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The acute scrotum
S6
Ultrasound in Medicine and Biology
result of friction of the iliotibial tract over the lateral epicondyle of the knee, producing a localized inflammatory response; it is most frequent in long-distance runners and cyclists. US can depict tendon thickening and peritendinous inflammatory changes. Dynamic US imaging performed during active flexion and extension of the knee can demonstrate abnormal movement of the iliotibial band over the epicondyle that correlates with the occurrence of pain. Other snapping syndromes involving the biceps femoris tendon and popliteus tendon have also been described. Injury to the superior peroneal retinaculum is a common sequela of trauma to the lateral ankle that can result in peroneal tendons subluxation or dislocation. US can demonstrate the abnormal displacement of the peroneal tendons during active dorsiflexion and eversion of the foot as well as the associated tenosynovitis and/or tears of peroneus brevis.
Sonography of the postoperative shoulder Bouffard J,* Craig JG, Diamond M, Diagnostic Radiology, Henry Ford Hospital, Detroit, MI The surgically operated shoulder can be evaluated for residual or recurrent disease by the different radiologic modalities including conventional arthrography, CT arthrography, MR arthrography, and musculoskeletal ultrasonography (MSUS). Ultrasound offers a non-invasive and accurate method of visualizing the integrity of the surgerized rotator cuff. Post-operative changes such as troughs, anchors, and bioscrews can be visualized with MSUS. Cuff re-tears after surgery can be correctly diagnosed. Recurrent cuff tears are often seen as an “all-or-nothing” phenomenon, with total dissolution of the cuff. Metachronous tears can be localized in relation to the surgical site. Fixation failures, such as detaching anchors or broken screws, can be evaluated in dynamic real time to confirm their instabilty and complications such as impingement or infection.
TOPICS IN EMERGENCY ULTRASOUND—PART I The acute scrotum Cohen HL, Radiology, SUNY-Stony Brook, Cedarhurst, NY Great strides have been made over the last 2 decades in the analysis of acute scrotal pain. Whereas in the past, nuclear medicine scintigraphy was the gold standard for the analysis of testicular torsion, the key clinical abnormality to rule out in the event of sudden testicular pain, today, ultrasound aided by color or power Doppler is the gold standard. The diagnosis has to be made rapidly and correctly. Immediate surgical exploration is necessary to avoid progressive ischemia leading to testicular necrosis, which occurs within hours of true testicular torsion. The development of ever-improving high-resolution transducers for the analysis of scrotal contents has improved diagnosis. However, the development of excellent triplex imaging (gray scale, color, and spectral Doppler) sensitive enough to image flow in the testes of all age groups has allowed ultrasound to replace the nuclear medicine examination. Testicular torsion can occur at any age. It is more common in the newborn period and around puberty. Its presentation may be simulated by torsion of testicular and epididymal appendages. Ultrasound can easily denote normal flow in the testes and a prominent circular mass near the testicle or epididymis in such cases. After the patient becomes sexually active, torsion may be simulated by epididymitis, whether at the head, body, or tail of the epididymis and whether associated with extension into the testicle as epididymorchitis, or not. Ultrasound will show a lack of flow in the affected testicle. The contralateral testicle can be assessed for what normal flow should look like. It is necessary to see central arterial flow in a testicle before diagnosing classic torsion. Patients with epididymitis have normal or
Volume 29, Number 5S, 2003 increased flow to their epididymis or testicle. The affected epididymis is usually at least focally enlarged. Other differential diagnostic concerns include testicular neoplasms with associated areas of hemorrhagic necrosis and the traumatized testis or scrotum.
The focused abdominal sonography for trauma (FAST) analysis of the traumatized patient: An emergency medicine perspective Lambert M, Emergency Medicine, Resurrection Medical Center, Chicago, IL The belated Dr. Cowley developed the idea that there is a “golden hour” just after a serious injury, during which prompt and coordinated medical treatment can save lives. Unless emergency physicians caring for traumatically injured patients are directly involved in pre-hospital care, a portion of the golden hour has been passed before their evaluation begins. Armed with ATLS skills and a cursory history, the emergency department team is well trained to stabilize, treat, and dispose the traumatically injured patient. Their eyes, ears, and hands help search for injuries requiring immediate intervention. Unfortunately, unless a penetrating injury is involved, the ability to clinically decipher which patients need emergent surgery can often be problematic. Therefore, an invasive procedure (diagnostic peritoneal lavage) or imaging study (computer tomography scan or ultrasound) is routinely undertaken to aid in this important process. Ultrasound is the best initial imaging modality to utilize in the quest to reveal a traumatically injured patient’s most life-threatening injury. Although there are more sensitive and specific tests available, they cannot be performed as quickly. In an unstable traumatically injured patient, the “golden hour” melts into minutes. When the chips are on the line, the emergency physician should reach for the probe.
The injured eye Blaivas M, Emergency Medicine, Medical College of Georgia, Augusta, GA This lecture will focus on ultrasound applications in the emergency department setting for evaluation of ocular injury and pathology. Ocular complaints routinely seen in emergency medicine patients may range from acute visual change to blunt and penetrating trauma, often requiring rapid and accurate evaluation. The physical examination offers considerable limitations without specialized technology, which is often lacking in the emergency setting. Although specialized and dedicated ocular sonography equipment is unlikely to be available to emergency sonologists, other sonographic tools can be substituted. The linear or vascular probe provides excellent imaging for pathology such as lens dislocation, globe rupture, foreign bodies, retinal detachment, and vitreous hemorrhage. Tissue surrounding the globe can also be evaluated for entities such as retrobulbar hematoma. Recent research in emergency ultrasound has even shown that increased intracranial pressure may be reliably detected in patients with significant head trauma. Typical findings, unusual examples, and future directions of emergency ocular sonography will be discussed.
PROSTATE ULTRASOUND The history of prostate ultrasound Watanabe H, Third Department of Basic Medicine, Meiji University of Oriental Medicine, Kyoto, Japan Transrectal sonography (TRS) is ultrasonography for the intrapelvic organs by means of the insertion of a special tube-type probe into the rectum through the anus. This was the pioneering technique to transmit
Ultrasound in Medicine and Biology
result of friction of the iliotibial tract over the lateral epicondyle of the knee, producing a localized inflammatory response; it is most frequent in long-distance runners and cyclists. US can depict tendon thickening and peritendinous inflammatory changes. Dynamic US imaging performed during active flexion and extension of the knee can demonstrate abnormal movement of the iliotibial band over the epicondyle that correlates with the occurrence of pain. Other snapping syndromes involving the biceps femoris tendon and popliteus tendon have also been described. Injury to the superior peroneal retinaculum is a common sequela of trauma to the lateral ankle that can result in peroneal tendons subluxation or dislocation. US can demonstrate the abnormal displacement of the peroneal tendons during active dorsiflexion and eversion of the foot as well as the associated tenosynovitis and/or tears of peroneus brevis.
Sonography of the postoperative shoulder Bouffard J,* Craig JG, Diamond M, Diagnostic Radiology, Henry Ford Hospital, Detroit, MI The surgically operated shoulder can be evaluated for residual or recurrent disease by the different radiologic modalities including conventional arthrography, CT arthrography, MR arthrography, and musculoskeletal ultrasonography (MSUS). Ultrasound offers a non-invasive and accurate method of visualizing the integrity of the surgerized rotator cuff. Post-operative changes such as troughs, anchors, and bioscrews can be visualized with MSUS. Cuff re-tears after surgery can be correctly diagnosed. Recurrent cuff tears are often seen as an “all-or-nothing” phenomenon, with total dissolution of the cuff. Metachronous tears can be localized in relation to the surgical site. Fixation failures, such as detaching anchors or broken screws, can be evaluated in dynamic real time to confirm their instabilty and complications such as impingement or infection.
TOPICS IN EMERGENCY ULTRASOUND—PART I The acute scrotum Cohen HL, Radiology, SUNY-Stony Brook, Cedarhurst, NY Great strides have been made over the last 2 decades in the analysis of acute scrotal pain. Whereas in the past, nuclear medicine scintigraphy was the gold standard for the analysis of testicular torsion, the key clinical abnormality to rule out in the event of sudden testicular pain, today, ultrasound aided by color or power Doppler is the gold standard. The diagnosis has to be made rapidly and correctly. Immediate surgical exploration is necessary to avoid progressive ischemia leading to testicular necrosis, which occurs within hours of true testicular torsion. The development of ever-improving high-resolution transducers for the analysis of scrotal contents has improved diagnosis. However, the development of excellent triplex imaging (gray scale, color, and spectral Doppler) sensitive enough to image flow in the testes of all age groups has allowed ultrasound to replace the nuclear medicine examination. Testicular torsion can occur at any age. It is more common in the newborn period and around puberty. Its presentation may be simulated by torsion of testicular and epididymal appendages. Ultrasound can easily denote normal flow in the testes and a prominent circular mass near the testicle or epididymis in such cases. After the patient becomes sexually active, torsion may be simulated by epididymitis, whether at the head, body, or tail of the epididymis and whether associated with extension into the testicle as epididymorchitis, or not. Ultrasound will show a lack of flow in the affected testicle. The contralateral testicle can be assessed for what normal flow should look like. It is necessary to see central arterial flow in a testicle before diagnosing classic torsion. Patients with epididymitis have normal or
Volume 29, Number 5S, 2003 increased flow to their epididymis or testicle. The affected epididymis is usually at least focally enlarged. Other differential diagnostic concerns include testicular neoplasms with associated areas of hemorrhagic necrosis and the traumatized testis or scrotum.
The focused abdominal sonography for trauma (FAST) analysis of the traumatized patient: An emergency medicine perspective Lambert M, Emergency Medicine, Resurrection Medical Center, Chicago, IL The belated Dr. Cowley developed the idea that there is a “golden hour” just after a serious injury, during which prompt and coordinated medical treatment can save lives. Unless emergency physicians caring for traumatically injured patients are directly involved in pre-hospital care, a portion of the golden hour has been passed before their evaluation begins. Armed with ATLS skills and a cursory history, the emergency department team is well trained to stabilize, treat, and dispose the traumatically injured patient. Their eyes, ears, and hands help search for injuries requiring immediate intervention. Unfortunately, unless a penetrating injury is involved, the ability to clinically decipher which patients need emergent surgery can often be problematic. Therefore, an invasive procedure (diagnostic peritoneal lavage) or imaging study (computer tomography scan or ultrasound) is routinely undertaken to aid in this important process. Ultrasound is the best initial imaging modality to utilize in the quest to reveal a traumatically injured patient’s most life-threatening injury. Although there are more sensitive and specific tests available, they cannot be performed as quickly. In an unstable traumatically injured patient, the “golden hour” melts into minutes. When the chips are on the line, the emergency physician should reach for the probe.
The injured eye Blaivas M, Emergency Medicine, Medical College of Georgia, Augusta, GA This lecture will focus on ultrasound applications in the emergency department setting for evaluation of ocular injury and pathology. Ocular complaints routinely seen in emergency medicine patients may range from acute visual change to blunt and penetrating trauma, often requiring rapid and accurate evaluation. The physical examination offers considerable limitations without specialized technology, which is often lacking in the emergency setting. Although specialized and dedicated ocular sonography equipment is unlikely to be available to emergency sonologists, other sonographic tools can be substituted. The linear or vascular probe provides excellent imaging for pathology such as lens dislocation, globe rupture, foreign bodies, retinal detachment, and vitreous hemorrhage. Tissue surrounding the globe can also be evaluated for entities such as retrobulbar hematoma. Recent research in emergency ultrasound has even shown that increased intracranial pressure may be reliably detected in patients with significant head trauma. Typical findings, unusual examples, and future directions of emergency ocular sonography will be discussed.
PROSTATE ULTRASOUND The history of prostate ultrasound Watanabe H, Third Department of Basic Medicine, Meiji University of Oriental Medicine, Kyoto, Japan Transrectal sonography (TRS) is ultrasonography for the intrapelvic organs by means of the insertion of a special tube-type probe into the rectum through the anus. This was the pioneering technique to transmit