Visualizing the tendon throughout passive and active

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tion is intact is essential but can be difficult in the setting of an acute injury. Visualizing the tendon throughout passive and active range of motion can facilitate the identification and diagnosis of tendon disruption – and expedite consultation, referral, and/or treatment. Therefore, bedside ultrasound’s role in the evaluation of orthopedic injuries is threefold. First, in a select group of injuries, diagnosis and treat- ment may be more rapid by using ultrasound rather than other modalities. There is some evidence that ultrasound is superior to plain x-ray in selected fractures (sternal, rib) [ 5 –7]. In addition, there are some clinical scenarios where bedside diagnoses can expedite traction, anesthesia, and other maneuvers such as alignment through closed reduction [ 8 , 9 ]. Second, advanced imaging modalities are not always available. In some emergency departments, even plain x-rays take a significant amount of time to be performed, especially when performed serially in reduction procedures. In austere environments, portable bedside ultrasound technology may be all that is available, given the setup costs and bulk of x-ray, CT, and MRI machines. Third, increasing awareness of radiation exposure parameters continues to challenge assumptions about “safe” levels of exposure, and x-ray radiation is relatively contraindicated in some patients, especially children. Radiation exposure can be minimized using ultrasound as an alternative diagnostic tool, and ultrasound can be especially helpful in monitoring reductions. Focused questions for soft tissue and musculoskeletal ultrasound The questions for soft tissue ultrasound are as follows: 1. Is there any fluid collection? 2. Are there signs of fasciitis? 3. Is there a foreign body? The questions for musculoskeletal ultrasound are as follows: 1. Is there an interruption in the bony cortex? 2. Can a degree of angulation or displacement be assessed? 3. Is the tendon injured? Anatomy As described previously, subcutaneous tissue and muscle are readily visual- ized with ultrasound because they transmit sound well. Bone acts as a bright 214 Diagnostic ultrasound Soft tissue and musculoskeletal ultrasound
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reflector, yielding a strong echogenic signal and distal shadowing. The different soft tissue and musculoskeletal layers, including the epidermis, dermis, subcutaneous tissue, fascia, muscle, and bone, all have characteristic ultrasound features and are distinguishable as shown in Figure 11.1 . Technique Probe selection Use a high-frequency linear probe to best assess the superficial soft tissue and gain the highest resolution for imaging bony structures. However, if there is substantial soft tissue present, lower-frequency probes can be used. Views At least two views are useful (longitudinal and transverse) for all soft tissue and musculoskeletal applications. Soft tissue Scan with the linear probe from an area of normal tissue, fanning through the area of abnormal tissue entirely. Observe “cobblestoning” or fluid tracking throughout the subcutaneous tissue in areas of cellulitis or edema ( Figure 11.2
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