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The carpal tunnel is an osteofibrous canal situated in the volar wrist. The boundaries are the carpal bones and the flexor retinaculum. In addition to the medial nerve, the carpal tunnel contains nine tendons: the flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus. Ultrasound (US) study of the carpal tunnel generally involves short-axis imaging of the tendons, and in the presence of disease, long-axis imaging and dynamic maneuvers are added. There are numerous reports of anatomical variants of the wrist involving vessels, nerves, tendons and muscles, and they can all be studied by US. Some are particularly relevant from a clinical point of view and will therefore be accurately described. The anatomy is complex, and the US operator should therefore be thoroughly familiar with the normal anatomy as well as the anatomical variants that may have a role in the pathogenesis of carpal tunnel syndrome or influence treatment.

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The male breast has been insufficiently explored in the medical literature, particularly that dealing with ultrasonography, although this topic is almost as vast and varied as that of the female breast. The purpose of this article is to provide a schematic review of the most frequent breast lesions encountered in males and their sonographic appearances. After a brief introduction on the anatomy of the male breast, the authors review the non-neoplastic (gynecomastia, pseudogynecomastia, cysts, inflammatory diseases, and Mondor disease) and neoplastic (benign and malignant) lesions encountered in this organ.

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A thorough knowledge of the anatomy of the shoulder is essential for the assessment of its condition. The purpose of this article is to provide a useful tool for the ultrasound (US) study of this joint. The shoulder girdle and upper arm are made up of a number of muscles and tendons: rotator cuff (supraspinatus, infraspinatus, teres minor and subscapularis), humeral biceps, deltoid and pectoral muscles, which can all be evaluated at US examination. Various and complex capsular ligamentous structures contribute to the stability of the shoulder, but only a few can be adequately evaluated by US and will therefore receive particular attention. Numerous serous bursae are situated among muscles, skin, subcutaneous tissues, joint capsule structures and bones to prevent friction and they can be evaluated by US only in the presence of pathologies. Subacromial-subdeltoid and subcoracoid bursa are most frequently involved and will therefore be described in detail. There are furthermore nerves and vessels providing the various components of the shoulder with innervation and vascularization, and they can also be studied by US. The shoulder girdle (humerus, scapula, clavicle and sternal manubrium) is situated in the deep layers; only the cortex of the bone can be seen at US as a continuous hyperechoic line. For a better understanding of the location and relationship between the structures which can be studied by US, magnetic resonance imaging (MRI) can be carried out as this method provides a wider and more complete view of the structures.

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Pilomatricomas (also known as calcifying epitheliomas of Malherbe) are benign subcutaneous tumors that arise from the cutaneous adnexa and usually affect young subjects. They typically present as solitary asymptomatic nodules located in most cases on the face or neck. On ultrasonography, pilomatricomas appear as hypoechoic lesions with inhomogeneous echo structures, well-defined margins, and posterior shadowing. Color Doppler generally reveals a single artery that penetrates the lesion and gives rise to multiple intralesional branches. Diagnosis is based on clinical and histological findings. The authors present a typical case of pilomatricoma diagnosed on the basis of clinical and sonographic findings that were subsequently confirmed by histology.

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PURPOSE: Splenic metastases from lesions in the genital system are an uncommon finding, both at staging and at follow-up. Most metastases are not an isolated finding but are quite frequently associated with metastases to lymph node or parenchymal sites. The aim of this paper is to describe the patterns of splenic metastasis at US and CT, the diagnostic imaging techniques most often employed in primary evaluation and follow-up of gynaecologic cancer. We consider both the issues of differential diagnosis and clinical decision making. MATERIALS AND METHODS: From January, 1996, to May, 2001, we retrospectively reviewed the CT and US findings of 16 (2.2%) patients with splenic metastases out of 724 patients examined for malignant gynaecologic lesions. US was performed on 479 patients with standard equipment, applying colour and power-Doppler. CT was performed with helical scan, at baseline and after the i.v. administration of a nonionic iodinated contrast agent (120-140 mL at 300-350 mgI/mL concentration, 2 mL/s flow, 70 s administration delay). We used pitch 1.2 with 5-7 mm collimation. We considered metastases lesions that appeared as roundish or irregular, avascular parenchymal nodules at US, and lesions which were hypodense both at baseline and after i.v. administration of iodinated contrast agent at CT. At baseline examination of serous ovarian cancer, metastatic calcifications due to the presence of psammomatous bodies were considered. The presence or absence of splenic metastasis was assessed for all patients by pathology of the surgical specimen, or based on the clinical evolution of the disease. RESULTS: Epithelial ovarian cancer was the most frequent tumour causing splenic metastases (14 cases), while the other two cases were due to advanced endometrial adenocarcinoma and squamous cell vaginal carcinoma. Splenic metastases were detected most frequently during the follow-up and were associated with other sites of recurrence. In two cases US gave false-positive results (multiple micronodular lesions, missed at CT). Negative follow-up at 12 months confirmed absence of recurrence. CT provided only one false-negative result (clinical and US-CT evidence of recurrent disease two months later). We recorded the diagnostic accuracy (99.9% vs 99.9%), sensitivity (100% vs 93.6%), specificity (99.9% vs 100%), positive (87.5% vs 100%) and negative (100% vs 99.9%) predictive value, for US and CT, respectively. CONCLUSIONS: Splenic metastases from female genital system cancers are an uncommon finding. These lesions must be considered with other recurrences, especially in follow-up patients. US and CT provided high accuracy and both can be used for lesion assessment. The micronodular splenic pattern may cause false-positive findings at US.

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We investigated the role of Power Doppler US in the diagnosis and follow-up of cholecystitis. We reviewed the examinations of 21 surgical patients aged 27-48 years with US findings of cholecystitis. We performed B-mode and then Power Doppler US. Wall thickness and US structure, the presence/absence of stones, and US Murphy's sign were assessed at B-mode US, whereas only the presence/absence of wall vascularization was studied with Power Doppler. B-mode and Power Doppler changes post treatment were also investigated. Ultrasound showed wall thickening in all patients. In addition, positive Murphy's sign and/or gallbladder stones were seen in 6 patients each at B-mode US and wall vascularization in 7 patients with Power Doppler. Acute cholecystitis was diagnosed in these patients. The other 14 patients presenting wall thickening but no vascularization and negative US Murphy's sign were diagnosed as having chronic cholecystitis; 10 of them had gallbladder stones. Two of seven acute cholecystitis patients were operated on in the acute stage for the onset of complications and histologic findings confirmed the US diagnosis. As for the remaining patients, histology diagnosed chronic cholecystitis in 17, whereas wall thickening was not inflammatory in 2 cases. All the cases with early wall vascularization were eventually diagnosed as cholecystitis. Power Doppler US permits confirmation of the diagnosis of acute cholecystitis and distinguishing of chronic disease, which helps in planning of surgery.

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INTRODUCTION: The role of ultrasound (US) in the postoperative assessment of tendon reconstruction is not clearly defined and there is no systematic arrangement of US patterns. MATERIAL AND METHODS: We examined 34 patients submitted to surgery or conservative treatment for total/partial tear or musculotendinous detachment of patellar or Achilles tendon in the last 5 years. All patients underwent physical and US examinations. RESULTS: The surgical tendon exhibited the same US patterns in 23/28 patients: it was markedly enlarged (three-/fourfold the normal diameter) and more rounded, with inhomogeneous and hypoechoic appearance not only at the tear/surgical site but also above and below it, for some cm. Small hyperechoic images, mainly dots, were seen in 19 cases, which were referrable to small calcifications and stitches. More and larger calcifications were found in 8 patients, where they were associated with anechoic degeneration areas. Color Doppler US showed moderate or strong hypervascularization around the tear in the first months postinjury. US patterns did not correlate with physical findings, but color Doppler patterns did. In 6 cases of musculotendinous detachment submitted to conservative treatment, US showed enlargement and hypoechogenicity in the injury site only, with no involvement of the remaining tendon. US was also used to time and guide drainage of perilesional hematomas, which were often quite large. CONCLUSIONS: US is the method of choice in the postoperative follow-up of tendon tears and musculotendinous detachments because it shows abnormal signs which are missed at clinics and provides additional information needed for treatment planning.

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INTRODUCTION: Rationalizing preoperative chest radiography remains a problem in our Country. Therefore, we tried to use preoperative chest films rationally in obstetrics and gynecology to assess their impact on anesthesia planning and patient management and their use in early postoperative complications. MATERIAL AND METHODS: We examined two groups of patients: group A consisted of 570 women (mean age: 31 years) scheduled to be submitted to cesarean section but with no preoperative chest radiography; group B consisted of 471 patients (homogeneous in age to group A patients) submitted to nononcologic gynecologic surgery and with a single-projection preoperative chest radiograph. Anesthesiologic assessment, preoperative biochemical tests and EKG were performed in all patients. All patients underwent abdominal surgery under general anesthesia. The first 24 postoperative hours were monitored for possible anesthesia-related complications. The anesthesiologist need of chest radiography based on clinical findings was investigated in group A patients, as well as the importance of chest film findings in possible anesthesia-related complications. RESULTS: Group A and group B were homogeneous by mean patient age and anesthesia duration; clinical findings never suggested the need of chest radiography in group A patients. Three cardiorespiratory complications occurred (two respiratory arrests in group A and a gas embolism in group B), but the (un)availability of chest film findings made no difference in treatment. DISCUSSION: The availability of the preoperative chest radiographs of a group of healthy women of 31 years mean age does not make any difference in anesthesia planning and type. In our series, the most severe cardiorespiratory complications were homogeneous in the two groups, which confirms their random character, and the (un)availability of preoperative chest film findings made no real difference, even though the lack of radiographic evidence made patient management more demanding for anesthesiologists.

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The present study was aimed at evaluating the information obtained from evoked motor and sensitive potentials in a population of non-insulin-dependent diabetics compared to information yielded by electroneurographic study. Besides, we wanted to check any possible correlation between metabolic control and changes of evoked potentials. Electroneurographic study of 20 patients revealed signs of peripheral nervous impairment in 11 of these while results were normal in the remaining 9. Analysis of findings resulting from testing of evoked potentials showed a statistically significant increase of these parameters both in the group of patients with neuropathy and in the controls. Since these methods explore longer stretches of the nervous pathways, they are apt to identify lesions located in areas not accessible to common diagnostic methods. Our data did not show a correlation between metabolic control, as assessed by fructosamine assay, and latency of evoked motor and sensitive potentials, thus indicating that other factors, such as environmental and genetic ones, are apt to influence the onset of diabetic neuropathy.

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