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T H E
O F
C A N A D I A N
J O U R N A L
MEDICAL SONOGRAPHY
Volume 2, Issue 3 • Fall 2011
• Renal Doppler Ultrasound Protocol
• Family Trip Can Lead to the ED
• Inexpensive Easy-to-Make
Scrotal Phantom
• Morel-Lavallee Lesion
www.csdms.com
Publications Agreement Number 40025049 • ISSN: 1923-0931
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e t al .
CSDMS News | Nouvelles deDelanisSCEM
Message from the President
Message du président
W
elcome to the fall 2011 edition of The
Canadian Journal of Medical Sonography! I
hope that everyone had a wonderful summer and
had a chance to relax and reload.
One of the biggest improvements that I can
appreciate as a CSDMS member over the past 14
years or so has been the introduction of our own
journal. Kathleen Foran and Kim Boles, along
with all the fine members of the new editorial
board, have worked extremely hard to make
CJMS a great success.
Another major factor in helping the journal run
so smoothly is the great guidance and knowledge
that we receive from Andrew John Publishing Inc. (AJPI). John
Birkby (president and publisher) and Susan Harrison
(managing editor) have been fantastic to work with and truly
have the best interests of our society on their mind. AJPI is a
“nuts and bolts” organization that is willing to assist in any way
possible to make CJMS successful. I want to encourage
sonographers to submit articles and not to fret over grammar,
context, etc. Susan will work out any bumps in a completely
professional manner.
There are a few avenues that CJMS is working toward/
investigating at this time: peer review, article collaboration
(possibly with Australia and America), and having articles
included that can be used for continuing professional
education (CPE) credits. This growth will take time but is
something that is on the horizon.
We had our Annual General Meeting and Education
Conference in Kelowna, British Columbia, this past May. I want
to thank the planning committee in Kelowna for putting
together a great program! The conference attendance was great,
and for the first time we offered a live webcast for our members
who could not attend. This was very successful, and we plan to
implement this option for future conferences. We also recorded
some lectures that we will make accessible at a later date on our
CSDMS website in the members-only section. This is another
step in giving our members increased opportunities for CPE
credits.
Finally, I would like to personally thank Kim Boles, not only
for all that he has done for CSDMS over the past couple of
years, but also for his contributions to CARDUP and the
sonography profession over many years (I won’t say how
many) and the mentorship that he has provided to me in my
new role. I know that Kim will continue to make his mark on
our profession as the editor-in-chief of CJMS and as a
sonographer who has a plethora of knowledge in every single
aspect of Canadian health care. Thanks Kim.
Tom Ball, MEd, BSc, CRGS, CRCS
V
oici donc l’édition automnale de La Revue
canadienne d’échographie médicale (RCEM)
qui nous réunit à nouveau. J’espère que l’été a été
agréable et reposant. Cette revue qui est la nôtre
représente à mes yeux de membre des
14 dernières années l’une des grandes avancées
qui marquent l’évolution de la Société
canadienne des échographistes médicaux
(SCEM). Le succès que connaît la RCEM, nous
le devons certes à Kathleen Foran, à Kim Boles
et à tous les membres de la nouvelle équipe de
rédaction qui veillent avec détermination à la
réussite de la publication.
Sur ce sujet de la réussite de notre revue, on ne saurait passer
sous silence les précieux conseils et le savoir d’Andrew John
Publishing Inc. dont nous bénéficions. John Birkby, président
et éditeur, et Susan Harrison, directrice de l’édition,
accomplissent un travail remarquable, toujours au mieux des
intérêts de la Société. Maison d’édition pour qui les rouages de
la publication n’ont plus de secrets, Andrew John Publishing
est prêt à tout mettre en œuvre pour assurer le rayonnement
de la RCEM. Que les échographistes n’hésitent pas à proposer
des articles même s’ils ont l’impression que leur grammaire ou
leur orthographe n’est pas au point, Susan les aidera à aplanir
les difficultés d’une main de maître.
La RCEM étudie des possibilités en ce moment, notamment
l’examen par des pairs, la publication d’articles en
collaboration avec d’autres revues (Australie et Amérique peutêtre) et la publication d’articles ouvrant droit à des unités de
formation dans l’optique du perfectionnement professionnel
continu. Cette expansion nécessite bien sûr une préparation,
mais déjà elle pointe à l’horizon.
Pour ce qui est de l’assemblée générale annuelle et de la
conférence à Kelowna (Colombie-Britannique) en mai dernier,
je remercie et je félicite le comité de planification local qui nous
a réservé une programmation hors pair! Les participants ont
été nombreux et, pour la première fois, nous avons pu offrir
un webinaire en direct aux absents, une diffusion très courue
d’ailleurs, au point que nous songeons à répéter l’expérience à
l’avenir. Nous avons également enregistré des exposés qui
paraîtront sous peu sur le site Web dans la section réservée aux
membres. Nous multiplions ainsi les possibilités pour les
membres d’obtenir des unités de formation dans le cadre du
perfectionnement professionnel continu.
Enfin, je tiens à remercier personnellement Kim Boles, non
seulement de son dévouement à la tête de la SCEM dans les
deux dernières années, mais également de sa contribution
exceptionnelle auprès de l’Association canadienne des
professionnels autorisés en échographie diagnostique et à la
profession durant toutes ces années (je ne dirai pas combien),
et du mentorat qu’il m’a bien volontiers offert avant mon
entrée en fonction. Pour bien longtemps encore, Kim brillera
au sein de la profession, que ce soit comme rédacteur en chef
de la RCEM ou comme échographiste qui connaît le système
de santé canadien comme le fond de sa poche. Merci Kim.
Tom Ball, MEd, BSc, CRGS, CRCS
www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
3
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Canadian Society of Diagnostic
Medical Sonographers
Société canadienne des
échographistes médicaux
Contents
Volume 2, Issue 3 • 2011
Volume 2, Issue 3 • 2011
Publications Agreement Number 40025049
EDITOR-IN-CHIEF
Kim Boles
CSDMS News
3
Message from the President • Message du président
Tom Ball, MEd, BSc, CRGS, CRCS
ASSOCIATE EDITOR-IN-CHIEF
Kathleen Foran
EDITORIAL BOARD
Lianne Broughton, Francine Caron,
Nanette Denis, Dal Disler, Cathy Fix,
Stuart Gibbs, Carol Gillis,
Chris Harrington, Wendy Lawson,
Verna Maschio, Vern Parkinson
MANAGING EDITOR
Susan Harrison
ART DIRECTOR
7
Meet the Editorial Board
Original Articles
10 Renal Doppler Ultrasound Protocol with Comparative Abnormal
Case Study
Lori Arndt, CRGS, CVRS, RDMS, RVT
Andrea Brierley
PROOFREADER
Scott Bryant
TRANSLATOR
18 A Long Car Trip with Your Family Can Lead You to the Emergency
Department: A Case Report
Wilson Miranda, BSc, RDCS, Shin-yee Chen, MD
Marie Dumont
ADVERTISING
John Birkby
(905) 628-4309
[email protected]
CIRCULATION COORDINATOR
Brenda Robinson
[email protected]
ACCOUNTING
Susan McClung
GROUP PUBLISHER
John D. Birkby
_______________________________________
22 An Inexpensive Easy-to-Make Scrotal Phantom
Leonardo Faundez, MA-Ed, BSc, CRGS, CRVS, RDMS, RVT
28 Morel-Lavallee Lesion: A Case Report
Megan MacNevin
Announcement
33 Maintaining the Schedule of Unit Values for the Medical Imaging
Workload Measurement System
Arlene L. Thiessen, RN, for the Canadian Institute for Health Information
For Instructions to Authors, please visit
www.andrewjohnpublishing.com/
CJMS/cjmsinstauthors.html
_______________________________________
Return undeliverable Canadian Addresses to:
115 King St W., Suite 220, Dundas, ON L9H 1V1
Canadian Journal of Medical Sonography, is published three
times a year by Andrew John Publishing Inc., with offices
located at 115 King Street West,Suite 220,Dundas, ON
L9H 1V1.
•••••
We welcome editorial submissions but cannot assume
responsibility or commitment for unsolicited material.Any editorial material, including photographs that are accepted from
an unsolicited contributor, will become the property of
Andrew John Publishing Inc.
The publisher and the Canadian Society of Diagnostic Medical
Sonographers shall not be liable for any of the views
expressed by the authors published in Canadian Journal of
Medical Sonography, nor shall these opinions necessarily
reflect those of the publisher.
www.csdms.com
Cover images (left to right): Forest river in the fall - Algonquin Provincial Park, Wild Bull Moose - Spray Valley
Provincial Park in Kananaskis Country Alberta, Bow Valley Parkway - Banff National Park, Alberta
Above images (left to right): Waterfalls in Sheep River Valley - Alberta, Elk Island National Park - Edmonton,
Forest Trail - Quebec
The Canadian Journal of Medical Sonography | Fall 2011
5
Located in the beautiful city of Edmonton, Alberta, we are seeking:
Diagnostic Medical Sonographers
Insight Medical Imaging has been providing Edmonton and surrounding areas with medical imaging services for over
50 years.
We offer competitive wages, employee benefits and pension, continuing education assistance, an attractive vacation
package and a relocation allowance.
We provide education, resources and programs such as: In-house training, consulting and assessments; work life
balance; massage therapy; and employee and family assistance programs.
Flexible Work Schedules/Time Away from Work:
Depending on business needs, employees may participate in one of several work options: Flexible start and end times
and job sharing.
We encourage personal time off with an initial annual vacation leave of three weeks, which increases based on years
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If you are a self directed, highly motivated individual who would enjoy practicing in a supportive team environment,
we would welcome the opportunity to review your qualifications and valued skills.
Successful applicants must be currently registered or be eligible for registration with ARDMS and/or CARDUP
Please forward your resume to:
Lori Neufeld, Director Human Resources
Cell: (780)278-6027, Fax: 1(780)638-6530; email: [email protected]
CSDMS News
Meet the Editorial Board
A
s of the current issue, the Canadian Journal of Medical Sonography has a new editor-in-chief, Kim Boles, an
associate editor-in-chief, Kathleen Foran, and a full slate of editorial board members committed to advancing
the journal and making it an essential publication for Canadian sonographers. We invite you to read on and
meet this dedicated group of individuals.
Kim Boles, CRGS, CRVS, RDMS, RVT
Editor-in-Chief
Many of you will know me from my previous roles as CSDMS president and CARDUP
chairperson. I am currently affiliated with the Ottawa Hospital, in Ottawa, Ontario, as the
charge sonographer in the Vascular Diagnostic Center, Division of Vascular Surgery,
Department of Surgery.
This new role as editor-in-chief of the CJMS will be a challenging one. Since the inauguration
of the journal in January 2010, the CSDMS Board of Directors and the executive director,
Kathleen Foran, have shared the editorial responsibilities. With the newly appointed editorial
board, the emphasis will be on encouraging more Canadian sonographers to make quality
submissions to the journal. Kathleen will be an integral member of the editorial board and as
the CSDMS executive director will oversee the financial aspects of the CJMS and fulfill a joint
leadership role, as associate editor-in-chief, to ensure continuity with CSDMS policies and
focus. With help from the editorial board and Susan Harrison at Andrew John Publishing, I
hope to make the journal one you will continue to enjoy and to which you will make a
submission for publication.
Kathleen Foran, BSc, CRGS, CRCS, CRVS, RDMS, RDCS, RVT
Associate Editor-in-Chief
I have been working as a sonographer since 1988, and I am registered in the fields of cardiac,
vascular, abdomen, OB/GYN, neurological, and breast sonography. During my career, I have
acted as a clinical instructor, lead sonographer, educational program coordinator, adjunct
professor, and consultant. My current activities are dedicated to the role of executive director
for CSDMS and CARDUP. I am excited to see the journal come to fruition and to participate
on the CJMS Editorial Board.
Lianne Broughton, CRGS, CRCS, CRVS, RDMS, RDCS, RVT
On the editorial board, I will be assisting in the generalist and vascular specialties. I am
currently the vascular director for CSDMS. I am currently the senior ultrasound technologist
and technical director of the Non-invasive Vascular Laboratory at the Hamilton General
Hospital, in Hamilton, Ontario. Most of my career has been spent in the Hamilton area, but
I have also worked in Bermuda over the years.
www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
7
Me e t the Editorial Board
Francine Caron, CRGS, CRVS, RDMS, RVT, TIM
Bonjour à tous. My specialty on the board of the CJMS is vascular. I work in a community
hospital of 405 beds in St-Jérome, Québec. We have a team of three surgeons and four vascular
sonographers. I have been working as a sonographer since 1984, and am registered in the fields
of abdomen, OB/GYN, neurosonology, and vascular, but my current activities are dedicated
to the vascular field. I have many sonographer friends all across Canada. It is a pleasure for
me to be part of this journal, and I hope to serve you well.
Nanette Denis, CRGS, RDMS
For the CJMS, my specialty is generalist. I am currently the ultrasound coordinator for the
Fetal Assessment Unit at the Royal University Hospital in Saskatoon, Saskatchewan. I have
been an active participant in many societies and committees over the years, most recently
completing two terms as the western director for CSDMS and accepting a third term as the
CSDMS liaison on the SOGC Diagnostic Imaging Committee. I am a member of the
Saskatchewan Licensure Committee as well as the Committee for the Responsible Use of
Ultrasound and have spent many years as a preceptor for the SAIT ultrasound students as well
an instructor for the Department of Obstetrics and Gynaecology Resident Training Program.
I have extensive experience in obstetrical ultrasonography and fetal echocardiography.
Dal Disler, CRGS, CRCS, RDMS, RDCS
My specialty on the editorial board is cardiac. Currently, I am the supervisor of the
Echocardiography Laboratory at the Alberta Children’s Hospital, in Calgary, Alberta.
Previously, I was the supervisor of the Foothills Hospital Echocardiography Laboratory,
developed the echocardiography curriculum and taught as an instructor for the SAIT
Polytechnic ultrasound program, and was the education coordinator of echocardiography for
the Calgary Health Region. I am a past board member and chair of CARDUP. Over the years,
I have published several articles in cardiology related to echocardiography. My interests are
varied and include echocardiography, technology, golf, and fishing.
Cathy Fix, CRGS, CRCS, RDMS, RDCS
For CJMS, my specialty is generalist. I have been actively involved in the ultrasound community
for over 25 years; my current position is the ultrasound supervisor for St. Paul’s Hospital, in
Vancouver, British Columbia. I became a clinical instructor with the UBC Department of
Radiology in 2003. During my career as a sonographer, I have had the opportunity to work as a
clinical application specialist in general and cardiac ultrasonography and also in ultrasound sales.
My background also includes working at BCIT for a short time as a clinical instructor. I have
lectured nationally and internationally and have co-authored and authored several papers. My
specialties include radiology, vascular sonography, and women’s health. I have a strong
commitment to image quality and expanding the knowledge of fellow sonographers. In my spare
time, I like holidays in the sun, enjoy time on a recently purchased float home, and paint.
Stuart Gibbs, BSc, CRGS, CRCS, CRVS, RDMS, RDCS, RVT
My specialties for CJMS are generalist, cardiac, and vascular. Throughout my career, I have
been actively involved in several professional associations: past president of the BC Ultrasound
Society, and western director and secretary of CSDMS. Presently, I am at the Abbotsford
Regional Hospital and Cancer Centre in British Columbia as the supervisor of general
sonography, cardiac sonography, and the Vascular Laboratory. It is an honour to be asked to
be on the editorial board of the CJMS.
8
The Canadian Journal of Medical Sonography | Fall 2011
www.csdms.com
Meet the Editorial Board
Carol Gillis, BHSc, MA Ed, CRGS, CRCS, CRVS, RDMS, RDCS, RVT
My specialties for CJMS are generalist, cardiac, and vascular. I have extensive experience as
both an ultrasound professional and educator, and am currently a faculty member with the
School of Health Sciences at Dalhousie University, in Halifax, Nova Scotia. Throughout my
career, I have been actively involved in several professional associations: past director (2003–
2007) for CSDMS; past president of the Nova Scotia Society of Diagnostic Medical
Sonographers; and a member of both CARDUP and the American Registry of Diagnostic
Medical Sonographers. I have been privileged to work with the Canadian Medical Association
as an accreditation surveyor/chair for diagnostic medical ultrasound programs since 1999.
Chris Harrington, CRGS, CRCS, CRVS, RDMS, RDCS, RVT
My specialty area is generalist. I am the program coordinator for the Ultrasound Training
Program at the Health Sciences Centre, in Winnipeg, Manitoba, a position I have held for
almost 20 years now. I teach ultrasound physics and abdominal and vascular sonography (and
some MSK). I continue to be excited by this ever-changing field, and have a particular interest
in how best to teach this specialty to both ultrasound students and residents.
Wendy Lawson, BSc, Dipl HS, CRGS, CRVS, RDMS, RVT
I bring knowledge and experience to the CJMS editorial board in my specialty areas of
musculoskeletal, obstetrical, and breast sonography. In addition to my role as a clinical
sonographer, I am a professor for the collaborative Mohawk-McMaster Medical Radiation
Sciences Program, in Hamilton, Ontario. My first love is teaching, mentoring a new generation
of sonographers and sharing my passion for the profession. I am active in the ultrasound
professional community; sitting on the CSDMS Board of Directors and co-chairing the
CSDMS/CARDUP National Education Council. I am pleased to be able to contribute to the
CJMS and look forward to facilitating the sharing of best practices and experiences within our
very dynamic profession.
Verna Maschio, BTech (Applied Health Science), CRGS, CRCS, CRVS, RDMS, RDCS, RVT
My area of specialty for CJMS is vascular. Presently, I am employed as a vascular instructor in
the Diagnostic Medical Sonography Program at the Northern Alberta Institute of Technology
(NAIT), in Edmonton, Alberta, and as a casual sonographer at the Sturgeon Community
Hospital, in St. Albert, Alberta. I have many years of clinical experience in general, cardiac,
interventional, neonatal, and high-risk obstetrical fields, attained while employed in both the
private and public sectors. I currently sit as one of the vascular representatives on the CARDUP
Board of Directors and have been actively involved with the Alberta Diagnostic Sonographers
Association (ADSA) in the past. I have presented lectures at CSDMS, ADSA, allied health care
professional conferences, and provincial radiology conferences.
Vern Parkinson, CRGS, CRCS
My area of specialty for the journal is cardiac. I look forward to helping to advance the spread
of knowledge in our profession; ultrasound training has come a long way since my days at the
University of Alberta Hospital, in Edmonton, Alberta, when “real-time” ultrasonography was
in its fairly early days and “static b-scanning” was an indispensible part of obstetrical,
abdominal, and superficial structure ultrasonography! I am involved with CSDMS in various
capacities, including a term on the board and chair, co-chair, and worker-bee on three
Conference Planning Committees. With CARDUP, I am currently enjoying a second term on
the board of directors (as cardiac director). Last year, I sat on the Cardiac Examination Item
Writing Committee, which was both an honour and a huge learning opportunity. Presently, I
am the supervisor of echocardiography for the Vancouver Island Health Authority, in Victoria,
British Columbia.
www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
9
Original Article
Renal Doppler Ultrasound Protocol with
Comparative Abnormal Case Study
Lori Arndt, CRGS, CVRS, RDMS, RVT
About the Author
Lori Arndt works for Radiology Consultants Associated, Mayfair Vascular Centre, in Calgary,
Alberta. Correspondence may be directed to [email protected].
T
he detailed renal Doppler ultrasound examination has
a somewhat-controversial role in many ultrasound
departments. Not only is the examination time lengthy, but
obtaining information that is consistently reliable and
diagnostic in providing an impression of the vascular status
of the kidney, and what that means for the management of
the patient, is often in question. Duplex scanning is limited
to 95% sensitivity and 90% specificity for detecting renal
artery stenosis when compared with digital subtraction
angiography (DSA).1 But since the contrast used in DSA is
nephrotoxic, the use of DSA presents a risk of worsening
renal function if it is already compromised.1 Other imaging
tests such as CT angiography (CTA) and MR angiography
(MRA) may be preferred, especially if the duplex scan is
technically inadequate. However, ultrasound studies, besides
being non-invasive, add a physiological component to
complement these imaging modalities when endeavouring
to determine the hemodynamic significance and severity of
renovascular disease, if present.
This article describes a protocol used in the examination of
a particular case. An incidental finding of a coarctation was
elicited during the renal Doppler study on this patient. The
characteristics of normal and abnormal waveforms of the
aorta, main renal arteries, and parenchymal arteries are
reviewed here.
The two methods for detecting renal artery stenosis
described in this essay are the direct and indirect methods.
The direct method refers to the interrogation of the main
renal arteries. The indirect method involves the assessment
of the parenchymal arteries within the kidney itself and the
distal renal artery at the hilum.2–4 Of course, the presence of
accessory renal arteries may not be noted as they are difficult
to image due to their small calibre and inconsistent site of
10
The Canadian Journal of Medical Sonography | Fall 2011
origin; but with increasingly superior equipment resolution,
these small arteries are being recognized more frequently.
Indication, Preparation, History, and
Technique
The main clinical indication for ordering renal Doppler
ultrasonography is hypertension, often with an inability to
medically control the high blood pressure. An acute rise in
blood pressure to above high normal limits, labile blood
pressure, or hypertension in a young patient (20–40 years)
are reason to investigate the kidney vessels to rule out
stenosis, obstruction, or pathology that may compromise the
flow to and within the kidney.1 Renal failure develops if the
amount of functioning renal tissue is reduced by greater
than 80%.1 Renal artery stenosis is usually caused by
atherosclerosis and less frequently by fibromuscular
dysplasia.1
The patient should be well hydrated by drinking three to
four glasses of water 1–2 hours prior to the examination and
should ideally fast 6–8 hours before the test.3 Abdominal gas
can never be obliterated, even with a prolonged fast, so
varied positioning of the patient to avail oneself to the ideal
scanning windows is essential.5
Obtaining a pertinent medical history is important,
specifically regarding cardiovascular risk factors such as
smoking, diabetes, and cholesterol levels. The acuity of
onset, duration, and treatment of the patient’s high blood
pressure are important to know. A brachial blood pressure
should be taken before the examination if not known by the
patient or indicated on the requisition. Some laboratories
routinely auscultate the abdomen to listen for bruits that
may be present in the abdominal midsection. It is helpful to
www.csdms.com
A r ndt
have knowledge of abnormal creatinine levels that would
indicate the possibility of decreasing renal function.
Obesity in a patient often presents a difficulty, but scanning
from the flank minimizes the distance to the kidney.4 When
imaging midline vasculature (the aorta and main renal
arteries), constant compression applied to the abdomen may
aid in moving obscuring gas.4 Lowering the bed and
standing for midline scanning allows pressure to be applied
from the sonographer’s body and shoulder rather than the
elbow and wrist, reducing repetitive strain. As this
examination can take up to 1 hour, attention to ergonomics
must be in the mind of the sonographer throughout.
Turning the patient in a decubitus position for a flank
approach eliminates scanning through the small bowel and
colon. A variable that is not controllable involves how well
the patient follows your instructions for the various
breathing manoeuvres needed in order to assess the vessels
as accurately as possible.4
Renal Doppler Protocol
The renal Doppler protocol includes a morphological
assessment of the kidney to include length, an evaluation of
cortical thickness, and documentation of pathology. Sagittal
measurements of each kidney should be obtained. The aorta
should be assessed followed by duplex Doppler evaluation
of the main renal arteries and the parenchymal vessels.
Aortic Assessment
A curvilinear probe with a frequency of 3.5–5 MHz is
preferred for imaging the aorta as well as the kidneys.6 With
the patient in a supine position, obtain sagittal and
transverse images of the aorta to document the calibre of
the aorta as well as the presence of atherosclerosis or
aneurysm. Colour Doppler images complement the black
and white images by enhancing the presence of
atherosclerotic disease or hypoechoic thrombus. Optimize
the colour scale and colour gain to ensure proper colour fill
in.6
Obtain a spectral signal in the aorta at the level of the
superior mesenteric artery (SMA), which is in close
proximity to the origin of the renal arteries. The peak
systolic velocity (PSV) at this level is used to calculate the
renal-aortic ratio (RAR). The usual velocity of the aorta
ranges from 80 to 100 cm/s, with a moderate-resistance
waveform. The kidney is a highly vascular organ, receiving
approximately 20% of the cardiac output.5 Therefore, the
vascular supply to the kidneys is reflected in a moderateresistance waveform, indicating forward flow throughout
diastole. The upstroke of the aorta waveform should be
straight with a sharp peak, which indicates no significant
disease upstream from that site (Figure 1). Distal to the renal
www.csdms.com
Figure 1. Aorta – normal waveform.
arteries, the aortic waveform takes on a triphasic pattern
reflecting the high-resistance flow into the lower extremities.
Figure 1 shows the appropriate level at which the PSV of the
aorta should be obtained. The RAR is the ratio of the highest
PSV of each renal artery divided by the PSV of the aorta at
the level of the SMA.1,6 An RAR of ≥3.5 is considered
abnormal, indicating the presence of a stenosis causing a
>60% diameter reduction in the renal artery.1,6
Renal Arteries: Direct Assessment
In a transverse plane, the main renal arteries are observed
arising from the aorta about 1 cm inferior to the origin of
the SMA.5,6 In transverse, the right renal artery arises from
the aorta just inferior to the left renal vein at about a 10
o’clock position.3,6 The usual course of the right renal artery
is found posterior to the inferior vena cava (IVC) as it travels
to the hilum. The left renal artery lies behind the left renal
vein at about the 5 o’clock position.3,6 It continues in a
posterior direction toward the left renal hilum. The renal
veins course parallel to the arteries.5 Figures 2 and 3 illustrate
the renal vessel anatomy.
Colour Doppler ultrasonography is helpful in identifying
the renal arteries and for observing whether there is any
significant aliasing that might indicate a stenosis. Generally,
renal artery stenosis due to plaque formation occurs at the
origin and proximal portion, whereas stenosis due to
fibromuscular dysplasia (FMD) occurs in the mid- to distal
portion of the artery.1,6 Doppler samples should be taken
from the origin to the distal segment of the renal artery. An
angle correction of 60° should be maintained.5,6
The velocity of the main renal arteries normally ranges from
50 to 150 cm/s, with anything higher than 180 cm/s
considered abnormal1,5,6 and indicating renal artery stenosis.
The PSV normally decreases as the arteries are followed
The Canadian Journal of Medical Sonography | Fall 2011
11
Re nal Doppler Ultrasound Protocol
V
A
R
L
Figure 2. Diagram of the transverse renal vessels.
Figure 3. Transverse renal vessels.
Figure 4. Origin of the right renal artery.
Figure 5. Mid-right renal artery.
Figure 6. Distal right renal artery.
Figure 7. Mid-left main renal artery.
Figure 8. Diagram of the
coronal flank approach
through the kidney to the
renal artery.
12
The Canadian Journal of Medical Sonography | Fall 2011
Figure 9. Hilar region sample (coronal).
www.csdms.com
A r ndt
Figure 10. Interlobar arteries (arrows).
Figure 12. Interlobar artery.
distally and into the kidney. The renal arteries have a lowresistance signal, with the resistive index (RI) normally <0.7
and increasing slightly with advancing age. Figures 4–6
demonstrate the correct placement of the sample volume
and an angle correction of 60° along the length of the right
renal artery.
The RI equation is (1 − EDV/PSV) × 100, where EDV
indicates end diastole velocity. The equation is calculated by
the machine with cursors placed at peak systole and end
diastole.1,6 The experienced sonographer should be able to
assess the waveforms qualitatively, but obtaining an RI is an
essential part of the complete examination. The left renal
artery has a steeper lie, creating some difficulty in
maintaining a 60° angle correction (Figure 7) from an
anterior approach. If an angle other than 60° is used to
remain parallel to the flow stream, this must be documented
for reference in follow-up studies.
Renal Arteries (Distal): Indirect Assessment
A flank approach to interrogate the distal (hilar portion)
renal arteries and the intrarenal vessels may prove to be the
easiest method in patients in whom it is difficult to
accurately assess the arteries from the anterior abdominal
window (Figures 8 and 9). With the patient in a lateral
decubitus position and scanning from the flank in line with
the coronal plane of the kidney, the distal (hilar) region of
www.csdms.com
Figure 11. Interlobar artery.
the renal artery is easily visualized. Waveforms change distal
to a significant stenosis; therefore, Doppler evaluation of the
hilar portion of the main renal artery indirectly shows the
effects of a >60% narrowing. The hemodynamic effect
downstream to a critical stenosis demonstrates a delayed
acceleration time as well as a tardus-parvus waveform in
stenoses >80%.3 Because the position of the transducer is
directly in line with the artery, a 0° angle of insonation is
used, along with a large sample volume of 3–5 mm. These
technical parameters allow for quick and easy sampling of
the artery as it enters the hilum of the kidney. The sweep
speed should be increased to 100 mm/s or “fast,” depending
on the “knobology” of the specific equipment.3 This allows
for better detail of the waveform components so that the
acceleration time can be measured more accurately and the
early systolic peak (ESP), when present, easily identified.3
The acceleration time (flow onset to peak systole interval)
should be ≤100 ms in a normal renal artery.3 Often, the
sonographer’s subjective observation is used to conclude
whether the upstroke to peak systole is delayed.
The remainder of the indirect assessment is composed of at
least one sample of the parenchymal arteries (segmental or
interlobar) at the superior and inferior poles and midkidney. The interlobar arteries are easy to locate as they
course between the medullary pyramids and their
somewhat-vertical position allows for a 0° insonation along
the vessel (Figure 10). The interlobar or segmental arteries
in the sinus of the kidney reflect changes in the waveform
when a significant (>60%) stenosis is upstream from the
sample site. Spectral samples from normal interlobar arteries
are shown in Figures 11 and 12. Note that the sweep speed
is increased, which extends each pulsed waveform allowing
for detailed waveform characterization.3
Figures 13 and 14 clearly illustrate the ESP. This compliance
peak, which appears as a pre-systolic notching, is a specific
marker that indicates an absence of a proximal significant
stenosis in the main renal artery. It may take some finetuning to visualize the ESP while sampling through the
parenchymal arteries.
As part of the protocol a sagittal measurement of each
kidney should be recorded and a note made of the cortical
The Canadian Journal of Medical Sonography | Fall 2011
13
Re nal Doppler Ultrasound Protocol
Figure 13. Early systolic peak.
Figure 14. Early systolic peak.
Figure 15. Normal right kidney with measurement.
Figure 16. Mid-left renal vein.
Figure 17. Proximal left renal vein.
Figure 18. Sagittal proximal aorta (abnormal).
thickness (Figure 15). As well, the right and left renal veins
should be interrogated to prove patency. Respiratory
phasicity is usually seen in the renal vein waveform, as
demonstrated in Figures 16 and 17.6
Each kidney measured 9 cm in length and demonstrated
normal morphology. The aorta was unremarkable in its
structure.
The patient’s body habitus allowed for excellent
visualization of the vasculature of the abdomen and kidneys.
The aorta, main renal arteries and veins, and parenchymal
arteries were interrogated. A survey with colour Doppler
showed generally good perfusion to the cortical edge of each
kidney.
The PSV of the aorta was 134 cm/s but did not appear to
have a normal moderate-resistance pattern (Figure 18).
Case Report
A 20-year-old female was referred for renal artery Doppler
study due to the finding during a routine physical of
hypertension. Her physician had also heard an abdominal
bruit. She was a generally well person with no other
pertinent medical history.
14
The Canadian Journal of Medical Sonography | Fall 2011
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A r ndt
Figure 19. Transverse right renal artery.
Figure 20. Transverse left main renal artery.
Figure 21. Superior interlobar artery.
Figure 22. Mid-interlobar artery.
Figure 23. Distal aorta (abnormal).
Figure 24. Superior mesenteric artery (abnormal).
Qualitative observation suggested that the increased
diastolic flow velocities throughout diastole were atypical
for a normal proximal aorta waveform.
The main renal arteries were widely patent, with the spectral
tracing revealing a tardus-parvus waveform bilaterally with
a PSV of 63 cm/s in the right renal artery and 86 cm/s in the
left renal artery. The waveforms demonstrated the
characteristic appearance of a tardus-parvus waveform, with
a significantly increased acceleration time, broad peak with
a gradual downslope, and dampened velocities. The RIs were
0.45 and 0.49, respectively (Figures 19 and 20).
The parenchymal interlobar arteries displayed similarly
abnormal waveforms throughout both the right and left
kidneys (Figures 21 and 22).
The differential strongly suggested a central pathology such
as coarctation of the aorta or an aortic stenosis. If this were
the case, then all peripheral arteries distal to the coarctation
should reflect the same change in their waveforms. It was
decided, therefore, to sample the distal aorta, SMA, and both
common iliac arteries. Normally the distal aorta and
peripheral arteries take on a high-resistance, triphasic flow
pattern, reflecting the distal high-resistance vascular bed of
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The Canadian Journal of Medical Sonography | Fall 2011
15
Re nal Doppler Ultrasound Protocol
Figure 25. Right common iliac artery (abnormal).
Figure 26. Left common iliac artery (abnormal).
Figure 27. Normal common iliac artery waveform.
Figure 28. Normal distal aorta waveform.
Figure 29. Coarctation of thoracic aorta.
the lower extremities.5,6 The result of our interrogation
found a low-resistance pattern in major arteries distal to the
renal arteries (Figures 23 and 24). Figures 25 and 26 show
the abnormal low resistance of the common iliac arteries.
As well, the PSVs in the common iliac arteries of 52 cm/s
and 35 cm/s are well below expected velocities, especially in
a patient of this age. For comparison, Figures 27 and 28
illustrate the normal triphasic pattern seen in the aorta and
common iliac arteries.
The radiologist report recommended further assessment,
and an urgent MRA was ordered by the patient’s physician
16
The Canadian Journal of Medical Sonography | Fall 2011
to rule out coarctation and aortic stenosis of the aorta. The
MRA confirmed a diagnosis of coarctation (Figure 29).
Coarctation is a narrowed segment of the aorta, generally
occurring in the thoracic aorta (proximal descending
portion), just beyond the left subclavian artery origin
(Figures 29 and 30). It can also occur, more rarely, in the
abdominal aorta. The generally accepted standard treatment
is open surgery with resection of the narrowed portion with
an end-to-end interposition graft insertion, with sutured
anastomosis to the aorta (Figure 31).
Of interest, there is a trend toward an endovascular
approach to repairing a coarctation. This procedure involves
dilating the area of interest with a large-diameter angioplasty
balloon inside a covered tubular stent graft. The intent is to
create a controlled rupture of the aorta at the coarctation
site only, with the covered endograft containing the rupture
itself. This method is best applied when only a slight
widening of the coarctation is needed as the risk in more
severe cases is an uncontrolled rupture of the aorta. In either
case, a coarctation should be repaired as the strain on the
heart to pump blood against the narrowed orifice of the
coarctation can cause long-term cardiac damage
(hypertrophic cardiomyopathy).
Conclusion
This essay presents a basic protocol to assess the vasculature
www.csdms.com
A r ndt
Figure 30. Coarctation of aorta.
Figure 31. End-to-end graft repair.
to the kidneys and within the parenchyma of the kidneys.
The differentiation between normal and abnormal
waveform patterns is clearly demonstrated. Whether a
sonographer chooses to use direct or indirect Doppler
assessment for a dedicated study of the vasculature of the
kidneys, the information obtained can be helpful in
determining if further imaging studies are needed. It is my
intent to encourage sonographers, when faced with the
question of renal artery stenosis in a general department, to
try to obtain spectral tracings from parenchymal arteries,
using the criteria outlined for indirect assessment. Even
though this essay shows comparative results from a
coarctation that is an uncommon pathology to be diagnosed
in this manner, it should be understood that a significant
arterial narrowing (>60%), whether in the aorta or main
renal arteries, shows the same changes to the parenchymal
vessels of the kidney. The hemodynamics of downstream
effects of arterial stenosis can be applied to the duplex
interrogation of any artery in the body; therefore, whether
disease is present or not in the sampled vessels, the
understanding of waveform characteristics is of critical
importance.
4.
5.
6.
Coombs P. Color duplex of the renal arteries:
diagnostic criteria and anatomical windows for
visualization. JVU 2004;28(2):89–97.
Dubbins PA, McAteer M, ed. Clinical Doppler
Ultrasound, 2nd edition. Philadelphia: Churchill
Livingstone (Elsevier) Publishers; 2006.
Zweibel WJ, Pellerito JS, Ross A, ed. Introduction to
Vascular Ultrasonography, 5th edition. Philadelphia:
Elsevier Saunders; 2005.
References
1.
2.
3.
Myers K, Clough A. Renovascular diseases. In Koster J,
ed. Making Sense of Vascular Ultrasound – A Handson Guide, 1st edition. London: Arnold Publishers;
2004.
Isaacson JA, Zierler RE, Spittell PC, Strandness DE.
Noninvasive screening for renal artery stenosis:
comparison of renal artery and renal hilar duplex
scanning. J Vasc Tech 1995;19(3):105–10.
Isaacson JA, Neumyer MM. Direct and indirect renal
arterial duplex and Doppler color flow evaluations.
J Vasc Tech 1995;19(5–6):309–16.
www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
17
Original Article
A Long Car Trip with Your Family Can Lead You to the
Emergency Department: A Case Report
Wilson Miranda, BSc, RDCS, Shin-yee Chen, MD
About the Authors
Wilson Miranda (left) and Shin-yee Chen are both members of the Ottawa Heart Institute,
in Ottawa, Ontario. Correspondence may be directed to [email protected].
T
he case presented here illustrates the usefulness of
echocardiography in the assessment of patients with
pulmonary embolism. In addition to providing information
regarding right ventricular function and pulmonary
pressure, it caught an impending paradoxical embolism
(IPDE) in the act as it traversed through a patent foramen
ovale. Recognition of this unusual entity and the
appreciation of its clinical implications by the sonographer
led to the activation of the appropriate treatment pathway,
which may have saved the patient from catastrophic
complications.
Case Report
A 67-year-old woman presented to the emergency
department with a 3-day history of generalized weakness,
dizziness, mild dyspnea, and chest pain. The chest pain was
described as a persistent retrosternal pressure, which became
worse with exertion. There was no pleuritic component. In
retrospect, she had been feeling unwell since her 10-hour car
trip, approximately 1 week prior to presentation. She had
initially experienced bilateral lower extremity weakness and
pain. The pain had since resolved, but the weakness
remained. Due to symptoms of urinary incontinence and
dysuria, she was seen at a local clinic 3 days prior to
presentation and was started on azithromycin. On the
evening of her presentation, she felt so weak and dizzy that
she could not get up. The emergency health service was
activated and the patient was brought to the emergency
department.
Due to a language barrier, the patient could provide only
limited information regarding her past medical history. She
indicated that she had received medical treatment for a
thyroid problem, but had otherwise been in good health and
18
The Canadian Journal of Medical Sonography | Fall 2011
was not on any regular medication. Physical examination
revealed a blood pressure of 123/82 mm Hg, a heart rate of
100 bpm, a respiratory rate of 25 breaths/min, an oxygen
saturation of 96% on room air, and a temperature of 36.3°C.
Results of an examination of the head, neck, and abdomen
were within normal limits. There was no lower extremity
erythema, warmth, or swelling.
Cardiac examination revealed normal heart sounds with no
systolic or diastolic murmur. The jugular venous pressure
could not be determined with certainty. A respiratory
examination revealed normal breath sounds bilaterally with
no wheezes or crackles.
The patient was reviewed by the medicine service and was
started on dalteparin sodium (Fragmin) for a suspected
pulmonary embolism. Computed tomography (CT) of the
chest confirmed a large saddle embolus with extensive
pulmonary embolic disease involving all lobar and multiple
peripheral arteries (Figure 1). Also present were right
chamber dilatation, interventricular septal straightening,
and reflux of contrast into the inferior vena cava suggestive
of elevated pulmonary pressure. CT of the head was
performed to rule out any intracranial pathology
contributing to the patient’s condition. This revealed no
evidence of an acute infarction or bleeding. The patient
remained hemodynamically stable in the emergency
department overnight.
An echocardiogram was requested the next day to assess
right ventricular function. This revealed a mild dilatation of
the right ventricle with moderately reduced systolic
function. The left ventricle was small with normal systolic
function. There was moderate tricuspid regurgitation and
mild pulmonary hypertension. The systolic pulmonary
pressure was estimated to be 44 mm Hg. A large sausage-like
www.csdms.com
Miranda and Che n
A
A
B
B
C
C
Figure 1. A–C, Computed tomography of the chest revealing a
large saddle embolus (arrows) with extensive pulmonary
embolic disease.
www.csdms.com
Figure 2. A–C, An impending paradoxical embolism caught in the
act as it traversed through a patent foramen ovale; images
obtained in the modified apical four-chamber and subcostal views.
The Canadian Journal of Medical Sonography | Fall 2011
19
Family Trip Can Lead to the ED
mass was identified in the right atrium, traversing through
a patent foramen ovale into the left atrium. The appearance
was diagnostic of an IPDE (Figure 2).
Cardiac surgery consultation was initiated, and the patient
was taken to the operating room to undergo pulmonary
embolectomy. By the time she arrived in the operating
room, she was in full-blown cardiogenic shock with severe
right ventricular heart failure. Upon anesthesia induction,
she went into cardiac arrest and required an emergency
sternotomy and open cardiac massage. She was stabilized,
and a large clot was evacuated from her atria upon
cannulation. The residual atrial septal defect was closed. A
thrombectomy of the main pulmonary artery and
thromboendarterectomies of the left and right pulmonary
arteries and the segmental arteries were performed. Despite
concerns regarding a significant residual clot burden in the
subsegmental level, she survived the surgery with enough
right ventricular function to carry her through. She was
started on heparin after the surgery. Ultrasonography of the
lower extremity was performed the next day but revealed no
evidence of any residual deep vein thrombosis. Her recovery
was slow, with complications of atrial fibrillation, shock
liver, renal insufficiency, and superficial sternal wound
infection. She was discharged from hospital approximately
1 month after her surgery.
Discussion
Deep vein thrombosis in the lower extremity may dislodge
and migrate through the inferior vena cava and the right
cardiac chambers to reach the pulmonary arterial
circulation, resulting in pulmonary embolism. With the
Valsalva manoeuvre, or in the setting of significantly
elevated right heart pressure due to massive pulmonary
embolism, the migrating thrombus may pass from the right
atrium into the left atrium through a patent foramen ovale,
which is estimated to be present in up to 35% of the normal
population.1 This phenomenon, known as paradoxical
systemic embolization, may lead to catastrophic
consequences, such as stroke or myocardial infarction. In
this case, a large thrombus became entrapped in the
foramen ovale as it migrated from the right to the left
atrium, enabling the sonographer to capture the
echocardiographic image of the IPDE.
IPDE is associated with high mortality, with most deaths
occurring within 24 hours of diagnosis.2 While the optimal
treatment for this condition remains controversial, early
diagnosis is of the utmost importance in clinical decision
making. In a systematic review, for this rare condition,
transthoracic echocardiography was diagnostic in 39.6% of
reported cases, whereas transesophageal echocardiography
was required in 56.9%. CT and magnetic resonance imaging
20
The Canadian Journal of Medical Sonography | Fall 2011
were used in 2.9 and 0.6% of patients, respectively.3 In this
case, the diagnosis was made with transthoracic
echocardiography within minutes of initiating the study.
The study was performed portably at the bedside, without
the inconvenience, invasiveness, medication or contrast
administration, radiation exposure, or patient discomfort
associated with other diagnostic modalities. However, it
behooves the sonographer to recognize this rare entity and
perform a thorough search for any intracardiac mass or
thrombus, with particular attention to the interatrial
septum. This is especially difficult since the reasons cited for
the diagnostic test referral may be wide and varied. The
majority of patients may present with symptoms consistent
with pulmonary embolism, including dyspnea, chest pain,
syncope, shock, and signs of right ventricular failure. About
half of these patients may have manifestations of systemic
emboli, such as cerebral vascular accidents, peripheral
vascular ischemia, myocardial infarction, or visceral
ischemia.4
The diagnosis of IPDE may be made by echocardiography
via direct visualization of the thrombus entrapped in the
patent foramen ovale. The thrombus is usually a mobile
mass of irregular shape, serpentine or lobulated, with
changing configuration throughout the cardiac cycle.
Sometimes only the right or the left atrial aspect of the IPDE
is seen, making it difficult to differentiate from atrial
mxyoma. Other differential diagnoses, such as congenital
structures, infectious vegetations, or sessile right atrial
thrombi, must also be excluded.5 At the same time,
echocardiography can be used to assess for findings
associated with concurrent pulmonary embolism, such as
right ventricular dysfunction, McConnell’s sign, and
elevated pulmonary pressure. It is also useful for ruling out
any significant dysfunction of the left ventricle and cardiac
valves in unstable patients. In this case, despite earlier
assessment with CT of the chest, which did detect right
cardiac chamber dilatation and evidence of pulmonary
hypertension, the diagnosis of IPDE was not made until the
assessment with echocardiography.
Treatment options for IPDE include anticoagulation,
thrombolysis, and surgical thromboembolectomy. As the
majority of deaths are due to cardiogenic shock or right
heart failure, it has been postulated that hemodynamic
compromise secondary to massive pulmonary embolism is
the main underlying mechanism. As such, thrombolysis has
been proposed as the treatment of choice. However, this is
associated with systemic embolization in 23.5% of patients.
While a recent systemic review failed to establish improved
survival with either thrombolysis or surgical thromboembolectomy over anticoagulation alone, surgical
thromboembolectomy showed a nonsignificant trend
www.csdms.com
Miranda and Che n
toward improved survival and reduced systemic embolism
and composite of mortality and systemic embolism.3
Thrombolysis showed a non-significant trend toward the
opposite.3 Treatment should be considered on a case-by-case
basis and individualized according to the patient’s clinical
profile and local expertise. Fortunately for the patient in this
case, pulmonary thromboendarterectomy was available at
our institution and the risk of systemic embolization was
minimized as much as possible. Had the diagnosis of IPDE
not been made by echocardiography, the patient would
likely have received thrombolysis for pulmonary embolism
given her progressive hemodynamic instability and may
have been left with a significant neurological deficit if she
survived the event. This case highlights the importance of a
full echocardiographic examination in patients with
suspected pulmonary or systemic embolism.
References
1.
2.
3.
4.
5.
Meacham R, Headley A, Bronze M, et al. Impending
paradoxical embolism. Arch Intern Med
1998;158:438–8.
Aboyans V, Lacroix P, Ostyn E, et al. Diagnosis and
management of entrapped embolus through a patent
foramen ovale. Eur J Cardiothorac Surg 1998;14:624–8.
Myers PO, Bounameaux H, Panos A, et al. Impending
paradoxical embolism: systemic review of prognostic
factors and treatment. Chest 2010;137:164–70.
Meacham RR III, Headley AS, Bronze MS, et al.
Impending paradoxical embolism. Arch Intern Med
1998;158:438–48.
Huwer H, Winning J, Isringhaus H, et al. Transit
thrombus entrapped in a patent foramen ovale. Heart
Lung 2004;33:191–3.
E
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www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
21
Original Article
An Inexpensive Easy-to-Make
Scrotal Phantom
Leonardo Faundez, MA-Ed, BSc, CRGS, CRVS, RDMS, RVT
About the Author
Leonardo Faundez is an ultrasound professor at the Michener Institute for Applied Health
Sciences in Toronto, Ontario. Correspondence may be directed to [email protected].
U
ltrasound phantoms have become useful tools in
training sonography students. Phantoms offer
advantages such as allowing sonographic concepts to be
more easily demonstrated1 and facilitating the scanning of
organs and structures without the need of a living patient.2
Despite the extensive list of commercially available
phantoms (see, e.g., 3-Dmed at http://www.3-dmed.com/
Phantoms_For_Ultrasound_&_X-ray_Ultrasound_Diagnostic_Training_Models.html; 3rd Rock Ultrasound at
http://www.emergencyultrasound.com/products.php?cat=1;
Blue Phantom at http://www.bluephantom.com/category.aspx?
cid=539; and CIRS at http://www.cirsinc.com/main_us.html),
there is currently only one scrotal phantom on the market
(from Blue Phantom), and its price is quite significant when
considering current budgetary limitations. Nevertheless, it
is possible to create an inexpensive scrotal phantom that will
enrich student learning.
Scrotal imaging is challenging for novice sonographers due
to its uniqueness in terms of anatomy, curved scanning
surface, and relatively mobile targets (testes). Prior to the use
of the homemade scrotal phantoms, students in the
Ultrasound Program at the Michener Institute for Applied
Health Sciences, in Toronto, Ontario, were exposed to scrotal
imaging on only a theoretical basis. They learned the scrotal
cross-sectional anatomy, normal sonographic anatomy, and
pathological findings. Having only theoretical background
before the clinical component definitely meant that our
students were at a disadvantage. In addition, scrotal
sonography carries a significant level of uneasiness,
especially for female sonographers. At our institution, the
number of female sonography students is greater than that
of male students, and having to wait until their clinical
rotations to scan scrota caused their uneasiness to escalate.
Taking all of this into account, there was a need at our
22
The Canadian Journal of Medical Sonography | Fall 2011
institution to better prepare our students via simulation of
scrotal imaging. To bridge this gap, I created an inexpensive
and relatively easy-to-make scrotal phantom.
Scrotal Phantom
Three scrotal phantoms were created, with a total cost of
materials of approximately C$8.00. To make this inexpensive
and relatively easy-to-make scrotal phantom, the following
steps were performed:
1.
2.
Hollow oval-shaped structures were used to simulate
the testes (Figure 1). The original purpose of these
hollow structures was to be a toy for a birthday loot bag.
Each of these came with a small touch-activated light
inside that was removed by a small cut made with
scissors so that it would have a hollow centre. Using a
syringe without a needle, various substances were
injected into the hollow space to see which produced
the best sonographic tissue equivalency. After several
trials, it was decided that the best substance was the
hand cream used in our laboratory (Surgipath
Aloeponic, Surgipath Medical Industries). Krazy Glue
was used as a sealer to close the cut in the structure to
prevent any spilling.
To simulate the epididymides, two items were used. One
was a worm-shaped item, also a birthday loot bag toy
(Figure 2). Only two of these worm-shaped items were
found when purchasing the materials. For the
remaining simulated epididymides, a jelly substance
was used (Figure 3). This latter item had to be cut into
an epididymis-like shape (Figure 4). These simulated
epididymides were glued with Krazy Glue to the outer
surface of the oval-shaped structures (Figure 5). This
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Faunde z
Figure 1. Hollow oval-shaped structures used for simulated testes
(Sticky Light).
Figure 2. Worm-shaped item used to simulate epididymides (All
New Sticky Toy).
Figure 3. Jelly substance used to simulate epididymides (item on
sale without package; unable to determine product name).
Figure 4. Jelly substance cut and shaped to simulate epididymides.
Figure 5. Simulated epididymis stuck to simulated testis.
Figure 6. Simulated testes and epididymis. Note the unrealistic gap
between these two structures.
3.
resulted in an unrealistic wide gap between the
simulated testis and epididymis (Figure 6).
An extra-large glove was used for the scrotal sac. The
fingers were tied together using an elastic band or
medical tape; then the glove was flipped inside out
www.csdms.com
creating a sac-like structure (Figures 7 and 8). Two
simulated testes with epididymides were then placed
inside the sac (Figure 9) so that the fingers taped
together were between the testes. In addition, the two
simulated testes were placed so that the epididymides
The Canadian Journal of Medical Sonography | Fall 2011
23
A n Inexpensive Easy-to-Make Scrotal Phant om
Figure 7. Extra-large glove utilized as scrotal sac. The fingers were
tied together using an elastic band or medical tape.
Figure 8. Glove was flipped inside out creating a sac-like structure.
Figure 9. Simulated testes/epididymides placed inside the sac-like
structure created with a glove.
Figure 10. Home-made scrotal phantom (ultrasound gel seen on its
surface).
Figure 11. Simulated testis in its long axis.
Figure 12. Simulated testis in its short axis.
4.
24
faced laterally to re-create their natural location.
The simulated testes with epididymides then needed to
be embedded in a liquid. Filtered water (from a Brita
filter) was found to be better than ultrasound gel and
tap water: it was extremely difficult to eliminate air
bubbles trapped in the ultrasound gel, which made
The Canadian Journal of Medical Sonography | Fall 2011
visibility challenging; as for tap water, when left for
some hours, air bubbles started to form, thus affecting
visibility. Sufficient filtered water was then poured into
the sac to cover the simulated testes with epididymides.
An elastic band was used to secure the top to prevent
spilling (Figure 10).
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Figures 11 and 12 show examples of sonographic images of
the simulated testes. The presence of tiny echogenic foci in
the simulated testes represents air bubbles trapped in the
hand cream. Although presence of air is not desirable, in this
case, it actually mimics tiny calcifications (microlithiasis).
To store the scrotal phantoms after use, drain the filtered
water, dispose of the gloves, and gently dry the simulated
testes and epididymides with paper towel and place them in
a dry box or container.
Laboratory Exercise
During a tutorial prior to the laboratory exercise, a
demonstration on how to scan the scrotal phantom was given.
The majority of the questions from the students were about
sonographer-patient interaction (e.g., explanation given to
the patient, patient set-up, etc.). For the laboratory exercise,
students were asked to work in pairs, as is routinely done at
our institution. The student playing the role of the patient was
asked to wear a gown (on top of his or her own clothes), lie
down on the stretcher, and hold the scrotal phantom from its
top with one hand during the examination to prevent
excessive movement. Students were asked to place the scrotal
phantom at the level of their knees to simulate the male pelvis
and legs. In addition, students were given an example of a
scanning protocol to follow. Each student had 25 minutes to
scan the phantom.
Of the four laboratory sessions, two were conducted by me
and two by another instructor. During these sessions, faculty
assisted students by emphasizing the scanning technique in
terms of using different windows, applying pressure, and
obtaining the long and short axes of each testis, and the
advantages and disadvantages of angling versus sliding for
sweeps, etc. Furthermore, students were encouraged to
imagine themselves in the real situation and anticipate any
issues regarding scanning and patient interaction.
Student Feedback
Students were asked to provide feedback about this
laboratory exercise by posting their comments on an
electronic platform, BlackBoard. (Students had the option
Table 1. Student Feedback Obtained after Scrotal Imaging Laboratory Sessions Using the Homemade Scrotal Phantoms
Student 1: “I thought scanning the scrotal phantom was good practice today; it was more difficult than I had anticipated. I’m glad I
got the opportunity to use it because I hadn’t realized getting the long or short axis would be so tricky.”
Student 2: “Using the scrotal phantom was good. I didn’t realize how movable they could be. Also I didn’t expect that the long and
short axes wouldn’t be in true sag [sagittal] or trx [transverse]. It was good practice to see that in the lab.”
Student 3: “The scrotal phantoms were invaluable for several reasons. Their mobility, contoured surfaces, and testes orientation all
contributed to excellent practice. What you used for the epididymis may be more confusing than helpful in its current form. Perhaps
a later model could have a structure located where the epididymis would be found, even if sonographically it did not resemble it.
That way, students could still practise locating the epididymis and using it as a landmark.”
Student 4: “First assumption, I was expecting that for this lab, we would be scanning the scrotal phantom laying on its own on the
stretcher. However, we actually simulated the patient as well. This was helpful as it let us practise the patient set-up and experience
the proper ergonomics when doing scrotal ultrasonography. Like our transvaginal practice labs, putting us in the patient’s shoes will
help us with our patient care skills.”
Student 5: “I think scanning that scrotal phantom was definitely helpful in preparing for our clinical semester. I was able to sweep the
scrotum as outlined in the manual. It was good practice since we have not scanned a very curved surface such as the scrotum. I think
the phantoms were made well, in that we were able to get scrotal images very similar to the pictures we have been seeing in class.
We were also able to experience the difficulty of scanning testis as it can be mobile within the scrotum. One area where I had difficulty
was finding the epididymis. I was able to catch the head [of the epididymis], but it was not located where the epididymis is expected
to be.”
Student 6: “I think that being able to practise scanning the scrotal phantom was a huge benefit. After all, we have the Medsim
[ultrasound simulator] as our only opportunity to experience transvaginal ultrasonography before clinical [the clinical component],
and I think that an outlet to experience patient interaction, patient gowning, and realistic scanning for scrotal ultrasonography is just
as important. After scanning the phantom, I feel I know more of what to expect and certainly more of how to scan (i.e., windows to
use, how and when to slide versus angle etc.).”
Student 7: “The scrotal phantom was great practice and provided a little bit of insight on what to expect in clinical.”
Student 8: “I thought it was a great experience and nice to experience scanning a scrotum before clinical. The movement of the
model was very similar to what I can imagine [occurs with] a real patient. Thanks for taking the time to develop this for us.”
Student 9: “It was definitely better than nothing. I got a feel for how I’d have my hand and arm and how I’d like to try to avoid
touching the patient’s inner thighs. The testicles were pretty great, realistic on screen and pretty realistic physically. The excess
fluid was obviously not an example of normal anatomy, but similar to a hydrocele, so not a huge drawback. I just reread the scrotal
protocol in the lab manual and realised how much we missed out on [the] epididymis. It’s a shame that part didn’t work out better
as I’m still feeling uncertain about how to manage those sweeps and images.”
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The Canadian Journal of Medical Sonography | Fall 2011
25
A n Inexpensive Easy-to-Make Scrotal Phant om
to submit their feedback anonymously.) Nine of 23 students
submitted feedback; eight used BlackBoard and one used email. The feedback received is included in Table 1.
Discussion
Overall, seven of nine students referred to the laboratory
exercise as a beneficial learning experience (students 1, 2, 3,
5, 6, 7, and 8). Their reasons varied in terms of why this was
a useful learning experience, from the exposure to scanning
to the patient care interaction.
One of the most imperative characteristics for an ultrasound
phantom to be effective is that it must mimic human tissue.3
Students found the scrotal phantoms realistic in terms of
their sonographic characteristics (“scrotal images very
similar to the pictures we have been seeing in class,”
“realistic scanning,” and “realistic on the screen” [students
5, 6, and 9]) and physical characteristics (“contoured
surfaces and testes orientation,” “curved surface,” and
“pretty realistic physically” [students 3, 5, and 9]). Because
of this, students were able to experience some of the
challenges of scanning the scrotum, including finding the
long and short axes (students 1 and 2). Students realized that
placing the transducer in true sagittal or true transverse
plane to the body did not guarantee obtaining the long and
short axes, respectively. The scrotal phantom also allowed
students to experience the mobility of the testes while
scanning (students 2, 3, 5, and 8). Students found it
frustrating to keep losing the long and short axes of the testes
when either increasing or decreasing the pressure applied
with the transducer or performing the heel-toe (or reversed)
manoeuvre, which is routinely done for these scans.
The scrotal phantoms also allowed the students to practise
the appropriate ergonomics for scrotal sonography
(“experience the proper ergonomics” and “I got a feel for
how I’d have my hand and arm” [students 4 and 9]). This is
important for novice sonographers in terms of learning how
to anchor their scanning forearm on the patient’s thigh, or
realizing they are not able to rest their scanning hand as
when, for example, scanning the abdomen. In fact, initially,
since novice sonographers take longer to scan, they may
experience more discomfort and fatigue in their scanning
arms when scanning scrota as proper anchoring may not be
possible.
During the initial scrotal phantom tutorial, the majority of
the questions were about the sonographer-patient
interaction. The anxiety level was quite evident, especially
in the female students. Students asked about what to do in
certain situations that may arise during scanning: giving
instructions to the patient, the positioning of towels under
the scrotum and the gown to secure the patient’s penis
against his pelvis, the refusal of a female sonographer by a
patient, etc. Based on their feedback, our students were able
26
The Canadian Journal of Medical Sonography | Fall 2011
to simulate these situations during the laboratory session
when using the homemade scrotal phantoms (“helpful as it
let us practise the patient set-up … putting us in the
patient’s shoes,” “patient interaction, patient gowning,”
“how I’d like to try to avoid touching the patients inner
thighs” [students 4, 6, and 9]). The scrotal phantoms
provided an opportunity for students to practise all of the
issues mentioned and to experience, to some degree, the
uncomfortable feelings associated with performing this type
of examination. The tutorial and laboratory session gave the
students a starting point to mentally prepare for such clinical
situations.
Regarding limitations, nine of 23 students gave feedback
about the homemade scrotal phantoms, which is a relatively
small number. In addition, the simulated epididymides had
some limitations (students 3, 5, and 9). First, there was an
unnatural gap between the simulated testis and epididymis
(see Figure 6). Second, the jelly substance used to make some
of the simulated epididymides partially dissolved in the
filtered water. As a result, students had difficulty finding
them. Another limitation involved some of the hollow ovalshaped structures used for the simulated testis not having
an entirely oval-shape inside. This resulted in some of the
testes having “square” indentations (Figure 13). In addition,
the simulated testes had no mediastinum.
Since filtered water was poured in the scrotal sac created by
the glove, the simulated testes were immersed in this water.
This created a “pseudo-hydrocele” (see Figures 11 and 12).
Furthermore, some tiny air bubbles got trapped while
injecting the hand cream into the hollow structures,
resulting in “pseudo-microlithiasis” or “pseudocalcifications” (see Figures 11, 12, and 14). It can be argued
that these last two limitations may actually be advantages
since they simulate pathologies. In fact, one student
commented on this: “excess fluid was obviously not an
example of normal anatomy, but similar to a hydrocele, so
not a huge drawback” (student 9).
There are other features worth emphasizing regarding these
homemade scrotal phantoms. The simple steps to make
them are highly reproducible provided the adequate
materials are available. The cost of the materials for three
phantoms is more than 600 times cheaper than one
commercially available phantom (from Blue Phantom). Not
only are the created phantoms inexpensive, they are also
reusable. Moreover, storage of these scrotal phantoms is
simple, and little space is required.
Overall, these homemade scrotal phantoms provided
students with an enriching scrotal imaging simulation. This
is further supported by comments such as: “I feel I know
more of what to expect and certainly more of how to scan”
(student 6), and “[this exercise] provided a little bit of
insight on what to expect in clinical” (student 7). These
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Figure 13. Simulated testis in its long axis having a “square”
indentation.
Figure 14. Simulated testis in its short axis with “pseudomicrolithiasis” and “pseudo-calcifications.”
phantoms have since become important tools in the training
of sonography students.
2003;86:3–5; http://www.rbrs.org/dbfiles/journalarticle
_0089.pdf. Accessed October 15, 2010.
Ophir J, Maklad NF, Jaeger PM. United States Patent.
1981; http://www.google.ca/patents?id=
AR84AAAAEBAJ&printsec=description&zoom=
4#v=onepage&q&f=false. Accessed October 15, 2010.
3.
Conclusion
In conclusion, these inexpensive, easy-to-make, and reusable
scrotal phantoms serve as a teaching tool for novice
sonographers during their didactic training. Despite their
limitations, the phantoms provide novice sonographers with
the opportunity to experience not only some of the scanning
challenges but also patient care–related challenges of scrotal
imaging. As stated by De Maeseneer et al.,2 an ultrasound
phantom can be adapted to meet specific needs, and this is
exactly the case for these homemade scrotal phantoms.
As for future steps, better items and planning are needed to
create more effective and realistic simulated epididymides.
Regarding future research, feedback is currently being
collected from the sonography students who used these
scrotal phantoms in the didactic portion and are currently
completing their clinical rotations. This feedback will assess
the effect, if any, these scrotal phantoms had in preparing
them for scanning real patients in the clinical setting.
Acknowledgements
I would like to thank Gail Rodrigues and Lorena Faundez
for helping me in the editing of this article.
References
1.
2.
Langer S, Kofler JM Jr. A series of teaching phantoms
for displaying diagnostic ultrasound image artifacts. J
Diag Med Sonogr 1997;13(1):22–7;
http://jdm.sagepub.com. Accessed October 15, 2010.
De Maeseneer M, De Wilde V, Gosselin R, Osteaux M.
The use of phantoms or tissue simulating test objects
in the evaluation of imaging methods. JBR–BTR
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The Canadian Journal of Medical Sonography | Fall 2011
27
Original Article
Morel-Lavallee Lesion: A Case Report
Megan MacNevin
About the Author
Megan MacNevin is a 4th-year student at the Mohawk/McMaster Institute for
Applied Health Sciences, Medical Radiation Science, Ultrasonography Program, in
Hamilton, Ontario. She is currently completing her clinical placement at the Ottawa Hospital
and will graduate in the spring of 2012. Correspondence may be directed to
[email protected].
A
Morel-Lavallee lesion is a closed degloving injury, where
the skin and subcutaneous tissue are forcibly detached
from the underlying fascia by a sudden severe shearing force.1
This type of injury is usually caused by high-speed trauma
such as in motor vehicle accidents or severe crushing. The
diagnosis of a Morel-Lavallee lesion often occurs some time
after the initial injury; this lesion can persist for months before
being identified. If the lesion persists for too long without
detection, infection may occur, resulting in surgery and a
more complicated treatment plan. Imaging modalities,
including magnetic resonance imaging and ultrasonography,
are the best options for diagnosis. The nature of the cavity
fluid should be determined to guarantee the best treatment
option for this lesion. Treatment procedures range from
minimally invasive compression to extremely invasive open
débridement.
abdomen. The homogeneous collection was of mixed
echogenicity and measured 10 cm × 20 cm × 3 cm in the
lateromedial, craniocaudal, and anteroposterior dimensions,
respectively. Septations and a fluid-debris level were present
throughout the lesion, contributing to the hyperechoic
features. Radiologists agreed that these findings were
compatible with a closed degloving injury, also known as a
Morel-Lavallee lesion.
The method of treatment chosen for this case was needle
aspiration. Using a 5-French catheter, the first drainage, at the
end of July 2009, removed 400 cc of blood. In the following
6 months, the patient attended eight follow-up appointments.
In six of these appointments, 70–360 cc of bloody fluid was
removed. During the sixth return of the patient, a 16 cm ×
Case Report
A 30-year-old man suffered a dirt biking accident in May of
2009. In July of the same year, he presented with continuous
pain and swelling of the right hip. He claimed that the pain
had persisted for the previous 2 months, and had been steadily
increasing in intensity for the 4 days prior to presentation.
Aside from the biking accident in May, the patient did not
have a medical history of injury, surgery, or disease.
To diagnose the patient’s condition, general radiography and
ultrasonography were ordered. The radiograph confirmed
that there was no fracture present in the hip or femur. The
ultrasound image displayed a large, elongated, lobulated
collection in the right hip region superficial to the gluteus
maximus and gluteus medius regions (Figures 1 and 2). It
appeared to extend between the skin and fascia from the
upper thigh region to the mid-axillary line of the lower
28
The Canadian Journal of Medical Sonography | Fall 2011
Figure 1. Ultrasonography of the patient’s right thigh revealed a
Morel-Lavallee lesion between the skin and fascia extending from
the upper thigh to the mid-axillary line. Note the septations and
fluid-debris level.
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MacN e v in
A
B
Figure 2. A and B, Transverse and longitudinal sonograms of the right thigh obtained 2 months after the initial injury. A large MorelLavallee lesion is present between the skin and fascia superficial to the gluteus maximus and medius muscles. A fluid-debris level is evident.
1.4 cm × 4.0 cm mostly echogenic hematoma in combination
with a small cystic area was found, suggesting that the blood
had coagulated and that the case had become more complex.
At the following appointment, 360 cc of blood was removed,
a positive indication that the lesion had recurred. The final
follow-up ultrasonography, in January of 2010, displayed a
very slender fluid collection over the right lateral thigh
measuring 4.0 cm × 0.4 cm. No drainage was performed at
this time as there was very little fluid to remove. The
remaining hematoma resolved, and the patient returned to
his daily life, with no reoccurrence of the fluid-filled lesion.
Discussion
As previously stated, a Morel-Lavallee lesion is an abrupt
traumatic separation of the skin and subcutaneous fatty tissue
from the underlying fascia. This causes a disruption of the
vascular and lymphatic plexus perforating through the fascia
lata, resulting in a cystic cavity filled with a combination of
blood, lymphatic fluid, and necrotic fat. The hemolymphatic
tissue is surrounded by granulation tissue that may become
organized into a fibrous pseudocapsule – this prevents the
reabsorption of fluid and may lead to the persistence of a
lesion for months, or years, after an injury.2 A pseudocapsule
may also contribute to the lesion’s propensity to recur; the
capsule is frequently an indication of a chronic hematoma.
The area of degloving is most common in the lower
extremities, such as the thigh, greater trochanter, knee, and
buttocks (Figure 3). Although rare, such injuries can also
occur in the lower back, abdomen, and upper extremities such
as the shoulder. A Morel-Lavallee lesion is caused by a blunt
tangential force, usually present in high-speed motor vehicle
collisions or severe crush injuries involving the entrapment
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Figure 3. The most common locations of Morel-Lavallee lesions.
Adapted from Hudson et al.3
of a limb between a tire of a motor vehicle and a fixed surface.3
Due to the nature of the cause of this condition, it is usually
associated with pelvic and acetabular fractures. However, any
blunt trauma without fracture can result in a post-traumatic
soft tissue cyst. The Morel-Lavallee lesion goes by the aliases
of post-traumatic soft tissue cyst, pseudocyst, Morel-Lavallee
extravasation, and Morel-Lavallee effusion.4
Clinical presentation includes variable ecchymoses,
commonly known as bruising, an enlarging painful mass, soft
fluctuant swelling, a loss of cutaneous sensation, and skin
hypermobility.5 Large, more severe lesions may include the
dermis and epidermis and can manifest as ischemia of the
The Canadian Journal of Medical Sonography | Fall 2011
29
Morel-Lavallee Lesion
Figure 4. T1 coronal image of the left thigh shows an encapsulated
Morel-Lavallee lesion close to the muscle bellies of the tensor fascia
lata and gluteus maximus. Reproduced with permission by Elsevier
from Kalaci et al.4
skin, necrosis, or wound sepsis. Local contusions or other
signs of injuries such as tire marks or friction burns may be
present. Hematomas occur at the site of injury and are usually
unilateral, although cases have been reported of severe
accidents where the lesion is found bilaterally. There is no
finite evidence that Morel-Lavallee lesions appear more
frequently in men or women, but it is believed that women
are more susceptible because of the difference in the
anchorage of their skin to underlying fascia. Hak et al. believe
that women have a higher risk of developing a pseudocyst due
to the pattern of female fat distribution, which is larger and
looser than that in males.6
The Morel-Lavallee extravasation has a slow, progressive
growth and is not always recognized during the initial posttraumatic examination. A study by Hudson et al.3 found that
in one third of patients, the diagnosis of a closed degloving
wound was missed at the initial assessment. If there is any
uncertainty about the diagnosis due to patient body habitus
or a lack of finite characteristics, a fine-needle aspiration of
the area should be performed to confirm the presence of a
hematoma.
Apart from physical examination, the most useful modalities
for diagnosing a post-traumatic soft tissue cyst are magnetic
resonance imaging (MRI) and ultrasonography, although
computed tomography and general radiography can be used
as well. An earlier diagnosis can lead to earlier and more
successful treatment. Prolonged diagnosis can lead to severe
infections, resulting in invasive surgery and a longer recovery
time. Since the identification of this hematoma is often
delayed, radiologists should be familiar with the acute and
chronic presentations. The appearance of a Morel-Lavallee
30
The Canadian Journal of Medical Sonography | Fall 2011
lesion depends on the age of the lesion, as well as the amount
of blood, fat, and lymph tissue within it.
The advantages of using MRI are that the morphology and
margins of the lesion can be accurately depicted. In acute
injuries, the blood clot and debris may be found within an
ovoid cavity of T2 hyper-intense fluid. A more chronic injury
will have increased or intermediate signal intensity on T1weighted images. As the periphery of a hematoma becomes
laden with hemosiderin, a pseudocapsule begins to form and
produces a hypo-intense concentric ring on T1 and T2
images. Mellado et al.7 state that there are three main
appearances of a pseudocyst on MRI. The first is a
homogeneous central hypo-intensity and water-like T2
hyper-intensity relative to skeletal muscle, compatible with a
seroma. The second is a homogeneous central T1 and T2
hyper-intensity with a hypo-intense pseudocapsule (Figure
4). The final is a variable central T1 and T2 hyper-intensity,
depending on the degree of internal granulation tissue,
methemoglobin, hemosiderin, fibrin, and fat necrosis.
Ultrasound is a useful tool in diagnosing Morel-Lavallee
lesions because it can confirm the presence of the suspected
pathology and determine its size, volume, and configuration.
In ultrasound images, fluid collections are characterized with
regard to echogenicity, homogeneity, shape, margins, and
location. Colour and power Doppler are also applied to check
for vascularity of the cyst (Figure 5). In a hematoma, there is
generally no vascular flow, and this is identified on power and
colour Doppler as the absence of colour on the image. For the
most part, Morel-Lavallee lesions present as anechoic due to
their aqueous nature. Debris and fat necrosis can appear
hyperechoic compared with the surrounding fluid and
muscle. The interaction of debris and blood in an acute injury
are displayed as internal echoes and appear heterogeneous on
an ultrasound image. As the hematoma ages, the contents of
the lesion organize to form fluid-debris levels that exhibit a
homogeneous appearance, which is also a result of the
reabsorption of blood and the production of serosanguineous
fluid within the cyst. The overall appearance of a lesion can
vary according to the stage of internal blood product
degradation. If a pseudocapsule develops, the margins are
likely to be smooth as opposed to the irregular contour of an
acute cyst. The Morel-Lavallee lesion has a variety of shapes,
including lobular, flat, and fusiform. Commonly, pseudocysts
are located between the severed subcutaneous tissue and
underlying fascia, although they have also been found within
the subcutaneous fat or muscle. Using ultrasound, Neal et al.8
examined 21 post-traumatic fluid collections. Results found
that the acute lesions had a heterogeneous appearance with
irregular borders, while chronic lesions were homogeneous
with smooth borders. In a study by Kalaci et al.4 an ultrasound
examination of the left lateral thigh revealed a large slightly
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MacN e v in
Figure 5. Transverse ultrasound image displaying a lack of colour in
a Morel-Lavallee effusion, indicating that there is no vascular flow
in the lesion.
Figure 6. Sonogram of the right posterior thigh post-aspiration. The
hematoma had been 10 cm × 20 cm ×3 cm.
hyperechoic mass with distal acoustic enhancement and
hyperechoic papillary extensions from its wall, both of which
are consistent with a complex cystic mass. The descriptions
of the ultrasound characteristics from the above studies all
adhere to those in general guidelines of ultrasound
appearances. In diagnosing a Morel-Lavallee lesion, it must
be recognized that the appearance of said lesions are
extremely various, as proven by the previous studies. The
differential diagnoses of the Morel-Lavallee effusion include
other post-traumatic injuries, such as fat necrosis or
coagulopathy-related hematoma, as well as a hemorrhagic
sarcoma and other soft tissue tumours. Biopsy or surgical
excision is necessary to exclude a hemorrhagic sarcoma due
to the resemblance of these two lesions in imaging
characteristics. Careful examination, as well as obtaining a full
patient history including prior surgeries, diseases, and trauma,
is pertinent to the correct diagnosis.
There is no consensus among authors and researchers on the
best treatment method. The various methods that have been
proposed include compression, aspiration, injection of a
sclerosing agent, percutaneous drainage, prolonged surgical
drainage, and open débridement. Compression is the least
invasive of these procedures and is often used for acute
scenarios of minimal severity. Injection of a sclerosing agent
is best used for chronic cases in which the hematoma has
begun to coagulate. Open débridement is the most invasive
treatment option and is performed in chronic or severe cases
of tissue necrosis where tissue has to be removed as well as the
contents of the lesion. It has been reported that a small, acute
lesion without a pseudocapsule can be completely resolved by
conservative management, such as compression.8 In an
analysis of results, Hudson et al.3 found that conservative
surgical intervention, such as compression, could be
combined with careful clinical evaluation to produce
exceptional results. Matava et al.9 describe the advantages of
percutaneous management as the preservation of the
remaining cutaneous blood supply as well as an accelerated
recovery time due to the small incisions. This method of
percutaneous drainage has proved successful in multiple
cases, an example of which is the biker from the above case
report (Figure 6). An operation of greater extent, such as
débridement, separates the subcutaneous tissues from the
underlying fascia and disrupts the underlying perforating
vessels. Tseng and Tornetta5 as well as Kalaci et al.4 suggest
percutaneous drainage in addition to débridement to prevent
infection and effectively treat the wound. In comparison, Hak
et al.6 recommend thorough débridement of the closed
internal degloving injury, and state that percutaneous
drainage without débridement of necrotic fat should not be
considered because it increases the risk of deep infection. It
can be concluded that the treatment of a Morel-Lavallee
effusion is a controversial matter with contradicting opinions.
Currently, the treatment procedure chosen is at the discretion
of the orthopedic surgeon.
www.csdms.com
Summary
Although the Morel-Lavallee lesion was first described in
1853, research is still ongoing due to its uncommon nature.
It is clear that this pathology is caused by the subcutaneous
tissue being torn away from the underlying fascia as a result
of high-speed trauma accidents. If not identified at the time
of trauma, patients may present months after the initial injury
and healing process with soft tissue swelling or unresolved
contour abnormalities. Imaging modalities such as MRI and
The Canadian Journal of Medical Sonography | Fall 2011
31
Morel-Lavallee Lesion
ultrasonography are the main tools used in diagnosing this
condition. The appearance of a Morel-Lavallee lesion in
imaging can vary depending on the complexity of the cyst’s
contents. There is no preferred treatment method at the
present time as opinions of authors, doctors, and researchers
differ significantly. A Morel-Lavallee lesion should be detected
as early as possible to prevent further infection, as well as longterm consequences, and to ensure effective management.
References
1.
2.
3.
4.
5.
6.
Phillips T, Jeffcote B, Collopy D. Bilateral Morel-Lavallee
lesions after complex pelvic trauma: a case report. J
Trauma 2008;65:708–11.
Borrero C, Maxwell N, Kavanagh E. MRI findings of
prepatellar Morel-Lavallee effusions. Skeletal Radiol
2008;37:451–5.
Hudson D, Knottenbelt J, Krige J. Closed degloving
injuries: results following conservative surgery. Plast
Reconstr Surg 1992;89:853–5.
Kalaci A, Karazincir S, Yanat A. 2007. Long-standing
Morel-Lavallee lesion of the thigh simulating a
neoplasm. Clin Imaging 2007;31:287–91.
Tseng S, Tornetta S. Percutaneous management of
Morel-Lavallee lesions. J Bone Joint Surg 2006;88:92–96.
Hak D, Olson S, Matta J. Diagnosis and management of
7.
8.
9.
closed internal degloving injuries associated with pelvic
and acetabular fractures: the Morel-Lavallee lesion. J
Trauma 1997;42:1046–51.
Mellado J, Perez del Palomar L, Diaz L, et al. Longstanding Morel-Lavallée lesions of the trochanteric
region and proximal thigh: MRI features in five
patients. Am J Radiol 2004;182:1289–94.
Neal C, Jacobson J, Brandon C, et al. Sonography of
Morel-Lavallee lesions. J Ultrasound Med
2008;27:1077–81.
Matava M, Ellis E, Shah N, et al. Morel-Lavallee lesion
in a professional American football player. Am J Orthop
2010;29:144–7.
Additional Resources
Chokshi F, Jose J, Clifford P. Morel-Lavallee lesion. Am
J Orthop 2010;39:252–3.
Puig J, Pelaez I, Banos J, et al. Long-standing MorelLavallee lesion in the proximal thigh: ultrasound and
MR findings with surgical and histopathological
correlation. Australas Radiol 2006;50:594–7.
Reddix R, Carroll E, Webb L. Early diagnosis of a MorelLavallee lesion using three-dimensional computed
tomography reconstructions: a case report. J Trauma
2009;67:57–9.
Alberta Health Services is inviting talented
Diagnostic Medical Sonographers to join our team
AHS values the diversity of the people and communities we serve and is committed to attracting, engaging and developing a diverse and inclusive workforce.
Alberta Health Services provides a full spectrum of ultrasound services. You may choose to work in a cuttingedge teaching centre where leading technology, advanced practice, and research go hand-in hand. Or, you may
choose to work in a smaller facility providing general ultrasound services to patients in a small community.
The staff at Alberta Health Services is appreciated and rewarded with highly competitive salaries. A variety
of incentive programs such as relocation packages, temporary accommodation assistance, and bursaries are
available to make your move as simple as possible.
Alberta Health Services has a variety of full-time, part-time and casual positions available throughout
the province. Whether you are seeking work in a large metropolitan area such as Calgary or prefer
suburban centres such as Red Deer and Medicine Hat, or communities like Lac la Biche, Westaskiwin
and Strathmore, we have an opportunity for you.
Requirements:
•
Active registration with CARDUP
and/or ARDMS
•
Graduate from a two year CARDUP
recognized diagnostic ultrasound training
program or two years of relevant Canadian
sonography experience
Contact: Nicole Rashidian, Recruitment Advisor Tel: 403-943-0225 Email: [email protected]
Need more reasons? Explore our website to learn more about the great opportunities available: www.albertahealthservices.ca
32
The Canadian Journal of Medical Sonography | Fall 2011
www.csdms.com
Announcement
Maintaining the Schedule of Unit Values for the Medical
Imaging Workload Measurement System
Make your recommendation count – and obtain solid data to assist your health
service organization in staffing, planning, budgeting, and performance monitoring
Arlene L. Thiessen, RN, for the Canadian Institute for Health Information
The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit corporation that provides
essential information on Canada’s health system and the health of Canadians. CIHI’s unbiased, credible, and
comparable data and information enables health leaders to make better-informed decisions.
T
his article introduces the medical imaging
workload measurement system (WMS)
continuous quality improvement maintenance
cycle for the Canadian Institute for Health
Information (CIHI) Standards for Management
Information Systems in Canadian Health Service
Organizations (MIS Standards). The MIS
Standards are a set of national accounting
standards used by health service organizations to
collect and report financial and statistical data
from their daily operations. The MIS Standards
were developed to generate better information
and measures of health service organizations’
functional centre activity (Figure 1). Medical
imaging services that are funded by provincial
and territorial ministries of health (except
Quebec and Nunavut) rely upon the MIS
Standards.
Part of the MIS Standards, the WMS is a tool that
measures in standardized units of time the
volume of activity provided by a specific
functional centre, such as ultrasonography or
mammography, etc. It serves two main purposes.
First, it systematically quantifies workload in
specific health care disciplines to assist managers
in staffing, planning, budgeting, and performance
monitoring. Second, it yields uniform data for
external reporting, which permits national and
Figure 1. Graphic representation of the data generated by the MIS Standards. Its
peer group comparisons.
components include accounting principles and applications (white boxes),
A schedule of unit values is a list of defined workload measurement system (WMS; light blue box), and the schedule of init
activities commonly performed in MI functional values (dark blue box).
centres and the unit values associated with each.
Its purpose is to facilitate tracking of the handson time, in minutes, required to perform medical imaging time estimates and reviewed by subject matter experts.
activities. The unit values are derived from time studies or Maintenance of the MI schedule of unit values enhances good
www.csdms.com
The Canadian Journal of Medical Sonography | Fall 2011
33
A nnouncement
data quality through more representative unit values.
During a 2-year project, CIHI redeveloped the 2011 MIS
Standards, with particular focus on the MI WMS, to ensure
it represented the current environment. In total, 30 volunteers
participated, including 11 MI experts who served as Advisory
Working Group members. They practised in varied settings
ranging from large urban tertiary hospitals to small rural
and/or remote hospitals. In all, 40 teleconferences and 4 fullday meetings were conducted.
Some of the key changes made to the 2011 MI schedule of
unit values include updated terminology, obsolete activities
deleted, and new activities created to match scientific
advances. Unit values and examination counts were reviewed
for accuracy. Activities are more granular, allowing each MI
functional centre to customize the workload for a particular
examination based on the specific activities performed at the
organization. The addendum schedule of unit values for
pediatric facilities was reintegrated into the main MI schedule
of unit values. A “TBD” (to be determined) value for certain
examinations in the 2011 MI schedule of unit values signifies
that at the time of publication there were no time studies
available nor subject matter experts within the Diagnostic
Imaging Advisory Working Group for certain activities.
After completing the 2011 maintenance of the schedule of
unit values for the clinical laboratory WMS, CIHI recognized
that the project was resource-intensive for subject-matter
experts in terms of person-hours, time away from their duties,
etc. Therefore, in the future, CIHI will leverage electronic
survey techniques to elicit feedback from a wider base of
subject-matter volunteers.
Starting in 2011, CIHI will conduct a biennial maintenance
project, which will focus solely on improving the schedule of
unit values for MI to keep pace with the ever-changing MI
clinical environment. The 2013 MIS Standards will include
the results of this project. Following this maintenance cycle,
CIHI will evaluate the efficacy of the 2013 MI maintenance
project so that the MIS Standards remain as relevant and
current as possible. CIHI anticipates a 6-month project
involving more than 100 volunteer MI professionals,
approximately 10 expert reviewers, and three teleconferences.
This fall, CIHI will survey MI professionals to obtain
suggested improvements to be made to the schedule of unit
values. MI managers/directors, MI technologists, MI
information systems (HIS/RIS) professionals, and members
from the Diagnostic Imaging Working Group committee
from the 2011 project will be invited to participate in the
survey.
To receive the Medical Imaging survey (for you or for a
colleague), for more information, or for specific MI WMS
questions, please contact CIHI by e-mail at [email protected] .
You can also visit www.cihi.ca > Standards and Data
Submission > Standards > MIS Standards.
American Registry for Diagnostic
Medical Sonography (ARDMS)
®
The Globally Recognized Standard of Excellence in Sonography
Credibility…ARDMS is the premier worldwide credentialing
organization with
with nearly
nearly 70,000
70,000 certified
certified sonography
sonography professionals.
professionals.
organization
Experience…ARDMS only
only accepts
accepts candidates
candidates who
who meet
meet the
the rigorous
rigorous
Experience…ARDMS
requirements for
for education
education and
and clinical
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requirements
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focuses on
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profession by
by setting
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requirements for
for
sonography
continuing medical
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education.
continuing
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34
The Canadian Journal of Medical Sonography | Fall 2011
www.csdms.com
Now Recruiting
Sonographers!
If you are interested in joining
a stable, growing company that
maintains a true dedication to
patient care, we’d like to hear
from you. To find out more about
Sonographer opportunities at CML
HealthCare, visit us online at:
www.cmlhealthcare.com
Discover the Benefits of a
Healthy Career
Total Rewards
CML HealthCare provides comprehensive compensation
and benefit packages.
Commitment to Patient Care
Our team is committed to providing patients with
“Care. Confidence. ComfortTM”.
Flexibility & Mobility
Full time, part time, and casual positions are available to fit
your lifestyle. As Canada’s largest provider of diagnostic
imaging services, CML HealthCare offers a variety of
medical imaging modalities:
MRI, CT, Nuclear Medicine, Ultrasound, X-Ray,
Mammography, Fluoroscopy, and Bone Densitometry.