Pe d i a t r i c I m a g i n g • R ev i ew

Hryhorczuk et al.
Practical Approach to Pediatric Musculoskel-
etal Ultrasound

Pediatric Imaging
Review
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Pediatric Musculoskeletal
FOCUS ON:

Ultrasound: Practical Imaging

Approach
Anastasia L. Hryhorczuk1 OBJECTIVE. The purpose of this article is to review some of the common indications for
Ricardo Restrepo2 pediatric musculoskeletal ultrasound examination, with emphasis given to imaging technique,
Edward Y. Lee 3 normal anatomy, and the spectrum of pathologic findings seen in the pediatric population.
CONCLUSION. Ultrasound is an essential first-line tool in pediatric musculoskeletal
Hryhorczuk AL, Restrepo R, Lee EY imaging. It aids in determining which patients may benefit from further imaging, including
radiography, CT, and MRI.

ltrasound is a valuable imaging children, who may undergo scanning in the

U technique for use in the pediatric

Keywords: musculoskeletal, pediatrics, soft-tissue
masses, ultrasound
DOI:10.2214/AJR.15.15858
Received November 11, 2015; accepted after revision
December 31, 2015.
1
Division of Pediatric Radiology, Department of
Radiology, Tufts Medical Center and Floating Hospital for
Children, 800 Washington St, Boston, MA 02111. Address
correspondence to A. Hryhorczuk
(ahryhorczuk@tuftsmedicalcenter.org).
2
Department of Radiology, Nicklaus Children’s Hospital,
Miami, FL.
3
Department of Radiology, Boston Children’s Hospital
and Harvard Medical School, Boston, MA.
This article is available for credit.
WEB
This is a web exclusive article.
AJR 2016; 206:W62–W72
0361–803X/16/2065–W62
© American Roentgen Ray Society
population. Well tolerated by
children, ultrasound is a typical
first-line modality for a wide array of pediat-
ric musculoskeletal imaging indications.
Readily accessible in both emergency and
outpatient settings, ultrasound allows radiolo-
gists to perform a dynamic assessment of the
musculoskeletal system without using ioniz-
ing radiation or sedation. Unlike MRI, which
requires the clinician to select a focal area of
concern, ultrasound allows the evaluation of
multiple joints or lesions in a single session
and permits a radiologist to rapidly compare
abnormal structures to the contralateral side.
Panoramic images also allow an expanded
FOV and can be useful when assessing larger
lesions. An ultrasound evaluation may assist
radiologists in directing the clinical manage-
ment of a child and in determining which pa-
tients may benefit from additional imaging,
including radiography, CT, or MRI. The pur-
pose of this article is to review common indi-
cations for pediatric musculoskeletal ultra-
sound, with emphasis placed on up-to-date
imaging techniques, normal anatomy, and the
spectrum of pathologic findings that may be
diagnosed in the pediatric population.
Imaging Techniques
High-quality musculoskeletal ultrasound
examination of children necessitates the use
of high-frequency (10–15 MHz) linear trans-
ducers, which provide optimal visualization
of small and superficial structures. Such ex-
aminations are usually easily tolerated by
presence of their parents, with the parents
often holding the children so as to provide
maximal comfort to them during the proce-
dure. Superficial structures of the hands and
feet may be visualized by using a standoff
gel pad or a water bath; the patient’s extrem-
ity and an ultrasound probe are placed in the
water, with the probe positioned near, but not
touching, the area of interest [1]. Water baths
may also be of benefit in assessing dynamic
motion when patients report a history of ten-
don snapping or trigger finger symptoms.
Normal Anatomy
Fat
Superficial fat is readily seen on ultrasound
images and generally appears hypoechoic,
with internal curvilinear echogenic striations
representing connective tissue (Fig. 1A). Ob-
servation of increasing echogenicity within
the fat and linear areas of fluid tracking along
connective tissue planes may reflect local in-
flammatory changes or infection.
Fascia
The investing fascia surrounding the mus-
cles and compartments appears as an echo-
genic band along the surfaces of the muscle
(Fig. 1A). The fascia should appear homoge-
neous without showing evidence of nodular-
ity or a defect that may suggest an underlying
pathologic finding.
Tendons
Assessment of tendons is one of the most
challenging aspects of a musculoskeletal ultra-

W62 AJR:206, May 2016

 Practical Approach to Pediatric Musculoskeletal Ultrasound
sound examination because of the presence of
anisotropy artifact, which may complicate im-
age interpretation. Normal tendons appear hy-
perechoic and uniform on ultrasound images
and are composed of multiple parallel echogen-
ic lines that represent fascicles. Anisotropy oc-
curs when the ultrasound beam is not perpen-
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dicular to the long axis of a tendon, ligament,
or muscle. As the beam is angled away from
90° to the long axis of a structure, a normal hy-
perechoic tendon or ligament appears to have
internal hypoechoic areas, which may errone-
ously be interpreted as an underlying patholog-
ic finding (Fig. 1B). This can occur with as little
as 5–10° of angling [2]. By carefully assessing
musculoskeletal structures with the ultrasound
beam positioned at 90°, anisotropy artifact can
be minimized, and accurate diagnostic infor-
mation can be obtained.
The special features of the tendons of
younger children may complicate sonograph-
ic interpretation. In children younger than
10 years, tendon vascularity may represent a
normal finding and should not necessarily be
interpreted as a pathologic finding [3]. Peri-
tendinous vessels can also be seen in healthy
children 10–13 years of age and should not be
confused with enthesitis [3]. In addition, ten-
don thickness maintains a linear relationship
with patient age, increasing as patients grow
older [3]. Each of these factors needs to be
carefully considered when interpreting the ul-
trasound appearance of the tendons of a child.
Cartilage
On ultrasound images, cartilage has a char-
acteristic hypoechoic appearance. Articular
cartilage should be regular in appearance,
without evidence of a defect or fraying [4].
In children, epiphyseal ossification centers
may be predominantly cartilaginous, with a
typical anechoic-to-hypoechoic appearance
noted on sonographic examinations (Fig.
1C). This unique feature allows ultrasound
evaluation of epiphyses that are not visual-
ized on conventional radiographs. Attention
to the normal appearance of epiphyses is also
critical for avoiding misinterpretation of the
normal hypoechoic appearance of epiphyseal
cartilage as joint or bursal fluid.
Spectrum of Disorders
Congenital Abnormalities
Developmental dysplasia of the hip—Per-
haps the most common application of ul-
trasound for pediatric musculoskeletal dis-
orders involves sonographic assessment of
developmental dysplasia of the hip (DDH).
AJR:206, May 2016 W63
Ultrasound has been widely validated as an
appropriate diagnostic tool for the classifica-
tion of DDH, and recent clinical investiga-
tions have shown that ultrasound assessment
of a hip clinically suspected to be dysplas-
tic leads to a change in diagnosis for more
than 50% of cases and a change in manage-
ment for 32% of cases [5–7]. Although uni-
versal ultrasound screening for DDH has
been advocated in some countries, in which
a reduced incidence of open pelvic surger-
ies and hip reductions has been associated
with the existence of a sonographic screen-
ing program, practice guidelines in the Unit-
ed States have emphasized using ultrasound
in the assessment of DDH only for specific
clinical circumstances, including abnormal
examination findings, family history, breech
birth, oligohydramnios, and neuromuscular
disorders [8]. When significant instability or
dislocation is not noted on physical exami-
nation, screening ultrasound is not typically
performed before 3–4 weeks of age, to di-
minish the risk of false-positive results oc-
curring secondary to physiologic laxity [9].
Guidelines for the assessment of DDH em-
phasize obtaining coronal and transverse views
of the hip [9]. Standard images in the coronal
plane should include the iliac wing parallel to
the transducer, the ischium, and the triradiate
cartilage (Fig. 2A). Coverage of the femoral
head by the acetabular roof should be greater
than 50%, and the α angle should be greater
than 60° in a normal hip (Fig. 2A). The ace-
tabular promontory should appear angular and
sharp. Images in the transverse plane can pro-
vide further information about femoral head
positioning in relation to the acetabulum. If the
femoral head moves posteriorly after gentle ap-
plication of pressure in the transverse plane,
the findings are compatible with hip instability.
Images of an abnormal hip may reveal dimin-
ished coverage or decentering of the femoral
head, reduction of the α angle, and a rounded
promontory (Fig. 2B). In severe cases of hip
dysplasia, ultrasound can identify interposition
of the labrum or hypertrophy of the pulvinar,
two factors that may impede successful reloca-
tion of the femoral head.
After hip dysplasia is diagnosed, ultra-
sound can provide important information
about the resolution or persistence of hip ab-
normalities after harnessing. Ultrasound may
identify a persistently unstable hip not detect-
ed on physical examination and may direct
clinicians to consider further harnessing [10].
Fibromatosis colli—Fibromatosis colli is
an uncommon cause of congenital muscular
torticollis in which a benign fibroblastic pro-
liferation of the sternocleidomastoid muscle
leads to masslike thickening and shortening
of the muscle. It occurs in infants and is com-
monly identified when parents notice persis-
tent tilting of the head to the affected side. Al-
though the specific cause of fibromatosis colli
is unknown, some researchers have postulated
that the condition may be caused by intrauter-
ine crowding that results in compression and
injury of the sternocleidomastoid muscle [11].
Ultrasound is typically used to diagnose fibro-
matosis colli, with the affected muscle show-
ing a heterogeneous and asymmetric fusiform
enlargement, with or without a focal mass [12]
(Fig. 3A). As long as surrounding soft tissues
appear to be normal and the abnormality is
confined to the sternocleidomastoid muscle,
further assessment with MRI or biopsy is un-
necessary [12].
Treatment typically includes either obser-
vation or physical therapy. Surgical treatment
and muscle lengthening are reserved for pa-
tients for whom more conservative manage-
ment fails [13].
Developmental Abnormalities: Muscle Hernia
Muscle hernias are a developmental abnor-
mality in which muscle protrudes through a
defect in the investing fascia. This pathologic
finding is most commonly seen in the lower ex-
tremities, with approximately 70% of cases in
one series involving the tibialis anterior [14].
Because of the dynamic nature of ultrasound,
which allows patients to undergo imaging
while provocative maneuvers are performed
to elicit symptoms, ultrasound is ideally suit-
ed for the detection of muscle hernias that may
not be suspected clinically or that may be oc-
cult on another imaging modality, such as MRI
[14] (Fig. 3B). Because this is a benign diagno-
sis that may respond to conservative treatment,
a confident diagnosis of a muscle hernia on ul-
trasound should obviate the need for surgery or
biopsy of a symptomatic “mass.” Surgical re-
pair can be considered for patients who do not
respond to conservative treatment or those with
a cosmetic defect [15].
Posttraumatic Abnormalities
Brachial plexus injury—Recent investiga-
tions have shown that ultrasound may play an
important role in the preoperative assessment
of neonatal brachial plexus injuries [16, 17]. Ul-
trasound may show traction neuromas at the
site of the initial trauma as well as the second-
ary joint dysplasia of the glenoid fossa and hu-
meral head, which may occur after the primary

injury [16]. Some suspect that ultrasound may
complement MRI in the assessment of brachi-
al plexus injuries, with MRI providing a more
accurate assessment of nerve root avulsion and
with ultrasound aiding in identification of post-
traumatic neuromas [17].
Intramuscular hematoma—Intramuscular
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hematomas may occur after injuries that me-
chanically disrupt muscle fibers. Secondary
to intramuscular bleeding, a focal hematoma
may coalesce at the site of muscular injury. In
healthy individuals, this usually results from a
significant musculoskeletal trauma, although
in patients with hemophilia, more minor trau-
mas may precipitate intramuscular hemato-
mas that require medical treatment [18].
Although muscle hematomas may be clin-
ically apparent in patients with a history of
trauma, ultrasound may aid in confident diag-
nosis of an intramuscular hematoma if a fo-
cal, heterogeneous, and avascular collection
is seen splaying intact muscle fibers. Ultra-
sound-guided drainage also plays an impor-
tant role in treatment of this injury, with ul-
trasound aspiration associated with decreased
pain as well as a quicker return to athletic par-
ticipation [19]. Early evidence suggests that
ultrasound drainage may also play a role in
the management of patients with hemophilia
with intramuscular hematomas [20].
Morel-Lavallée lesion—Unlike intra-
muscular hematomas, which are contained
within a segment of disrupted muscle, Mo-
rel-Lavallée lesions represent an internal de-
gloving injury in which skin and subcutane-
ous tissues are separated from deeper fascial
structures. Secondary to the disruption of
lymphatic channels and blood vessels, a col-
lection develops along the facial plane con-
taining both blood and lymphatic fluid (Fig.
4A). These lesions typically occur in the re-
gion of the greater trochanter, but they can be
seen along any fascial plane.
Because the fluid collection of the Mo-
rel-Lavallée lesion can compromise dermal
blood supply, local pressure exerted by larger
lesions can cause tissue damage. Evacuation
of the lesion is often indicated to prevent skin
necrosis and superinfection. Although small-
er lesions may be amenable to aspiration per-
formed with ultrasound guidance, larger le-
sions that drain more than 50 mL of fluid
may be best treated using an open drainage
procedure [21].
Myositis ossificans—Posttraumatic myosi-
tis ossificans may occur after a single episode
of trauma or after repetitive small traumas oc-
curring in a discrete area. However, because
W64 AJR:206, May 2016
Hryhorczuk et al.
up to 40% of patients may not recall a specific
inciting trauma, myositis ossificans is not al-
ways initially considered as a possible cause
of a palpable soft-tissue mass in patients [22].
Ultrasound examination of a palpable
mass can assist in diagnosing myositis ossi-
ficans. Typically, myositis ossificans appears
as an ovoid hypoechoic mass that does not
infiltrate adjacent structures [22] (Fig. 4B).
In its early stages, myositis ossificans may
display mild vascularity and ill-defined mar-
gins on ultrasound images, whereas mature
myositis ossificans should appear avascular
with an echogenic shadowing rim compat-
ible with calcification [22]. Radiographs of
the area of concern show a mass with periph-
eral calcifications gradually extending to the
center of the lesion.
Foreign body—For pediatric patients sus-
pected of having a radiolucent soft-tissue
foreign body, ultrasound is a useful tool for
further evaluation. Although the literature
on ultrasound identification of foreign bod-
ies is limited and varies in quality, a recent
meta-analysis reported that ultrasound had a
pooled sensitivity and specificity of 72% and
92%, respectively, for the detection of for-
eign bodies [23]. Given the accessibility and
ease of performing ultrasound for a patient
with a suspected foreign body, this modality
represents an important tool for the detection
of these structures.
On ultrasound, foreign bodies typically
appear linear and echogenic, and they of-
ten show posterior acoustic shadowing (Fig.
4C). A superficial soft-tissue puncture may
be identified and associated with the visual-
ized foreign body. Surrounding fluid or hy-
poechoic granulation tissue can be present,
depending on the timing of the injury. Ultra-
sound can also assist in identifying foreign
bodies associated with deeper soft-tissue
structures, including tendon sheaths or bur-
sae. After identification of the foreign body,
sonographic visualization may be used dur-
ing its removal [24].
Tendon laceration—Ultrasound has been
shown to be sensitive, specific, and accurate
in the diagnosis of tendon tears, both in out-
patient and emergency department settings
[25, 26]. Lacerated tendons typically appear
as a hypoechoic area with disruption of fibril-
lar tendon structures and possible surround-
ing soft-tissue edema. If complete, separation
of the tendon at the site of injury is easily iden-
tified. Soft-tissue echoes compatible with gas
may be identified in cases of penetrating in-
jury, which can be confirmed by radiography.
Careful attention should be paid to the posi-
tion of the ultrasound probe, because beam
angling can create anisotropy artifact and can
falsely suggest tendon disruption.
Infectious and Inflammatory
Disorders
Transient Synovitis
Transient synovitis of the hip is a self-
limited inflammatory condition that is pre-
sumed to be secondary to a viral infection
[27]. Most pediatric patients with transient
synovitis may present with a limp but with-
out fever or abnormal findings of laboratory
investigations [27]. Conversely, a septic hip
should be considered when patients are un-
able to bear weight, are febrile, and have an
elevated sedimentation rate and WBC count
[28]. Ultrasound is unable to accurately dif-
ferentiate between toxic synovitis and a sep-
tic hip, and it may provide a false-negative
result in early stages of the disease [29].
However, the use of ultrasound can be con-
sidered for patients with suspected transient
synovitis if the clinical picture is ambigu-
ous, and clinicians need to confirm the pres-
ence of an effusion before hip aspiration is
attempted (Fig. 5A).
Osteoarticular Infections
A great amount of overlap exists among
children presenting with bone and joint in-
fections. Recent research has indicated that
approximately 40% of children with osteoar-
ticular infections have a combination of sep-
tic arthritis and osteomyelitis, whereas 40%
have isolated osteomyelitis and 20% have
isolated septic arthritis [30]. Isolated osteo-
myelitis is more commonly seen in older
children, whereas isolated septic joints are
most commonly seen in children younger
than 2 years [30].
Because of the relationship between septic
arthritis and osteomyelitis, many advocate
for MRI as the primary diagnostic test in the
workup of children with osteoarticular infec-
tions [30, 31]. However, ultrasound is an im-
portant corollary that may be useful when an
effusion is not palpable or if prompt drainage
of a joint is clinically warranted. Ultrasound
examination of a septic joint shows an effu-
sion, possibly with internal debris, synovial
thickening, or hyperemia. Adjacent osseous
structures should be examined for subperi-
osteal fluid collections that may correspond
to an osteomyelitis that necessitates surgi-
cal drainage (Fig. 5B). Attention to the bony
cortex is also imperative, because careful so-
 Practical Approach to Pediatric Musculoskeletal Ultrasound
nographic evaluation may also show areas of
cortical destruction secondary to adjacent
infection. Indeed, ultrasound of a bone with
suspected osteomyelitis in a pediatric patient
may provide more detailed information than
expected because of the cartilaginous nature
of the physis and epiphysis. In most cases, so-
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nographic findings can be confirmed by radi-
ography or MRI before surgical intervention.
Soft-Tissue Infection
Although a physical examination and the
patient’s history may confirm the presence of
a soft-tissue infection, clinical examination
alone is unreliable in accurately identifying
focal soft-tissue abscesses [32]. Ultrasound
may provide an important adjunct to phys-
ical examination and may aid clinicians in
identifying otherwise occult abscesses [33].
Subtle collections, including those within
the deeper soft tissues or along the fascial
planes, may be more difficult to identify on
direct examination and may benefit from so-
nographic evaluation.
Intramuscular infections of the extremities
are also well depicted on ultrasound imaging.
In the early stages of pyomyositis, a change
in echogenicity within the affected muscle is
typically seen, corresponding to the inflam-
matory change in the area of infection. After
symptoms have been present for 10–21 days,
suppurative pyomyositis with a discrete intra-
muscular fluid component may develop [34]
(Fig. 5C). Although ultrasound is appropriate
for the assessment of possible muscle infec-
tion involving the extremities, concern about
possible pelvic pyomyositis necessitates fur-
ther assessment with MRI, because pelvic ul-
trasound is insensitive for the assessment of
possible muscular infections [34, 35].
Lymphadenitis
Enlarged lymph nodes, secondary to ei-
ther infection or inflammation, are common
among children. However, this finding on
physical examination often generates signifi-
cant concern as clinicians seek to distinguish
neoplastic lymph nodes from those enlarged
secondary to nonmalignant causes. Although
the medical literature reports a wide varia-
tion in the sensitivity and specificity of ul-
trasound in distinguishing neoplastic lymph
nodes from other causes of lymphadenopathy,
certain features may be suggestive of a benign
diagnosis [36]. A rounded configuration in a
lymph node or an absent hilum is more com-
monly seen with lymphoma or bacterial infec-
tion, whereas reactive lymph nodes typically
AJR:206, May 2016 W65
appear ovoid with a preserved hilum that con-
forms to the nodal shape [37]. Surrounding
inflammatory changes may suggest an infec-
tious or inflammatory cause for an enlarged
lymph node; in some cases, liquefaction and
necrosis may be identified [38] (Fig. 5D). In
many cases, tissue biopsy is still required for a
definite diagnosis [36].
Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis encompasses
a heterogeneous group of inflammatory ar-
thritides, which are currently divided into
seven specific subtypes [39]. The hallmark of
this disease, however, is synovitis, which can
be readily detected on ultrasound examina-
tion. Current strategies for assessing disease
activity in children with juvenile idiopathic
arthritis primarily rely on physical exami-
nation and clinical evaluation to determine
the presence or absence of active inflamma-
tion [40]. However, early evidence points to
a role for ultrasound as a complementary
technique to detect synovitis that may not be
evident on physical examination [41]. Ultra-
sound can show joint effusions and synovi-
al hypertrophy in identified areas of concern
(Fig. 6A). Color or power Doppler imaging
may be especially helpful in revealing the sy-
novial hyperemia that signifies active syno-
vitis [42] (Fig. 6B). Ultrasound also plays an
important role in identifying enthesitis and
tenosynovitis, allowing clinicians to identify
inflammatory changes occurring outside the
joint space. Finally, ultrasound can be used
to perform targeted intraarticular cortico-
steroid injections for patients with identified
disease [43].
Soft-Tissue Masses
Vascular Malformations
Vascular malformations provide an im-
portant opportunity for radiologists to both
diagnose these lesions and direct their man-
agement through image-guided therapy. Vas-
cular malformations typically are divided
into two general categories: low-flow lesions
(lymphatic, venous, capillary, and mixed
malformations) and high-flow lesions (ar-
teriovenous malformation and fistula) [43].
The flow characteristics of the lesions deter-
mine the type of intervention that should be
offered for definitive treatment.
Lymphatic malformations—Lymphatic mal-
formations are one type of slow-flow vascular
malformation seen in children, and they can be
microcystic or macrocystic or can have mixed
components. Approximately 50% of lymphatic
malformations are found in the head and neck,
whereas 40% are seen on the extremities, and
10% are visceral [44]. Macrocystic lymphatic
malformations may appear on ultrasound as
multiple cystic spaces with intervening septa-
tions; no Doppler flow should be seen within
the cystic spaces (Fig. 7A). If a macrocystic
malformation has been complicated by inter-
nal hemorrhage, echogenic material may fill
the cystic spaces. Microcystic malformations
may sonographically appear as small cysts
measuring less than 1 cm. However, because of
their small size, the tiny cystic cavities may not
be discretely identified, and a microcystic mal-
formation may simply appear as an echogen-
ic mass on ultrasound [44]. Ultrasound-guided
percutaneous sclerotherapy is usually the ini-
tial treatment option if a macrocystic compo-
nent is present, with excellent responses occur-
ring in 20–64% of cases [45].
Venous malformations—Venous malfor-
mations are also slow-flow vascular malfor-
mations and are composed of ectatic venous
structures. Although venous malformations
are congenital lesions, they may not become
symptomatic until later in life. On physical
examination, venous malformations may be
blue, cool, and compressible and may in-
crease in size after maneuvers designed to
increase venous pressure [46]. Venous mal-
formations can present as a localized mass or
as multiple infiltrative tortuous varicosities
that traverse multiple tissue planes. Ultra-
sound examination of venous malformations
typically shows a compressible, hypoecho-
ic, and heterogeneous lesion [47] (Fig. 7B).
Phleboliths may be seen in a minority of pa-
tients [47]. On pulsed Doppler examination,
monophasic low-velocity flow may be identi-
fied. In some cases, vascular flow within le-
sions may be too slow to be detected on so-
nographic examination [47]. Similar to the
treatment of lymphatic malformations, ultra-
sound-guided percutaneous sclerotherapy is
the first-line treatment for venous malforma-
tions [48].
Arteriovenous malformations—Unlike lym-
phatic and venous malformations, arteriove-
nous malformations and fistulas are high-flow
vascular lesions with arteriovenous shunting
in the absence of a capillary bed. Ultrasound
examination of these lesions usually reveals
multiple serpiginous vascular channels with
arterial and venous waveforms. Arterialized
venous flow can be seen in the draining veins.
A soft-tissue mass should not be present [49]
(Fig. 7C). Definitive treatment of arteriove-
nous malformations may be technically diffi-

cult and should be reserved for children who
are symptomatic. Embolization of the malfor-
mation is the preferred treatment of these le-
sions, with possible selective catheterization
and targeting of the nidus of a lesion with em-
bolizing agents [50].
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Vascular Neoplasms: Hemangiomas
Infantile hemangioma—The term “hem-
angioma” is reserved for vascular neoplasms
characterized by the proliferation of endo-
thelial cells. The vast majority of hemangi-
omas seen in clinical practice are infantile
hemangiomas that are not present at birth,
grow rapidly in early life, and involute slow-
ly over a few years [51]. The medical history
of the patient and the findings from a clini-
cal examination typically reveal a lesion that
developed during the first 3 months of life,
with a classic appearance noted on physical
examination [51].
The appearance of infantile hemangiomas
on ultrasound is quite variable, depending on
the stage of its evolution. A focal hemangioma
presents as a discrete solid mass. In contrast,
segmental hemangiomas appear plaquelike
with a geographic configuration [52]. Infan-
tile hemangiomas readily show arterial and
venous flow on Doppler imaging, unless they
are imaged during their involution. If a le-
sion has a typical clinical and sonographic ap-
pearance, no treatment is necessary, because
the lesion involutes in the first several years
of life. Complications, however, may arise
from hemangiomas that develop in critical ar-
eas (known as “endangering hemangiomas”),
such as the orbital or perioral region, which
place a child at risk for a functional compro-
mise or permanent cosmetic deformities [51].
Although routine imaging of hemangiomas is
usually unnecessary, it may be requested to
evaluate the extent of a lesion and its relation-
ship to vital structures, if treatment is being
considered [53]. Many hemangiomas require
no intervention. When hemangiomas devel-
op in critical locations, the first-line treatment
for these lesions is systemic propranolol, al-
though other systemic medications or surgical
excision can be considered for refractory cas-
es. Laser therapy may be used for treatment of
cosmetically troublesome hemangiomas (i.e.,
facial lesions).
Congenital hemangioma—Hemangiomas
that are present and fully grown at birth can
be divided into two categories: noninvolut-
ing congenital hemangiomas and rapidly in-
voluting congenital hemangiomas [51]. Al-
though the patient presentation and history
W66 AJR:206, May 2016
Hryhorczuk et al.
associated with these types of hemangio-
mas differ from the patient presentation and
history associated with infantile hemangio-
mas that typically grow in early life, certain
sonographic findings may also suggest that
a lesion is a noninvoluting congenital hem-
angioma or a rapidly involuting congeni-
tal hemangioma. In comparison with infan-
tile hemangiomas, congenital hemangiomas
have been described as being more heteroge-
neous on ultrasound, showing distinct vessels
and possible small calcifications [54] (Fig. 8).
Rapidly involuting congenital hemangiomas
typically involute over the first 14 months of
life [51]. Noninvoluting congenital hemangi-
omas should not grow after birth and typical-
ly do not require treatment. However, for le-
sions that are painful or disfiguring, surgical
resection can be considered [55].
Epidermoid and Dermoid Cysts
Multiple cystic soft-tissue masses can be
seen in the pediatric population. Epider-
moid and dermoid cysts are both ectoder-
mally lined inclusion cysts; although epider-
moid cysts contain squamous epithelium only,
dermoid cysts contain squamous epithelium,
hair, sebaceous glands, and sweat glands [56].
These cysts are often seen in the head and
neck, and they may be seen in a midline loca-
tion. In these lesions, vascular flow is absent
but echogenic internal debris is present. Se-
baceous cysts are often confused with epider-
moid cysts secondary to their similar clinical
and sonographic appearance. These lesions,
however, arise from the sebaceous glands.
Ganglion Cysts
Although ganglion cysts may occur at
any site where synovium is present, they are
most typically observed at the dorsum of the
wrist, where they may be identified in asso-
ciation with the flexor tendon sheath or the
carpal joint space [57]. Intraarticular gan-
glions can be definitively diagnosed on ul-
trasound by locating a small neck that con-
nects the cyst to the joint space (Fig. 9). They
should not have any solid component or vas-
cularity. Ganglion cysts can also be associat-
ed with the synovium that envelops a tendon
sheath. Observation, aspiration, and surgical
excision are common treatments that may be
considered for symptomatic ganglia.
Lipoma and Lipoblastoma
Adipocytic tumors are uncommon in chil-
dren, representing approximately 6% of soft-
tissue tumors in the pediatric population
[44]. If a fatty tumor is present in an older
child or an adolescent, it most likely is a li-
poma, the imaging characteristics of which
are similar to those noted for fatty tumors in
adults. Lipoblastomas, however, are uniquely
pediatric tumors and are histologically com-
prised of adipocytes, lipoblasts, and a myx-
oid stroma [44]. These tumors are typically
located in the extremities of young children,
with 80–90% of cases occurring in children
younger than 3 years [58]. Ultrasound exam-
ination of lipoblastoma typically reveals a
well-circumscribed homogeneous mass, al-
though some lipoblastomas may appear as
internal cystic spaces and septations [58, 59]
(Fig. 10A). A more infiltrative mass suggests
lipoblastomatosis [59]. Although the natural
history of the lipoblastoma is to evolve into a
lipoma, excision may be performed to obtain
a definite diagnosis or to remove a function-
ally or cosmetically troublesome lesion [60].
Peripheral Nerve Sheath Tumors
Neurofibromas and schwannomas are the
two main peripheral nerve sheath tumors that
may undergo initial imaging evaluation with
soft-tissue ultrasound. Neurofibromas are typi-
cally homogeneous, avascular, and concentric
tumors that disrupt the fascicular architecture
of the nerve [61]. Multiple types of neurofibro-
mas have been reported, including localized
neurofibromas that are focal and well circum-
scribed (Fig. 10B), plexiform neurofibromas
that spread along multiple nerves to create ser-
piginous masses, and diffuse neurofibromas
that have a plaquelike configuration. Although
pediatric patients without an underlying abnor-
mality may have a solitary neurofibroma, the
presence of two or more neurofibromas or a
plexiform neurofibroma raises concern about a
diagnosis of neurofibromatosis type 1, and fur-
ther clinical evaluation is typically warranted.
On ultrasound examination, cross-sectional
sonographic images of the neurofibroma may
show a classic targetoid appearance, with an
echogenic fibrous center surrounded by a hy-
poechoic myxoid periphery [61]. Unlike neu-
rofibromas that disrupt fascicular architecture,
schwannomas typically show an elongated and
spindle-shaped configuration that displaces
nerve fascicles. In some cases, schwannomas
may contain internal calcifications or evidence
of cystic degeneration [61].
Pilomatrixoma
Most frequently seen among children, pi-
lomatrixomas are benign soft-tissue tumors
that arise from follicular hair cells. These le-
 Practical Approach to Pediatric Musculoskeletal Ultrasound
sions are commonly found on the head and
neck, although they can occur in any site
where hair follicles are present. Ultrasound
examination of pilomatrixoma may show a
well-defined, heterogeneous, and predomi-
nantly echogenic mass with internal calci-
fication and peripheral Doppler vasculari-
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ty [62] (Fig. 10C). Calcifications may range
from small punctate echogenicities to large
coarse calcifications with dense posterior
acoustic shadowing. Because these lesions
arise from hair follicles, a close relationship
to the overlying skin should be readily identi-
fied on sonographic evaluation [63].
Malignant Neoplasms
Malignant soft-tissue neoplasms are rare
in the pediatric population, and most chil-
dren referred for ultrasound examination of a
soft-tissue mass usually have a benign abnor-
mality. An exception to this general principle
is children with premalignant conditions or
tumor predisposition syndromes; these pa-
tients certainly have a higher risk for soft-
tissue malignancies and require more ag-
gressive management if they present with a
palpable mass [64]. Specific clinical features
may also raise suspicion of a soft-tissue ma-
lignancy. If a soft-tissue tumor is identified
in the extremity of an infant, infantile fibro-
sarcoma should be considered, especially if
intratumoral hemorrhage is identified [65]
(Fig. 10D). Sonographic features such as ill-
defined margins or a heterogeneous and in-
filtrative lesion should raise suspicion for a
possible neoplasm, such as rhabdomyosar-
coma, and should spur the use of rapid bi-
opsy for making a definitive diagnosis (Fig.
10E). However, masses that appear to be
even more innocuous may be malignant. Al-
though some sarcomas can grow rapidly, oth-
ers, such as synovial sarcoma, often show an
indolent course with very slow growth, fre-
quently leading to a delay in diagnosis [66].
Synovial sarcomas may also be homoge-
neous and well defined or predominantly
cystic, adding further confusion to the clini-
cal picture [66]. Other imaging features, such
as fluid-fluid levels, are not specific for dif-
ferentiating between a malignant or benign
lesion and should not be used to direct man-
agement [67].
Conclusion
Ultrasound is a widely accessible and ra-
diation-free tool that is invaluable in the
imaging evaluation of the pediatric patient
with musculoskeletal complaints. With the
AJR:206, May 2016 W67
use of high-frequency probes and appropri-
ate techniques, ultrasound can be used in the
evaluation of congenital and developmental
abnormalities, posttraumatic lesions, and in-
fectious and inflammatory entities. Vascular
anomalies, vascular masses, and cystic and
solid soft-tissue masses are all amenable to
ultrasound evaluation. Familiarity with the
specific pathologic findings seen in the pedi-
atric population and the typical appearances
of these lesions on ultrasound may aid in pro-
viding a timely diagnosis of a variety of mus-
culoskeletal concerns.
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(Figures start on next page)
 Practical Approach to Pediatric Musculoskeletal Ultrasound

Fig. 1—Musculoskeletal anatomy.

A, 14-year-old girl. Ultrasound image shows normal soft-tissue anatomy, including dermis (D), subcutaneous fat
(SQ), superficial muscle fascia (F), muscle (M), and myotendinous junction (asterisk)
B, 11-year-old girl. Left ultrasound image shows normal appearance of patellar tendon (arrows) with
homogeneous fibrillar pattern. Right ultrasound image obtained with probe not perpendicular to tendon shows
anisotropy with patchy hypoechoic areas (arrows) throughout heterogeneous tendon. T = tibia.
C, 6-month-old girl with developing epiphysis and apophysis in knee. Gray-scale sagittal ultrasound image of
normal knee shows cartilaginous femoral epiphysis (F) as anechoic structure. Unossified patellar apophysis (P)
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is hypoechoic. Ossified nucleus (asterisk) in femoral condyle appears as echogenic rim with posterior acoustic
shadowing.

B C

Fig. 2—Two patients with developmental dysplasia

of the hip.
A, 1-month-old healthy girl. Sagittal hip ultrasound
obtained using α angle of 62° (lines) shows normal
appearance of cartilaginous labrum (arrow),
nonossified femoral head (FH), ischium (I), and
triradiate cartilage (asterisk).
B, 12-week-old girl with hip dysplasia, examined
in harness. Sagittal ultrasound image of right hip
shows decreased α angle of 41° (lines) and blunted
promontory (thin arrow), thickened labrum (thick
arrow), and substantial subluxation of femoral head
(FH) with no acetabular coverage. Hypertrophy of
pulvinar cartilage (asterisk) is also shown.
A B

Fig. 3—Two patients with

congenital lesions.
A, 1-month-old boy with
fibromatosis colli. Ultrasound
image shows focal fusiform
enlargement (between calipers) of
sternocleidomastoid muscle.
B, 9-year-old boy with painless
pretibial lump. Ultrasound image
shows disruption of superficial
fascia (between arrows) with focal
muscle herniation (asterisk) across
fascial plane. TA = tibialis anterior.
A B

AJR:206, May 2016 W69

 Hryhorczuk et al.
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A B
Fig. 4—Three patients with posttraumatic lesions.
A, 17-year-old female ballet dancer with painful thigh swelling after fall. Panoramic sagittal
ultrasound image of the left inner thigh superior to knee shows Morel-Lavallée lesion (middle
of image) with fusiform well-defined hypoechoic structure (arrows) with internal septations.
Internal echogenic foci (asterisks) likely denote fat within superficial subcutaneous soft
tissues. There is disruption and increased echogenicity of surrounding fat planes.
B, 16-year-old girl with myositis ossificans presenting as painful hard thigh lump after recent
trauma. Sagittal ultrasound image of area of concern shows collection with low-level echoes
(asterisk) overlying femoral diaphysis (D). Small calcifications are seen within wall (arrows).
C, 6-year-old girl with foreign body injury to midfoot. Transverse panoramic ultrasound image
of right plantar midfoot at level of metatarsals (with “first” through “fifth” identifying each
metatarsal) shows linear echogenic wooden splinter (arrows) embedded in subcutaneous
soft tissues overlying fifth metatarsal diaphysis.
C

A B C
Fig. 5—Four patients with postinfectious complications and infections of joints and bone.
A, 5-year-old girl who presented with limping after having recently had upper respiratory infection. Ultrasound
image shows anechoic fluid distending left hip joint (asterisk). Contralateral hip (not pictured) was normal.
Patient had toxic synovitis diagnosed. H = femoral head, N = femoral neck.
B, 2-year-old boy with fibular osteomyelitis and subperiosteal abscess who presented with fever, leg pain, and
swelling. Sagittal ultrasound image of lateral left ankle shows subperiosteal fluid collection containing debris
along distal fibular metadiaphysis (arrows). M = fibular metaphysis, E = fibular epiphysis.
C, 16-year-old boy with staphylococcal pyomyositis with painful thigh swelling and fever. Panoramic sagittal
ultrasound image of medial distal thigh above left knee shows hyperechoic enlarged vastus medialis muscle
with loss of internal architecture (arrows) and central hypoechogenicity (asterisks), likely representing early
liquefaction.
D, 13-year-old girl with suppurative adenitis with painful axillary swelling and erythema. Sagittal color Doppler
image of the left axilla shows oval lymph node with heterogeneous parenchyma and peripheral hyperemia (arrows)
surrounded by inflammatory changes. Swirling internal low-level echoes (asterisk) indicate liquefaction. D

W70 AJR:206, May 2016

 Practical Approach to Pediatric Musculoskeletal Ultrasound

Fig. 6—13-year-old girl with juvenile idiopathic

arthritis who presented with persistent knee swelling
and pain.
A, Sagittal ultrasound image of left knee shows joint
effusion (E) in suprapatellar fossa with synovial
thickening (arrows) and proliferation (asterisk). F =
femoral head.
B, Color sagittal Doppler image of left knee
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(corresponding to image shown in A) shows

hyperemia (arrows) of thickened synovium. E = joint
effusion, F = distal femur.

A B

A B C
Fig. 7—Vascular malformations.
A, 1-year-old boy with lymphatic malformation who presented with painless soft lump on right posterior arm. Sagittal ultrasound image shows multiloculated cystic mass
(arrows) with septations in subcutaneous soft tissues of arm. This lymphatic malformation has predominantly macrocystic (M) components. Color Doppler image (not
shown) showed only minimal septal and peripheral vascularity.
B, 9-year-old boy with venous malformation with painful soft bluish lump in hand. Ultrasound image shows well-defined heterogeneous soft-tissue mass (arrows) with
anechoic venous channels (asterisks). Doppler image (not shown) showed no significant color flow in venous channels.
C, 12-year-old girl with arteriovenous malformation with intermittent painful swelling of cheek. Gray-scale sagittal ultrasound image (top) of right cheek shows poorly
defined area of abnormal increased echogenicity and thickening in subcutaneous soft tissues. Although this obliterates fat planes of cheek (arrows), no discrete mass
is identified. Few hypoechoic vessels are scattered superficially (asterisks). Spectral sagittal color Doppler image of arteriovenous malformation (bottom) in right cheek
shows prominent draining vein with classic arterialized waveform.

A B
Fig. 8—3-week-old girl with congenital hemangioma that has remained unchanged since birth.
A, Gray-scale sagittal ultrasound image of right lower leg shows well-defined lobulated echogenic solid mass (arrows) in subcutaneous soft tissues of ankle involving dermis.
B, Spectral sagittal color Doppler image of same lesion shows marked increased vascularity inside hemangioma with arterial waveforms (left) and venous waveforms (right).

AJR:206, May 2016 W71

 Hryhorczuk et al.

Fig. 9—6-year-old boy with painful soft lump identified as ganglion cyst in left wrist. Sagittal ultrasound
image of wrist shows well-defined anechoic structure (arrows) in subcutaneous soft tissues of wrist, with tail
(asterisk) extending deep into joint. No vascular or soft-tissue component was identified.
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A B C

D E
Fig. 10—Five patients with solid masses.
A, 12-month-old boy with lipoblastoma presenting as slow-growing and soft lump in neck. Gray-scale sagittal ultrasound image of right side of neck shows well-defined
solid mass (arrows) confined to subcutaneous soft tissues of right supraclavicular region. Lesion contains both hyperechoic fatty elements (F) and hypoechoic myxoid
components (M).
B, 12-year-old girl with neurofibromatosis type 1 with multiple subcutaneous neurofibromas. Gray-scale ultrasound image of neck shows three well-defined hypoechoic
and homogeneous solid nodules (asterisks) within subcutaneous soft tissues overlying sternocleidomastoid muscle (M).
C, 10-year-old boy with pilomatrixoma with painful skin nodule. Gray-scale ultrasound image of neck shows round solid nodule (arrows) involving dermis (asterisks) and
superficial subcutaneous soft tissues. Nodule has hypoechoic peripheral halo. Color Doppler image (not shown) revealed increased vascularity in periphery of nodule.
D, 6-month-old girl with congenital fibrosarcoma who presented with hard lump on back. Color Doppler image shows solid well-defined mass with significant internal
vascularity.
E, 3-year-old boy with Li-Fraumeni syndrome with rhabdomyosarcoma, which presented as soft and painless lump on left posterior thigh. Patient previously underwent
foot amputation because of primary tumor. Gray-scale sagittal ultrasound image shows round predominantly solid mass (arrows) with anechoic cystic spaces (asterisks)
centered in deep tissues of thigh. Color Doppler image (not shown) shows internal vascularity in solid mass.

W72 AJR:206, May 2016