VOTW: HAND me the probe and let me FLEX my POCUS skills!

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HPI: 44 year old male with no PMH presenting to the ED for worsening left 3rd finger pain and swelling after sustaining trauma and laceration to affected area 9 days ago. The team's differential included finger cellulitis, abscess, flexor tenosynovitis, and underlying fracture.

The patient’s hand was placed in a water bath and the following images were obtained using the linear probe:

POCUS evaluation of flexor tenosynovitis

  1. Use a water barrier between probe and fingers to improve image quality(ex: plastic basin, emesis bag, glove filled with water, bag of NS/LR).

  2. Use the linear probe on the flexor side of the fingers.

  3. Evaluate the flexor tendon which overlies the bone. Look for fluid (anechoic) within the flexor tendon sheath surrounding the flexor tendon. Remember, tendons are anisotropic which means they can appear hyperechoic or hypoechoic depending on the angle of your probe. Hypoechoic areas can be confused for edema so it is important to fan through the entire tendon. If the area of concern remains consistently hypoechoic, that is more concerning for fluid/edema.

  4. The tendon may also appear thicker compared to fingers. If you apply color doppler, you may see surrounding hyperemia.

  5. You can scan an unaffected finger also for real time comparison on what “normal” should look like.

Case conclusion: After this bedside POCUS, orthopedics team was consulted for concern for flexor tenosynovitis!

Learn more about POCUS findings for flexor tenosynovitis here:

  1. https://coreultrasound.com/fts/

  2. https://www.ultrasoundgel.org/posts/q08ayJgg3rmHtiQgs9n82w

"Abscessed" with Bowel POCUS: Diverticulitis

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HPI: 42 yo male with no PMH presenting for abdominal pain x 2 days. His physical exam was significant for LLQ tenderness with guarding and rebound.

POCUS showed (see video):

We initially thought the outpouching connected to the abscess was a diverticulum but on further review, it’s more likely to be a loop of bowel given its size.

What a diverticulum should look like:


CT scan for reference:


Diagnosing Diverticulitis on POCUS

  • Use curvilinear vs linear probe

  • Start at maximal point of pain > lawnmower technique

  • #1: Find diverticula

    • Looks like outpouching attached to loop of bowel

  • Secondary findings:

    • Bowel wall diameter >5 mm

    • Prominent, fluid-filled bowel loops

    • Pericolic fluid collections

    • Increased pericolic fat (hyperechoic fat anterior to diverticula)

    • Intraabdominal abscesses

Case conclusion: CTAP showed perforated diverticulitis with multiple intraabdominal abscess. Patient was taken for IR drainage with feculent/purulent drainage noted. Patient is still doing well on surgical service.

References

  1. https://coreultrasound.com/diverticulitis/

  2. https://www.ultrasoundgel.org/posts/SFPsfN9yJ-9uSp640QlWtg

  3. https://www.ultrasoundcases.info/diverticulosis---diverticulitis-531/

VOTW: Small Bowel Obstruction

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HPI: 60 yo male with PMH of cerebral palsy, hx of SBO s/p resection and PEG tube presented to ED for vomiting. 

POCUS showed:

Note the to and fro peristalsis. Usually bowel is not visualized this well on POCUS due to air artifact. This, in itself, is a sign of surrounding edema and fluid filled structures.

Note that this is small bowel because of the “keyboard” sign representing plicae circulares (vs haustra seen in large bowel)

SBO POCUS findings:

  1. 3 dilated small bowel loops >2.5 cm

  2. To and fro peristalsis

  3. Bowel wall edema >3 mm

  4. Free fluid (previously known as “tanga sign”)


Case conclusion: Patient was admitted to surgical service for management of SBO!


Happy Scanning!

  • The US Team