*John L.

Kendall, MD, FACEP Director, Emergency Ultrasound, Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado; Associate Professor, Department of Emergency Medicine University of Colorado School of Medicine, Denver Colorado

Soft Tissue Sonography

Imaging of soft tissue pathology is time consuming. CT and MRI require prolonged delay to diagnosis and are expensive. Focused sonography by the emergency physician provides a rapid cost-effective evaluation of pathology. The speaker will use a case-based approach to the application of musculoskeletal sonography in the ED. Recognize the appearance of normal soft tissue by ultrasound. Identify areas of inflammation with ultrasound and incorporate into your clinical practice. Improve diagnostic efficiency by applying ultrasound to diagnose tendonitis, tenosynovitis, bursitis, and muscle and tendon rupture. Discuss how to localize an abscess by sonography and incorporate into your clinical practice. Describe the technique and principles of foreign body localization.

SU-103 10/16/2011 10:00 AM - 10:50 AM Moscone Convention Center

*Book Royalties

Soft Tissue Sonography: A Case-Based Tour

John L. Kendall, MD FACEP Director, Emergency Ultrasound Department of Emergency Medicine Denver Health Medical Center Denver, Colorado I. Course Description: Imaging of soft tissue pathology is time consuming. CT and MRI prolong time to diagnosis and are expensive. Focused sonography by the emergency physician provides a rapid costeffective means for evaluating for pathology in the ED. The speaker with use a case-based approach to the application of soft tissue sonography in the ED. II. Learning Objectives: Recognize the appearance of normal soft tissue by ultrasound. Learn how do identify areas of inflammation with ultrasound and incorporate it into your clinical practice. Improve diagnostic efficiency by applying ultrasound to diagnose tendonitis, tenosynovitis, bursitis, and muscle and tendon rupture. Describe the techniques and principles of foreign body localization. III. Course Outline: A. Scanning Technique: 1. Linear-array high frequency transducer (> 7MHz) 2. Scan in two planes 3. Compare any findings to unaffected (contralateral) side B. Appearance of normal soft tissue by ultrasound 1. Subcutaneous: a) Composed primarily of fat b) Appears sonographically hypoechoic and is traversed by irregular strands of hyperechoic connective tissue c) Image:

Subcutaneous Tissue

2. Fascia: a) Brightly hyperechoic and of regular thickness b) Image:

Fascia

3. Muscle: a) Striated appearance when scanned in long axis plane b) Image:

Muscle

4. Bone: a) Brightly echoic cortex and dense acoustic shadows b) Often seen in the far field of a soft tissue scan plane c) Image:

Bone

5. Tendon: a) Brightly echogenic synovial sheath surrounding the tendon b) Linear bands in longitudinal plane c) Horizontal movement with flexion and extension of extremity d) Image:

Tendon

C. Learn how to identify areas of inflammation and incorporate into your clinical practice: 1. Cellulitis: a) Findings arise from edema formation (nonspecific) b) Increased distance between the skin and underlying fascial planes or bone c) Echogenicity of subcutaneous tissue is diffusely increased d) Subcutaneous tissue traversed by a lattice of broad hypoechoic bands (1) Cobblestone-like appearance 2. Necrotizing fasciitis: a) Marked thickening of the subcutaneous layer b) Layer of anechoic fluid, measuring greater than 4 mm, adjacent to the deep fascia c) Acoustic shadowing and reverberation artifact may be clues to the presence of subcutaneous gas 3. Abscess: a) Appearance is highly variable b) Hypoechoic roughly spherical hypoechoic areas c) Contour may be lobulated or interdigitate with surrounding edema and tissue planes d) Interior may contain hyperechoic sediment, septae, or gas e) Movement of the material may be induced by pressure or movement of the transducer D. Improve diagnostic efficiency by applying ultrasound to diagnose: 1. Tendonitis: a) Diffuse thickening and hypoechogenicity of the tendon b) May loose normal sharp outline displaying indistinct margins c) Chronic tendonitis may slowly calcify (1) Discrete echogenic foci with posterior acoustic shadowing 2. Tenosynovitis: a) Pathologic quantity of fluid or thickening of the tendon sheath b) Increased peritendinous color Doppler flow may be present 3. Bursitis: a) Bursal distention, peribursal edema, and bursal wall thickening b) Infected bursa: fluid is mixed echogenicity and may contain swirling internal debris or echogenic shadowing foci 4. Muscle rupture: a) Hypoechoic gap in muscle fibers b) Intramuscular hematoma appears as hypo- or anechoic circumscribed lesion 5. Tendon rupture: a) Tendon retracts b) Gap between retracted ends fills with hematoma c) Tendon may appear diffusely thickened, heterogeneous, and nodular in contour E. Describe the techniques and principles of foreign body localization: 1. Appearance depends to type of foreign body a) Wood: (1) Hyperechoic foci with acoustic shadowing (2) Hypoechoic halo may develop over time

(a) Represents an inflammatory response b) Metal: (1) Brightly echogenic proximal surface with distal acoustic shadowing c) Glass: (1) Acoustic profile less consistent (a) Acoustic shadows, comet-tail artifacts, and diffuse beam scattering can be seen 2. Pitfalls: a) Near field acoustic dead space can impede identification of very superficial objects (1) Standoffs or a water bath elevate the transducer from the skin surface b) Tissue planes may make identification extremely difficult (1) Most are seen when transducer is directly parallel or perpendicular to the object (2) Scan in multiple planes c) Air in soft tissue can mask presence of the foreign body (1) Steady transducer pressure can displace air (2) Water bath can fill wounds, displace air, and improve visualization d) Small foreign bodies may exceed limits of a transducers resolution F. Billing: 1. No specific code for soft tissue ultrasound 2. These codes should be used for evaluation of foreign body 3. Coding is based on location of subcutaneous abnormality 4. Codes for musculoskeletal ultrasound is not well developed 5. Codes for miscellaneous MSK indications including fracture evaluation, tendon rupture, or muscle tear would all be coded 76880-26 6. Specific codes:

US STUDY Soft Tissue Ultrasound Neck

CPT CODE

CPT Description / Notes

76536-26 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with image documentation 76880-26 Ultrasound, extremity, non-vascular, B-scan and/or real time with image documentation 76604-26 Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentation 76645-26 Ultrasound, breast, B-scan and/or real time with image documentation 76604-26 Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentation 76705-26 Echography, abdomen, B-scan and/or real time with image documentation, limited (eg, single organ, quadrant, follow-up) 76705-26 Echography, abdomen, B-scan and/or real time with image documentation, limited (eg, single organ, quadrant, follow-up) 76857-26 Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documenation, limited or follow-up 76880-26 Ultrasound, extremity, non-vascular, B-scan and/or real time with image documentation 76942-26 10160 or 10161 accompanying I and D code 76942-26 42700 accompanying I and D code 76942-26 10120 or 10121 accompanying FB removal code

Axilla Chest Wall Breast Upper Back Lower Back Abdominal Wall Pelvic Wall Lower Extremity US-Guided Abscess Drainage US-Guided Peritonsillar Abscess US-Guided FB Removal