And look at the fascial plane to evaluate whether

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) and look at the fascial plane to evaluate whether there is fluid tracking along the fascia ( Figure 11.3 ). If a fluid collection is seen, use Doppler flow to ensure that the anechoic space is not a vessel and to identify nearby Figure 11.1 Image demonstrating the normal ultrasound appearance of soft tissue and musculoskeletal layers. Note the hypoechoic subcutaneous tissue layer (*) separated from the linear striations of the muscle ( ± ) by a dense bright fascial line and the bright hyperechoic reflection of the bone (B). Diagnostic ultrasound 215 Soft tissue and musculoskeletal ultrasound
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vessels that may complicate incision and drainage ( Figure 11.4 ). Often, because abscesses are filled not with clear fluid but with debris, the echotexture of abscesses can be more heterogeneous and have increased gray-scale tones compared to simple fluid ( Figure 11.5 ). If it is difficult to see the outline of the collection because of this increased gray-scale, gentle pressure can be applied and the “squish sign” or movement of purulent material within the abscess can be seen in real time. Make sure to warn the patient before attempting this maneuver, however, since it has the potential to be painful. Musculoskeletal Scan along the entire extremity to be assessed – from its proximal to distal articulation. Begin in a longitudinal plane, and note the depth of soft tissue Figure 11.2 Cobblestoning. Figure 11.3 Dark fluid lining the fascial plane. 216 Diagnostic ultrasound Soft tissue and musculoskeletal ultrasound
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and the intact cortex (with distal shadowing). As the site of suspected fracture is approached, soft tissue swelling or hematoma, as well as a more obvious break in the cortex, may be noted. Although the longitudinal view is often more useful, transverse views may also demonstrate these findings and give information as to the degree of angulation or displacement. When evaluating the tendons, the longitudinal plane is better. Line up the probe in a position parallel to the length of the tendon. Occasionally a standoff pad or water Figure 11.4 Image demonstrating the proximity of vessels to a large abscess (A) and the clinical benefit of using Doppler prior to incision and drainage. Figure 11.5 The echotexture of an abscess (A) is often mixed, showing the debris and cellular material present in a purulent collection. B marks the bony shadows of the metacarpals. Diagnostic ultrasound 217 Soft tissue and musculoskeletal ultrasound
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bath (see Chapter 16 ) will be necessary for very superficial structures. Then observe the linear, fibrillar tendon ( Figure 11.6 ) throughout passive and active range of motion. Disruption in the tendon will cause the defect to widen with flexion and/or extension ( Figure 11.7 ). Figure 11.6 A normal tendon (T). Figure 11.7 A disrupted tendon. The break, with darker hemorrhage, shows as a disruption (D) of the normal linear, fibrillar pattern of the tendon (T).
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