Emergency Ultrasound (EUS)教學(9)

急診超音波在骨骼軟組織之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
30M, abdominal pain for one week
 Outlines
• US anatomic considerations
• Skin and soft tissue infection
• Foreign body localization
• Abdominal wall mass evaluation
• Bony fracture evaluation
• Imaging of tendons, joints, and muscles
 正常組織超音波影像
• Skin
– Echogenic
• Subcutaneous tissue
– Hypoechoic
– Traverse by irregular strands of hyperechoic connective tissue
• Fascial planes
– Hyperechoic; regular thickness
• Muscles
– Striated appearance on long axis scan
• Tendon
– Fibrillar; echogenic
• Vascular structures
– Anechoic (Artery versus Vein)
• Lymph nodes
– Irregular, circular, echogenic; with hypoechoic rim
• Bones
– Echogenic cortices and dense acoustic shadows
 掃描注意事項
• 高解析線形探頭 (5-10MHz)為第一首選
• 注意深度(depth)和焦點(focus)的設定
• 適當應用探頭施壓
• 至少掃描兩個介面 (longitudinal & transverse)
• 考慮和對側比較 & 呈現在同一畫面 (Split
screen)
• 如何改善掃描品質
– Stand-off pad
– Water/gel-filled glove
– Water bath technique
Water/gel-filled glove
皮膚 & 軟組織感染
EUS在皮膚 & 軟組織感染的應用
• 須熟悉正常超音波軟 • 正確診斷不明顯膿瘍
組織影像  診斷
• 正確定位不明顯膿瘍
• 認識週遭組織及結構  定位
• 協助膿瘍引流
• 協助設定最佳切除及  處置
引流路徑
 皮膚 & 軟組織感染
• Cellulitis • Necrotizing fasciitis
– Cobblestone-like appearance – Marked thickened of SC layer
• Subcutaneous abscess – A layer of anechoic fluid,
– Variable appearance • greater than 4 mm
– Most: hypoechoic; spherical • adjacent to deep fascia
mass – Subcuatneous gas
– Content: • Acoustic shadow
• Hyperechoic sediment • Reverberation artifact
• Septae
• Gas
• Isoechoic or hyperechoic
• Liquefied pus
– induced motion of the
content
 Cellulitis
• Nonspecific
• Indicative of
edema
• Skin
• Subcutaneous
tissue
• Compare to
unaffected side
Normal v.s. Cellulitis
Soft-tissue US changes cellulitis
management (56%, 71/126)

Tayal VS, et al. AEM. 2006;13:384-388

EUS improves accuracy of superficial
abscess detection

Squire BT, et al. AEM. 2005;12:601-606

Chest wall cellulitis & abscess
70F, PN with chest wall abscess
Dorsal foot cellulitis with clinically
unsuspected coexistent abscess
Soft tissue with abscess
 Thigh abscess
(Lesion side v.s. Normal side)
Soft tissue abscess
Thigh abscess
Subcutaneous abscess (Thigh)
Buttock abscess
Thigh cellulitis and abscess
Antecubital fossa abscess
Post-op abdominal wall abscess
Gas-forming abscess
L’t groin pulsatile mass
 NTUH experience
• diffuse thickening of the
SC tissue
• a layer of fluid
accumulation more than
4 mm in depth along the
deep fascial layer
• 66 patients (17,NF)
• Sensitivity: 88.2%
• Specificity: 93.3%
• PPV: 83.3%
• NPV: 95.4%
• Accuarcy: 91.9

Yen ZS, et al. AEM. 2002;9:1448-1451

72M, NF of left forearm
Chronic Lymphedema
 Skin & Soft Tissue Infections
Clinical decision making
Skin and soft tissue infection

Obvious abscess Possible or suspected abscess Cellulitis

Fluctuant or draining No fluctuance No suspicion of abscess

I&D EUS Abx

Consider NSTI

Localize Abscess seen No abscess seen

collection
 Pitfalls
• Abscess are not always hypoechoic

• Failure to consider necrotizing soft tissue

infections

• Failure to recognize adjacent structures

軟組織異物
 軟組織異物診斷及定位
• 殘留軟組織異物
– 易使受傷的皮膚及軟組織產生併發症
– 常不易由病史和理學檢查查覺
– 38% 在第一次就診時無法診斷出來
– 為常見的醫療糾紛原因之一
 軟組織異物診斷及定位
臨床應用
• 協助診斷X-ray不易查覺異物 (radiolucent)

• 定位異物及辦識其特性及週遭結構

• 協助異物移除
 軟組織異物
• 常見異物
– glass, wood, metal, plastic, gravel
• 異物:
– Size; material; retained period
– Hyperechoic
– Variable acoustic shadow
– Variable reverberation artifact
• 殘留異物超過24-48小時
– 因組織反應，會在異物周圍形成一圈 (hypoechoic halo)
 軟組織異物
移除技巧
• Ultrasound-guided incision
• Real-time ultrasound to guide placement
of forceps or a hemostat next to the FBs
(linear FB)
• Ultrasound-guided needle localization
Normal thenar eminence
Chicken thigh with stand-off pad
Wooden toothpick
Wooden FB
Needle
Broken needle fragment
Chest wall bullet
BB
Linear glass shard
Broken glass bottle
Plastic toothpick
Gravel
Left thigh FB
 Case
Swollen digit
Finger X-ray
Wood fragment
Time matters
30M carpenter
Wood splinter
Needle approaches FB
 Pitfalls
• Inadequate knowledge of the regional
sonographic anatomy
• Failure to take necessary steps to optimize
scanning of small superficial objects
• Other pitfall
• Foreign body removal
骨折評估
 骨折評估
• 肋骨骨折
• 胸骨骨折
• 長骨骨折
• 堅困環境骨折
• 骨折復位
• 脫位復位
• FASTER
 骨折評估
• 骨表面產生不連續線條
• 骨折周圍低回音血腫
• 掃描時注意最痛點
• 至少進行兩個介面掃描
Rib
Normal rib
Rib fracture
Rib fracture
Rib fracture
Normal sternum
Sternal body fracture
Femur
Femoral shaft fracture
Tibial shaft fracture
 Pitfalls
• General pitfalls
• Rib pitfalls
– Pseudofracture
– Misidentify pleura for a rib
• Sternum fracture pitfalls
– Sternomanubrial junction
– Hypoechoic pectoralis muscle
• Long bone fracture pitfalls
– Exellent for only midshaft fractures
關節液評估
 Elbow effusion
(Olecranon fossa)
 Hip X-ray
Axis for imaging hip effusion
Normal v.s. Hip effusion
Septic arthritis of right hip
Suprapatellar effusion
US guided arthrocentesis
Ankle sonogram
肩關節復位評估
Verify shoulder reduction

AJEM 2009
40F, Should dislocation
& post-reduction
 Take Home Message
• 急診超音波可協助骨骼軟組織之臨床診斷，
及協助進行相關處置

• 第一首選為高頻線形探頭

• EUS對臨床診斷及決策有立即幫助的應用
才是最需要學習的項目
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