Sonographic Landmarks Research Articles

Sonographic localisation of neck lymph nodes using surgical neck level classifications

AbstractSonographic imaging of the lymph nodes (LNs) of the neck is used to differentiate between those that are benign or suspicious of malignancy. The size, number and location of suspicious appearing LNs must be documented and reported. Cervical LN location should be described in terms of surgical neck levels. Knowledge of the sonographic differentiation between benign and suspicious appearances of LNs, and surgical neck levels is required, including sonographic landmarks that can be used to correctly locate LNs to a specific neck level.

Sonographic anatomy and technique to image the plantar digital nerves and aid identification of a Morton's neuroma.

The anatomy of the forefoot is complex, and the sonographic assessment to image the plantar digital nerves and exclude, diagnose or discriminate between a Morton's neuroma and intermetatarsal bursitis can be challenging. A good appreciation of the sonographic anatomy, technique, normal and abnormal appearances is required to undertake a sonographic assessment of the forefoot and its interspaces, particularly the plantar digital nerves. This is unpacked in this paper with associated pictorial aids. Muscles, tendons, and ligaments of the interspaces and the nearby metatarsophalangeal joints and their associated soft-tissue structures are helpful sonographic landmarks to guide imaging and assessment of the common and proper plantar digital nerves and the intermetatarsal bursa. These need to be appreciated from both dorsal and plantar sonographic approaches, in both short- and long-axis imaging planes. Improved understanding of the anatomy and sonographic appearances of the interspace structures can enhance the sonographic assessment of the forefoot and improve diagnosis of a Morton's neuroma and/or intermetatarsal bursitis when present to guide patient management.

Effects of a focused training on first-year osteopathic medical students' ability to incorporate point-of-care ultrasound in assessment of the anterior knee.

Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery. The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis. First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires. Of 101 students completing the written pretest andpretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest andposttest for identification of all three pathologies (allp<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis andcellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee. Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.

Malformation of cortical development with abnormal cortex: early ultrasound diagnosis between 14 and 24 weeks of gestation.

To describe neurosonographic findings diagnostic or highly suggestive of the presence of malformations of cortical development involving the cortex that may be identified before 24 weeks of gestation. This was a retrospective single-center study of fetuses referred for neurosonography, during 2012-2019, with an abnormal cortical or sulcation pattern diagnosed early in the mid trimester. Stored files were analyzed for demographic data, abnormal brain findings, non-central nervous system abnormalities, final diagnosis and postnatal outcome. The study cohort included 20 fetuses, with a mean gestational age at diagnosis of 18.7 (range, 14.4-23.6) weeks, in 11 of which the diagnosis was made before 20 weeks of gestation. Reasons for referral were: midline anomaly (n = 7), ventriculomegaly (n = 4), infratentorial findings (n = 3), suspected malformation of cortical development (n = 3), 'abnormal brain' (n = 2) and skeletal dysplasia (n = 1). On neurosonography, both the sulcation pattern and the cortical layer were abnormal in four cases, only the sulcation pattern was considered abnormal in seven and only the cortical layer was abnormal in nine. Nineteen fetuses presented with associated central nervous system anomalies and six also had non-central nervous system malformations. One case was recurrent. Eighteen parents opted for termination of pregnancy, including one selective termination in a twin pregnancy, and two fetuses were liveborn. Familiarity with fetal brain anatomy and its early sonographic landmarks allowed early diagnosis of malformations involving cortical development. These patients are likely to represent the most severe cases and all had associated malformations. The presence of an abnormal cortical layer and/or abnormal overdeveloped sulci appear to be early signs of malformation of cortical development. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Overview of Thigh and Leg Anatomical and Sonographic Landmarks in Rheumatic Patients.

Musculoskeletal ultrasound has become a practical and accessible diagnostic tool for musculoskeletal diseases. It is used to examine joints, tendons, vessels, and nerves due to its wide availability in rheumatology practice. Ultrasound has also been applied for years in other areas such as muscular injuries in sports activities and rheumatic diseases with inflammation such as myositis. The knowledge among rheumatologists about muscle ultrasound is increasingly growing taking into account it is not the main target of their ultrasound activity but mainly based on the evaluation of joint, synovitis, tenosynovitis, vasculitis in giant cell arteritis, and parotid gland evaluation in Sjögren´s syndrome. Thus, the present review describes anatomical and ultrasound findings including all muscles of the thigh (anterior, posterior, medial aspects) and leg (anterior, lateral, posterior superficial, deep posterior compartments) of lower limb structures to ease a comprehensive clinical and sonographic evaluation.

Sonographic Location of Distal A1 Pulley by Means of a Bony Acoustic Landmark on the Proximal Phalanx: An Anatomic Study

To identify the anatomic relationship between the distal extent of the A1 pulley and the distalmost insertion point of the palmar plate into the base of the proximal phalanx at a metaphyseal bony ridge, the "P1 peak" (P1P), which is a bony acoustic landmark easily identifiable on sonography of the finger. We studied 48 fingers (no thumbs) from 12 fresh frozen cadavers with high-resolution ultrasound. A 20-gauge hypodermic needle was directed perpendicular to the long axis of the tendon sheath along a plumb line drawn at the level of the bony flare of the proximal metaphyseal-diaphyseal junction of the proximal phalanx, or the P1P, under high-resolution ultrasound guidance. Dissection was then performed, and the distance of the needle barrel and the actual distance of the P1P from the distal edge of the A1 pulley were recorded. The study demonstrated that accurate placement of the needle within 1 mm of the actual P1P was possible using ultrasound guidance and that the P1P was within 1 mm of the distal edge of the actual A1 pulley in all specimens studied. In all the specimens studied, we found that the P1P may be used as a clearly identifiable sonographic reference landmark to identify the distal extent of the A1 pulley. Using the P1P landmark as a guide to judge the completeness of ultrasound-guided percutaneous trigger finger release may reduce the risks of incomplete distal release and inadvertent release of the A2 pulley.

Derivation of a Standardized Method to Identify the Anterior Compartment of the Lower Extremity Using Point-of-Care Ultrasonography

Introduction: Anterior compartment syndrome (ACS) of the lower extremity is a well-recognized surgical emergency. The anterior compartment is the most frequently missed of the four compartments during lower extremity fasciotomy. This study describes a novel approach that combines sonographic measurements and physical examination landmarks to accurately identify the anterior compartment. Materials and Methods: This study was conducted as a prospective anatomical study of 94 volunteers at a single institution. Physical exam and sonographic methods were utilized to derive measurements of the anterior compartment, followed by biometric and validation data. Results: Volunteers for the derivation and validation phases of study were similar regarding gender, height and weight, age, and BMI. The derivation set revealed the distance to the anterior compartment to be 2.77 cm (median 2.6 cm, range 1.5 - 5.4 cm) from the mid-axial line and resulted in identification of the anterior compartment 100% of the time (p < 0.001). Findings were reproducible in the internal validation set with 100% accuracy. Conclusion: The fascial planes of the anterior compartment can be identified with 100% accuracy when utilizing physical examination and sonographic methods. This can serve as a foundation for future studies evaluating ways to reduce of the number of missed anterior compartment fasciotomies in the setting of ACS.

Quadratus lumborum block in pediatric patients - a case series

Introduction. The quadratus lumborum block (QLB) was the first interfascial plane block introduced to the Leskovac General Hospital thanks to the Kybele Inc. international teaching program in April 2017. Outlines of cases. During the period from April 2017 to December 2019, 22 pediatric patients underwent various surgical procedures and had the QLB type 1 block as a part of a multimodal perioperative pain management plan. Unilateral QLB was provided for unilateral inguinal hernia repair, orchidopexy, testicular torsion repair, and open appendectomy. Bilateral QLB was provided for laparoscopic appendectomy and cholecystectomy. Decreased use of fentanyl and sevoflurane was noticed in the cases when QLB was performed preoperatively. All the patients had well controlled pain. Conclusion. QLB is a simple and safe technique. Clear sonographic landmarks allow it to be easily performed. QLB has great potential to improve and facilitate postoperative pain management.

Ultrasonography of the Peripheral Nerves of the Forearm, Wrist and Hand: Definition of Landmarks, Anatomical Correlation and Clinical Implications.

Peripheral nerve pathologies of the upper extremity are increasingly assessed by high-resolution ultrasonography (HRUS), yet rapid identification of nerve segments can be difficult due to small nerve diameters and complex regional anatomy. We propose a landmark-based approach to speed up and facilitate evaluation and intervention in this region. Relevant landmarks and section planes for eleven nerve segments of the forearm, wrist and hand were defined by ultrasonography in cadaver arms before cryosection and topographical neurovascular preparation. Information on all nerve segments and a pictorial guide including anatomical cross-sections, topographical preparations and HRUS images are provided. The identification rates of these nerve segments were then assessed in 20 healthy volunteers. Sonographic landmarks and guidelines for the rapid identification and assessment of nerves of the forearm, wrist and hand are presented in pictorial and tabular form, including discussion of normal variants. Utilizing this overview should facilitate training, diagnostic examinations and intervention for nerves of the upper extremity. · High-resolution ultrasound enables assessment of peripheral nerves of the forearm, wrist and hand.. · A landmark-based approach can facilitate and speed up nerve evaluation in these regions.. · High detection rates could be reproduced using the proposed landmark-based approach.. · Gruber L, Loizides A, Peer S et al. Ultrasonography of the Peripheral Nerves of the Forearm, Wrist and Hand: Definition of Landmarks, Anatomical Correlation and Clinical Implications. Fortschr Röntgenstr 2020; 192: 1060 - 1072.

Evaluation of the proximal adductor canal block injectate spread: a cadaveric study

Background and objectivesQuadriceps sparing adductor canal block has emerged as a viable intervention to manage pain after total knee arthroplasty. Recent studies have defined ultrasound (US) landmarks to localize the...

Ultrasound Measurements of the First Extensor Compartment: Determining the Transection Limits for Ultra-minimally Invasive Release of De Quervain Tenosynovitis.

Background: De Quervain syndrome is the second most common compressive tendinopathy. Although the length of the first extensor compartment (FEC) has been studied previously, there is no documented reported comparison study of short-axis and long-axis sonographic measurements. The thread technique, or Guo Technique, has been applied to carpal tunnel syndrome, trigger finger, and superficial peroneal compressive neuropathy. To perform this procedure, it is critically important to accurately identify the boundaries for transection. Methods: Twenty-one fresh frozen cadaver upper extremities were examined under ultrasound to determine the length of the extensor retinaculum (ER) over the FEC. Using the sonographic landmarks, the ERs were measured in short axis and long axis over their proximal to distal margins and from the distal margins to the distal edges of the radial styloids. These sonographic measurements were then compared with gross anatomical measurements. Results: The short-axis sonographic measurement of the ER on average was 22.53 mm (95% confidence interval [CI] = 20.79-24.05 mm). The long-axis sonographic measurement of the ER on average was 15.65 mm (95% CI = 13.70-17.78 mm). The average length of the ER by gross anatomical dissection was 22.40 mm (95% CI = 21.15-23.51 mm). Conclusions: The short axis is not significantly different from the gross anatomical measurement; however, the long axis is significantly lower than the gross anatomical measurement. The results support the idea that the short axis is more accurate than the long axis.

Morphological Aspects in Ultrasound Visualisation of the Suprascapular Notch Region: A Study Based on a New Four-Step Protocol.

Background: Sonographic evaluation of the suprascapular notch (SSN) region is clinically important, because it is the most common location for performing suprascapular nerve block. The aim of the study was to describe the morphology of the SSN region based on ultrasound examination and in accordance with the patients’ body mass index (BMI). Material and Methods: The SSN region was sonographically examined in 120 healthy volunteers according to our new four-step protocol. The morphometry of the SSN and the neurovascular bundle was assessed, and patients’ BMI were calculated. The shape of the suprascapular notch was classified based on its superior transverse diameter (STD) and maximal depth (MD). Result: The type III scapular notch was the most prevalent (64%). The BMI was higher in type IV/V (27.38 ± 3.76) than in type I (24.77 ± 3.49). However, no significant differences were observed in the distribution of SSN notch types with regard to BMI (p = 0.0536). The suprascapular artery was visualised in all of the recognised SSNs, while the suprascapular vein and nerve were visualised only in 74.9% and 48.1% of the SSNs, respectively. The suprascapular nerve was significantly thicker on the right side (3.5 ± 1.1 mm) than on the left (1.3 ± 0.4 mm) (p = 0.001). In contrast, the suprascapular vein (1.5 ± 0.9 mm) was found to be a significantly wider on the left side than the right (1.2 ± 0.7 mm) (p = 0.001). Conclusion: Our original four-step sonographic protocol enabled characterising the morphology of the SSN region, despite the SSN notch types. The suprascapular artery is the best sonographic landmark for the suprascapular notch region. No significant differences were found between sides regarding the thickness of the soft tissue above the suprascapular nerve and vessels. Recognition of the SSN morphology is not affected by the BMI.

Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation

BackgroundThe posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site. MethodsAfter a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection. ResultsMuscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases. ConclusionsWe describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.

Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study.

The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space.We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. Twenty-six fresh cadavers were dissected bilaterally. The number, location, and course of the pectoral nerves were recorded. Distances to surface landmarks (sternum, clavicle, and costae) and ultrasound landmarks (thoracoacromial artery [TAA] and pectoralis minor muscle [Pm]) were recorded. The lateral pectoral nerve and the TAA entered together into the IP space 8.9 cm (range, 8.0-12.0 cm) lateral to the midsternal line. The medial pectoral nerve (MPN) had between 1 and 4 branches that pierced the Pm, and 69% had additional branches lateral to the Pm. The muscle-piercing MPN branches were located 3.8 cm (range, 0.4-8.1 cm) and the lateral MPN branches 5.4 cm (range, 3.0-8.4 cm) from the lateral pectoral nerve. The IP course was 2.6 cm (range, 0.7-6.5 cm). All specimens were asymmetrical in location or number of MPN branches. The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA.

Maxillo–occipital line: a sonographic marker for screening of open spina bifida in the first trimester of pregnancy

Objective: To describe a new first-trimester sonographic landmark the maxillo–occipital line which may be useful for early screening of open spina bifida. Methods: Maxillo–occipital line was prospectively evaluated in 100 low-risk pregnancies at the time of first-trimester sonographic screening examination between 11 and 13 + 6 weeks’ gestation. All the pregnant women subsequently had a normal second-trimester scan and normal outcomes. Midsagittal brain images of 14 fetuses with known diagnosis of open spina bifida were evaluated retrospectively to review the maxillo–occipital line. Results: None of the 100 fetuses evaluated prospectively with the maxillo–occipital line below the junction of the midbrain and brain stem were affected by open spina bifida. The aqueduct of Silvius to occiput distance measurement was not obtained in five cases. In all, 14 cases with a diagnosis of open spina bifida, the junction between the midbrain and brain stem, were below the maxilla–occipital line. Conclusion: Maxillo–occipital line is an easy addition to the evaluation of first-trimester screening of open spina bifida. Further studies are needed to determine the false-positive and false-negative rates of this technique.

Inter-Rater and Intra-Rater Reliability of Sonographic Median Nerve and Wrist Measurements.

Background:Electrophysiologic studies have been considered the “gold standard” in diagnosing carpal tunnel syndrome (CTS); however, reports of false-negative results, as well as discomfort for the patient during the procedure has paved the use of ultrasound, being a painless and cost-efficient tool, as an alternative means for its diagnosis. Various ultrasound parameters assessing the median nerve and wrist dimensions have been described, but description of landmarks to assess these in a reliable manner has been lacking.Methodology:A systematic search of different databases yielded data regarding ultrasound parameters for CTS diagnosis, the landmarks used, and presence of reliability testing. Based on this, three sonologists discussed the external and sonographic landmarks that will be used in measuring the median nerve measurements, bowing of the flexor retinaculum and the carpal tunnel dimensions. A pilot test with two consecutive healthy participants using the discussed ultrasound parameters was carried out, and results were subjected to inter- and intra-rater reliability testing. Modifications were accordingly made on the acquisition of ultrasound image using external landmarks. The reliability testing proper was done with ten consecutive healthy participants.Results:Based on the systematic review and the pilot study, external landmarks were used to locate the median nerve in the forearm, carpal tunnel inlet and outlet. For the forearm measurement, it was taken 10 cm proximal from the distal palmar crease. The distal palmar crease was the external landmark used for the carpal tunnel inlet, while for the carpal tunnel outlet; it was measured 1 cm distal to the distal palmar crease. Instead of using the inner edge of the hook of hamate and trapezium, the apices of these bones were used as the landmarks in measuring the carpal tunnel outlet dimensions. There was excellent intra-rater reliability (mid-forearm, carpal tunnel inlet and outlet) except for the following: cross-sectional area (CSA) of the median nerve at the carpal tunnel inlet and outlet; and bowing of the flexor retinaculum. All the parameters had an excellent inter-rater reliability measured at the three levels (intraclass correlation [ICC]: Of 0.77–0.99) except for CSA of the median nerve at the levels of the forearm (fair-to-good with ICC of 0.71) and the carpal tunnel inlet (fair-to-good reliability of ICC: 0.43).Conclusion:There was an improved inter- and intra-rater reliability when external landmarks were used instead of sonographic landmarks.

Ultrasound of the knee in rheumatology

The knee joint, surrounding ligaments, and extensor mechanism (quadriceps and patellar tendon), given their superficial nature, are easily accessible and accurately assessed with high-resolution musculoskeletal (MSK) ultrasound. Its bedside availability, lower cost than magnetic resonance imaging (MRI), and its high sensitivity in the detection of a small effusion, synovitis, and Baker's cyst, together with its ability to be used for needle guidance in invasive procedures, make ultrasound a highly desired diagnostic tool. In this article, we will focus on common rheumatologic indications of MSK ultrasound in the knee and discuss scanning technique and sonographic findings. Transducer positioning and essential sonographic bony landmarks will be reviewed and scanning in two orthogonal planes (both long and short axis of the structure) will be emphasized. With advances in technology, cost reduction, and easy availability, it is expected that more and more clinicians will be utilizing ultrasound in their clinics in management and treatment of rheumatologic diseases. The diagnostic ability of MSK ultrasound is based on an operator's training and experience, the patient's habitus and aptly chosen clinical indications. A good grasp of anatomy, sound ultrasound technique, and knowledge of limitations of ultrasound modality is essential for a safe ultrasound practice. It is also important to keep in mind that ultrasound provides limited information about internal structures such as meniscus and cruciate ligament pathologies and it has a complementary role with MRI.

P09.11: Maxillo‐occipital line: a sonographic marker for the screening of open spina bifida in the first trimester

To describe a new first-trimester sonographic landmark, the maxillo-occipital line, which may be useful in the early screening of open spina bifida. The Maxillo-occipital line is a straight line drawn along the superior border of the maxilla until it reaches the inner border of the occiput in the mid sagittal plane of the fetal face. In normal fetuses at 12–13 weeks the junction between the midbrain and brain stem is above this line. In case of open spina bifida, the line is below the junction of the midbrain and thalamus. The maxillo-occipital line was prospectively evaluated in 100 low risk pregnancies at the time of routine first trimester sonographic screening at 11+ 0 to 13 + 6 weeks' gestation. All these women subsequently had a normal 20 week morphology scan and normal outcome. Mid sagittal brain images of 14 fetuses with a known diagnosis of open spina bifida were evaluated retrospectively to review the maxillo-occipital line in the mid sagittal plane, taken to measure the nuchal translucency. In all the cases with a diagnosis of open spina bifida, the junction between the midbrain and brain stem was below the maxillo-occipital line. None of the 100 fetuses evaluated prospectively with the maxillo-occipital line below the junction of the midbrain and brain stem were affected by open spina bifida. The maxillo-occipital line is an easy addition to the evaluation of the first trimester assessment of the Nuchal translucency and fetal brain. The contribution of this sign in the early detection of spina bifida remains to be determined in larger studies. Further studies are needed to determine the false-positive and false-negative rates of this technique.

Sonographic landmarks to differentiate “false labor” and “early true labor” as a possible new application of ultrasound in labor ward

ObjectiveTo evaluate discrimination of clinical parameters and ultrasound examination to differentiate “false labor” and “true labor”. MethodsIn a prospective study during a period of 6 months, a total of 178 patients in term (37–41 weeks) consulting our obstetric unit for uterine contraction, were enrolled. Patients were examined separately by a midwife and a resident and separated into “true labor group” and “false labor group”. The clinical characteristics of true versus false labor patients were compared. ROC curves were developed to determine an optimal cervical length and uterocervical angle for prediction of true labor. ResultsThe prevalence of real labor was 57.3%. Patients who were in true labor had more painful and more frequent contractions. The “true labor” group had shorter cervical length and larger uterocervical angle. The optimal CL cut-off was 1.4mm with a specificity of 73% (RR 4.3, sensibility 63%, PPV 14%, NPV 95%). The optimal UCA cut off was 123° (RR 6.7, sensitivity 50%, specificity of 83%, PPV 10%, NPV 96%). The best performance was demonstrated by combined testing, yielding LHR+ that rich 13. ConclusionIn this study, we reported a new application of ultrasound to identify false labor and avoid unnecessary hospitalization with obstetric and adverse economic impacts.

Anatomic Relationship and Imaging Relevance of the Perforating Branches of the Peroneal Vessels to the Anterior Talofibular Ligament

BackgroundPatients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging. ObjectiveOur aim was to estimate prevalence of perforating branches (PBs) of the peroneal vessels and determine their most frequent position relative to the ATFL. If these vessels are located in a predictable position at the level of the ATFL, they may serve as a sonographic landmark for the correct imaging plane. MethodsMagnetic resonance imaging (MRI) scans of 105 ankles were reviewed to determine the PB prevalence and location at the ATFL. Inter-observer agreement was determined. Additionally, 16 ankles from 8 asymptomatic subjects were scanned using a high-frequency linear transducer and PB prevalence and location were noted. ResultsBy MRI, PBs were detected in 85% of the ankles and 93% of ankles after consensus. In 73% of cases with agreed PB visualization, vessels assumed a medial position with respect to the ATFL. By US, PBs could be seen in 100% of cases, with the arterial PB seen in 81% of cases and assuming a medial position in 88%. ConclusionsPBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.