IOTW: Image Of The WEEK

#USFTW (Ultrasound For The Win)


Septic Arthritis - Dr. Cameron Shoraka

Case: 53yo male p/w atraumatic left ankle pain. Hx of IVDU and previous endocarditis.

Xray left ankle: Soft tissue edema. No fractures.

POCUS left ankle: joint effusion.

Hospital Course: arthrocentesis, MRI + for septic arthritis. OR with intra-op cx + for Staph Aureus. IV Vanco and Cefepime, d/c'd with PICC line and continued IV abx.


Granulomatous Disease - Dr. Henry Gemino

41 y/o M from Chile presents with flank pain and fevers

  • Recently completed outpatient course of antibiotics for pyelonephritis, presumed to be refractory to outpatient therapy

  • GU US- did not demonstrate hydronephrosis or significant renal inflammation, however small hyperechoic areas were noted scattered throughout the parenchyma of the liver and spleen.

  • CT abd/pelvis was read as “innumerable calcifications in the liver, spleen, and mesentery likely a sequelae of prior granulomatous disease”

  • Patient ultimately left AMA


Hydronephrosis - Dr. Charles Brown


Cholangitis - Dr. Miguel Ribe

Case: 81yo male presented by EMS with severe hypotension and AMS. He was endorsing diffuse abdominal pain on exam. Initial assessment with EFAST/ HIMAP was negative, however while scanning RUQ, there was an abnormal GB with the following findings:

- Stone in GB neck, seen as the hyperechoic object with posterior acoustic shadow, which would not move with changes in patient position.

- Thickened GB wall

- Positive sonographic Murphy’s sign.

Teaching point: Hypotension + AMS... don't forget to look for all possible sources of sepsis, including the GB.

Follow-up: Workup revealed elevated liver enzymes, leukocytosis, as well as signs of end organ damage 2/2 shock. Patient was admitted on antibiotics and surgery was consulted for concerns of ascending cholangitis.


The Search for the Gallbladder - Dr. Naomi Newton

Case: 38-year-old male w/ PMH sickle cell disease (admitted for sickle cell crisis and recurrent seizures), with known cholelithiasis.

Biliary POCUS Pearls:

In can be easy to confuse the gallbladder with other walled-off, anechoic structures, such as surrounding blood vessels. Some tips for correctly identifying the gallbladder are as follows:

- Identify for the main lobar fissure, which connects the gallbladder to the portal vein.

- Use color Doppler and Pulse Wave features.

In this case, a walled-off, anechoic structure that looked suspiciously like the gallbladder was first identified in the sagittal view. However, this structure did not contain any gallstones, even though the patient had known cholelithiasis.

Color Doppler was placed over the image; perhaps due to the particular cut of the structure, no flow through the structure was visualized. (Image 3)

However, when the pulse wave Doppler was placed over the structure, blood flow was demonstrated. (Image 2)

In this case, it was not enough to simply use color; both color and pulse wave features were required to ultimately distinguish this surrounding blood vessel from the true gallbladder.

By moving the probe in a more anteromedial direction, the true gallbladder (containing a stone) was identified. The video clips (videos 1&2) and still image (Image 7) clearly demonstrate the main lobar fissure connecting the true gallbladder to the portal vein. The stone is also visualized.

Note: This patient didn't have pericholecystic fluid, common bile duct dilation, or gallbladder wall thickening. (Images 4 & 5)This presentation is consistent with his known cholelithiasis.


Flank Pain - Dr. Torey Alling

  • 23-year-old man presents with 3 days of flank pain

  • +Nausea

  • +Urinary urgency

  • No significant pmh, no family history

POCUS: hyrdo-ureteronephrosis.

Patient avoided radiation, extra costs, and increased length of stay.

You can avoid radiation with POCUS with: appropriate history, no UTI, no fever, no AKI, <age 55, and if pain is well-controlled.


Mitral Regurgitation - Dr. Josh Goldstein

  • 62-year-old woman presents w/ 3 mo of gradually worsening SOB

  • Worse with exertion

  • No chest pain, fever, or history of cardiac/pulmonary disease

  • Vitals: HR 98 RR 16 BP 135/70 Temp 37.0 O2 96%

  • US: enlarged LA and MV regurgitation on color flow.

  • CT Surgery consulted and patient admitted for mitral valve replacement.


Gallbladder Stones and Polyps - Dr. Daniel Cohen

26 yo M with a PMHx of asymptomatic cholelithiasis presents with an unrelated complaint and was amenable to an educational ultrasound of his right upper quadrant.

-Denies skin changes, abdominal pain, nausea, vomiting, discomfort with PO intake

-Exam without abdominal tenderness, peritoneal signs, or Murphy’s sign

-dependent stone at the neck as well as incidentally noted polyps along the walls. The stone can be differentiated by the presence of posterior shadowing.

-Prevalence of gallbladder polyps is 4-7%, more common in men, 2/3 of polyps are diagnosed incidentally

-Polyps may decrease the likelihood of stone formation by blocking formation at the walls, making polyps and stones a more rare finding

-Patients should be worked up with a formal RUQ U/S and possibly CT/MRI imaging as indicated

-<6 mm in size do not need to be followed.

6-9 mm in size get serial U/S for growth monitoring.

> 10 mm are managed surgically because of increased risk of cancer.

Andrén-Sandberg, Åke. "Diagnosis and management of gallbladder polyps." North American journal of medical sciences 4.5 (2012): 203.​


A-FIB and Dyspnea on Exertion - Dr. Brian Knight


58yo M with PMH of A-fib comes in with worsening DOE and bilateral lower extremity edema. Some mild abdominal discomfort as well on physical exam.

LUQ clip:

-jellyfish sign (lung tip floating in pleural effusion) at start of the clip off to the left

-spine sign

-free fluid between spleen and diaphragm (pointed out with arrows in LUQ frame free fluid PDF)

RUQ clip:

-free fluid Morrison’s pouch

-spine sign


Back Pain after a fall. - Dr. Alain Artiles

-60 y/o M presents with back pain after a fall.

-PMH of HTN, DM, and alcoholic cirrhosis.

-Negative ROS

-Negative CXR & negative XR lumbosacral

-Note the cystic structure atop the superior pole of the right kidney. There appears to be a hyperechoic wall surrounding hypoechoic contents (likely fluid), also note the septations. No mass effect of the kidney or surrounding structures is noted.

-CT abd+pelvis (2017): Large mixed density mass (6.2 x 7.8 x 6.9 cm) in the right suprarenal location with central and peripheral calcification. Mass is favored to represent an adrenal mass or retroperitoneal mass. Differential considerations includes adrenal cortical carcinoma, pheochromocytoma, adrenal metastasis, and retroperitoneal sarcoma with other etiologies not excluded.

-No change in size was noted from comparison to CT scan in 2017.

-Patient was already aware of suprarenal mass, he was advised to follow-up outpatient for continued investigation of mass. Patient was discharged with diagnosis of rib contusion.





63yo M with PMHx of HTN, DM, medication non-adherence presents with 1.5 weeks of worsening right foot pain and expanding wound. * Patient provided written consent for use of photograph.

WBC 12,1000, Gluc 518, CRP 22


Nephrolithiasis - Struvite Stone. Dr Carlos Garcia-Rodriguez

•67 yo M w/ hx of HTN, DM, EtOH abuse, Renal Colic 2/2 nephrolithiasis who presents for hematuria, left flank pain, dysuria, and increased hesitancy x 1 day.

•Pain started the night prior to ED presentation, localized to the left flank radiating to the left groin. Pain is constant, but denies F/NS/C, no N/V.

•HR:106, BP: 197/104, RR: 18, T:37, SpO2, 95% ORA

POCUS: US LT Kidney Noted large hyperechoic structure involving inferior calyx into the renal pelvis. Notice the hydronephrosis as well towards the end of the video clip

CT Abd/Pelvis w/o contrast: Moderate left hydronephrosis with perinephric fat stranding secondary to a large obstructing staghorn calculus involving the inferior calyx and extending into the renal pelvis.

Hospital Course: Urology Recommended IR intervention for nephrostomy catheters. Pt s/p IR Placement of B/L 8 Fr nephrostomy catheters. Pt started on Zosyn.


  • Struvite stones made out of Magnesium-ammonia-phosphate

  • More common in women

  • Struvite occurs 10-15% and is made out of urea splitting organisms (Proteus, Staph, Klebsiella)

  • Surgical management requires complete removal via endoscopic techniques such as percutaneous nephrolithotomy.

  • High risk pts require suppressive antibiotics to prevent recurrent infections

  • Metabolic evaluation is recommended for individuals who develop these stones


IVC Thrombus - Dr. Phillip Plevek

•26 yo F presents from pre-transplant (kidney) evaluation for abnormal echocardiogram

•Negative ROS, femoral dialysis catheter in place

•Hx of ESRD (FSGS), HTN, Anemia, Pancreatitis

Note the hyperechoic distal tip of the dialysis catheter in the IVC with a mobile, hypoechoic thrombus attached

•No signs/symptom of PE on arrival

•Started on Heparin, tunneled cath exchange after 3 days of A/C completed.

•CTA showed small asymptomatic subsegmental PE, continued on heparin drip


Flank Pain - Dr. Anna Culhane

45 year old male with a history of renal colic

•4 hours of 10/10 RLQ excruciating pain that radiates to R flank

•Associated with nausea/vomiting and blood clots in urine

Hydronephrosis + Shadowing on POCUS

•Patient diagnosed with obstructing staghorn calculi and he was admitted for nephrostomy tube placement

•Staghorn calculi can be common in those with recurrent UREASE-PRODUCING bacteria, neurogenic bladder, reflux or certain HIV meds


Finger Pain - Dr. Max Rippe

53 year-old female presents with right 2nd distal phalangeal pain, redness, swelling x 2 weeks.

•Bactrim without improvement

•Slow blackening of cuticle 6 months ago with loss of nail

•New nail grew over

Notice the ovioid lesion within the phalanx.

XR finger: lytic lesion in distal phalanx

MRI finger: T2 hyperintense lesion centered in the index finger distal phalanx. Differential includes abscess or inclusion cyst. No evidence of peritumoral osteomyelitis.

Taken to OR for resection of intraosseous mass

Surgical Path: Intraosseous epidermal inclusion cyst.

Original US finger: “No drainable collection visualized. No obvious mass or vascular abnormality.” Did not use hand immersion – missed mass!!!

Using a water bath can reduce discomfort as no skin contact is needed. Additionally, the technique can improve imaging as the “step-off” allows for the object of interest to fall into the Focal Zone. This increases the likelihood of identifying objects just below the skin’s surface



  • 2yo healthy female with inconsolable crying, abdominal pain.

  • Afebrile, diffuse abd ttp, worse in the RLQ

Intussusception: Target Sign, Pseudokidney Sign, Crescent in a Donut Sign

•Over 75% ileo-colic likely 2/2 prominent lymphoid tissue in the area allowing for a lead point

•Enema is diagnostic and therapeutic


"Squish" Sign - Dr. Melissa Velasquez

  • •41 yo M with history of IVDU presenting with diffuse buttocks pain with subjective fevers

  • Denies history or trauma to buttocks or rectal bleeding

  • Afebrile, tachycardic to 105, other vitals wnl

  • Physical exam notable for extensive L perirectal fluctuance extending to base of penis, tender to palpation with overlying erythema

Is there a drainable fluid collection? The "mass" is ISOECHOIC..... try COMPRESSION:

  • If you see heteroechoic material, you can differentiate abscess vs soft tissue mass with squish sign!

  • When you have an isoechoic abscess, try compressing it and you’ll see movement of abscess debris

  • Some other tips are the irregular, hyperechoic borders

  • This patient was obvious given clinical picture but it can be useful in a well-appearing patient with minimal overlying cellulitis or tenderness on exam

CT showed rim-enhancing fluid collection measuring approximately 9.2 x 3.5 x 5.7 cm, concerning for abscess.


Sternal Fracture

  • 31 y/o male with no pmh p/w a cc of chest pain after an MVC. Chest struck the steering wheel.

  • All VS WNL. Sternal tenderness to palpation.

Sternal Fracture on CT, CXR, and Ultrasound.


Left Flank Pain/Renal Colic - Dr. Oswald Perkins

  • 52 YO M with PMH of HTN well controlled and HLD presents to ED with small amount of hematuria as well as L groin pain that comes and goes.

  • Note the mild left hydronephrosis, and the twinkle artifact at the left UVJ. Pain was well-controlled, normal creatinine, and no UTI. The patient received a diagnosis of renal colic and avoided CT imaging!


Clavicle Fracture - Dr. Sarah Jabre

Case: 37 year old male previously healthy brought in by EMS s/p MVA in which he was ejected at a low speed from his motorcycle. Patient complaining of left sided chest pain and left arm pain upon arrival to the ED with no associated left arm/hand weakness or numbness.

PE was positive for mid clavicle deformity with tenderness upon palpation. Normal motor/sensory function of left UE.

Bedside US highlighted a cortical irregularity with displacement along the mid clavicle.

Findings were confirmed by an Xray that showed a comminuted midshaft left clavicle fracture with 2.7 cm displacement.

Is US enough to diagnose a clavicle fracture in the ED?

Sensitivity 89 to 95% - Specificity 89.5-98.25 % (3 studies using XRay as control - 2 studies in pediatrics)

Treatment is with a sling or figure-of-eight brace for 2 to 3 weeks.

ONLY the rare clavicle fracture with neurovascular or mediastinal injury by severely displaced fractures needs orthopedics consultation!


Complex pleural effusion and pneumonia - Dr. Robert Barry

  • 63 y/o M W/PMH of HCV, cirrhosis s/p TIPS, substance abuse presenting with R sided chest pain and SOB

  • HR 84, afebrile, RR 18, BP 120/64

  • Diminished lung sounds at R base, increased WOB, pupils icteric

  • US more detailed than CXR: fibrinous pleural effusion, air bronchograms, and hepatization


"Not so FAST" - Dr. Bialeck

  • 24 YO M MVC with normal vitals, no ab ttp, + Humerus FX

  • First "quick glance" of the FAST ....

  • Free Fluid or no free fluid?

  • Where do we look for free fluid in the RUQ?

  • Is there a “distracting” injury?

  • FAST doesn’t mean go FAST… Slow down, especially in the bladder view where subtle free fluid can be missed.

  • The FIRST place where fluid may accumulate in the RUQ is the inferior pole of the right kidney/liver tip.

  • Isolated view of Morrison’s pouch may not be sufficient!

  • “Distracting Injury” can be subjective.


ATRIAL MASS - Dr. Ryan Lynch

  • 59 yo male in minor MCC presents with chest pain and shortness of breath

  • XR shows 8 fractured ribs

  • PMH of BPD, pre-diabetes, HLD, polysubstance abuse

  • Difficult to distinguish mass vs thrombus on ultrasound by echogenicity

  • Most helpful distinguishing feature is presence or absence of stalk connecting abnormality to atrial wall as well as mobility

  • Thrombus more likely to have accompanying acute dyspnea or respiratory symptoms

  • Of primary cardiac tumors, atrial myxoma is most common and more often found on left

  • Secondary cardiac masses are 100 times more likely than primary and are usually found in right side of heart

  • Most require further imaging such as TEE, cardiac CT or MRI

  • Cardiac tumors can present with findings such as CHF 2/2 obstruction, PE, or even mimic tricuspid stenosis if found in RA like this patient



  • 31 y/o male with uncontrolled DM p/w 5 days of worsening “abscess” of right thigh

  • Afebrile, appears uncomfortable, but does not appear toxic. BS >500.

  • No crepitus, although exam limited by severe tenderness

***Written consent obtained by patient to obtain and use image for educational purposes.

Right thigh, distant from bullae.

Right thigh, near bullae.

NSTI Findings (STAFF):

  • Subcutaneous Thickening

  • Air

  • Fascial Fluid (>4mm deep along deep fascial layer)

  • Sensitivity 88.2%, Specificity 93.3%, PPV 83.3%, NPV 95.4% for Necrotizing Fasciitis

  • Air in tissue present in advanced cases, and may obscure visualization of deeper structures

Acute Care Surgery was immediately consulted and CT obtained after their evaluation:

•Patient taken emergently to OR for debridement of necrotizing fasciitis, and did well following surgery.


CARDIAC TAMPONADE - US Save by Dr. Sam Cochran

50s yo woman presents with generalized fatigue, tachycardia, and shortness of breath.

Note the circumferential effusion with diastolic collapse of the RV. Cardiology was consulted and the patient had an emergent pericardiocentesis. Great Save!


AAA - US Save by Dr. Dumi Presuma

An elderly male presents with back pain thought to be 2/2 musculoskeletal strain.

CTA confirmed AAA. Vascular surgery consulted, operative repair performed and patient did well! Great Save!



  • 52 yo M with DM, HTN presents with abdominal pain for one day.

  • The pain is constant, fluctuating in intensity, sharp, diffuse, radiating to his chest. Denies chest pain, N/V

  • HR: 75, BP: 139/77, RR: 18, T: 36.7 C, SpO2: 96% ORA

  • EKG & CXR: normal

Dx: Aortic Dissection extending from below left subclavian to right external iliac.

  • Labetalol and Nicardipine drip initiated.

  • Admitted to Vascular Surgery à TEVAR for thoracic descending aortic aneurysm.


  • Emergency US is 92-100% sensitive in diagnosing a AAA but it is can also aid in the diagnosis of other aortic pathology such as an aortic dissection.

  • Using the parasternal long axis view is important in assessing RV strain, global ventricular function, and pericardial effusion. It also allows you to identify aortic .pathology in both the ascending aortic root and the descending thoracic aorta.

  • Make sure your depth is sufficient to see this important structure deep to the heart!


HIP FRACTURE - Dr. Dennis D'Urso

•65 M patient with pmh dementia brought in from ALF after being found on the ground

•No complaints, states he accidentally rolled out of bed; no h/o falls or mobility issues

•No bruising or obvious deformities, able to reposition freely in bed, noted to favor right leg in externally rotated position



•31 y.o. male bicyclist hit by car presents to ED with left shoulder pain and limited ROM

•Denies head trauma, LOC, or neck pain

•VS WNL, AAOx4, GCS 15

•Diffuse tenderness around L shoulder; ROM limited by pain (active > passive); distal pulses, sensation, motor intact. No obvious deformities, but PE limited by body habitus. Skin exam unrevealing (no ecchymosis, no swelling)

Preliminary report: AP (internal and external rotation) and Y view X-rays negative for fracture or dislocation.

POCUS: C6-2 curvilinear probe placed on posterior shoulder at level of humeral head. LEFT and RIGHT shoulders.

Left humeral head (HH) displaced posteriorly in relation to spine of scapula (SS) = diagnosis of posterior shoulder dislocation


•Dislocated L shoulder reduced with moderate sedation using traction-counter traction

•Patient’s pain and mobility improved

•Discharged home with sling, pain medication, and orthopedics f/u

•Final report by attending radiologist = posterior shoulder dislocation (missed by resident)



56M p/w crampy, intermittently sharp RLQ and LLQ abd pain x 3 days.

•Pain well controlled with morphine and IVF

•No CT findings warranting surgical intervention

•Remained non-toxic appearing, d/c home with po abx