Sept ultrasound case of the month
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Transcript of Sept ultrasound case of the month
Ultrasound Case of the Month
September 2013
53 year old female with right forefoot pain and
tingling in the toes
Sagittal Axial
Grayscale Images Through the Third Webspace
Grayscale Images Through the Third Webspace
+ D = 15.1 mmx D = 7.4 mm
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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
Neuroma Case Points
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
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
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
Neuromas: US• Typically hypoechoic on US
Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler
Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler• Can see continuity with the digital
nerve
Neuromas: US• Typically hypoechoic on US• May be hypervascular on power
Doppler• Can see continuity with the digital
nerve
Digital Nerve
Neuroma
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
Neuromas: MRI
• Teardrop shaped
Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2
Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2 • May be associated with
intermetatarsal edema/bursitis
Neuromas: MRI
• Teardrop shaped• Iso/hypointense on T1 and
iso/hyperintense T2 • May be associated with
intermetatarsal edema/bursitis• Variable enhancement or
nonenhancing
Neuromas: Treatment
• Conservative: Modify footwear, US-guided steroid/lidocaine injection
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
Neuromas: Treatment
• Conservative: Modify footwear, US-guided steroid/lidocaine injection
• Advanced: Alcohol injections, radiofrequency ablation, and cryoablation
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)
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”
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
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