Atlas of Musculoskeletal Ultrasound P.K. Srivastava
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Sonography of MusclesCHAPTER 1

High-resolution sonography can provide more information about muscles than other imaging modalities like MRI or CT scanning. The availability of examination and low cost make it more practical and affordable technique than MRI. In today era the sport injury makes the largest group, as it constitutes about 40% of the patients who are referred to HRSG evaluation.
Since muscles are dynamic structures therefore, they need dynamic real time study for proper evaluation of muscles and related injury. State-of-the-art equipment with cine loop facility is excellent and very helpful for muscle evaluation. Identification of muscle can be made by its location, origin, insertion and function. All these can be easily done under sonographic vision.
 
Muscle Pathology
Majority of muscle pathology are traumatic either job related or sports injury. A small group falls into tumor category.
The lesions can be grouped into two:
  1. Intramuscular
  2. Muscle boundary lesion.
 
Intramuscular Lesion
The intramuscle lesions are the lesions confined to the muscles. They are as follows:
 
Muscle Rupture
Muscle rupture can be caused by direct trauma or indirect trauma as muscles are crushed against under lying bones. HRSG is good to evaluate compressive muscle rupture. Irregular cavity and shaggy borders characterize USG findings. USG clearly shows disruption of muscle fibers. Complete muscle rupture is rare, partial muscle rupture is more common.
 
Hematoma
Hematoma formation is hallmark of muscle rupture. Size of Hemorrhage is related to extent of injury. USG is very good for evaluation of Hemorrhage and resorption of Hemorrhage can be studied on USG. Muscle cysts may be chronic or traumatic. They may be extension of synovial cyst.
 
Myositis Ossificans
Muscle contusion with intramuscular hemorrhage may calcify and then ossify. These lesions are the frequent findings in athletes involved in contact sports. Evaluation of myositis ossificans is easy with sonography. Maturation of these lesions takes about 5–6 months. It is identified as soft tissue mass with disorganized inhomogeneous consistency. It is at time difficult to differentiate it from soft tissue neoplasm. 2
 
Myositis
HRSG is very helpful in early detection of myositis when the clinical picture is nonspecific. The muscle becomes hypoechoic due to exudation and muscle edema. Comparison with normal side will differentiate the affected side. A fulminating myositis will result in abscess formation secondary to osteomyelitis.
 
Tubercular Abscess
Tuberculosis of the muscle is not very common. Now it is seen frequently in more resistant type of tuberculosis. Most of the time it is seen as an isolated abscess formation involving the muscle groups in the body. However, it may be associated with systemic disease. Many times it can present as vascular ischemic contracture when seen involving the muscle group of forearm. HRSG findings are non-specific. But it shows irregular hypoechoic low-level echo complex abscesses with loss of normal muscle texture. Central area of necrosis is seen in the abscess. Perifocal edema may present when superadded infection is seen.
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Figures 1.1 to 1.3: Normal Anatomy. HRSG shows typical normal bipinnate pattern of skeletal muscle. Echogenic fibrous septa are seen running through the muscle. The muscle fibers are seen arranged in bipinnate fashion.
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FigURES 1.4 AND 1.5: Acute Myositis. A patient presented with calf pain with swelling. HRSG shows diffuse edema of gastrocnemius muscle. The muscle fibers show sparse appearance. Soft tissue edema is seen in the muscle fibers. Muscle texture is hazy due to edema.
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Figures 1.6 to 1.10: Acute Myositis. A patient presented with marked soft tissue edema and acute pain while walking. HRSG shows swollen edematous calf muscles. Muscle fibers edema is present. A hypoechoic pocket of collection of fluid is also seen in the muscle. But no calcification is seen. No tear is seen. On color flow imaging, poor flow is seen in the muscles. Findings are consistent with acute infection of the calf muscle.
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FigURES 1.11 TO 15: Acute Fasciitis with Myositis. A patient presented with marked soft tissue swelling over the thigh with acute pain. High resolution ultrasound shows marked soft tissue edema in the subcutaneous tissue plane. Dermis and hypodermis edema is present. The subcutaneous fat shows focal area of necrosis. Fascial plane is obliterated. On 3D imaging dermis and hypodermis edema with inflammation is clearly seen. The underline thigh muscles are also hypoechoic and edematous suggestive of acute cellulitis, fasciitis with myositis.
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Figures 1.16 to 1.18: Muscle Abscess. A young child presented with soft tissue swelling over the flexor group of muscles of Rt forearm. HRSG shows pocket of thick collection in the flexor group of muscles. Marked soft tissue edema is also present. Perifocal edema is present in the muscle plane. Hypoechoic pockets of low level echo collection is also seen in the subcutaneous tissue planes. Disorganization of normal texture of muscle is seen. Findings are suggestive of cellulitis with subcutaneous soft tissue abscess formation with acute myositis.
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FigURES 1.19 AND 1.20: A young child presented with soft tissue swelling over the Lt arm, which is red and hot. The child was suffering with high fever. HRSG shows a big low level echo complex mass in the belly of biceps muscle. Central area of necrosis is seen in the mass. Perifocal edema is also present. Pressure is seen on the adjoining tissue. Thick capsule is seen around it. It appears as a big abscess in the belly of biceps muscle. But no evidence of any bony involvement is seen.
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Figures 1.21 to 1.25: Elbow Abscess. A patient presented with soft tissue mass over medial side of elbow. It was hot and tender. HRSG shows a well encapsulated thick walled mass. Central area of necrosis is seen in it. Echogenic debris is also seen in the mass. Marked soft tissue edema is also seen around it. On color flow imaging no flow is seen into it. However, pressure is also seen on the ulnar artery and nerve by the mass.
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Figures 1.26 to 1.31: Arm Abscess. A patient presented with soft tissue swelling over the Rt arm on the lateral aspect with acute pain and restricted movements. HRSG shows a diffuse swelling with low level echo complex mass involving the deltoid muscle. Thick echoes are seen in it. Hypoechoic areas are also seen suggestive of small abscess. The margins are shaggy. There is also evidence of pressure seen on the radial nerve by the abscess. Subcutaneous soft tissue edema is also seen associated with the mass.
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FigURES 1.32 AND 1.33: Acute Abscess in the Forearm. A four years child presented with fever and soft tissue swelling on the flexor surface of Rt forearm. HRSG shows a low level echo complex mass in the flexor group of muscles. Homogeneous echoes are seen in it. But no cystic degeneration is seen suggestive of acute abscess formation.
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Figure 1.34: Muscle Abscess. A patient presented with soft tissue mass over the Rt arm, which was tender and associated with restricted arm movement. HRSG shows a low level echo complex mass in the belly of biceps muscle. It shows shaggy margins. Thick echoes are seen into it. But no central area of necrosis is seen into it. Findings are suggestive of acute muscle abscess.
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Figures 1.35 to 1.39: Pyogenic Muscle Abscess. A-19-year-old boy presented with acute painful swelling over the Lt shoulder girdle over the scapular region. HRSG shows a big irregular hypoechoic low-level echo complex mass involving the Lt infraspinatus muscles. The muscle was edematous. The thick collection is seen in the belly of muscles suggestive of abscess. Layering sign was positive. On color flow imaging, no flow seen in the abscess.
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Figure 1.40: Tubercular Muscle Abscess. A young lady presented with a soft tissue mass swelling over the flexor surface of the Lt forearm. The fingers are flexed.
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Figures 1.41A and B: X-ray of the forearm shows normal bone with soft tissue.
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Figure 1.42: HRSG shows low-level echo complex mass in the flexor group of muscles. The normal texture is lost. However, muscle capsule is intact, suggestive of an abscess.
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Figure 1.43: Power Doppler imaging of the mass shows peripheral flow. The FNAC of the mass was tubercular abscess.
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Figure 1.44: A young boy presented with flexion deformity of fingers and wrist. Soft tissue swelling is seen over the flexor surface of the arm. Clinically it was suspected as vascular ischemic contracture (VIC).
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Figure 1.45: Shows an abscess in the flexor group of muscles. Multiple internal echoes are seen in it.
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Figure 1.46: Color Doppler imaging shows pressure on the vessels. But no vessels wall involvement is seen. FNAC shows tubercular abscess.
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Figure 1.47: Forearm Abscess Presented as VIC. A young girl presented with flexion deformity in the wrist with a palpable lump on the forearm. Clinically it was suspected as vascular ischemic contracture.
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Figure 1.48: HRSG shows low-level echo complex mass in the flexor group of muscles of forearm. Central area of necrosis is seen in it suggestive of an abscess.
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Figure 1.49: A young child presented with Lt flank swelling, which is seen extending to the lower part of the flank and to the anterior part of the thigh.
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Figures 1.50 to 1.52: HRSG extended field of view shows a big pocket of collection which is seen extending from Lt paralumbar region to the lower flank. The pocket of collection is also seen extending to medial to the Lt thigh. Thick echo collection is seen into it. The collection was aspirated under ultrasound guidance and straw-color fluid came out.
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FigURES 1.53 AND 1.54: Multiple enlarged nodal shadows are seen in the neck in supraclavicular and mid-cervical region. The findings are suggestive of tubercular collection.
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Figures 1.55 to 1.57: Tubercular Abscess in Rt Paraspinal and Iliac Fossa. A young girl presented with a big soft tissue mass over the Rt paraspinal region. Ultrasound shows a big pocket of collection in the Rt paraspinal region, which is seen going down and reaching upto the Rt iliac fossa. The collection is also seen displacing and compressing the Rt kidney from its normal position. Findings are consistent with big paraspinal tubercular collection extending to the Rt iliac fossa as described above.
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Figures 1.58 to 1.60: A young girl presented with soft tissue swelling over the Lt hip medial side, which is seen extending medially. HRSG shows a pocket of thick collection at medial side of Lt hip. Homogeneous echoes are seen in the collection. The collection is also seen extending to the Lt suprapelvic region. However, no suggestion of any extension is seen in the hip joint. On aspiration, straw colored fluid came out suggestive of tubercular collection.
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FigURES 1.61 AND 1.62: Paraspinal Tubercular Collection. A young girl presented with soft tissue swelling over the Lt lower paraspinal region. A well-defined pocket of collection is seen in the Lt paraspinal space. Homogeneous echoes are seen into it. The collection is also seen extending to the Rt paraspinal region. Irregular bony erosion is also seen in the appendage of lower lumbar vertebra suggestive of tubercular collection with bony erosion.
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Figures 1.63A and B: Gluteal Abscess. A young child presented with hard soft tissue mass over the Rt gluteal region. On HRSG, pocket of thick collection is seen in the gluteal region. Irregular and ill-defined areas are seen in the collection. But no cystic necrosis is seen. On color flow imaging poor flow is seen into it suggestive of organized abscess.
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FigURES 1.64 AND 1.65: A patient presented with painful Lt hip and difficulty in walking. He could not able to stretch his leg. HRSG shows a pocket of thick collection in Lt iliac fossa. It is seen extending to Lt paralumbar region and displacing the Lt kidney from its axis suggestive of big psoas abscess extending to the Lt iliac fossa.
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Figures 1.66 to 1.68: Paraspinal Abscess. HRSG shows a big pocket of collection in Lt lower paraspinal region. Thick echoes are seen in the collection, which is seen extending and crossing the midline.
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Figures 1.69 to 1.71: Paraspinal Abscess with Sinus Formation. HRSG shows a pocket of thick collection in Rt paraspinal space. The collection is seen extending to the opposite side. A sinus tract is also seen communicating with the collection. Low level echoes are seen in the sinus tract. Associated bony erosion is also seen in the vertebra.
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FigURES 1.72 AND 1.73: Psoas Abscess. A patient presented with painful walking and unable to extend Rt leg. On USG, a thick pocket of collection is seen in Rt iliac fossa, which is seen extending to the Rt paralumbar region involving the psoas muscle. On color flow imaging no flow is seen in it suggestive of big iliac psoas abscess.
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FigURES 1.74 AND 1.75: Paraspinal Abscess. A young female child of 1 year of age presented with big soft tissue swelling over the Lt paraspinal space at the back. HRSG shows a big pocket of low level collection in Lt paraspinal space involving the lower lumbar region. Homogeneous low-level echoes are seen in it. But no septation is seen suggestive of big paraspinal tubercular abscess.
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Figures 1.76 to 1.78: A young patient presented with acute pain and swelling in the flexor compartment of forearm. HRSG shows a low-level echo complex mass in the flexor group of muscles. Marked soft tissue edema is seen around it. On color flow imaging poor flow is seen in it. Central area of necrosis is also seen in it. Findings are consistent with pyogenic abscess.
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Figures 1.79 to 1.81: Acute Pyogenic Abscess at Rt Arm. A patient presented with painful swelling in arm. HRSG shows a big low-level echo complex mass at the medial side of the bone. It shows inhomogeneous texture. Central area of necrosis is seen into it. Marked soft tissue edema is seen around it. Subcutaneous soft tissue edema is also seen. On color flow imaging low flow is seen into it suggestive of pyogenic abscess.
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Figures 1.82 to 1.86: Synovial Membrane Granuloma. A patient presented with soft tissue swelling over the Rt wrist. She complains of pain in the movement of fingers. HRSG shows a big soft tissue membranous shadow seen in the flexor compartment of wrist joint. It is seen extending in the Rt palm. The membranous shadows show gliding movements with the movements of the tendon. On color flow imaging no flow is seen in it. On USG guided biopsy it turned out to be tubercular granulomatous tenosynovitis.
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Figure 1.87: A patient presented with marked soft tissue swelling over the knee and involving the lower thigh with painful knee movements.
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Figures 1.88 to 1.91: HRSG of the knee shows thick collection in the knee joint. Synovial membrane proliferation is also seen. The collection is also seen in the suprapatellar bursa, lateral and medial recess and capsule of joint. But no associated bony erosion is seen. On biopsy of membranous mass suggests chronic tubercular tenosynovitis.
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Figure 1.92: Cystic Degeneration of the Shoulder Girdle Muscle. A young girl presented with freely hanging Lt arm. Plane X-ray of the shoulder shows soft tissue mass shadow. However, the bones are absolutely normal.
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FigURES 1.93 AND 1.94: HRSG shows cystic degeneration of the muscles involving the Lt shoulder girdle. The deltoid biceps and triceps muscle show cystic degeneration with low-level echo collection in the muscles. Normal muscle anatomy was lost. The collection is also seen anterior to the humerus shaft. The bony shaft was normal.
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Figure 1.95: On color flow imaging the vessels are seen intact.
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Figure 1.96: Cystic Degeneration of Calf Muscles. X-ray of the patient shows soft tissue mass over the Lt calf. The bones are normal.
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FigURES 1.97 AND 1.98: HRSG shows a big cystic degeneration of the calf muscles. The degenerated muscle bundles are seen floating in the cyst. Normal muscle texture is lost. Aspiration of the cyst shows chronic degeneration of the muscle.
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FigURES 1.99 AND 1.100: Pilonidal Sinus with X-ray Sinogram. A young boy presented with discharging sinus in the gluteal region just above the anal opening on the Lt side. Sinogram shows a sinus tract with pooling of the dye in the sinus cavity. Branching of the sinus is also seen on X-ray sinogram.
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Figures 1.101 to 1.103: Pilonidal Sinus in the Gluteal Cleft. High-resolution sonography of the same patient shows obliquely running sinus in the Lt gluteal cleft. Highly echogenic linear band-like shadow is seen embedded in the sinus suggestive of hair tuft. Exploration confirmed the sonographic findings.
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Figure 1.104: Pilonidal Sinus. A patient presented with discharging sinus in the gluteal region. HRSG shows obliquely sinus in the gluteal region. An echogenic linear shadow is seen in the sinus running obliquely suggestive of hair tuft.
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Figure 1.105: On color flow imaging low flow is seen in the wall. Exploration confirmed the sonographic findings.
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Figures 1.106 to 1.110: Pilonidal Sinus. A patient presented with complaint of hair in the natal cleft. HRSG shows a tuft of hair in the natal cleft, which is seen buried in the perineum and extending in the deeper tissue. On 3D imaging the tuft of hair stands out clearly.
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Figures 1.111 to 1.114: A patient presented with acute pain in Rt arm with soft tissue swelling and restricted arm movement. HRSG shows a pocket of thick collection in the belly of biceps muscle. A well defined cyst is seen in the collection. The cyst shows an echogenic nidus fixed with the inner wall of the cyst. It is seen surrounded by the collection. On 3D ultrasound and tomographic ultrasound imaging, the cyst with nidus is seen clearly. It appears to be a cysticercus cyst with hemorrhagic collection around it.
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Figures 1.115 to 1.119: On 3D ultrasound imaging, another ruptured cyst is seen in the biceps muscle. An echogenic nidus is seen floating in the collection suggestive of free floating scolex. The acute pain in arm was due to rupture of another cyst resulting into hemorrhagic collection. The 3D and TUI imaging show clearly the intact cyst with free floating scolex of ruptured cyst in hemorrhagic collection.
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Figures 1.120 to 1.122: A patient presented with painful soft tissue swelling of the Lt arm. HRSG shows a well defined cyst in the forearm muscle. The cyst shows well defined echogenic nidus fixed with inner wall of cyst. On 3D imaging it stands out clearly. On color flow imaging poor flow is seen around it. Findings are consistent with cysticercus cyst.
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Figures 1.123 to 1.125: Cysticercus Cyst in Forearm. A young child presented with painful swelling in Rt forearm on flexor surface. HRSG shows a thick walled cystic mass in the flexor group of muscles. A dense echogenic nidus is seen fixed with the inner wall of cyst. The wall of cyst is shaggy in outline due to muscle edema. On color flow imaging poor flow is seen around the cyst. Findings are suggestive of cysticercus cyst.
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Figures 1.126 to 1.128: Contusion Injury to the Muscle. A patient presented with direct injury to muscle in the Rt thigh on anterior aspect. HRSG shows disorganized texture of quadriceps femoris muscle. Soft tissue edema is present in the muscle. Echogenic texture of the muscle is seen suggestive of muscle edema. A small pocket of echogenic collection is also seen in the belly of muscle suggestive of hematoma.
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Figures 1.129 to 1.32: Acute Injury with Fresh Hematoma Formation. A patient presented with marked soft tissue swelling over the anterior aspect of Rt thigh by direct trauma. Ultrasound shows a pocket of echogenic collection in the belly of anterior surface of muscle. It shows homogeneous echoes which show slow movement on pressure. Collection shows ground glass appearance with layering. Fresh blood looks echogenic on HRSG. It is a typical feature of acute fresh bleed.
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Figures 1.133 to 1.137: Muscle Rupture. A patient presented with acute pain in Rt thigh on the anterior aspect after sustaining trauma. Ultrasound shows a big linear cleft in the belly of quadriceps femoris muscle. Low level echoes are seen in the cleft. The extended field of view shows the entire length of tear in muscle.
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FigURES 1.138 AND 1.139: Oblique Muscle Tear. A patient presented with soft tissue trauma to Rt calf muscle with painful movement and soft tissue swelling. HRSG shows diffuse edema of gastronemius muscle. Oblique cleft is seen running in the belly of muscle suggestive of tear. Disruption of muscle fibers are seen at the site of tear. On color flow imaging no flow is seen in the tear.
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Figures 1.140 to 1.142: Contusion Injury to the Calf Muscle with Muscle Edema. A young boy presented with complaint of soft tissue trauma to Rt leg and calf with painful swelling. HRSG shows diffuse edema of the soleus muscle in the calf. The echogenic foci in the muscle show diffuse edema. A hypoechoic cleft is also seen in the posterior belly of soleus muscle suggestive of radial tear.
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Figures 1.143 to 1.145: Contusion Injury in the Calf Muscle. A patient presented with history of soft tissue trauma in Rt calf with painful swelling. HRSG shows diffuse muscle edema involving the calf muscles. The muscle fibers show echogenic foci dispersed in the muscle suggestive of small hemorrhagic pockets. A small hypoechoic cleft is also seen in the belly of muscle suggestive of small tear.
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Figures 1.146 to 1.148: A Big Oblique Tear in the Gastrocnemius Muscle. A patient presented with marked pain, swelling over the Rt calf with limping after sustain direct trauma. HRSG shows a big obliquely running cleft in the belly of gastrocnemius muscle. Low level echoes are seen in the tear suggestive of associated hemorrhage. On extended field of view complete extent of the tear is seen in the gastrocnemius muscle. This tear is caused due to elongation injury to the muscle.
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Figures 1.149 to 1.152: Quadriceps Muscle Tear. A patient presented with soft tissue injury in quadriceps muscle of Rt thigh by a sharp object. HRSG shows a big obliquely running radial cleft in the belly of quadriceps muscle suggestive of a oblique cut tear. The tear is seen running from the posterior belly to the anterior muscle fibers suggestive of through and through tear. Echogenic collection is also seen in the tear suggestive of hemorrhagic collection. Few calcified shadows are seen in the collection, which are accompanied with acoustic shadowing suggestive of organization.
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Figure 1.153: Crush Injury. A patient presented with compression trauma on posterolateral aspect of Rt thigh. HRSG shows a big cleft with complete disorganization of muscle texture in the cleft suggestive of compression injury in the muscle. Low level echoes are seen in the crushed part of the muscle. Echogenic shadows are seen floating in the collection suggestive of fat globules due to necrosis.
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Figures 1.154 to 1.156: Compression Injury to the Muscle. A patient presented with direct trauma to the medial aspect of Rt thigh in a car accident. There is evidence of compression injury of abductor group of muscles in Rt thigh. Complete disorganization of muscle fibers is seen. Marked soft tissue edema is seen around the muscle. On color flow imaging few vessels is seen feeding it.
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Figures 1.157a and b: Crush Injury of the Calf Muscle with Big Hematoma Formation. A patient presented with soft severe trauma to the Lt calf. HRSG shows complete rupture of gastrocnemius muscle. The muscle is seen compressed and torn. The normal anatomy is distorted. Hemorrhagic collection is seen in the ruptured and crushed gastrocnemius with big hematoma formation.
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Figure 1.158: Calf Muscle Tear. HRSG shows a big hypoechoic tear involving the Rt calf muscle in blunt injury to the leg. The fibers are torn. Echogenic collection is also seen suggestive of hematoma formation.
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FigURES 1.159 AND 1.160: HRSG shows big tear in the muscle running through the belly of the muscle.
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FigURES 1.161 AND 1.162: Biceps Muscle Tear. HRSG shows a big tear in the belly of biceps muscle of Rt arm. The muscle capsule is ruptured. Fibers are torn and disrupted suggestive of acute rupture of the muscle.
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Figures 1.163 to 1.167: A patient presented with direct trauma to Rt arm. A branch of a tree resulting into soft tissue mass swelling over the Rt arm with problem in elevation of the arm. HRSG shows rupture of the long head of biceps tendon at musculotendinous junction. Fluid is seen at the site of rupture. There is also associated hematoma formation seen in the biceps muscle. The organized hematoma shows echogenic foci. The biceps muscle is seen retracted and is seen as a soft tissue mass.
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FigURES 1.168 AND 1.169: Hamstring Muscle Tear. A patient presented with acute pain by performed exercise near the medial side of the thigh. HRSG shows rupture of the hamstring muscle before its insertion in the ischial tuberosity. Echogenic collection is seen in the rupture suggestive of fresh hemorrhage. The margins are irregular in outline.
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FigURES 1.170 AND 1.171: On color flow imaging no flow is seen in the rupture.
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Figures 1.172 to 1.176: Multiple Tears in the Shoulder Girdle Muscles. A patient presented with acutely painful shoulder joint with marked swelling. The muscles were red and hot. HRSG shows the shoulder girdle muscles are hypoechoic edematous. They are swollen. Big irregular clefts are seen in trapezius, deltoid, biceps and triceps muscles. The clefts are seen running through the muscle belly. The muscles are swollen. HRSG is very good for the assessment of muscle tear and small tears are very well picked up on HRSG.
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FigURES 1.177 AND 1.178: Shoulder Abscess. A patient presented with soft tissue swelling over the Rt shoulder with restricted shoulder movements. HRSG shows a big low level echo complex mass over the Rt shoulder. Low level echoes are seen in the mass. Cystic areas of degeneration is also seen. Thick fluid collection is seen in the subdeltoid bursa. Collection is seen extending to the medial side of the shoulder. Necrotic tissue is seen in it. Findings are suggestive of big abscess.
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FigURES 1.179 AND 1.180: Myositis Ossificans. A lady presented with hard soft tissue swelling over the Rt elbow after sustaining trauma with having plaster cast. X-ray of the elbow showed soft tissue swelling with radio dense calcification seen in the soft tissue.
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FigURES 1.181 AND 1.182: HRSG shows a soft tissue mass in the elbow muscle. Multiple echogenic-calcified specks are seen in the mass. They are accompanied with acoustic shadowing. Normal muscles texture is lost. The muscles are seen ossified. Small amount of collection is seen in the olecranon bursa.
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Figure 1.183: On color flow imaging no flow was seen in the mass. The arm vessel was seen separate from the mass. Sonographic findings are suggestive of myositis ossificans.
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Figures 1.184 to 1.186: Muscle Hematoma with Calcification. A patient presented with acute rupture of adductor group of muscles after sustaining trauma. HRSG shows a big hematoma formation in the belly of the muscles. Dense echogenic rim calcification is seen around the hematoma. Echogenic calcified specks are also seen in the substance of hematoma.
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Figure 1.187: The 3D imaging of the same patient shows the details of hematoma clearly.
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Figures 1.188 to 1.190: Resolving Muscle Hematoma. Same patient scanned after 8th months of initial injury, showed the resolving hematoma. The hematoma remarkably has reduced in size in comparison to the previous study. A thin rim calcification is seen around the hematoma. 3D imaging of the hematoma showed the details of the rim calcification. The extent of hematoma has reduced markedly in comparison to the previous study.
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FigURES 1.191 AND 1.192: Myositis Ossificans in the Arm Muscle. A young girl presented with painful swelling in the arm muscle. HRSG shows heterogeneous mass in the muscle belly. Dense echogenic calcified specks are seen in it, which are accompanied with acoustic shadowing. 3D imaging shows better details of the calcifications.
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Figure 1.193: Arm Muscles Calcification. HRSG shows calcified mass in the Lt biceps muscle. The calcified specks are seen casting strong acoustic shadowing suggestive of acoustic shadowing in myositis ossification.
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Figures 1.194 to 1.196: Myositis Ossificans in Thigh. A young girl presented with hard mass in the Rt thigh on the posterior aspect above the popliteal fossa. On 2D USG imaging a soft tissue mass is seen. Dense rim calcification is seen around the mass. It shows dense acoustic shadowing, therefore, detailed study was not possible. But no 3D imaging. A dense calcified mass is seen in muscle suggestive of myositis ossificans.
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Figures 1.197 to 1.200: A patient presented with a hard mass over the posterior aspect of Rt hip. She gave the history of developing the mass after having IM injection on hip. On ultrasound imaging densely calcified soft tissue mass is seen in the hip muscle. On 2D imaging, dense capsule of the mass is seen. On TUI imaging, rim calcification is seen around the mass. On excision biopsy, it turned out to be chronic granulomatous organized abscess.
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Figures 1.201 to 1.203: Calf Muscle Trauma with Tear and Hematoma. A patient presented with history of direct trauma to Lt calf with soft tissue mass and painful leg. HRSG shows markedly edematous gastrocnemius muscle. Echogenic foci are seen in the muscle suggestive of muscle edema. A big elongated cleft is seen in the substance of muscle suggestive of big muscle tear. Hemorrhagic collection is also seen in the torn part with hematoma formation.
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Figures 1.204 to 1.206: Compression Injury to Calf Muscle. A patient presented with compression injury to the calf and leg by direct trauma. HRSG shows grossly disorganized muscle texture of the gastrocnemius muscle. Muscle is seen compressed. Hypoechoic areas are seen in the muscle. Normal texture of the muscle is lost. Associated soft tissue edema is also seen.
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Figures 1.207 to 1.210: Hematoma in the Thigh. A patient presented with history of developing soft tissue mass on the medial side of the Rt upper thigh after angiography. Ultrasound shows a big encapsulated low level echo complex mass on the medial side of Rt thigh. Multiple echogenic foci are seen floating in it. But no septation is seen in it. The mass is seen pressing over the thigh vessels. On ultrasound guided aspiration, clotted blood is seen coming out from it. Findings are suggestive of big hematoma formation after angiography.
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Figures 1.211 to 1.214: Muscle Tear with Herniation of Muscle. A patient presented with history of injury on the anterolateral aspect of Rt leg. He complained of developing swelling over the anterior aspect of leg after walking. On ultrasound examination, there is a big tear is seen in the capsule of peroneous longus muscle in its distal part. The muscle is seen herniating through the defect anteriorly resulting into the bulge formation. On 3D imaging the defect is seen clearly.
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Figures 1.215 to 1.217: A patient presented with history of swelling in the calf after walking with developing pain in the calf. HRSG shows a defect in the anterior capsule of the soleus muscle. The muscle bundles are seen herniating through the defect on sustained walking resulting into bulge in the calf.
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Figures 1.218 to 1.220: A patient presented with history of developing a bulge on tightening of thigh muscle. HRSG shows a defect in the muscle capsule and muscle fibers are seen herniating through the defect on tightening of the muscle. The whole muscle bundle is seen herniating through the defect and mimicking as a mass.
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Figures 1.221 to 1.226: Large Wound Assessment by Ultrasound. HRSG is an excellent modality for evaluation of raw surface of the large wound and also underneath surface of the wound for proper healing. A patient presented with a big wound with large raw area involving entire anterior aspect of the leg below knee. Due to large size of wound skin grafting was not possible. HRSG shows the healthy granulation tissue of the wound. The musculocutaneous junction is also well evaluated by ultrasound. The undersurface of the wound also shows healthy tissue. No evidence of any necrosis or abscess formation is seen under the surface of wound. On color flow imaging multiple vessels are seen feeding the deeper tissue under with wound and also healthy granulation tissue below the raw area suggestive of neovascularization. The musculotendinous junction shows normal healthy muscle tissue with normal bipennate pattern of the muscle. The patient improved on conservative treatment with follow up ultrasound and normal complete healing was achieved.
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Figure 1.227: AV Malformation over the Rt Knee. An infant was born with a soft tissue mass over the Rt lower thigh, knee and upper part of leg.
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Figures 1.228 to 1.234: HRSG shows multiple dilated vessels in the mass. They are seen crisscrossing the mass. Color flow imaging shows high blood flow in the vessels. Venous and arterial flow pattern is seen in the vessels. Blood flow is seen in the vessels crisscrossing the mass. But no calcification is seen in them. Spectral Doppler tracing shows high venous flow with pulsatile waveform in the veins suggestive of arterovenous malformation. Spectral Doppler tracing shows arterial flow in the vessels.
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Figure 1.235: AV Malformation of Rt Lower Limb. A child was born with marked enlargement of the Rt lower limb. The Rt limb is more than twice the size of the Lt limb.
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Figures 1.236 to 1.239: HRSG shows multiple dilated vessels in the limb. The dilated vessels are seen in the thigh, leg and also on dorsum of the foot. On color flow imaging arterial flow is seen in them. Dilated vessels also show venous flow pattern. Echogenic calcified specks are also seen in the vessels. On spectral Doppler tracing low arterial flow is seen in the vessels. Sonographic findings are consistent with AVM.
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Figure 1.240: Cavernous Venous Malformation involving Upper Limb. A young boy presented with enlarged hypertrophied Rt upper limb with multiple dilated vessels in the limb.
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Figures 1.241 to 1.248: HRSG shows multiple dilated vessels in the upper limb. Echogenic calcified shadows are also seen in the vessels suggestive of phlebolith. On color flow imaging low blood flow is seen in the vessels with venous flow pattern. Spectral Doppler tracing shows venous flow. High flow is seen in the Rt axillary vein and venous flow is seen in the Rt brachial vein suggestive of cavernous venous malformation.
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Figure 1.249: Vascular Mass in the Rt Hip. A child was born with a soft tissue mass over the Rt gluteal region.
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Figures 1.250 to 1.253: HRSG shows multiple dilated vessels in the mass. The vessels are running in crisscross section. Multiple dilated vessels are seen in the mass, which are confirmed on color flow imaging.
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FigURES 1.254 AND 1.255: A baby was born with hypertrophy of Rt hip, thigh, leg and foot. The limb is more than double the size of the Lt limb. Big radish pigmentation is seen over the Rt hip and thigh.
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Figures 1.256 to 1.262: HRSG shows marked soft tissue hypertrophy involving the entire Rt lower limb. Low level echo masses are seen in the soft tissue of the limb mainly seen in the gluteal region and thigh. Pockets of low level collection is seen in them suggestive of venous lakes. Echogenic foci are also seen in them. On color flow imaging low venous flow is seen in the soft tissue. However, the major vessels of the thigh are normal and they are not seen supplying hypertrophy soft tissue mass. Findings are suggestive of diffuse cavernous venous hemangioma involving the entire Rt lower limb.
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Figure 1.263: A young girl presented with hypertrophy of Rt upper limb, which is more pronounced in the Rt forearm, wrist, hand, finger and thumb.
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Figures 1.264 to 1.271: High resolution ultrasound with color flow imaging show multiple pockets of low level collection over the Rt forearm, Rt hand and Rt palm. Multiple vessels are seen feeding the soft tissue masses. On color flow imaging pooling of the blood is seen in the pockets suggestive of venous lakes. Echogenic foci are also seen in the venous lakes suggestive of phlebolith. On spectral Doppler tracing low venous flow is seen in the veins. Findings are suggestive of cavernous venous malformation.
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FigURES 1.272 AND 1.273: A patient presented with soft tissue swelling of the middle finger. The swelling is seen increasing in size slowly and involve flexor surface of finger.
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Figures 1.274 to 1.280: Ultrasound shows soft tissue mass mainly confined to flexor surface of Rt middle finger. Multiple dilated vessels are seen in the soft tissue mass. The vessels are seen extending to the Rt palm and also going to the hypothenar eminence. On color flow imaging high flow is seen in the vessels. On spectral Doppler tracing, high arterial flow is seen in the vessels. Few vessels also show venous flow. Findings are suggestive of highly vascular mass involving the high arterial flow in the Rt palm and middle finger suggestive of AV malformation.
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Figure 1.281: Klippel-Trenaunay Syndrome. A young child presented with Rt lower limb hypertrophy. On clinical examination, discoloration of the skin is seen in the Rt flank, thigh and also on the Rt knee. Dilated veins are also seen over the Rt leg.
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Figures 1.282 to 1.290: On high resolution ultrasound soft tissue mass is seen over the Rt lower lumbar region and Rt flank. Multiple dilated vessels are seen in the soft tissue mass. Rt saphenofemoral junction shows gross valvular incompetence. Reversal of flow is also seen in great saphenous vein. Dilated perforators are also seen in the leg suggestive of incompetence.
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Figures 1.291 to 1.300: A patient presented with progressive increase in soft tissue mass over the distal part of the sole is mainly confined in the region of 1st, 2nd and 3rd metacarpal region. Patchy discoloration is also seen in it. HRSG shows an irregular ill-defined inhomogeneous soft tissue mass over the Rt sole. Multiple low level pockets are seen into it. Echogenic foci are also seen in the mass. Multiple vessels are also seen feeding the mass. On color flow imaging the vessels show low arterial flow. Findings are consistent of moderate arterial and low venous flow suggestive of AV malformation.
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Figures 1.301 to 1.307: A patient presented with a soft tissue mass over the Lt heel. He gave the history of chronic wart formation of the Lt heel. However, he developed a soft tissue swelling which started increasing slowly and also become painful. High resolution ultrasound shows a low level echo complex mass over the Lt heel. Thick echoes are seen in the mass. No calcification is seen in it. No septation is seen in the mass. On color flow imaging multiple vessels are seen feeding the mass. On spectral Doppler tracing low arterial flow is seen in it. The findings are suggestive of cystic degeneration of the wart and new vascularization.
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Figures 1.308 to 1.310: A patient presented with multiple masses over the dorsum of the anteromedial aspect of the Rt foot.
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Figures 1.311 to 1.318: HRSG shows multiple big low level echo complex masses over the dorsum of the foot. Echogenic foci are also seen in them. Which are accompanied with dense acoustic shadowing. No septation is seen in the masses. On color flow imaging multiple vessels are seen in the capsule of the masses, which are seen confined to the periphery. However, no intrasubstance vascularization is seen. On spectral Doppler tracing moderate arterial flow is seen in the masses. Findings are suggestive of lymphangioma.
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FigURES 1.319 AND 1.320: A patient presented with progressively increasing soft tissue mass over the Lt palm and hypodense nidus is seen in the center of the mass. It is seen confined to the distal part of the palm and reaching upto second and third metatarsal base.
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Figures 1.321 to 1.328: HRSG shows a well encapsulated soft tissue mass over the Lt palm. Homogeneous echoes are seen in the mass. No calcification is seen in it. No cystic degeneration is seen. On color flow imaging multiple vessels are seen feeding the mass. On power Doppler imaging and 3D power angio, the vessels are seen feeding the entire mass. On spectral Doppler tracing, high venous and high arterial flow is seen in the mass suggestive of highly vascular angiomatous tumor.
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Figures 1.329A and B: A young child presented with multiple soft tissue masses over the Rt axilla, anterolateral chest wall and Rt elbow. Big soft tissue masses are also seen over the Rt hand and palm, and also involving the fingers.
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Figures 1.330 to 1.336: HRSG shows multiple loculated cystic masses over the Rt arm and infraclavicular region. Cystic masses are also seen over the Rt thumb and finger. Well-defined septa are seen in the cystic masses. Marked soft tissue hypertrophy is seen over the Rt thumb. Echogenic calcified specks are seen in the mass. On color flow imaging low flow is seen in the capsule of the masses. Low venous flow is also seen in the soft tissue mass. Findings are suggestive of diffuse lymphangioma.
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Figures 1.337 to 1.340: A patient presented with a soft tissue mass over the Rt middle finger and also a bulge is seen over the Rt palm. Digital X-ray of the hand does not show any bony abnormality. However, radiodense small shadow is seen in the soft tissue around the little finger. Ultrasound shows a soft tissue mass around the Rt finger, which is extending to the Rt palm. Multiple dilated vessels are seen in it. On color flow imaging high flow is seen in the vessels suggestive of AVM.
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Figures 1.341 to 1.345: A young lady presented with soft tissue swelling over the Rt ankle. The swelling is seen extending to the Rt heel and plantar surface of the sole. HRSG shows a soft tissue mass over the Rt ankle and Rt heel. Multiple cystic loculations are seen in the mass. Thick septa are also seen in the mass. On color flow imaging no flow is seen in the cystic mass. However, low arterial flow is seen in the soft tissue component of the mass. Findings are suggestive of consistent lymphangioma.
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Figures 1.346 to 1.348: Diffuse Lymph Edema of Rt Lower Limb. Young child presented with diffuse hypertrophy of Rt lower limb. HRSG shows diffuse soft tissue edema over the Rt lower limb. No evidence of any focal mass is seen in the muscles. No abnormal arterial malformation is seen. On color flow imaging, normal venous flow is seen in the lower limb venous tree. Findings are suggestive of diffuse lymphatic edema involving lower limb.
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Figures 1.349 to 1.353: Traumatic Aneurysm of Ulnar Artery. A young man presented with soft tissue mass swelling over the distal part of forearm. HRSG shows a cystic mass in the forearm. A feeding vessel is also seen in the mass. On color flow imaging the feeding vessel is the ulnar artery and blood flow seen in the mass in bizarre fashion suggestive of an aneurysm of the ulnar artery. Power Doppler imaging shows the aneurysm in the feeding vessels very clearly.
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Figures 1.354 to 1.357: Arterovenous Fistula in the Thigh. A patient presented with pulsatile swelling in the Lt thigh in its lower part reaching up to the popliteal fossa. HRSG shows well-defined vessels. They are dilated. There is also evidence of communication seen between the two vessels. On color Doppler imaging, high flow is seen in the vein with pulsatile flow pattern. The flow is so high that it caused aliasing suggestive of arterovenous fistula between superficial femoral artery and popliteal vein after trauma. The cause of the fistula was the trauma. On spectral Doppler tracing, high flow is seen in the fistula with marked aliasing.
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Figures 1.358 to 1.362: A patient presented with soft tissue mass in the Rt thigh upper and medial side, which was increasing slowly. HRSG shows a big low level echo complex mass in the thigh. Homogeneous echoes are seen in it with blood flow in whirlpool fashion. On color Doppler imaging, a big aneurysm is seen on the medial side of the thigh. A big clot is seen around the aneurysm. On power Doppler imaging the aneurysm is seen communicating with superficial femoral artery. On 4D STIC angio, the relationship of the aneurysm with the artery is clearly seen.
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Figures 1.363 to 1.370: A young girl presented with soft tissue swelling over the Rt forearm. HRSG shows a low level echo complex mass in flexor group of muscles. Echogenic foci are also seen in the mass. Multiple dilated vessels are seen in the mass, which are confirmed on color flow imaging. On spectral Doppler tracing low venous flow is seen in it. MRI of the soft tissue confirms the ultrasound findings. Findings are suggestive of venous malformation in the arm.
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Figures 1.371 to 1.373: A newborn baby born with soft tissue swelling over the Rt thigh. Digital X-ray of the thigh shows a soft tissue mass in the thigh. A big amorphous calcification is also seen in the soft tissue. HRSG of the thigh shows soft tissue mass. Dense echogenic foci are seen in the mass. The mass is seen mainly in the anterior compartment of the thigh. It is predominantly solid. Multiple echogenic specks are seen filling the mass, which is accompanied with faint acoustic shadowing. Biopsy of the mass shows idiopathiac calcified mass.
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Figures 1.374 to 1.378: Angiomatous Mass. A young boy presented with progressive swelling over the Lt forearm. It was nonpulsatile on clinical examination. X-ray of the forearm shows normal bones with soft tissue mass. Calcified radiodense shadows are also seen in the soft tissue mass. HRSG shows a big lobulated mass with heterogeneous texture in the muscles of the forearm. Multiple dilated vessels are seen in it. Echogenic calcified shadows are also seen in the mass. They are accompanied with acoustic shadowing. But no cystic degeneration is seen. On color flow imaging few vessels are seen feeding the mass. Spectral Doppler tracing shows arterial flow in the vessel. Biopsy of the mass shows angiomatous mass.
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Figures 1.379 to 1.386: Lt Lower Limb Gigantism. A patient presented with marked hypertrophy of whole Lt lower limb. It is more than double the size of Rt lower limb. Marked skin edema is present with loss of normal muscle tone. On clinical examination, there is also evidence of cystic masses seen over the Lt knee. HRSG shows gross disorganization of the normal muscle texture involving the thigh muscles. Multiple echogenic globular shadows are seen in the muscles. Normal muscle texture is lost. The muscle capsules are also broken. However, normal residual muscle texture is seen in calf muscles. Marked skin and hypodermis edema is present. On color Doppler imaging few vessels are seen in the muscles with low flow. No vascular abnormality is seen. HRSG shows gross amount of fluid collection over the Lt lower thigh and knee region. It shows homogeneous low-level echoes. Normal muscles are not seen. On color Doppler imaging normal flow is seen in the thigh vessels and the veins. No suggestion of any AV malformation is seen. Biopsy shows cystic degeneration of the muscle with lymphangitis.
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Figures 1.387 to 1.391: A patient presented with soft tissue mass over the medial side of the Rt ankle. The mass is tender. HRSG shows a soft tissue mass over the medial side of Rt ankle over the medial malleolus. A linear echogenic shadow is seen embedded in the mass, which looks like a foreign body. Soft tissue edema is seen around it. Small amount of fluid is also seen around the foreign body. On color flow imaging few vessels are seen feeding the soft tissue mass. Findings are consistent with a foreign body and a soft tissue grarnuloma formation. On operation, it came out to be a big thorn.
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Figures 1.392 to 1.396: Foreign Body with Abscess Formation. A patient presented with a soft tissue mass over the dorsum of the foot. It is associated with soft tissue skin edema. It is red and hot with marked tenderness. X-ray of the foot shows soft tissue swelling, but bones are normal. HRSG of the foot shows a big echogenic mass embedded in the soft tissue. Soft tissue proliferation is seen around it. 3D ultrasound of the mass clearly shows a foreign body. On color flow imaging few dilated vessels are seen feeding the mass. Findings are consistent with embedded foreign body with soft tissue granuloma formation.
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FigURES 1.397 AND 1.398: Small Foreign Bodies in the Sole. A patient presented with pain on the undersurface of the great toe while walking. There was history of fall on rough surface of the land. HRSG shows multiple small echogenic foci in the sole, which are seen embedded in soft tissue. They are discrete. Associated soft tissue edema is present suggestive of small pebbles embedded in the soft tissue.
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Figures 1.399 to 1.401: Small Glass Piece Embedded in Soft Tissue. A patient presented with soft tissue swelling in sole of foot. HRSG shows a soft tissue mass in the sole. Small echogenic shadow is seen embedded in it. On color flow imaging few vessels are seen feeding the mass suggestive of granuloma formation. On exploration of soft tissue, a small glass piece was removed.
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FigURES 1.402 AND 1.403: Foreign Body in the Arm. A patient presented with soft tissue swelling over Rt arm, which was nontender. HRSG shows an echogenic linear shadow embedded in the arm. Marked soft tissue formation is seen around it. On color flow imaging few vessels are seen feeding the soft tissue mass. On exploration, a thorn was removed and chronic inflammatory granuloma is seen around the thorn.
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Figures 1.404 to 1.407: Benign Muscle Tumor. A middle aged man presented with well-defined mass over the elbow. Plain X-ray of the arm shows soft tissue mass near the elbow. However, bones are normal. HRSG shows well-defined, well and capsulated lobulated mass in the belly of the muscle. It is homogenous and hypoechoic in texture. No cystic degeneration is seen in it. On color flow imaging, low blood flow is seen in it. Biopsy shows fibroma.
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Figures 1.408 to 1.411: Big Lipoma Over the Lt Shoulder. A lady presented with soft tissue mass over the Lt shoulder. HRSG shows a big echogenic soft tissue mass over the shoulder. It is well defined with sharp margins. It is highly echogenic in texture. No necrosis or calcification seen in it. On color flow imaging no flow was seen in it. Findings are suggestive of lipoma.
A Big Lipoma over the Rt Arm. HRSG shows a big well-defined echogenic mass in the Rt arm. It is homogeneous in texture. It is seen anterior to the humeral shaft suggestive of big lipoma. 3D imaging of the mass shows that it is confined to the anterior compartment of the muscle. On color flow imaging no flow was seen in the mass.
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Figures 1.412 to 1.415: A patient presented with a well-defined soft tissue mass over the superior surface of Lt shoulder. HRSG shows a well-defined and well encapsulated soft tissue mass over the Rt shoulder. It is homogeneous in texture with fat density. No calcification is seen in the mass. No cystic degeneration is seen. On color flow imaging no flow is seen in the mass. On 3D imaging the mass stands out clearly and appears to be a well-defined lipoma.
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Figures 1.416 to 1.419: A patient presented with a soft tissue mass over the Lt elbow. HRSG shows a well encapsulated soft tissue mass over the Lt elbow. The mass is homogeneous in texture. It is similar to the fat density. No calcification is seen in the mass. On color flow imaging no flow is seen in the mass. No cystic degeneration is seen in the mass. Findings are consistent with a well-defined lipoma.
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Figures 1.420 to 1.423: Benign Muscle Tumor. A well-defined homogeneous soft tissue mass seen in the Lt arm. HRSG shows well and capsulated soft tissue mass in the muscle. It is homogeneous in texture. No calcification is seen in it. On color flow imaging high flow seen in the mass. Biopsy of the mass confirmed fibroma.
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Figures 1.424 to 1.427: Benign Tumor in the Muscle. A patient presented with soft tissue mass in the triceps muscle in the Lt arm. HRSG shows homogeneous soft tissue mass in the muscle belly. On color flow imaging little flow seen in the mass. 3D imaging of the mass shows depth of the mass in the muscle.
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Figures 1.428 to 1.433: Malignant Tumor (Rhabdomyosarcoma). A patient presented with irregular soft tissue mass over the Rt arm. HRSG shows a big irregular ill-defined hypoechoic mass in the deltoid muscle. The mass has broken the muscle capsule. It is seen invading the normal tissue planes. Normal anatomy is distorted. On color flow imaging poor flow is seen in the mass. No calcification is seen in it. No cystic degeneration is seen. It appears to be a malignant tumor. Biopsy confirmed rhabdomyosarcoma.
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Figures 1.434 to 1.438: Synovial Sarcoma of Rt Shoulder. A patient presented with a soft tissue mass over the Rt shoulder, which was nontender with restricted shoulder movements. HRSG shows a big heterogeneous low level echo complex mass coming out from the Rt shoulder. The mass has destroyed the distal clavicle. Normal anatomy is distorted. Low level thick echoes are seen in the mass. On color flow imaging multiple vessels are seen feeding the mass. On 3D imaging the mass shows grossly heterogeneous texture. On ultrasound guided biopsy it turned out to be malignant tumor synovial cell sarcoma.
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Figures 1.439 to 1.443: Malignant Soft Tissue Tumor Over the Lt Shoulder. A patient presented with a big predominantly solid mass over the Lt shoulder with restricted shoulder movements. HRSG shows a big heterogeneous soft tissue mass over the Lt shoulder. The mass is hypoechoic in texture and irregular in outline. It is seen involving the muscles of the shoulder joint. Normal anatomy is distorted. Fascial planes are obliterated. Synovial membrane proliferation is seen. Associated bony destruction is also seen. On color flow imaging increased flow is seen in the mass. The proximal humeral shaft also shows fracture of the shaft. On biopsy of the mass it turned out to be highly malignant tumor involving the Lt shoulder muscles.
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Figures 1.444 to 1.452: Synovial Sarcoma of Rt Shoulder. A patient presented with soft tissue mass over the Rt shoulder. X-ray of the shoulder is not remarkable. However, on ultrasound of the shoulder, a big soft tissue mass seen involving the Rt shoulder joint. It is seen coming out from the capsule involving the subacromial, subdeltoid bursa and also seen involving the rotator cuff tendons. Membranous shadows are seen in the mass. Normal anatomy is distorted. The articular surface of the greater tuberosity of humerus is also seen eroded by the mass. On color flow imaging increased flow is seen in the mass. Ultrasound guided biopsy confirms synovial sarcoma.
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Figures 1.453 to 1.456: Muscle Tumor Invading the Bone. A patient presented with mass in the Rt iliac fossa. The mass was seen invading the iliac bone and also the muscles capsule was broken. It was seen invading in the surrounded tissue. 3D imaging of the mass gave the much better details tumor. CT of the same patient showed the details of the tumor and confirmed the ultrasound findings. Biopsy of the mass confirmed malignant sarcoma.
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Figures 1.457 to 1.462: Huge Thigh Muscle Tumor. A patient presented with a huge mass in the Lt thigh. X-ray of the thigh shows a huge soft tissue swelling. However, the femur bone appears to be normal. No evidence of any bony erosion seen. HRSG shows a huge mass in the muscle with normal muscle texture was lost. The mass was predominantly solid. No cystic necrosis was seen in the mass. On color flow imaging superficial femoral artery was seen embedded in the mass and giving the feeding branches to the mass. However, the vessel was seen intact. On spectral Doppler tracing, high resistance flow was seen in the SFA due to pressure on the artery. But no flow was seen in superficial femoral vein. Biopsy of the mass confirmed fibrosarcoma.
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Figures 1.463 to 1.465: Metastasis in the Muscle. A known patient of non-Hodgkin lymphoma presented with acutely painful swelling in the Lt arm muscle. HRSG shows a big mass in the Lt triceps muscles. The mass was heterogeneous. Hypoechoic areas are seen in it. Biopsy of the mass confirmed metastasis of the NHL.
Metastatic Invasion of Arm Muscle in Carcinoma Rectum. HRSG shows big irregular heterogeneous mass invading the triceps muscle in a known case of carcinoma rectum. Biopsy of the mass showed metastatic deposits from adenocarcinoma rectum.
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Figures 1.466 to 1.469: Lymphoma of Medial Side of Thigh Extending into the Hip. A patient presented with multiple lobulated masses in upper medial part of thigh with restricted hip movements. HRSG shows big multiple hypoechoic lobulated soft tissue masses. On color Doppler imaging, they show moderate flow. Biopsy of the mass shows lymphoma. HRSG shows extension of the masses in the mass of thigh. The masses are seen pressing over the common femoral vessels. Fluid is seen also in the joint capsule.
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Figures 1.470 to 1.474: Malignant Tumor of the Thigh with Neoangiogenesis. A patient presented with non-tender soft tissue mass over the Rt thigh. HRSG shows a big irregular ill-defined inhomogeneous soft tissue mass involving the extensor group of muscles of Rt thigh. The mass is seen extending in the surrounding tissue plane. A broken capsule is seen. No cystic degeneration is seen in the mass. On color flow imaging multiple vessels are seen feeding the mass. On 3D power Doppler imaging the vessels are seen running in all the directions with low flow suggestive of neoangiogenesis. Biopsy of the mass shows infiltrating rhabdomyosarcoma.