Chapter
4
Basic Approach to Ultrasound
of Other Structures in the
­Extremities
Christopher Harker Hunt, MD
KEY POINTS
l  Simple cysts have the following ultrasonographic features:
anechoic, thin wall, posterior acoustic enhancement, and no
evidence of color Doppler flow.
l Soft-tissue masses in the extremities typically possess
the features that simple cysts do not, and when seen
in approximation to peripheral nerves it is important
to determine if the mass appears to disrupt the nerve
architecture (as can be seen with a traumatic neuroma or
malignant nerve sheath tumor) or if it is more peripherally
located next to an otherwise normal-appearing nerve (as is
seen with schwannomas).
l Color Doppler is helpful for assessing vascular structures in
the extremities, including aneurysms, pseudoaneurysms,
arteriovenous fistulas, and venous thromboses.
l When imaged with ultrasound, some structures are more
anisotropic than others, with higher anisotropic structures
changing brightness based on the angle of the transducer.
For example, tendons are very anisotropic, so they are
bright when perfectly perpendicular to the transducer and
dark when the transducer is at an angle to the tendons.
Nerves and muscles have less anisotropy than tendons,
and knowledge of this helps in identifying structures in the
extremities.
One of the critical functions of the peripheral nerve ultraso-
nographer is to not only study the structure of interest (i.e.,
peripheral nerve) for potential pathology, but to also be sure
that incidental findings within the field of view of the ultra-
sound probe are examined. Although these incidental findings
may or may not be related to the patient’s chief complaint and
the reason for the examination, their significance should not
be overlooked. They are important for examination comple-
tion and documentation and can be crucial findings to signal
systemic disease or potentially life-threatening conditions that
must be recognized. With the improvement in memory and
the ability for longer “clip-stores,” these findings are often
able to be reviewed retrospectively at a later date should their
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presence go unnoticed on the initial examination, leading to
the possibility of increased liability.
This chapter examines some of the more common inciden-
tal findings that can be seen as well as a few rare entities, which
are of such importance when seen that their presence should
not be overlooked. As with most things in medicine, it is help-
ful to have a framework in which to put findings. This chap-
ter, although certainly not all-inclusive, attempts to provide
the neuromusular ultrasonagrapher with a system for describ-
ing and diagnosing other processes in the extremity that are
not directly related to the peripheral nerve but that may be of
equal, or perhaps greater, importance. In addition, this chap-
ter provides a basic framework for communication of these
results so as to guide the referring physician in the next step
of the workup.
In an effort to do all this in a logical fashion, the chapter is
divided into (1) cystic soft-tissue masses, (2) solid soft-tissue
masses, (3) abnormalities related to the veins and arteries, and
(4) common artifacts that can mimic or obscure disease.
Cystic or Partially Cystic
Soft-Tissue Masses
Before discussing individual disease processes, it is necessary
to understand the ultrasonographic definition of a simple
cyst. This is important in terms of accurate diagnosis and to
allow the peripheral nerve ultrasonographer to communicate
in commonly understood terms in the report to other clini-
cians and imagers.
Simple Cyst
A simple cyst must have all of the following: (1) anechoic,
(2) thin or barely perceptible wall, (3) posterior acoustic
enhancement, and (4) no evidence of flow on color ­Doppler
evaluation.1 If a mass has all of these features, it can ­confidently
be called benign by the imager. Unfortunately, in the extremi-
ties, pure simple cysts are rare (as opposed to within the
kidneys or liver, for example). These rules, ­however, are still
applicable and appropriate for describing the features of
cystic masses and make a good framework for a report and
57
58 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
Fig. 4.1.  Typical features of a benign cyst in the subcutaneous tissues.
Note the cyst is anechoic, has a thin barely perceptible wall, and has pos-
terior acoustic enhancement. Doppler ultrasound (not shown) confirmed
no internal flow.
communication. Expert technique with the use of the appro-
priate frequency transducer, careful observation and analysis,
and documentation of these findings are necessary to prevent
errors that might falsely reassure a referring physician or lead
to a failure in recognition of significant findings (Fig. 4.1).
Abscess, Cellulitis, and Foreign Body
One of the more unexpected findings for the peripheral nerve
ultrasonographer can be an occult abscess. Patients who have
these are often referred for limb pain and may have focal
tenderness and erythema. Although systemic septicemia can
hematogenously seed the soft tissues and set up the necessary
components for an abscess, these patients frequently have a
history of prior instrumentation (i.e., biopsy or surgery) or
trauma at the site of the abscess.2,3 Careful examination to
exclude the presence of a foreign body is critical because this
can change management. Even without the presence of cel-
lulitis or abscess, the most sensitive method for detection of a
foreign body in an extremity is an ultrasound.
In general, foreign bodies should be seen as hyperechoic
reflectors. Depending on the composition of the foreign body,
this reflector may or may not have posterior acoustic shadow-
ing. Identification of the foreign body and marking its loca-
tion on the overlying skin can be invaluable to the surgeon
in terms of limiting the exposure required for its removal.4
Given the high spatial resolution of ultrasonography, as well
as the fact that the majority of foreign bodies are not radi-
opaque (i.e., wood), ultrasound is the modality of choice the
majority of time for imaging small superficial foreign bod-
ies as opposed to fluoroscopy, conventional radiographs, or
magnetic resonance imaging (MRI).
Cellulitis and abscess can be viewed as similar processes
along a spectrum of organization. Cellulitis typically appears
ultrasonographically as edema in the subcutaneous tissues
with a characteristic “marbled” appearance. Although the soft
tissues in cellulitis may be hyperemic on Doppler, this can be
difficult to quantify and less useful than the gray scale appear-
ance and appropriate clinical setting.
In contrast, an abscess, either with or without associated
cellulitis, has a different ultrasonographic appearance. Unlike
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RT
MID
2 1
THIGH
TRANS 1
2
----1----
Dist = 4.85cm
----2----
Dist = 2.32cm
Fig. 4.2.  Collage of images from an abscess with a retained Teflon-
coated piece of gauze. Note the complex, hypoechoic mass with internal
echoes that appears to have an internal lacelike structure (arrow). Surgi-
cal drainage and excision of the abscess confirmed the foreign body,
which was unsuspected in this patient prior to the ultrasound.
cellulitis, an abscess is typically well formed, and as a result
a discrete measurement of the size and extent can be made.
Usually complex in appearance, the typical abscess has a
thick wall, which may have increased Doppler flow. Inter-
nally, there may be some low level echoes representing com-
plex fluid within the abscess. Again, careful examination is
necessary to exclude a foreign body because the presence
of a foreign body most often necessitates surgical drainage
and removal as opposed to percutaneous drainage alone
(Fig. 4.2).2,5-7
Ganglion Cysts
Typically located around the hand and wrist, ganglion cysts
are common causes of palpable abnormalities as well as pos-
sible generators for extremity pain. The majority arise on
the dorsal surface of the hand, with proximity to the scaph-
olunate joint seen in approximately 70% of cases.8 They can
also be intimately associated with the flexor tendons of the
hand, most commonly around the flexor carpi radialis ten-
don. Ultrasonographically, these should appear as true cysts,
although faint low-level echoes are allowed, given that gan-
glion cysts may be filled with complex proteinaceous material.
Especially in cases in which faint low-level echoes are pres-
ent, Doppler evaluation is crucial to exclude confusion with a
profoundly hypoechoic mass, which is worrisome for a solid
soft-tissue mass (Fig. 4.3).9-12
Treatment of these cysts is variable, from observation,
to manual rupture, ultrasound-guided steroid injection,
and surgery. Unfortunately, given their complex nature,
recurrence rates can be quite high and as a result a prior
 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities 59

TRANS

RADIAL LONG

Fig. 4.3.  Two gray scale images from a patient with a palpable nodule on the dorsal surface of the wrist. Features of a benign cyst associated with
a slightly hyperechoic tendon are consistent with a benign ganglion cyst.

A B

Fig. 4.4.  Gray scale transverse (A) and longitudinal spectral Doppler (B) views through the popliteal fossa. Note the large cyst in the superficial tissues
on the transverse image with smaller cystic lesion in the deeper tissues. On the longitudinal image, the typical appearance of a popliteal cyst (Baker’s
cyst) is seen diving between the semimembranosus and medial head of the gastrocnemius. The second “cystic” structure is shown to be the popliteal
artery, thereby reinforcing the importance of multiplanar imaging and the use of Doppler.

history of treatment of a ganglion cyst should not exclude the
diagnosis.13-15
Popliteal (or Baker’s) Cysts
A popliteal, or Baker’s cyst, arises on the posteromedial
aspect of the knee within the popliteal fossa. Often a marker
for degenerative changes in the knee joint, the popliteal cyst
arises between the semimembranosus and medial head of the
gastrocnemius.16,17 Patients can present with a palpable mass,
swelling, and knee effusion, or they may be asymptomatic.18,19
In addition, given that they have a valve-like mechanism
because the cyst neck is trapped between the two muscles,
popliteal cysts can wax and wane both in terms of size and
degree of symptoms.
On ultrasound, popliteal cysts are typically purely cystic. The
larger they get, the more likely they are to be complex and can
even be multiloculated. Internal echoes can be seen, especially
in the setting of hemorrhage into the cyst or joint space. Often
the neck of the cyst can be identified tapering to dive between
the medial head of the gastrocnemius and semimembranosus.
Perhaps the most important thing to exclude when imaging
a potential popliteal cyst is a popliteal arterial aneurysm. The
main way to do this is with color Doppler demonstrating no
flow within a popliteal cyst or arterial flow within an aneu-
rysm. This differentiation, obviously, becomes absolutely criti-
cal prior to pondering an intervention (Fig. 4.4). In patients
with more acute pain with a known popliteal cyst, examina-
tion for fluid around and tracking to the cyst can signify recent
rupture, which may account for the patient’s symptoms.9,16,19

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60 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities

Treatment includes reassurance and observation, intracys-
tic ultrasound-guided steroid injection, and surgical resection.
Unfortunately, as with ganglion cysts in the wrist, recurrence
rates regardless of treatment modality are high.19,20
Tenosynovitis
Tenosynovitis is an inflammatory process involving the ten-
dons, either single or multiple, that typically manifests with
pain, swelling, and tenderness of the involved tendons.21
Because tenosynovitis can only involve tendons that are
encased with synovium, this condition involves primarily
the wrists and, to a lesser extent, the ankles. Unfortunately,
in some patients the manifesting symptoms can mimic car-
pal tunnel syndrome and can lead to inappropriate treatment,
including surgery.
Although tenosynovitis can manifest acutely and be infec-
tious, most often this condition is due to a chronic inflamma-
tory process. Potential etiologies include chronic inflammatory
arthritides such as psoriatic and rheumatoid arthritis, overuse
injury, and rarely gout. The classic ultrasound picture is that of
fluid accumulation with hyperemia within the tendon sheath
(Fig. 4.5). The tendon itself is often normal in thickness with-
out hyperemia, which helps distinguish tenosynovitis from
tendinosis. MRI is probably more sensitive for the detection
of this condition; however, ultrasound can be invaluable in
diagnosing tenosynovitis, especially in unsuspected clini-
cal situations such as carpal tunnel syndrome evaluations.
Finally, ultrasound is certainly the modality of choice for fluid
aspiration for analysis in tenosynovitis.21-23
Joint Effusions
A frequent cause and marker of joint pathology is a large
joint effusion. Although a nonspecific finding that can be
seen in joints with an underlying infectious/inflammatory
process, posttraumatic, or other degenerative process, a
significant joint effusion is an important observation in a
patient with limb pain. The effusion itself can cause capsular
distention and pain directly or be a marker of an underly-
ing internal derangement of the joint, which can prompt
further evaluation with additional clinical and/or imaging
examinations.
Typically, when evaluating joint effusions, the ultrasonog-
rapher examines large joints such as the shoulder, elbow, hip,
knee, and ankle.17,24,25 Although the distribution of the effu-
sion varies depending on the shape of the joint and capsule,
some rules for the appearance of the effusions can be made.
In general, reactive effusions from associated inflammatory,
degenerative, or posttraumatic causes should be relatively
anechoic with few, if any, internal echoes. The more complex
the appearance with internal echoes the effusion becomes,
especially in the acute setting, the more one needs to worry
about a potentially septic joint. The septic joint is an ortho-
pedic emergency and needs immediate referral with consid-
eration of ultrasound-guided aspiration for diagnosis. When

B
Fig. 4.5.  In this collage of gray scale and Doppler images in the transverse (A) and longitudinal planes (B), a minimally thickened tendon can be seen
to be surrounded by fluid and hyperemic synovium consistent with tenosynovitis.

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 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
suspicion is high, especially in deeper joints such as the hip, a
lower-frequency transducer should be used to penetrate and
better visualize the joint capsule.
Solid Soft-Tissue Masses
of the Extremities
When evaluating solid soft tissue masses of the extremities,
especially in the context of just having discussed cystic masses,
it may seem intuitive that solid masses possess the features
that cystic lesions do not. Although this may be true for the
majority of these masses, be wary of the partially cystic mass,
which has a prominent soft tissue component. For the most
part, especially in the setting of peripheral nerve ultrasound
in a clinical neurophysiology laboratory, these masses should
be thought of as primarily solid and caution should be shown
prior to assigning a benign label to them. In general, when
in doubt about the nature of a solid soft-tissue mass, these
should be referred on for additional imaging (i.e., MRI or
computed tomography [CT]).
Normal Lymph Nodes
One of the most commonly encountered soft-tissue masses
during peripheral ultrasound is not a true mass at all, but a
normal structure. Lymph nodes are commonly encountered,
especially when scanning proximally within the extremities.
Normal lymph nodes are ubiquitous, but especially distally,
may be too small to appreciate unless they are pathologically
enlarged. As with many aspects of imaging though, it is neces-
sary to have a firm grasp on the spectrum of normal in order
to not over- or underdiagnose pathology.
The macroscopic structure of a normal lymph node fre-
quently can be seen with ultrasound. The typical structure
includes an outer cortex of lymphoid follicles with a central
medulla and a hilum composed of follicles, fat, and vessels.
When examining a lymph node with ultrasound and trying
to determine whether it is normal, trying to identify these two
components can be invaluable. Because the central medulla
is largely composed of fat, it should be hyperechoic. In addi-
tion, with the use of color Doppler, the hilar feeding vessels
can be identified. The peripheral cortex gives definition and
shape to the normal lymph node. Typically reniform in shape,
a normal lymph node’s greatest dimension is often oriented
in a craniocaudal direction with the axial dimension being the
1
X
A 2
Fig. 4.6.  Transverse (A) and longitudinal (B) views of a normal lymph (arrows) with slightly hypoechoic cortex that appears uniform in thickness with
a normal hyperechoic fat-containing hilum.
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61
shortest dimension. The cortex should be relatively symmet-
ric in thickness as well (Fig. 4.6).26
Pathologic Lymph Nodes
In addition to understanding the previously described fea-
tures of normal lymph nodes, knowing the patient’s clinical
history can also be critical. A history of prior malignancy or
systemic inflammatory process can often be added to the sus-
pected abnormal ultrasound features to make a stronger case
for further evaluation and possible biopsy. Especially in the
setting of a clinical neurophysiology laboratory, where the
physician is often the primary ultrasound operator, this cru-
cial clinical history is usually readily available from the patient
or medical record.
The major hallmark of pathology in a lymph node is archi-
tectural distortion. Typically this is most readily appreciated
in terms of increased size. An absolute number for abnor-
mal size is difficult to provide. Instead, a ratio of long axis to
short axis of greater than 1.5 has been suggested as a potential
marker for pathology. Especially in cases of suspected neo-
plastic disease, normal adjacent lymph nodes may be visible
(especially in the neck and axilla) that can provide an inter-
nal control for what is normal and what is not. Beside overall
increased size, another key feature can be asymmetric growth
and enlargement of the cortex. Any nodular appearance, espe-
cially if it is more hypoechoic, should be looked upon suspi-
ciously. This feature is typically seen in neoplastic processes
rather than inflammatory/reactive nodal disease. In abnormal
lymph nodes, architectural distortion can also be seen in the
central medulla with obliteration of the normal fatty hilum
and a loss of the normal hyperechoic appearance. Normal
lymph nodes should also not have cystic areas, which will
appear as anechoic areas without internal flow on Doppler, or
calcifications, which will appear as areas of acoustic shadow-
ing. Both of these features are again suspicious for malignancy
with nodal involvement (Fig. 4.7). In general, when faced with
a possibly abnormal lymph node, it is probably best to err on
the side of describing it and suggesting further workup, short-
interval follow-up, or ultrasound-guided biopsy or fine-nee-
dle aspiration.27,28
One special case that may be encountered depending on
local demographics is silicone-filled lymph nodes, usually
seen within the axilla. Associated with ruptured silicone breast
implants or direct silicone injections for breast augmentation,
the axillary lymphatics are usually the first line of drainage
1
X
B
62 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
A B
Fig. 4.7.  Collage of images of a worrisome lymph node (arrows). A and B, Note the profoundly hypoechoic cortex with near-complete obliteration of
the fatty hilum. C, Fine-needle aspiration of this node confirmed metastatic breast carcinoma.
X
Fig. 4.8.  Snowstorm appearance of a silicone-containing axillary node
(arrows) in this patient with arm pain. Careful review of the patient’s his-
tory confirmed a prior history of ruptured silicone implants.
for the breast tissue. Silicone-infiltrated nodes have a fairly
pathognomonic “snowstorm” appearance, which refers to the
echogenic mass seen on ultrasound that obscures the normal
architecture of the node (Fig. 4.8).29-31 Careful review of the
patient’s history can avoid confusion over this situation.
Lipoma
A very common benign mass in the extremity is the lipoma,
which is often detected by patients who present with a palpa-
ble mass that they may blame for neurogenic pain. The ability
to accurately describe, diagnose, and then discount the inci-
dental subcutaneous lipoma is key for the peripheral nerve
ultrasonographer.
Some of the physical examination features are mirrored
on the ultrasonographic examination. Typically soft and
compressible on physical examination, with gentle pressure
applied with the ultrasound transducer, the subcutaneous
lipoma can be seen to deform. This feature is quite unusual
for other benign tumors and unheard of in malignant soft-
tissue masses. Composed almost entirely of fat, it should
be no surprise that most lipomas are isoechoic or slightly
hypoechoic relative to the surrounding subcutaneous fat,
with relatively little or no internal Doppler flow. Fine, thin
septations with a hyperechoic thin-walled capsule may also be
seen. Suspicious features include the presence of thick, inter-
nal septations, especially with evidence of significant Dop-
pler flow.8,32 Although the diagnosis of a benign lipoma can
usually be confidently made with ultrasound, if in doubt, it
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C
can be confirmed with limited MRI examination with T1 and
fat-saturated T2 images (Fig. 4.9). Typically, unless there are
cosmetic reasons, lipomas require no treatment and surgical
referral for removal should be uncommon.
Giant Cell Tumor of the Tendon Sheath
The second most common mass of the hand after ganglion
cysts is giant cell tumors of the tendon sheath. These tumors
are intimately associated with the tendons of the hand and
pathologically are similar to pigmented villonodular synovi-
tis.33 Although benign, these tumors can be locally aggressive
and can recur after surgery. Clinically, these tumors manifest
with pain as well as a palpable abnormality that has a tendency
to be located distally within the fingers.
Unfortunately there is nothing specific on ultrasound to
solidify the diagnosis and exclude rarer tumors of the ten-
don sheath and joints (i.e., synovial sarcoma). Instead these
tumors appear as solid masses that rarely have internal cal-
cifications. The main role of ultrasound is to document that
the mass is solid and not cystic, thereby ruling out the more
common ganglion cyst that can be managed conservatively
(Fig. 4.10). Further evaluation with plain films to document
internal calcification or matrix, as well as MRI, is indicated in
all cases to document extent as well as to confirm diagnosis
prior to surgical excision.11,34-38
Tumors Involving the Peripheral Nerve
The ultrasound appearance of peripheral nerve sheath tumors
has been described since 1986.39 Given the relative frequency
of nerve sheath tumors as well as their tendency to cause neu-
rologic symptoms such as dysesthesias and Tinel’s phenom-
enon, it is not too surprising that with careful examination
these tumors frequently are encountered by the peripheral
nerve ultrasonographer. In general, these masses can be sub-
divided into masses due to trauma and benign nerve sheath
tumors.
The traumatic neuroma can arise with either partial or
complete disruption of the peripheral nerve. Most often there
is a compelling history of trauma or surgery with pain local-
ized at or near the neuroma. The neuroma itself has been
described as a bulbous concentric enlargement usually at the
end of the disrupted nerve or along the course of the nerve
if the disruption is only partial. This bulbous appearance at
the distal end of the nerve has been described as a “polly-
wog” appearance of a relatively hypoechoic mass at the nerve
 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
Fig. 4.9.  Classic appearance of a benign lipoma that is slightly hypoechoic to the adjacent subcutaneous fat. Little, if any, internal flow on Doppler
imaging was noted. In the correct clinical setting, no further evaluation would be needed. If, however, there was concern for any atypical features,
magnetic resonance imaging (MRI) could be used to confirm the diagnosis as well.
TENDON SHEATH
MASS
TRANS LT
Fig. 4.10.  Hypoechoic mass (arrows) intimately associated with a ten-
don sheath in a finger. Note the mass is not cystic and as a result can-
not be called benign. Doppler confirmed low-level flow within this giant
cell tumor of the tendon sheath (arrowheads), which was later surgically
excised.
terminus. The neuroma along the course of the nerve in cases
of partial disruption can be harder to detect and is typically
appreciated as a nodularity to the contour of the nerve, best
seen in a longitudinal view.
True benign tumors of the peripheral nerve are most often
peripheral schwannomas or solitary neurofibromas and can
grow quite large prior to detection. Usually hypoechoic on
ultrasound, especially the larger tumors can have internal
cystic areas. As opposed to the nodularity or “pollywog”
appearance of the posttraumatic neuroma, these peripheral
nerve sheath tumors are focal, with the normal-appearing
nerve entering and exiting the focal mass. This appearance
is pathognomonic and can be confirmed with MRI, thereby
obviating the need for biopsy to establish a diagnosis
(Fig. 4.11).40
Unfortunately, although exceedingly rare, malignant periph-
eral nerve sheath a tumors can also occur. These malignant
tumors, of which the most common is a spindle cell sarcoma,
typically manifest differently than benign tumors, with rapid
enlargement and progressive neurologic symptoms. Just as
their clinical presentation is usually more aggressive, so too is
their ultrasonographic appearance. These sarcomas are more
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63
likely to be poorly defined, hypoechoic, and heterogeneous;
for example, they can also develop prominent areas of cystic
of necrosis. In addition, they can also have an internal matrix
with cartilage or heterotopic ossification that appears as pos-
terior shadowing on ultrasound. Any suspicious presentation
or ultrasound features should be treated with due caution and
consideration for referral. Additional imaging with MRI should
be strongly considered.40
Salivary Glands
The salivary glands of the head and neck are likely to be
rarely imaged by the peripheral ultrasonographer. Although
the facial nerve does pierce the parotid glands, in general,
their location in the head and neck is far enough removed
from the peripheral nerves of the extremity to be of little
concern. That being said, especially given the growing prac-
tice of ultrasound-guided botulinum toxin for the treatment
of refractory sialorrhea, the salivary glands merit a brief
discussion.41,42
The major salivary glands imaged are the parotid and
submandibular glands. There are multiple other minor sali-
vary glands throughout the head and neck, but these are
most often too small to characterize and resolve with ultra-
sound, let alone attempt ultrasound-guided injection. The
normal ultrasonographic appearance of the salivary glands
is isoechoic and fairly uniform in appearance. Focal areas of
architectural distortion with masslike enlargement should
be viewed with suspicion. Most masses of the parotid gland
are benign, although benign tumors become less common
in the smaller salivary glands, including the submandibular
glands. Tumors of the salivary glands are typically hypoechoic
and uniform in appearance. Larger tumors, especially War-
thin’s tumors, can have internal cystic components that may
help one favor their diagnosis over other tumors such as the
more common pleomorphic adenoma.43-46 Especially for the
peripheral nerve ultrasonographer who inadvertently images
one of these tumors, no interventions should be made and
the patient should be referred for further workup and surgical
excision, if indicated (Fig. 4.12).
In addition to masses, autoimmune disorders such as
Sjögren’s disease can also be seen in the salivary glands, espe-
cially the parotid gland. This autoimmune disease, which
can also have associated neurologic symptoms, involves pri-
marily the salivary glands, but the lacrimal glands can also
be involved, although they are harder to image with ultra-
sound. Early in the disease course the gland appears diffusely
hypoechoic relative to a normal gland. With progression of
64 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities

1
1

A B
Fig. 4.11.  A, Gray scale ultrasound image shows a hypoechoic mass with peripheral nerve entering and exiting from its sides. In this patient with neu-
rofibromatosis type 1, this appearance is consistent with a benign nerve sheath tumor. B, Fat-saturated T2 magnetic resonance imaging (MRI) sequence
confirms the typical and multiple appearance of these tumors.

Fig. 4.12.  The submandibular gland in this patient that appears normal on the left with an isoechoic and gently lobulated contour. On the right, a
linear dense reflector can be seen within the gland that is a 25-gauge needle for the administration of botulinum toxin in this patient with intractable
sialorrhea.

the disease, a more heterogeneous appearance with inter-

nal cystic areas and increased vascular flow on Doppler
with associated glandular enlargement is seen. (Fig. 4.13).
In patients with known Sjögren’s disease, ultrasound is
mainly used to survey the glands for possible lymphomatous
transformation.45,47,48
Metastatic Disease and Soft-Tissue
Sarcomas
Ultrasound is usually not the modality of choice for evalua-
tion of soft-tissue sarcomas and metastatic disease with sub-
cutaneous nodules. Both of these can initially manifest with

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 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
Fig. 4.13.  Classic ultrasound findings in Sjögren’s disease. Note the coarsened architecture to the parotid gland with internal hypoechoic cystic areas
and profound hyperemia compared with a normal parotid gland.
pain and possible focal neurologic symptoms due to com-
pression and, as a result, the peripheral nerve ultrasonog-
rapher can be the first clinician to encounter these diseases.
Whereas usually metastatic disease is seen in lymph nodes, it
can also manifest with focal deposits in the subcutaneous tis-
sues and muscles, especially melanoma. Sarcomas are patho-
logically heterogeneous with a wide variety of derivative cells
of origin. A full discussion of sarcomas is obviously beyond
the scope of this chapter, but fortunately most sarcomas and
metastatic disease deposits in the soft tissues have a similar
appearance, which is relatively characteristic and should
prevent the careful ultrasonographer from labeling them as
benign.
Metastatic or sarcomatous masses should be markedly
hypoechoic and ill-defined. Sarcomas can become quite large
and have an infiltrating appearance. Doppler evaluation will
reveal internal flow, although if the mass is quite large, inter-
nal cystic areas of necrosis may be without Doppler flow.
Depending on the cell of origin, internal calcified matrix may
be seen, which will appear as a hyperechoic reflector with
posterior acoustic shadowing. These masses should not be
biopsied except after referral and surgical evaluation because
potential for tumor seeding along the biopsy tract is possible
and may preclude a limb-salvage operation. Instead, referral
with plain-film and MRI evaluation is recommended in all
cases in which the peripheral nerve ultrasonographer is suspi-
cious (Fig. 4.14).3,49-51
Disorders of Peripheral Veins
and Arteries
When examining peripheral nerves in the extremities, the
ultrasonographer will become very acquainted with arte-
rial and venous anatomy that previously may have been
dismissed. Not only can the vasculature in the extremi-
ties provide important landmarks, it is also obviously quite
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65
important to document the location of nearby blood vessels
prior to any attempted intervention. In addition, in patients
with unexplained limb pain that may be referred for evalua-
tion, disorders of the arteries and veins are important to be
able to grossly screen for and recognize abnormalities that
may account for the patient’s symptoms or be important inci-
dental findings to document to prevent future disability.
Aneurysms
Aneurysms, by definition, involve dilation of the artery,
which involves the entire wall in which the artery exceeds
1.5 times the normal diameter. More common in the lower
extremity, especially involving the popliteal artery, aneu-
rysms only rarely have been reported to cause neuropathic
symptoms. Instead, they are important to recognize because
(1) they are relatively common, and (2) they may progress
leading to rupture.
A thorough evaluation with gray scale imaging in longitudi-
nal and transverse dimensions is important to document not
only the maximal cross-sectional diameter but also the length
of segment involved. Careful measurements must include the
entire aneurysm from outer wall to outer wall. In order to
measure the maximal measurements correctly, the maximal
anteroposterior measurement should be made on the longi-
tudinal view to prevent overestimation of the measurement
on the transverse view by imaging at an oblique view. Doppler
evaluation can certainly make aneurysms more conspicuous
and confirm the fact that it is arterial in nature, but Doppler
will often underestimate the transverse dimension as aneu-
rysm walls may have mural thrombus within them that will
not have flow (Fig. 4.15).52
Conventional atherosclerotic aneurysms are most often
uniform or fusiform in shape. The more eccentric or saccular
they appear, especially within any atypical features, should at
least raise the question of a pseudoaneurysm or mycotic aneu-
rysm and prompt further evaluation.
66 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities

A B
Fig. 4.14.  Typical features of a soft tissue sarcoma on ultrasound. A, This leiomyosarcoma shows an irregular, poorly defined contour with internal
hypoechoic features and prominent Doppler flow. B, This sagittal magnetic resonance image gives a perspective of the size of this mass.

A 1

2
2

A B C

Fig. 4.15.  Gray scale (A and B) and Doppler (C) images of a right popliteal aneurysm. Note in B that the true size of the aneurysm is correctly measured
from wall to wall with a large amount of mural thrombus included. The Doppler image (C) confirms the mural thrombus but should not be used to
measure the true aneurysm size.

Pseudoaneurysm layers with the appearance of a saccular outpouching. Beside

As opposed to true aneurysms, pseudoaneurysms have on
occasion been reported to cause nerve compression syn-
dromes, particularly in the upper extremities.53 Usually
posttraumatic in origin, pseudoaneurysms differ from true
aneurysms in that there is a defect in the two inner layers of
the arterial wall with an intact and normal external adventitia
layer. Most commonly seen after angiography involving the
femoral artery, pseudoaneurysms can also be seen after phle-
botomy with accidental arterial injury, direct external trauma,
as well as an adjacent infectious or inflammatory process,
which can damage the arterial wall.54,55 This defect causes
an asymmetric bulging of the lumen through these defective
the potential for peripheral nerve compression, pseudo­
aneurysms are also important to recognize because they can
rupture, become infected, and serve as an embolic source for
peripheral emboli.
One of the more classic ultrasound findings is that of a
pseudoaneurysm. Typically, direct communication with the
artery can be demonstrated via a slender neck. Within the
pseudoaneurysm itself, color Doppler demonstrates a clas-
sic “yin-yang” appearance (Fig. 4.16). This appearance is
the Doppler representation of the “to-and-fro” flow into the
pseudoaneurysm sac and then back out in the parent artery.
Documentation of the pseudoaneurysm size is important, as

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 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities 67

A B

Fig. 4.16.  A, Classic yin-yang appearance of a pseudoaneurysm of the common femoral artery. B, With spectral Doppler, note the to-and-fro flow
through the neck, which is also typical. This pseudoaneurysm was successfully treated with percutaneous, ultrasound-guided thrombin injection.

is measurement of the width of the neck. Both of the mea-

surements are important for determination of appropriate
management because these can be treated by direct compres-
sion to obliteration, percutaneous ultrasound-guided throm-
bin injection, and surgery. Typically, pseudoaneurysms with
wide necks or those associated with arteriovenous fistula can-
not be treated percutaneously with thrombin because of the
increased risk of distal emboli and the need for a vascular sur-
geon’s referral for surgical treatment.54-56

Arteriovenous Fistula
A close relative of the posttraumatic pseudoaneurysm is the
postcatheterization arteriovenous fistula. An arteriovenous
fistula occurs when a direct connection is inadvertently made
between a vein and the adjacent artery. Typically, this occurs
after attempted venous or arterial catheterization, which
inadvertently breeches the companion vessel.54,57 Although
most of the time this connection spontaneously heals, in some
cases a persistent channel remains and develops an arteriove-
nous fistula. Although most of these are asymptomatic unless
they become quite large, they can overload and result in limb
ischemia, limb edema, and potentially cardiac failure. Fig. 4.17.  In this patient with neck pain after attempted central line
On ultrasound these are most often encountered in the placement in the jugular vein, the classic appearance of an arteriovenous
inguinal region involving the common femoral artery and fistula is seen. Note the speckled appearance in the adjacent tissue with
vein. In the upper extremity they can also be found in the marked spectral broadening in the affected vessel. This fistula involving
the carotid artery and jugular vein ultimately required surgical repair.
antecubital fossa, which can be a source for arm pain that can
be incorrectly diagnosed as a postphlebotomy median neu-
ropathy at the elbow by a referring clinician. Unlike pseudo­
aneurysms, no discrete mass can be seen on gray scale imaging. Venous Thrombosis
As a result, demonstrating an arterial waveform within the Upper or lower extremity venous thrombosis remains a
vein makes the diagnosis. In addition, the arterial waveform common cause of extremity pain and edema. From a treat-
can be low resistance showing excessive diastolic flow. Finally, ment point of vein, it is important to be able to differentiate
because the arteriovenous fistula has a turbulent pattern of between thrombus involving the deep venous system versus
flow, Doppler imaging demonstrates a speckled pattern of the superficial system, as well as to judge the extent of limb
tissue vibration around the fistula (Fig. 4.17). Ultimately, the involvement. From a practical point of view though, patients
majority of these in the peripheral vasculature need to be sur- with known or suspected venous thrombosis will not be
gically repaired to prevent further symptoms and risk to the referred to the dedicated peripheral nerve ultrasonographer
extremity. An increasing number of arteriovenous malforma- and, as a result, one needs only to recognize the unsuspected
tions are also being treated via an endovascular arterial route thrombosis that may be completely incidental to the patient’s
with covered stents that effectively seal the communication.58 chief complaint or mimicking neurologic symptoms.

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68 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities

V V
V
A V
A

A A

A RT POP W/C B LT POP W/C

Fig. 4.18.  A, Bilateral deep venous thrombosis, with echogenic material in the right popliteal vein (RT POP), which is noncompressible on the adjacent
image with compression from the transducer (W⁄ C ). B, Thrombosis is also noted in the left popliteal vein (LT POP), which is anechoic. This clot can
only be reliably detected with compression (W⁄C ), which shows the vein does not compress.

Larger in diameter than their accompanying arteries, periph-
eral veins typically have thinner walls with low-flow appear-
ance on Doppler, which may be continuous or demonstrate
respiratory phasicity, especially the more proximal they are in
the extremity. A hallmark of all normal peripheral veins is that
they are compressible with relatively gentle pressure from the
transducer. Although a thrombus can have a variable appear-
ance, ranging from hypoechoic to anechoic and can be occlu-
sive or nonocclusive, the sine qua non of venous thrombosis is
noncompressibility of the vein (Fig. 4.18). If this noncompress-
ibility is seen, assessment with color Doppler should be per-
formed to document whether the thrombosis is occlusive and
an attempt to localize the extent of limb involvement is sug-
gested prior to referring the patient for urgent dedicated vascu-
lar ultrasound. Another subtle sign of venous obstruction is the
loss of the normal respiratory phasicity seen in proximal large
veins. This can be an especially important clue in large, proxi-
mal veins that cannot be compressed due to overlying struc-
tures such as the subclavian vein with the overlying clavicle.
In terms of dating the age of the thrombosis, the size of
the thrombosed vein, presence of collateral veins, and the
echogenicity of the clot can help the clinician. In general, with
acute thrombosis the vein is distended with anechoic clot and
no collateral veins. As the clot matures, the thrombus con-
tracts and the vein becomes less distended and more echo-
genic.59-63 In addition, collateral veins have time to develop
and can be seen on Doppler evaluation. Although these rules
are not absolute, they do provide a guideline for discussing
the thrombus that may be incidentally noted.
Miscellaneous Findings
and Artifacts That May Simulate
Disease
Inherent to all imaging modalities are artifacts. Understand-
ing these artifacts is key to optimizing image resolution
and diagnostic accuracy. Ultrasound is relatively unique in
that the artifacts encountered are relatively predictable and
often related to the intrinsic properties of the tissue imaged.
As a result, although these artifacts cannot always be elimi-
nated, they can, when properly recognized, provide use-
ful ­information about the tissue type and actually increase
­diagnostic accuracy. The issue of artifact is also discussed in
Chapter 1.
Anisotropy
Anisotropy is the intrinsic property of tendons, and to a
lesser extent peripheral nerves, in which the amount of sound
reflected back to the transducer varies with the angle of
insonation (i.e., the angle at which the transducer is held rela-
tive to the tendon). This property of tendons results in loss of
signal in discrete areas along a tendon, especially as it curves
through the field of view, much the way that polarizing glass
blocks varying amounts of light, because the angle with which
one looks through glass is varied. As a result of anisotropy,
tendons require careful examination in multiple planes and
with multiple angles to not erroneously diagnose a tendon
tear (Fig. 4.19).64,65 In-depth discussion of the diagnosis of
tendon tears and evaluation of commonly effected joints such
as the shoulder and ankle lies outside the scope of this text;
however, limited discussion is useful in case tendon pathology
is encountered.
Keeping in mind the danger of anisotropy, careful inspec-
tion of a tendon should reveal a fluid-filled gap that persists at
all angles in order for a tendon tear to be diagnosed. In gen-
eral, most large tendons typically tear transversely, whereas
smaller tendons can tear either longitudinally or transversely.
Careful examination in both planes is critical to the detection
of these smaller tendon tears. If possible, careful examina-
tion to determine if the tear is complete or partial, and the
length of separation between the two tendon ends, is useful to
include within the report prior to referral for further clinical
evaluation or dedicated musculoskeletal ultrasound or MRI
(Fig. 4.20).

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 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities 69

A B

Fig. 4.19.  Two views of the suprapatellar tendon taken just a few seconds apart are presented. A, There was initial concern for tendon rupture in this
patient with knee pain. B, By angling the transducer plain relative to the tendon, this image confirmed the “hypoechoic gap” seen in A was actually
artifact due to anisotropy and that the tendon was completely intact.

A B

Fig. 4.20.  A, Single view of the supraspinatus tendon shows a several-centimeter gap in the tendon with proximal retraction of the remaining tendon
consistent with a complete tear. B, This finding was later confirmed on magnetic resonance imaging.

Reverberation Artifact
Reverberation artifact can obscure the object of interest in the
field of view. This artifact is most commonly seen when two
parallel surfaces are positioned orthogonally to the scan plane,
especially if one of the surfaces is a strong acoustic reflector.
The other surface, which is more superficial, allows only par-
tial transmission of the reflected sound wave while reflecting
some of the returning sound wave back into the deeper tissue.
This can set up multiple shadows that can mimic false images
deep to the initial reflector (Fig. 4.21).66,67 These echoes
should be equally spaced. Typically, the artifact can be elimi-
nated by adjusting the angle at which the transducer is held
or by adjusting the transducer frequency. Finally, because
the most superficial of the reflectors is often the skin, appli-
Fig. 4.21.  Typical appearance of reverberation artifact with innumerable
cation of more coupling gel can often eliminate this artifact
false echoes seen, which obscure much of the field of view. Elimination
altogether. or reduction of this artifact is key to a thorough examination because
pathology could be missed.
Posterior Acoustic Shadowing
Posterior acoustic shadowing occurs when the transmitted with the tissue, no echoes are returned, with the result being
sound wave is either entirely reflected back to the transducer an anechoic area deep to the calcification. Depending on the
or severely attenuated and absorbed due to the nontransmis- size of the calcification, this may be a small area such as coarse
sible property of the tissue. This is most commonly seen with calcification in a mass, or much larger such as when imaging
calcifications, which do not permit transmission of the acous- bone (Fig. 4.22). Other causes of posterior acoustic shadow-
tic wave. The result is that deep to the calcification interface ing include foreign bodies, gas, or air.67

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70 Chapter 4—Basic Approach to Ultrasound of Other Structures in the Extremities
TRANS
Fig. 4.22.  In this view of a ganglion cyst of the wrist, the cyst is seen
in the superficial soft tissues. Note the posterior acoustic enhancement
deep to the cyst (arrows) with anechoic posterior acoustic shadowing
(circles) deep to the soft-tissues/bone interface.
Conclusion
Ultrasound is capable of discovering a large variety of pathol-
ogies in the extremities. A thorough study of the peripheral
nervous system cannot be lightly undertaken without a com-
mitment to also recognize these other disease entities that
cannot help but be encountered during a career of study.
In general, when an unexplained finding is encountered,
the safest approach is a thorough attempt to document the
abnormality as well as a comprehensive report describing the
abnormality prior to referral for further characterization.
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