm , 280
Aortic coarctation (CoA) , 178, 179
Aplasia , 195
Appendicitis , 313–315
Arnold Chiari malformation ,
92–93
Artefacts. See also Colour Doppler
sonography (CDS)
anisotropy , 15
beam width artefact/increment or slice
thickness , 14
bowing artefacts , 11
marginal shadowing , 12–13
mirror image artefact , 14, 15
noise , 12
posterior enhancement , 13
refraction artefact , 15
reverberation enhancement , 14
shadowing , 15
side loop artefact , 12
Arteriosclerosis , 158
Arteriovenous fi stula (AVF) , 350
Arthritis
capsular thickening , 407
hip osteoarthritis , 408
joint fl uid/effusion , 407–408
Asplenia , 260
Atelectasis , 204–205
Atresia , 7–8
Atrial septal defect (ASD) , 173, 174
Atrioventricular septal defects (AVSD) , 173–174
B
B-(brightness) mode , 10
Biliary tract and gall bladder
aerobilia , 248
cholestasis and jaundice , 252
cholestatic changes/inspissated bile/gall
stone , 248–249
congenital conditions and normal variants
choledochal cyst , 247–248
hypo-/aplasia , 246–247
intrahepatic gall bladder , 245
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9, © Springer Berlin Heidelberg 2014
427