Sept ultrasound case of the month
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Transcript of Sept ultrasound case of the month
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Ultrasound Case of the Month
September 2013
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53 year old female with right forefoot pain and
tingling in the toes
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Sagittal Axial
Grayscale Images Through the Third Webspace
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Grayscale Images Through the Third Webspace
+ D = 15.1 mmx D = 7.4 mm
xx
xx
Sagittal and axial grayscale sonographic images at the level of the third metatarsal head demonstrate an
ovoid hypoechoic mass
+
+
+
+
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Diagnosis: Third Webspace
Neuroma
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Neuroma Case Points
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Neuroma Case Points
Tibial n.
Medial Plantar
n.Lateral
Plantar n.
• Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves
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Neuroma Case Points
Tibial n.
Medial Plantar
n.Lateral
Plantar n.
• Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves
• Found on the plantar side of the transverse metatarsal ligament
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Neuroma Case Points
Tibial n.
Medial Plantar
n.Lateral
Plantar n.
• Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves
• Found on the plantar side of the transverse metatarsal ligament
• Patients present with metatarsalgia
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Neuromas: US• Typically hypoechoic on US
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Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler
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Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler• Can see continuity with the digital
nerve
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Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler• Can see continuity with the digital
nerve
Digital Nerve
Neuroma
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Neuromas: US
• Typically hypoechoic on US• May be hypervascular on power Doppler• Can see continuity with the digital nerve• Sonographic Mulder’s sign: Palpable ‘click’
from the neuroma popping out of the intermetatarsal space upon tranverse compression of the metatarsal heads while the transducer applies pressure on the plantar surface of the neuroma
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Neuromas: MRI
• Teardrop shaped
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Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2
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Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2 • May be associated with
intermetatarsal edema/bursitis
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Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2 • May be associated with
intermetatarsal edema/bursitis• Variable enhancement or
nonenhancing
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Neuromas: Treatment
• Conservative: Modify footwear, US-guided steroid/lidocaine injection
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Neuromas: Treatment
This 34 year old dancer has a history of two prior steroid injections of a second webspace neuroma. Note the foci decreased echogenicity consistent with scarring. Foci of increased echogenicity are related to microbubble formation and the inherent contrast effect of the steroid/ anesthetic mixture
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Neuromas: Treatment
• Conservative: Modify footwear, US-guided steroid/lidocaine injection
• Advanced: Alcohol injections, radiofrequency ablation, and cryoablation
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Neuromas: Treatment
36 year old male with a third webspace neuroma, status post prior steroid/anesthetic injection with only temporary relief
US guided placement of a cryoablation needle into the third webspace neuroma
Post cryoablation image with formation of an “ice ball” (see next slide)
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Neuromas: Treatment
Cryoablation of neuromas typically involves 2-3 cycles of freezing with intervening shorter cycles of thawing, resulting in the formation of the characteristic “ice ball”
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Neuromas: Treatment
• Conservative: Modify footwear, US-guided steroid/lidocaine injection
• Advanced: Alcohol injections, radiofrequency ablation, and cryoablation
• Surgical: Resection of the neuroma, interdigital nerve, and/or transverse metatarsal ligament release
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References• Bencardino J, Rosenberg ZS, Beltran J, et al. Morton’s neuroma:
is it always symptomatic? AJR Am J Roentgenol 2000; 175: 649-653
• Hughes RJ, Ali K, Jones H, et al. Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AHR Am J Roentgenol 2007;188: 1535-1539
• Quinn TJ, Jacobson JA, Craig JG, et al. Sonography of Morton’s Neuromas. AJR Am J Roentgenol 2000;174: 1723-1728
• Sofka CM, Adler RS, Ciavarra GA, et al. Ultrasound-guided Interdigital Neuroma Injections: Short-term Clinical Outcomes after a Single Percutaneous Injection- Preliminary Results. HSSJ, 2007;3: 44-49
• Neumann V, O’Connor RJ, Bush D. Cryoprobe treatment: an alternative to phenol injections for painful neuromas after amputation. AJR Am J Roentgenol, 2008;191: W313