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+fig_num,image_path,image_caption,golden_corpus,positive_corpus
+Figure 11-1,ultrasound/images/Figure 11-1.jpg,Figure 11-1: Locations that need to be examined during the FAST and eFAST exams.,"The FAST exam evaluates the right upper quadrant, the left upper quadrant, and the pelvis, as shown in Figure 11-1.[5] Most famous because of the more defined areas are Morrison’s pouch (in the right upper quadrant, highlighted by the contrasting bright, hyperechoic Gerota’s fascia) and the pouch of Douglas (in the low midline of the pelvis between the hyperechoic borders of the bladder in males or vagina in females superiorly and the rectum inferiorly). The splenic-renal recess in the left upper quadrants and the paracolic gutters in both the right and left lower quadrants are important to access but less easy to navigate.","{'ba40d9af-b271-432e-8e15-74c42cb63074': 'As early as the 1990s, there was discussion in the literature regarding the usefulness of ultrasound in the rapid assessment of blunt trauma.[3] The natural advantage of ultrasound over pure clinical intervention is the accuracy of visualization, sensitivity (49–99% versus 27–45%), and specificity (95–100%). The advantage of ultrasound over CT scanning is the rapidity of the exam and the fact that the physician may remain at the bedside to make critical decisions regarding the potential rapidly changing condition of the patient. In a patient who has received blunt trauma (often from a motor vehicle accident) or penetrating trauma (such as a gunshot wound), the presence of free blood or free air in the abdomen may be seen within a few minutes by an experienced clinician.[4]', 'ea3f77ee-61c4-4b93-bdc6-68136f16cb9e': 'The original basis of trauma ultrasound was that the blood that escaped the vascular system due to trauma (e.g., bleeding inside the abdomen) would be seen as an abnormal hypoechoic entity in the abdomen. This concept is greatly aided by the fact that there are anatomic “potential spaces” where fluid, mostly extravascular blood, collects. Potential spaces had been known for centuries as locations where abnormal fluid collections could be reliably found and removed. It is with the more sophisticated radiology modalities that the fluid can be located before surgery and used diagnostically to help determine if surgery is necessary. Ultrasound imaging quickly and reliably indicates emergent surgery to stop the bleeding from a liver laceration, a splenic laceration, an ectopic pregnancy rupture, a bladder rupture, an injury to a major blood vessel, or less frequent injuries to other organs.', '8399d2c2-db05-43e5-b65c-9b555284b7d7': 'The FAST exam evaluates the right upper quadrant, the left upper quadrant, and the pelvis, as shown in Figure 11-1.[5] Most famous because of the more defined areas are Morrison’s pouch (in the right upper quadrant, highlighted by the contrasting bright, hyperechoic Gerota’s fascia) and the pouch of Douglas (in the low midline of the pelvis between the hyperechoic borders of the bladder in males or vagina in females superiorly and the rectum inferiorly). The splenic-renal recess in the left upper quadrants and the paracolic gutters in both the right and left lower quadrants are important to access but less easy to navigate.', '60158f42-1320-4af2-967f-a191fc3c3889': 'The rapid ultrasound exam for trauma has extended to areas above the diaphragm as ultrasound has progressed. The eFAST (the extended FAST exam) also evaluates the lungs and heart[6] in addition to the abdomen, as shown in Figure 11-1. The probe is pointed superiorly from the xiphoid area to gain views of the heart and lungs. Again, the hypoechoic reflection of free, abnormal fluid is used as an indication of emergent surgery.'}"
+Figure 11-1,ultrasound/images/Figure 11-1.jpg,Figure 11-1: Locations that need to be examined during the FAST and eFAST exams.,"The FAST exam evaluates the right upper quadrant, the left upper quadrant, and the pelvis, as shown in Figure 11-1.[5] Most famous because of the more defined areas are Morrison’s pouch (in the right upper quadrant, highlighted by the contrasting bright, hyperechoic Gerota’s fascia) and the pouch of Douglas (in the low midline of the pelvis between the hyperechoic borders of the bladder in males or vagina in females superiorly and the rectum inferiorly). The splenic-renal recess in the left upper quadrants and the paracolic gutters in both the right and left lower quadrants are important to access but less easy to navigate.","{'ba40d9af-b271-432e-8e15-74c42cb63074': 'As early as the 1990s, there was discussion in the literature regarding the usefulness of ultrasound in the rapid assessment of blunt trauma.[3] The natural advantage of ultrasound over pure clinical intervention is the accuracy of visualization, sensitivity (49–99% versus 27–45%), and specificity (95–100%). The advantage of ultrasound over CT scanning is the rapidity of the exam and the fact that the physician may remain at the bedside to make critical decisions regarding the potential rapidly changing condition of the patient. In a patient who has received blunt trauma (often from a motor vehicle accident) or penetrating trauma (such as a gunshot wound), the presence of free blood or free air in the abdomen may be seen within a few minutes by an experienced clinician.[4]', 'ea3f77ee-61c4-4b93-bdc6-68136f16cb9e': 'The original basis of trauma ultrasound was that the blood that escaped the vascular system due to trauma (e.g., bleeding inside the abdomen) would be seen as an abnormal hypoechoic entity in the abdomen. This concept is greatly aided by the fact that there are anatomic “potential spaces” where fluid, mostly extravascular blood, collects. Potential spaces had been known for centuries as locations where abnormal fluid collections could be reliably found and removed. It is with the more sophisticated radiology modalities that the fluid can be located before surgery and used diagnostically to help determine if surgery is necessary. Ultrasound imaging quickly and reliably indicates emergent surgery to stop the bleeding from a liver laceration, a splenic laceration, an ectopic pregnancy rupture, a bladder rupture, an injury to a major blood vessel, or less frequent injuries to other organs.', '8399d2c2-db05-43e5-b65c-9b555284b7d7': 'The FAST exam evaluates the right upper quadrant, the left upper quadrant, and the pelvis, as shown in Figure 11-1.[5] Most famous because of the more defined areas are Morrison’s pouch (in the right upper quadrant, highlighted by the contrasting bright, hyperechoic Gerota’s fascia) and the pouch of Douglas (in the low midline of the pelvis between the hyperechoic borders of the bladder in males or vagina in females superiorly and the rectum inferiorly). The splenic-renal recess in the left upper quadrants and the paracolic gutters in both the right and left lower quadrants are important to access but less easy to navigate.', '60158f42-1320-4af2-967f-a191fc3c3889': 'The rapid ultrasound exam for trauma has extended to areas above the diaphragm as ultrasound has progressed. The eFAST (the extended FAST exam) also evaluates the lungs and heart[6] in addition to the abdomen, as shown in Figure 11-1. The probe is pointed superiorly from the xiphoid area to gain views of the heart and lungs. Again, the hypoechoic reflection of free, abnormal fluid is used as an indication of emergent surgery.'}"
+Figure 11-2,ultrasound/images/Figure 11-2.jpg,Figure 11-2: Parasternal long-axis view of the heart.,"Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-4,ultrasound/images/Figure 11-4.jpg,Figure 11-4: Subxiphoid view of the heart.,"The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-6,ultrasound/images/Figure 11-6.jpg,Figure 11-6: Cross-sectional diagram demonstrating Morrison’s pouch (hepatorenal) and the splenorenal recess.,"Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-7,ultrasound/images/Figure 11-7.jpg,Figure 11-7: Hepatorenal view in the right upper quadrant.,"First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-9,ultrasound/images/Figure 11-9.jpg,Figure 11-9: Splenorenal view in the left upper quadrant.,"Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-11,ultrasound/images/Figure 11-11.jpg,Figure 11-11: Pouches (recess) in the male and female.,"The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 11-12,ultrasound/images/Figure 11-12.jpg,Figure 11-12: Ultrasound of the bladder.,"Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.","{'270c98af-5359-4807-bc97-af7da4012da7': 'Above the diaphragm, this fluid collection indicates emergent action in the form of a pericardial or pleural effusion. In the case of pericardial effusion, cardiac tamponade can occur and must be treated immediately. Cardiac tamponade is a medical condition that causes the restriction of ventricular filling due to pressure of fluid in the pericardium. In the case of pleural effusion, the restriction is not the initial problem. However, there may be ongoing bleeding contributing to the effusion that must be stopped. Cardiac imaging is used to evaluate pericardial effusion. There are two different cardiac views. The parasternal long-axis view is obtained by placing the transducer just left of the sternum in the fourth or fifth intercostal space oriented to the right shoulder, as shown in Figure 11-2. The parasternal sagittal ultrasound view of the heart is shown in Figure 11-3. The abbreviations LV, RV, LA, RA, and A have been used for the left ventricle, right ventricle, left atrium, right ventricle, and aorta, respectively, in some of the following ultrasound images.', '78c81975-a844-4172-ad96-37d4ac7b248e': 'The subxiphoid view can sometimes be challenging in a patient who is considered obese. First, locate the xiphoid process, place the transducer down in a transverse position with the indicator facing toward the right, and aim between the head and left shoulder, as shown in Figure 11-4. Gently apply pressure downward, and visualize the cardiac contractility during respiration to identify the best visualization. Figure 11-5 shows the four-chamber view of the heart during this evaluation. Assess for hemopericardium, or fluid around the heart.', '9fbd8784-efc8-4dd6-9ee8-56ec001639d6': 'Pulmonary imaging in trauma has evolved over the years. Most recently, with the COVID-19 pandemic, it has become a more detailed and important part of the evaluation addressed in Chapter 8.', 'ffd3bebc-83f4-4d32-8193-06bdc7f4b345': 'Peritoneal imaging of the abdomen/pelvis evaluates fluid in the hepatorenal recess (also referred to as Morrison’s pouch), splenorenal recess, and pelvic cavity. Figure 11-6 shows a cross-sectional diagram of the abdomen, demonstrating Morrison’s pouch (hepatorenal recess) and the splenorenal recess. The most straightforward abdominal view is to place the transducer in the midaxillary line at the 8th to 11th intercostal space with cephalad orientation.', 'e0518679-61bf-40f3-9fe7-7ca825910af2': 'First, start on the right abdominal region in the midaxillary line between the 8th to 11th intercostal spaces, as shown in Figure 11-7. Maneuver the transducer by sliding, fanning, angling, and rotating until you can visualize the liver and kidney well. The abbreviations L, R, K, P, and S have been labeled in some of the following ultrasound images, representing liver, recess (hepatorenal and splenorenal), kidney, pleura, and spleen, respectively. Figure 11-8 represents the hepatorenal view, showing the liver, hepatorenal recess, kidney, and pleura.', '8b9c69d7-5d3d-4334-8ff4-108681b628b3': 'Next, place the transducer in the longitudinal plane with the indicator facing the patient’s head, evaluating between the fifth to ninth intercostal spaces, as shown in Figure 11-9. Again, maneuver the transducer until you can visualize the spleen and kidney well. Figure 11-10 represents the splenorenal view, showing the spleen, splenorenal recess, and kidney.', 'b13e2beb-cea9-42f1-acf2-41dfa0693370': 'The pelvic cavity also has an area where peritoneal fluid can collect within the pouch. In women, it is called the rectouterine pouch or pouch of Douglas (peritoneum between the rectum and uterus). In men, it is referred to as the rectovesical pouch (peritoneum between the rectum and bladder), as shown in Figure 11-11.', '5fa5147c-08f5-4ff7-bf65-fa584ec2ee2b': 'Figure 11-12 shows an ultrasound image of the bladder (abbreviated B on the image) obtained by placing the transducer in the patient’s midline, right above the pubic symphysis. This concludes the eFAST exam.', 'ac905635-2981-4e4a-b7b6-f55b10013a80': 'The best time to stop bleeding is as soon as possible. When the bleeding is not apparent or external, ultrasound has made leaps of progress regarding rapid diagnosis. The first hour after trauma, known as the “Golden Hour of Trauma,” is a recognized time entity in which medical professionals aim to provide definitive care. In the future, it may well be a standard of care for paramedics to perform ultrasound on the scene. In this case, the image will be transmitted to an emergency department and a trauma surgeon’s cell phone so that preparations for emergent surgery may be made before the patient arrives. Perhaps in the future, the patient will be taken immediately off the ambulance and directly to surgery. Trials of this technology are ongoing all over the world.'}"
+Figure 10-1,ultrasound/images/Figure 10-1.jpg,Figure 10-1: Anatomy of the venous system.,"The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-2,ultrasound/images/Figure 10-2.jpg,Figure 10-2: Valves in the venous system of the leg.,"The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-3,ultrasound/images/Figure 10-3.jpg,Figure 10-3: Side-by-side transverse ultrasound views of the right common femoral vein without compression and with compression.,"A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-5,ultrasound/images/Figure 10-5.jpg,Figure 10-5: Side-by-side transverse image of the right profunda femoral vein without and with compression.,"Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-7,ultrasound/images/Figure 10-7.jpg,Figure 10-7: Side-by-side right femoral vein transverse view without and with compression.,"Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-9,ultrasound/images/Figure 10-9.jpg,Figure 10-9: Side-by-side right popliteal vein transverse view without and with compression.,"Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-11,ultrasound/images/Figure 10-11.jpg,Figure 10-11: Side-by-side right gastrocnemius vein transverse view without and with compression.,"Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-13,ultrasound/images/Figure 10-13.jpg,Figure 10-13: Side-by-side right posterior tibial veins transverse view without and with compression.,"Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-15,ultrasound/images/Figure 10-15.jpg,Figure 10-15: Side-by-side right peroneal veins transverse view without and with compression.,"Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-17,ultrasound/images/Figure 10-17.jpg,Figure 10-17: Side-by-side right anterior tibial vein transverse view without and with compression.,"Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-19,ultrasound/images/Figure 10-19.jpg,Figure 10-19: Side-by-side right great saphenous vein at the saphenofemoral junction transverse view without and with color Doppler.,"Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-21,ultrasound/images/Figure 10-21.jpg,Figure 10-21: Right great saphenous vein transverse view above the knee.,"Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-23,ultrasound/images/Figure 10-23.jpg,Figure 10-23: Right great saphenous vein below the knee transverse view.,"Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-25,ultrasound/images/Figure 10-25.jpg,Figure 10-25: Right small saphenous vein at the saphenopopliteal junction transverse view.,"The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.","{'b93950ed-22b5-4904-b90e-f16e9013bf8e': 'The primary physiologic functions of the venous system are to return the deoxygenated blood to the heart, thermoregulate, store blood (at any instance, the venous system contains up to 70% of the circulating blood), and regulate the cardiac output. It is divided into three systems: superficial, perforating, and deep veins. Figure 10-1 shows the anatomy of the venous system. Blood flows from the superficial to deep veins through branching perforating veins. The deep veins usually follow the arteries in the same areas and often have similar names. For example, the femoral vein is beside the femoral artery. The deep venous system eventually returns blood to the right side of the heart. Since the venous system is usually a low-pressure system, veins have bicuspid valves to allow flow in one direction from superficial to deep (the foot is the exception) and from distal to proximal. Muscular contraction helps with venous flow, such as in the calf muscle pump in the leg.[1]', '632ce9e8-b8a4-48b9-a4af-145661e9f41a': 'Venous pathophysiology has many etiologies, such as trauma and genetic predisposition, and can occur when outflow is impaired by dysfunctional valves, resulting in retrograde flow and causing a condition known as chronic venous insufficiency. Vein thrombosis is another condition with many hereditary and acquired etiologies, such as trauma or prolonged immobilization. Deep vein thrombosis is especially important to evaluate and treat.[2]', '9d40ab2e-c955-4112-89a5-d26d863909cc': 'The great saphenous vein (GSV) is the longest vein in the human body, as shown in Figure 10-2. It originates in the medial aspect of the foot as part of the dorsal arch. It continues proximally along the medial aspect of the foot and passes anterior to the medial malleolus on the tibia. It ascends along the medial aspect of the leg between the superficial and deep fascia. It typically has 10–20 valves and terminates at the saphenofemoral junction (SFJ). Once flow enters the femoral vein, it is in the deep venous system. Venous anatomy can vary from individual to individual. However, the GSV typically has branching superficial veins, such as the anterior and posterior accessory saphenous veins in the thigh.[3]', '0ce8893b-65d3-4a6e-922b-ae4aedcb93ec': 'The small saphenous vein (SSV) is the second most significant superficial vein that joins the dorsal venous arch in the lateral aspect of the foot. It ascends proximally behind the lateral malleolus and terminates into the deep popliteal vein, although this is highly variable and can extend into the thigh. The SSV typically has 9–12 valves. Like the GSV, the SSV lies between the superficial and deep fascia and can have many branching superficial veins. Perforating veins connect superficial to deep veins. They usually contain a bicuspid valve.[4]', 'cdce2c10-7107-4b98-9a9f-5963cc01100b': 'The deep venous system includes the common femoral vein, profunda femoral vein, deep femoral vein, popliteal vein, gastrocnemius veins, soleus veins, anterior tibial veins, posterior tibial veins, and peroneal veins. The direction of venous flow is described as antegrade, retrograde, or absent. In both the deep and superficial venous systems, it is essential to check for the following characteristics: compressibility, spontaneous flow, respiratory variation, augmentation, intraluminal defects, and venous reflux.', '87edb9d1-080e-4869-9f1b-64ead1f3211d': 'Compressibility evaluates if the vein collapses by applying downward pressure with the transducer. Typically, it should compress, since it is a low-pressure vessel. A thrombus can occlude the lumen and prevent compression. Spontaneous flow is observed when the blood flow moves actively without external influences, such as an augmentation maneuver. Respiratory variation, also known as phasicity, refers to regular venous flow changes that occur secondary to intrathoracic pressure during breathing cycles. Augmentation is a maneuver that is used to evaluate possible abnormal flow patterns. For example, by squeezing a distal portion in the calf, an increase in venous flow should be observed just proximal to this area. Absent or diminished flow could suggest obstruction, such as in a thrombus formation, and reversal of flow could indicate incompetent venous valves, such as in venous reflux disease.', '248e1ec2-a018-40e1-902d-e3963a654a30': 'Intraluminal defects usually describe a thrombus formation within the lumen of the vein. It is crucial to describe the details of the thrombus formation and whether it is obstructive.', '07e3fe47-442c-4991-ac90-f39130a2560a': 'Finally, venous reflux describes blood flow going in the wrong direction, usually from incompetent valves. Maneuvers are usually done to augment blood flow to test for reflux, which is significant if it exceeds seconds in the superficial venous system, seconds in perforators, and 1 second in the deep venous system.', '4d557358-6ca5-4b8b-85bc-d2b3a1e36e00': 'A complete venous duplex ultrasound of the lower extremities starts with a proximal to distal evaluation of the deep venous system in a transverse (TRV) side-by-side image without compression and with compression (COMP). This is followed by a sagittal (SAG) view with augmentation (AUG) using the color Doppler. The veins that are evaluated in succession include the common femoral vein (CFV), profunda femoral vein (PROF V), femoral vein (FV), popliteal vein (POP V), gastrocnemius vein (GASTROC V), posterior tibial vein (PTV), peroneal vein (PERO V), anterior tibial vein (ATV), great saphenous vein (GSV), and small saphenous vein (SSV). The abbreviations given in parentheses in the last few sentences have been labeled in some of the following ultrasound images for venous system discussion. Figure 10-3 shows a side-by-side transverse ultrasound view of the right common femoral vein without compression and with compression, while Figure 10-4 represents the sagittal view of the right common femoral vein with augmentation.', '73ecf0b4-cd2c-40ac-a0af-43305c53777a': 'Figure 10-5 shows a side-by-side transverse ultrasound view of the right profunda femoral vein without compression and with compression, while Figure 10-6 represents the sagittal view of the right profunda femoral vein with augmentation.', 'ae0a41c0-35dd-4d6a-9699-1e3d3b08c89a': 'Figure 10-7 shows a side-by-side transverse ultrasound view of the right femoral vein without compression and with compression, while Figure 10-8 represents the sagittal view of the right femoral vein with augmentation.', '18b2cb77-a6c1-4fef-8094-dfd2d69bcf68': 'Figure 10-9 shows a side-by-side transverse ultrasound view of the right popliteal vein without compression and with compression, while Figure 10-10 represents the sagittal view of the right popliteal vein with augmentation.', '8b196d0e-2c9b-486a-8a13-a47093c403a2': 'Figure 10-11 shows a side-by-side transverse ultrasound view of the right gastrocnemius vein without compression and with compression, while Figure 10-12 represents the sagittal view of the right gastrocnemius vein with augmentation.', '273ff9a6-4b2e-42f7-9cbe-2fdd18e43e13': 'Figure 10-13 shows a side-by-side transverse ultrasound view of the right posterior tibial vein without compression and with compression, while Figure 10-14 represents the sagittal view of the right posterior tibial vein with augmentation.', '004926eb-ed66-4ae4-afe3-5b5a9f521f91': 'Figure 10-15 shows a side-by-side transverse ultrasound view of the right peroneal vein without compression and with compression, while Figure 10-16 represents the sagittal view of the right peroneal vein with augmentation.', '079f0445-b767-43b9-a975-3ee5d53e3245': 'Figure 10-17 shows a side-by-side transverse ultrasound view of the anterior tibial vein without compression and with compression, while Figure 10-18 represents the sagittal view of the right anterior tibial vein with augmentation.', '833c69a2-b385-4b33-afd0-087b1e083eb4': 'Next, in the complete venous duplex ultrasound, we look at the superficial venous system from proximal to distal, starting with the GSV at the SFJ in the transverse plane with a side-by-side image without and with color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-19 shows a side-by-side transverse ultrasound view of the right GSV at the SFJ, while Figure 10-20 represents the sagittal view of the right GSV at the SFJ with augmentation.', '14d6c230-ba8c-43e3-91b4-134eeb29be3a': 'Next, we continue to follow and evaluate the GSV distally from above the knee (AK) to below the knee (BK) in the transverse plane without color, followed by the sagittal plane with augmentation with color Doppler. The abbreviations AK and BK have been used in the ultrasound images discussed here. Figure 10-21 shows a side-by-side transverse ultrasound view of the right GSV above the knee. Figure 10-22 represents the sagittal view of the right GSV above the knee with augmentation.', '2006bafb-e7f9-4370-868d-1d8efe73b50b': 'Figure 10-23 shows a transverse ultrasound view of the right GSV below the knee, while Figure 10-24 represents the sagittal view of the right GSV below the knee with augmentation.', 'b8f859e9-52cb-4e7a-b656-915686b480ac': 'The next superficial vein to be evaluated is the SSV, starting in the popliteal area of the lower extremity and using the same approach as the great saphenous vein. We first start with a transverse image at the saphenopopliteal junction (SPJ) without color Doppler, followed by a sagittal image with augmentation with color Doppler. Figure 10-25 shows a side-by-side transverse ultrasound view of the right SSV at the SPJ, while Figure 10-26 represents the sagittal view of the right SSV at the SPJ with augmentation.', '98d923c3-87d9-4816-bc06-fb301173a6f5': 'Also, anterior and posterior accessory saphenous veins are often evaluated as part of the superficial venous system, and perforating veins that connect superficial to deep veins are often evaluated during the study.', '848a0bae-b4da-4b21-811e-109e271e68bd': 'The template shown in the next couple of pages can be used to perform a complete venous duplex Doppler ultrasound examination of the lower extremities.'}"
+Figure 10-27,ultrasound/images/Figure 10-27.jpg,Figure 10-27: Anatomy of the arterial system.,"Figure 10-27 shows the anatomy of the arterial system, which will be helpful in discussing and understanding various ultrasonography images of the arteries.","{'8b7c6a6e-54d6-4c37-bdc3-56bc6cd5a295': 'Figure 10-27 shows the anatomy of the arterial system, which will be helpful in discussing and understanding various ultrasonography images of the arteries.'}"
+Figure 10-28,ultrasound/images/Figure 10-28.jpg,Figure 10-28: Transcranial Doppler probe.,"Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).","{'f21a23d7-1ed0-4d43-9af1-60e0e148f375': 'Norwegian physicist Rune Aaslid developed intracranial ultrasound in 1982. Transcranial imaging was subsequently developed by a German neurologist, Ulrich Bogdahn, in 1990. It was the first noninvasive way to evaluate the circle of Willis using a low-frequency transducer (2 MHz).[5],[6]', '2f10db14-ef44-4f68-b9da-74c786178474': 'Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).', 'de8dbeb8-e1bf-474f-bc9c-2505312a4c31': 'A high PI (>) can indicate increased intracranial pressure, microvascular disease, or distal vasospasm. Also, a low PI (<) can be seen with carotid stenosis or occlusion as well as arteriovenous malformations.[7],[8]', 'a8931776-ed59-4704-b984-e5fa3c9e2f93': 'The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]', 'b8e09b8c-3314-4b65-be3a-592b86544531': 'When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]', '9b4c0284-15fd-4a8b-b09c-a49f26bf8340': 'The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.', '504c2b01-6a86-4ccd-9eb3-73d048d5a69b': 'The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.', '417ca75c-1e42-4c39-9bbc-986a4bb357cf': 'In the vertebral arteries, normal blood flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 27–55 cm/sec. In the basilar arteries, normal blood flow is away from the probe, the depth is 80–120 mm, and the velocity is 30–57 cm/sec.'}"
+Figure 10-30,ultrasound/images/Figure 10-30.jpg,"Figure 10-30: The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows.","The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]","{'f21a23d7-1ed0-4d43-9af1-60e0e148f375': 'Norwegian physicist Rune Aaslid developed intracranial ultrasound in 1982. Transcranial imaging was subsequently developed by a German neurologist, Ulrich Bogdahn, in 1990. It was the first noninvasive way to evaluate the circle of Willis using a low-frequency transducer (2 MHz).[5],[6]', '2f10db14-ef44-4f68-b9da-74c786178474': 'Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).', 'de8dbeb8-e1bf-474f-bc9c-2505312a4c31': 'A high PI (>) can indicate increased intracranial pressure, microvascular disease, or distal vasospasm. Also, a low PI (<) can be seen with carotid stenosis or occlusion as well as arteriovenous malformations.[7],[8]', 'a8931776-ed59-4704-b984-e5fa3c9e2f93': 'The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]', 'b8e09b8c-3314-4b65-be3a-592b86544531': 'When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]', '9b4c0284-15fd-4a8b-b09c-a49f26bf8340': 'The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.', '504c2b01-6a86-4ccd-9eb3-73d048d5a69b': 'The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.', '417ca75c-1e42-4c39-9bbc-986a4bb357cf': 'In the vertebral arteries, normal blood flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 27–55 cm/sec. In the basilar arteries, normal blood flow is away from the probe, the depth is 80–120 mm, and the velocity is 30–57 cm/sec.'}"
+Figure 10-31,ultrasound/images/Figure 10-31.jpg,"Figure 10-31: Side-by-side flow patterns and velocities of the anterior cerebral artery, middle cerebral artery, and posterior cerebral artery on transcranial Doppler.","When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]","{'f21a23d7-1ed0-4d43-9af1-60e0e148f375': 'Norwegian physicist Rune Aaslid developed intracranial ultrasound in 1982. Transcranial imaging was subsequently developed by a German neurologist, Ulrich Bogdahn, in 1990. It was the first noninvasive way to evaluate the circle of Willis using a low-frequency transducer (2 MHz).[5],[6]', '2f10db14-ef44-4f68-b9da-74c786178474': 'Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).', 'de8dbeb8-e1bf-474f-bc9c-2505312a4c31': 'A high PI (>) can indicate increased intracranial pressure, microvascular disease, or distal vasospasm. Also, a low PI (<) can be seen with carotid stenosis or occlusion as well as arteriovenous malformations.[7],[8]', 'a8931776-ed59-4704-b984-e5fa3c9e2f93': 'The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]', 'b8e09b8c-3314-4b65-be3a-592b86544531': 'When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]', '9b4c0284-15fd-4a8b-b09c-a49f26bf8340': 'The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.', '504c2b01-6a86-4ccd-9eb3-73d048d5a69b': 'The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.', '417ca75c-1e42-4c39-9bbc-986a4bb357cf': 'In the vertebral arteries, normal blood flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 27–55 cm/sec. In the basilar arteries, normal blood flow is away from the probe, the depth is 80–120 mm, and the velocity is 30–57 cm/sec.'}"
+Figure 10-32,ultrasound/images/Figure 10-32.jpg,Figure 10-32: Side-by-side velocities and flow patterns of the right ophthalmic artery and carotid siphon on transcranial Doppler.,"The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.","{'f21a23d7-1ed0-4d43-9af1-60e0e148f375': 'Norwegian physicist Rune Aaslid developed intracranial ultrasound in 1982. Transcranial imaging was subsequently developed by a German neurologist, Ulrich Bogdahn, in 1990. It was the first noninvasive way to evaluate the circle of Willis using a low-frequency transducer (2 MHz).[5],[6]', '2f10db14-ef44-4f68-b9da-74c786178474': 'Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).', 'de8dbeb8-e1bf-474f-bc9c-2505312a4c31': 'A high PI (>) can indicate increased intracranial pressure, microvascular disease, or distal vasospasm. Also, a low PI (<) can be seen with carotid stenosis or occlusion as well as arteriovenous malformations.[7],[8]', 'a8931776-ed59-4704-b984-e5fa3c9e2f93': 'The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]', 'b8e09b8c-3314-4b65-be3a-592b86544531': 'When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]', '9b4c0284-15fd-4a8b-b09c-a49f26bf8340': 'The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.', '504c2b01-6a86-4ccd-9eb3-73d048d5a69b': 'The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.', '417ca75c-1e42-4c39-9bbc-986a4bb357cf': 'In the vertebral arteries, normal blood flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 27–55 cm/sec. In the basilar arteries, normal blood flow is away from the probe, the depth is 80–120 mm, and the velocity is 30–57 cm/sec.'}"
+Figure 10-33,ultrasound/images/Figure 10-33.jpg,Figure 10-33: Side-by-side velocities and flow patterns of the left vertebral artery and basilar artery on transcranial Doppler.,"The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.","{'f21a23d7-1ed0-4d43-9af1-60e0e148f375': 'Norwegian physicist Rune Aaslid developed intracranial ultrasound in 1982. Transcranial imaging was subsequently developed by a German neurologist, Ulrich Bogdahn, in 1990. It was the first noninvasive way to evaluate the circle of Willis using a low-frequency transducer (2 MHz).[5],[6]', '2f10db14-ef44-4f68-b9da-74c786178474': 'Transcranial Doppler (TCD) can detect intracranial stenosis, vasospasm secondary to subarachnoid hemorrhage, and arteriovenous malformations and assess suspected brain death. A TCD system usually has a 2 MHz pulsed Doppler with a spectrum analyzer. A typical TCD probe is shown in Figure 10-28. Blood flow in TCD is usually measured in cm/sec, and Figure 10-29 represents a TCD velocity distribution. When evaluating intracranial vessels, it is vital to know the acoustic window, depth, direction of blood flow, velocity, and angle of insonation. One important principle when evaluating pathology is the pulsatility index (PI).', 'de8dbeb8-e1bf-474f-bc9c-2505312a4c31': 'A high PI (>) can indicate increased intracranial pressure, microvascular disease, or distal vasospasm. Also, a low PI (<) can be seen with carotid stenosis or occlusion as well as arteriovenous malformations.[7],[8]', 'a8931776-ed59-4704-b984-e5fa3c9e2f93': 'The three most common acoustic windows that provide direction to evaluate the intracranial vessels are the transtemporal, transorbital, and transforaminal windows, as shown in Figure 10-30. The transcranial evaluation begins with the transtemporal approach on each side to identify the anterior, middle, and posterior cerebral arteries, and sometimes, the most distal aspect of the internal carotid artery (ICA) may also be evaluated.[9],[10]', 'b8e09b8c-3314-4b65-be3a-592b86544531': 'When evaluating the anterior cerebral artery, normal flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 41–76 cm/sec. The middle cerebral artery has normal flow toward the probe, a depth of 30–60 mm, and a velocity that ranges from 46–86 cm/sec. The posterior cerebral artery typically has flow toward the probe, a depth of 60–70 mm, and a velocity range of 33–64 cm/sec, as shown in Figure 10-31.[11],[12],[13]', '9b4c0284-15fd-4a8b-b09c-a49f26bf8340': 'The transorbital approach is followed and used to evaluate the ophthalmic artery and carotid siphon on each side, as shown in Figure 10-32. The location for of obtaining flow patterns is essential in this window, since it is difficult to determine the anatomic structure, as in the transtemporal approach demonstrating the circle of Willis. Comparisons can be made between different flow patterns.', '504c2b01-6a86-4ccd-9eb3-73d048d5a69b': 'The transforaminal approach is then used to evaluate the intracranial vertebral arteries and the basilar arteries, as shown in Figure 10-33.', '417ca75c-1e42-4c39-9bbc-986a4bb357cf': 'In the vertebral arteries, normal blood flow is away from the probe, the depth is 60–70 mm, and the velocity ranges from 27–55 cm/sec. In the basilar arteries, normal blood flow is away from the probe, the depth is 80–120 mm, and the velocity is 30–57 cm/sec.'}"
+Figure 10-34,ultrasound/images/Figure 10-34.jpg,Figure 10-34: Carotid Doppler probe.,"Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.","{'8ebf445d-b3df-4c01-99cd-3db6494256ca': 'Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.', 'ce1340e3-b56c-4112-bbce-201c0030fb81': 'Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.', '32e398b1-097a-4150-b31b-4d8abdf29c31': 'Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.', 'f2a96a7d-486c-4569-8f45-78a1a7cdd901': 'The Doppler characteristics of the carotid artery system are different. The ICA and CCA usually have low flow resistance, as shown in Figures 10-37 and 10-38, respectively. Flow occurs throughout the cardiac cycle. The diastolic segment does not touch the baseline. The ECA has high flow resistance with little or no diastolic or reversed diastolic flow. Reproducible and consistent velocity measurements require an angle of 60 degrees or less. Although a zero-degree angle of insonation provides the most remarkable Doppler shift because this depends on the angle’s cosine, this would be difficult with most vessels. The criteria used for the interpretation of velocity measurements were established using a 60-degree angle.[16],[17]', 'b3467db5-ffd6-44f2-8cd5-c306a8ac0e52': 'Since the brain is a low-resistance vascular bed, the ICA is less pulsatile with increased flow during diastole. The typical waveform of the ICA has a rapid upstroke during systole and a high diastolic component with a possible dicrotic notch and gradual downslope.', 'f074685e-b117-45de-a014-504a95073394': 'With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.', '4a722eaa-e710-4357-aec1-b8f9b6b40190': 'The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.', '70753ce5-5b81-4532-bf03-9257d002fba7': 'Both the CCA and vertebral arteries have low flow resistance. The flow characteristics are similar to the ICA. Multiple guidelines and trials are used to determine the percentage of diameter stenosis and clinically relevant stenosis. The ICA is of the most importance for surgical intervention. The Society of Radiologists in Ultrasound Consensus, one of the most widely used guidelines to assess ICA stenosis, is presented in Table 10-1 the table below.[18]'}"
+Figure 10-35,ultrasound/images/Figure 10-35.jpg,"Figure 10-35: Right common carotid artery in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in opposite directions.","Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.","{'8ebf445d-b3df-4c01-99cd-3db6494256ca': 'Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.', 'ce1340e3-b56c-4112-bbce-201c0030fb81': 'Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.', '32e398b1-097a-4150-b31b-4d8abdf29c31': 'Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.', 'f2a96a7d-486c-4569-8f45-78a1a7cdd901': 'The Doppler characteristics of the carotid artery system are different. The ICA and CCA usually have low flow resistance, as shown in Figures 10-37 and 10-38, respectively. Flow occurs throughout the cardiac cycle. The diastolic segment does not touch the baseline. The ECA has high flow resistance with little or no diastolic or reversed diastolic flow. Reproducible and consistent velocity measurements require an angle of 60 degrees or less. Although a zero-degree angle of insonation provides the most remarkable Doppler shift because this depends on the angle’s cosine, this would be difficult with most vessels. The criteria used for the interpretation of velocity measurements were established using a 60-degree angle.[16],[17]', 'b3467db5-ffd6-44f2-8cd5-c306a8ac0e52': 'Since the brain is a low-resistance vascular bed, the ICA is less pulsatile with increased flow during diastole. The typical waveform of the ICA has a rapid upstroke during systole and a high diastolic component with a possible dicrotic notch and gradual downslope.', 'f074685e-b117-45de-a014-504a95073394': 'With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.', '4a722eaa-e710-4357-aec1-b8f9b6b40190': 'The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.', '70753ce5-5b81-4532-bf03-9257d002fba7': 'Both the CCA and vertebral arteries have low flow resistance. The flow characteristics are similar to the ICA. Multiple guidelines and trials are used to determine the percentage of diameter stenosis and clinically relevant stenosis. The ICA is of the most importance for surgical intervention. The Society of Radiologists in Ultrasound Consensus, one of the most widely used guidelines to assess ICA stenosis, is presented in Table 10-1 the table below.[18]'}"
+Figure 10-36,ultrasound/images/Figure 10-36.jpg,Figure 10-36: Pulsed wave Doppler with spectral analysis of the common carotid artery in the distal sagittal plane.,"Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.","{'8ebf445d-b3df-4c01-99cd-3db6494256ca': 'Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.', 'ce1340e3-b56c-4112-bbce-201c0030fb81': 'Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.', '32e398b1-097a-4150-b31b-4d8abdf29c31': 'Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.', 'f2a96a7d-486c-4569-8f45-78a1a7cdd901': 'The Doppler characteristics of the carotid artery system are different. The ICA and CCA usually have low flow resistance, as shown in Figures 10-37 and 10-38, respectively. Flow occurs throughout the cardiac cycle. The diastolic segment does not touch the baseline. The ECA has high flow resistance with little or no diastolic or reversed diastolic flow. Reproducible and consistent velocity measurements require an angle of 60 degrees or less. Although a zero-degree angle of insonation provides the most remarkable Doppler shift because this depends on the angle’s cosine, this would be difficult with most vessels. The criteria used for the interpretation of velocity measurements were established using a 60-degree angle.[16],[17]', 'b3467db5-ffd6-44f2-8cd5-c306a8ac0e52': 'Since the brain is a low-resistance vascular bed, the ICA is less pulsatile with increased flow during diastole. The typical waveform of the ICA has a rapid upstroke during systole and a high diastolic component with a possible dicrotic notch and gradual downslope.', 'f074685e-b117-45de-a014-504a95073394': 'With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.', '4a722eaa-e710-4357-aec1-b8f9b6b40190': 'The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.', '70753ce5-5b81-4532-bf03-9257d002fba7': 'Both the CCA and vertebral arteries have low flow resistance. The flow characteristics are similar to the ICA. Multiple guidelines and trials are used to determine the percentage of diameter stenosis and clinically relevant stenosis. The ICA is of the most importance for surgical intervention. The Society of Radiologists in Ultrasound Consensus, one of the most widely used guidelines to assess ICA stenosis, is presented in Table 10-1 the table below.[18]'}"
+Figure 10-39,ultrasound/images/Figure 10-39.jpg,Figure 10-39: Sagittal view of the right vertebral artery with color flow.,"With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.","{'8ebf445d-b3df-4c01-99cd-3db6494256ca': 'Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.', 'ce1340e3-b56c-4112-bbce-201c0030fb81': 'Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.', '32e398b1-097a-4150-b31b-4d8abdf29c31': 'Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.', 'f2a96a7d-486c-4569-8f45-78a1a7cdd901': 'The Doppler characteristics of the carotid artery system are different. The ICA and CCA usually have low flow resistance, as shown in Figures 10-37 and 10-38, respectively. Flow occurs throughout the cardiac cycle. The diastolic segment does not touch the baseline. The ECA has high flow resistance with little or no diastolic or reversed diastolic flow. Reproducible and consistent velocity measurements require an angle of 60 degrees or less. Although a zero-degree angle of insonation provides the most remarkable Doppler shift because this depends on the angle’s cosine, this would be difficult with most vessels. The criteria used for the interpretation of velocity measurements were established using a 60-degree angle.[16],[17]', 'b3467db5-ffd6-44f2-8cd5-c306a8ac0e52': 'Since the brain is a low-resistance vascular bed, the ICA is less pulsatile with increased flow during diastole. The typical waveform of the ICA has a rapid upstroke during systole and a high diastolic component with a possible dicrotic notch and gradual downslope.', 'f074685e-b117-45de-a014-504a95073394': 'With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.', '4a722eaa-e710-4357-aec1-b8f9b6b40190': 'The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.', '70753ce5-5b81-4532-bf03-9257d002fba7': 'Both the CCA and vertebral arteries have low flow resistance. The flow characteristics are similar to the ICA. Multiple guidelines and trials are used to determine the percentage of diameter stenosis and clinically relevant stenosis. The ICA is of the most importance for surgical intervention. The Society of Radiologists in Ultrasound Consensus, one of the most widely used guidelines to assess ICA stenosis, is presented in Table 10-1 the table below.[18]'}"
+Figure 10-40,ultrasound/images/Figure 10-40.jpg,Figure 10-40: Normal waveform of the right external carotid artery.,"The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.","{'8ebf445d-b3df-4c01-99cd-3db6494256ca': 'Figure 10-34 shows the positioning of the ultrasound probe for carotid artery evaluations. A high-frequency linear transducer (–10 MHz) is most appropriate for carotid sonography. Transverse and longitudinal views are both imaged in B-mode, color, and spectral Doppler. In the sagittal plane, the ICA, external carotid artery (ECA), and right common carotid artery (CCA) are followed from the clavicle to the mandible with anterior, oblique, lateral, and posterior projections to identify plaque formation. Comparison flow characteristics are made from one side to the other as well as from proximal to distal segments of the ICA, ECA, and CCA.[14] In the transverse plane, the ICA and CCA are followed to evaluate plaque formations. The percentage of stenosis can then be evaluated by looking at the diameter reduction. Plaque characteristics can be evaluated for calcification, thrombosis, and fibrosis.', 'ce1340e3-b56c-4112-bbce-201c0030fb81': 'Figure 10-35 shows the CCA in the proximal transverse plane with the jugular vein on top, demonstrating blood flow in the opposite direction following the BART principle. Prox is the abbreviation used for proximal in the image for Figure 10-35 and some of the other following ones. Pulsed Doppler with spectral analysis is the primary tool for evaluating blood flow in the vascular study.', '32e398b1-097a-4150-b31b-4d8abdf29c31': 'Figure 10-36 shows the pulsed wave (PW) Doppler with spectral analysis of the right CCA in the distal sagittal plane. Spectral analysis is a method of displaying the variety of frequencies of blood flow during systole and diastole. The scanner technology automatically analyzes and displays the individual frequencies of the returned signals, creating a velocity profile consisting of time on the horizontal axis, frequency shifts on the vertical axis, and amplitude as brightness. This combination of blood flow analysis and anatomic information is the basis of duplex ultrasonography,[15] as discussed in Chapter 2.', 'f2a96a7d-486c-4569-8f45-78a1a7cdd901': 'The Doppler characteristics of the carotid artery system are different. The ICA and CCA usually have low flow resistance, as shown in Figures 10-37 and 10-38, respectively. Flow occurs throughout the cardiac cycle. The diastolic segment does not touch the baseline. The ECA has high flow resistance with little or no diastolic or reversed diastolic flow. Reproducible and consistent velocity measurements require an angle of 60 degrees or less. Although a zero-degree angle of insonation provides the most remarkable Doppler shift because this depends on the angle’s cosine, this would be difficult with most vessels. The criteria used for the interpretation of velocity measurements were established using a 60-degree angle.[16],[17]', 'b3467db5-ffd6-44f2-8cd5-c306a8ac0e52': 'Since the brain is a low-resistance vascular bed, the ICA is less pulsatile with increased flow during diastole. The typical waveform of the ICA has a rapid upstroke during systole and a high diastolic component with a possible dicrotic notch and gradual downslope.', 'f074685e-b117-45de-a014-504a95073394': 'With the common carotid artery in the longitudinal plane, the transducer is angled more posterolaterally to identify the vertebral artery. Vertical shadows will appear running through the vertebral arteries, which are the transverse processes of the vertebrae, as shown in Figure 10-39. Vert in the image represents the vertebral artery. Flow direction is documented.', '4a722eaa-e710-4357-aec1-b8f9b6b40190': 'The ECA supplies blood to vascular areas with higher resistance, such as the scalp. It has a rapid upstroke in systole and rapid downstroke in diastole with a dicrotic notch, as shown in Figure 10-40.', '70753ce5-5b81-4532-bf03-9257d002fba7': 'Both the CCA and vertebral arteries have low flow resistance. The flow characteristics are similar to the ICA. Multiple guidelines and trials are used to determine the percentage of diameter stenosis and clinically relevant stenosis. The ICA is of the most importance for surgical intervention. The Society of Radiologists in Ultrasound Consensus, one of the most widely used guidelines to assess ICA stenosis, is presented in Table 10-1 the table below.[18]'}"
+Figure 10-41,ultrasound/images/Figure 10-41.jpg,Figure 10-41: Schematic of the abdominal aorta showing that it branches into the right and left iliac arteries.,"The aorta is the largest artery in humans. It branches off the heart’s left ventricle into the thoracic and abdominal cavities, as shown in Figure 10-41. The abdominal aorta branches into the right and left iliac arteries at the level of the umbilicus, where it carries oxygenated blood to each lower extremity. When the wall of the aorta weakens and expands, an aneurysm develops (with an increased risk of rupture under this high-pressure system).","{'f9e32249-c52e-433d-9c02-4e2c22855481': 'The aorta is the largest artery in humans. It branches off the heart’s left ventricle into the thoracic and abdominal cavities, as shown in Figure 10-41. The abdominal aorta branches into the right and left iliac arteries at the level of the umbilicus, where it carries oxygenated blood to each lower extremity. When the wall of the aorta weakens and expands, an aneurysm develops (with an increased risk of rupture under this high-pressure system).', '3b0dc5bf-a6f0-4e9b-912a-14409d9e8d1b': 'Each year, 200,000 people in the United States are diagnosed with an abdominal aortic aneurysm (AAA). Of these, nearly % have a life-threatening risk of rupture. The majority of patients with AAA are asymptomatic. The aorta’s diameter must be greater less than 3 cm to be diagnosed as an aneurysm. When it reaches 5 cm or greater, very close monitoring and surgical options are entertained. Risk factors for an AAA include hypertension, smoking, and genetic factors, especially involving immediate relatives with AAA. Men over the age of 60 are also at greater risk.[20]', 'c2ffb4cf-6483-4409-b8c1-e2dd95678652': 'The ultrasound evaluation of the abdominal aorta (A or AA) should include the proximal, mid, and distal aorta to the bifurcation in the transverse and longitudinal planes, as shown in Figure 10-42. Evaluation of the branches of the aorta should include the celiac artery (C), superior mesenteric artery (SMA), and renal artery branches, as shown in Figures 10-43 and 10-44, without and with color Doppler, respectively.[21] The abbreviations given in parentheses in this paragraph have been labeled in some of the ultrasound images discussed below.'}"
+Figure 10-42,ultrasound/images/Figure 10-42.jpg,Figure 10-42: Transducer position in the transverse and sagittal planes to evaluate the abdominal aorta.,"The ultrasound evaluation of the abdominal aorta (A or AA) should include the proximal, mid, and distal aorta to the bifurcation in the transverse and longitudinal planes, as shown in Figure 10-42. Evaluation of the branches of the aorta should include the celiac artery (C), superior mesenteric artery (SMA), and renal artery branches, as shown in Figures 10-43 and 10-44, without and with color Doppler, respectively.[21] The abbreviations given in parentheses in this paragraph have been labeled in some of the ultrasound images discussed below.","{'f9e32249-c52e-433d-9c02-4e2c22855481': 'The aorta is the largest artery in humans. It branches off the heart’s left ventricle into the thoracic and abdominal cavities, as shown in Figure 10-41. The abdominal aorta branches into the right and left iliac arteries at the level of the umbilicus, where it carries oxygenated blood to each lower extremity. When the wall of the aorta weakens and expands, an aneurysm develops (with an increased risk of rupture under this high-pressure system).', '3b0dc5bf-a6f0-4e9b-912a-14409d9e8d1b': 'Each year, 200,000 people in the United States are diagnosed with an abdominal aortic aneurysm (AAA). Of these, nearly % have a life-threatening risk of rupture. The majority of patients with AAA are asymptomatic. The aorta’s diameter must be greater less than 3 cm to be diagnosed as an aneurysm. When it reaches 5 cm or greater, very close monitoring and surgical options are entertained. Risk factors for an AAA include hypertension, smoking, and genetic factors, especially involving immediate relatives with AAA. Men over the age of 60 are also at greater risk.[20]', 'c2ffb4cf-6483-4409-b8c1-e2dd95678652': 'The ultrasound evaluation of the abdominal aorta (A or AA) should include the proximal, mid, and distal aorta to the bifurcation in the transverse and longitudinal planes, as shown in Figure 10-42. Evaluation of the branches of the aorta should include the celiac artery (C), superior mesenteric artery (SMA), and renal artery branches, as shown in Figures 10-43 and 10-44, without and with color Doppler, respectively.[21] The abbreviations given in parentheses in this paragraph have been labeled in some of the ultrasound images discussed below.'}"
+Figure 10-45,ultrasound/images/Figure 10-45.jpg,Figure 10-45: Schematic showing normal anatomical branches of the arterial system in the lower extremity.,"Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-48,ultrasound/images/Figure 10-48.jpg,Figure 10-48: Sagittal image of the right common femoral artery with color Doppler and waveform analysis.,"An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-51,ultrasound/images/Figure 10-51.jpg,Figure 10-51: Sagittal image of the right profunda femoral artery with color Doppler and waveform analysis.,"Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-54,ultrasound/images/Figure 10-54.jpg,Figure 10-54: Sagittal image of the right proximal superficial femoral artery with color Doppler and waveform analysis.,"Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-57,ultrasound/images/Figure 10-57.jpg,Figure 10-57: Sagittal image of the right middle superficial femoral artery with color Doppler and waveform analysis.,"Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-60,ultrasound/images/Figure 10-60.jpg,Figure 10-60: Sagittal image of the right distal superficial femoral artery with color Doppler and waveform analysis.,Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.,"{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-63,ultrasound/images/Figure 10-63.jpg,Figure 10-63: Sagittal image of the right popliteal artery with color Doppler and waveform analysis.,"Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-66,ultrasound/images/Figure 10-66.jpg,Figure 10-66: Sagittal image of the right posterior tibial artery with color Doppler and waveform analysis.,"Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-69,ultrasound/images/Figure 10-69.jpg,Figure 10-69: Sagittal image of the right peroneal artery with color Doppler and waveform analysis.,"Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.","{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-70,ultrasound/images/Figure 10-70.jpg,Figure 10-70: Side-by-side sagittal images of the right anterior tibial artery without color Doppler and with color Doppler.,Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.,"{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-72,ultrasound/images/Figure 10-72.jpg,Figure 10-72: Side-by-side transverse images of the right dorsalis pedis artery without color Doppler and with color Doppler.,Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.,"{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 10-73,ultrasound/images/Figure 10-73.jpg,Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler and waveform analysis.,Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.,"{'7875d3f8-b4eb-4b87-aa2b-1f6ac49e503f': 'Figure 10-45 shows the normal anatomical branches of the arterial system in the lower extremity. Peripheral artery disease (PAD) is a condition in which the arteries of the lower extremities are narrowed primarily from atherosclerosis. Approximately 8 million people in the United States have PAD. Men and women are affected equally. Risk factors include smoking, diabetes, hypertension, high cholesterol, and being over 60 years of age. A classic symptom of PAD is claudication, or pain when walking. Lower-extremity arterial duplex scanning is a noninvasive way to identify the presence and severity of arterial occlusive disease.', '3b8c1cb7-15bc-47a6-b95f-bd41798bf7f8': 'It can also be used to follow the progression of the disease. The patient must rest for at least 20 minutes before testing, since this can affect the results, especially if the patient has PAD. The patient is then positioned supine with the lower extremities at the heart level so the hydrostatic pressure cannot falsely elevate the measurements.', 'bdb38034-e378-4f1b-bb82-0453154a23af': 'During an arterial Doppler exam, various cuffs are placed on the patient’s legs and arms. This exam uses color wave (CW) Doppler. CW Doppler employs two crystals contained in the same probe: one that transmits the signal and one that receives the reflected sound wave of the blood cells. The reflected frequency is either higher or lower than the transmitted frequency, depending on the flow direction. This change in frequency is called the Doppler shift. The ankle brachial index (ABI) is recorded, and the waveforms are analyzed. The ABI is a simple test that compares the blood pressure in the upper and lower limbs. The ABI is calculated by dividing the blood pressure in an ankle artery by the blood pressure in an arm artery. An ABI value of less than indicates PAD.', '619edc60-d14a-4b53-987f-4a81e9cda247': 'An arterial duplex is another type of evaluation that uses ultrasound. It starts proximally at the common femoral artery with a side-by-side transverse image without and with color Doppler, followed by a sagittal image of the artery in red and sometimes the corresponding vein(s) in blue, and finally, a sagittal image of the artery with waveform analysis, which includes peak systolic velocity (PSV) and end-diastolic velocity (EDV). As the arterial study is performed from proximal to distal, the same approach is obtained with each artery, including, in succession, the common femoral artery (CFA), profunda femoral artery (Prof A), superficial femoral artery (SFA), popliteal artery (Pop A), posterior tibial artery (PTA), peroneal artery (Pero A), anterior tibial artery (ATA), and dorsalis pedis artery (DPA). The abbreviations given in parentheses in the previous sentence have been labeled in some of the ultrasound images discussed below. The abbreviation Trans used in some of these images is for transverse. Figures 10-46 and 10-47 show the transverse and sagittal views, respectively, of the side-by-side images of the right common femoral artery without and with color Doppler. Figure 10-48 shows the sagittal view of the right common femoral artery with color Doppler and waveform analysis.', '2581c6ab-0aac-4157-a843-2c1496881d43': 'Figures 10-49 and 10-50 show the transverse and sagittal views, respectively, of the right profunda femoral artery without and with color Doppler. Figure 10-51 shows the sagittal view of the right profunda femoral artery with color Doppler and waveform analysis.', '43d08458-5c86-4a25-aff3-98d30a37c21a': 'Figures 10-52 and 10-53 show the transverse and sagittal views, respectively, of the right proximal superficial femoral artery without and with color Doppler. Figure 10-54 shows the sagittal view of the right proximal superficial femoral artery with color Doppler and waveform analysis.', 'bb438e72-e30f-4886-831e-ed5dd480fec6': 'Figures 10-55 and 10-56 show the transverse and sagittal views, respectively, of the right middle superficial femoral artery without and with color Doppler. Figure 10-57 shows the sagittal view of the right middle superficial femoral artery with color Doppler and waveform analysis.', '9a922b13-37ac-40e7-ab87-f0abf8bafe82': 'Figures 10-58 and 10-59 show the transverse and sagittal views of the right distal superficial femoral artery without and with color Doppler. Figure 10-60 shows the sagittal view of the right distal superficial femoral artery with color Doppler and waveform analysis.', '19d7d0f6-9820-4d8c-a234-46958e7de23c': 'Figures 10-61 and 10-62 show the transverse and sagittal views, respectively, of the right popliteal artery without and with color Doppler. Figure 10-63 shows the sagittal view of the right popliteal artery with color Doppler and waveform analysis.', 'c6108d25-ac76-4792-b31d-d908d2ffe791': 'Figures 10-64 and 10-65 show the transverse and sagittal views, respectively, of the right posterior tibial artery without and with color Doppler. Figure 10-66 shows the sagittal view of the right posterior tibial artery with color Doppler and waveform analysis.', '50756455-bf16-4a78-971a-d9c061217434': 'Figures 10-67 and 10-68 show the transverse and sagittal views, respectively, of the right peroneal artery without and with color Doppler. Figure 10-69 shows the sagittal view of the right peroneal artery with color Doppler and waveform analysis.', '7892e433-90f3-4778-bae9-26cbfc843d85': 'Figure 10-70 shows the side-by-side sagittal view of the right anterior tibial artery without and with color Doppler. Figure 10-71 shows the sagittal view of the right anterior tibial artery with color Doppler and waveform analysis.', 'eb3e2998-f1ef-40f7-8375-2b107aa016e6': 'Figure 10-72 shows the transverse view of the right dorsalis pedis artery without and with color Doppler. Figure 10-73 shows the sagittal view of the right dorsalis pedis artery with color Doppler and waveform analysis.', '8dac82d2-2320-40d3-9abe-fa0d7d5b54f3': 'Figure 10-73: Sagittal image of the right dorsalis pedis artery with color Doppler.', '4aad36ce-bbd0-4e22-b52f-27c1b9666a00': 'When evaluating the lower extremities for diagnostic criteria for PAD, the PSV and velocity ratio (VR) are often used. The VR is defined as the ratio of the PSV of the stenotic area to the PSV of the standard proximal segment. The degree of stenosis is determined by these values of the PSV and VR, as illustrated in Table 10-2.[22]'}"
+Figure 9-1,ultrasound/images/Figure 9-1.jpg,Figure 9-1: Ultrasound image of the longitudinal view of the normal left kidney. Kidney ultrasound 110315132820 1329070 by Nevit Dilmen licensed under CC BY-SA 3.0,"In a typical ultrasound fashion, we will look at the end anatomic result of renal function and formulate a theory of a patient’s condition. Figure 9-1 shows an ultrasonography scan of the longitudinal view of the usual left kidney.","{'fa16e870-67a3-4f62-9870-23f6aaeab1d9': 'Kidneys are interesting because understanding renal function and disease involves several disciplines, including chemistry, biology, and physics. In clinical medicine, we often analyze renal function using standard lab tests such as urinalysis, serum creatinine, and serum blood urea nitrogen (BUN). These tests give us clues about both normal function and etiologies of pathology. Examples of how the three tests help us begin abound: too much protein in the urine in the shape of a glomerulus (called “casts”) may indicate immune-mediated glomerulonephritis, too-high creatinine alone may indicate diffuse renal failure and intravascular fluid overload, and an altered creatinine-BUN ratio may indicate intravascular fluid depletion.', '1af6b45f-cc53-4158-a3b9-ce6da84e45a8': 'In a typical ultrasound fashion, we will look at the end anatomic result of renal function and formulate a theory of a patient’s condition. Figure 9-1 shows an ultrasonography scan of the longitudinal view of the usual left kidney.', '4ee7dc40-e07a-4002-9723-16304e36c6e4': 'Although it might be challenging to view a nephron or its functional parts on ultrasound, we can observe the results of renal malfunction with our gross anatomic view and make some rapid observations that may help a patient. The fascia is the outer fibrous covering of many organs, and Gerota’s fascia is the one that surrounds the kidneys and adrenal glands. This fascia is particularly dense and hyperechoic, most often producing a bright reflection (white) back onto the screen in the B-mode. From this distinct outline, we can determine the size, shape, location, and consistency of the surrounding structures near the kidney. The kidney measures approximately 11–14 cm in length, 6 cm in width, and 4 cm in thickness. You may measure these at first, but you may soon only estimate the size visually. Other hyperechoic structures typically surround the kidney. The liver is located superior to the right kidney, and the spleen is located superior to the left kidney. The kidneys are retroperitoneal, or behind the peritoneal cavity. Difficulties in visualizing a kidney are due to the presence of air-filled lungs superior to it as well as the ribs. Air, of course, disperses the ultrasound waves so that reflection is complex. Ribs cause shadowing, which may completely prohibit your initial viewing attempts. Because the liver does not fully extend to the left side, the left kidney is often partially covered by the thoracic cavity and more challenging to visualize.', '6fb9dba2-7f71-4324-9224-043f32d51c0c': 'Other than size and shape, a general clinician ultrasound exam may include lobules, evaluation of cortex thickness, evaluation of the renal pelvis, a survey to evaluate hyperechoic renal calculi (kidney stones), and observation of the vessels entering and leaving the renal pelvis (renal arteries, renal veins, and ureters). If atrophy is noted or a patient has marked hypertension, renal artery blood flow velocity is calculated via Doppler technology to determine if there is renal artery stenosis. This latter exam is usually outside the realm of general clinical ultrasound. It may be best for the general ultrasound clinician to refer this exam to those who do the exam often.', '9952ffed-02e2-4753-a6a9-9b590efebbf5': 'Large kidneys, or hydronephrosis, may be due to congenital variation, but this most often is a condition due to distal obstruction. Figure 9-2 shows an ultrasound image of end-stage hydronephrosis. Most often, there is only unilateral obstruction of the ureter. As the kidney continues to make urine in the presence of ureteral obstruction, there is backflow pressure and renal swelling. This is often seen in patient care with ureteral calculi obstructing a ureter. Hematuria (blood in the urine), unilateral pain, and unilateral hydronephrosis are diagnostic of ureteral calculi, even if a calculus is too small to be seen (usually less than 3 mm). Treatment is begun based on this clinical presumption.', '28bcd32e-af5d-4d70-b78d-c0d899dc808c': 'Choices to diagnose kidney and ureteral stones include intravenous pyelogram (IVP), plain radiographs, CT scans (which allow the synthesis of a 3D picture from multiple radiologic views), and ultrasound. Plain radiography, or shooting an X-ray through the abdomen, is the oldest evaluation method but is still used. Often hydronephrosis and occasionally an actual stone may be visualized. This method is often used to follow a visible stone over several days. IVP production involves injecting dye into a patient’s vein and taking serial plain X-rays to observe the flow of dye through the kidney and ureter. This method has lost great popularity due to the dye load on the kidney occasionally causing renal malfunction and less accuracy in diagnosis. CT technology is fast, does not require dye in this particular study, and is most accurate. The clarity of this technology is evident to the most inexperienced patient. Even a very small stone with a typical size of 1 mm may be measured more accurately. The stone may be more easily seen even if it does not contain calcium to reflect ultrasound waves. CT is used most often, but ultrasound is becoming more popular due to cost and the lack of ionizing radiation. Figure 9-3 shows an ultrasound image of a renal stone located at the pyeloureteral junction.', 'e6681785-c04e-4f7c-bd54-0d1710fc83e1': 'Over 70 million CT scans are performed in the United States every year.[1] The malignant potential of CT scans was most famously brought to the forefront in 2007 by David Brenner and Eric Hall in the New England Journal of Medicine.[2] Determining the medical cost of a CT scan is also a complex issue. There is a wide range of costs for CT imaging, typically running from $900 to $3,000. It is conceded by most that clinician-generated ultrasound avoids both of these menacing issues.', '9a6fd7a4-f37f-48b5-b16e-7a0e07269571': 'Clinically, significantly small bilateral kidneys with a thin cortex may indicate chronic renal disease from a diffuse process such as glomerulonephritis or chronic urinary tract infections causing scarring. This condition is distinct from a single small kidney and indicates a localized problem, such as decreased blood flow to only one kidney, known as renal artery stenosis.'}"
+Figure 9-2,ultrasound/images/Figure 9-2.jpg,"Figure 9-2: Ultrasonography of end-stage hydronephrosis. End-stage hydronephrosis with cortical thinning by Hansen KL, Nielsen MB, Ewertsen C licensed under CC BY 4.0","Large kidneys, or hydronephrosis, may be due to congenital variation, but this most often is a condition due to distal obstruction. Figure 9-2 shows an ultrasound image of end-stage hydronephrosis. Most often, there is only unilateral obstruction of the ureter. As the kidney continues to make urine in the presence of ureteral obstruction, there is backflow pressure and renal swelling. This is often seen in patient care with ureteral calculi obstructing a ureter. Hematuria (blood in the urine), unilateral pain, and unilateral hydronephrosis are diagnostic of ureteral calculi, even if a calculus is too small to be seen (usually less than 3 mm). Treatment is begun based on this clinical presumption.","{'fa16e870-67a3-4f62-9870-23f6aaeab1d9': 'Kidneys are interesting because understanding renal function and disease involves several disciplines, including chemistry, biology, and physics. In clinical medicine, we often analyze renal function using standard lab tests such as urinalysis, serum creatinine, and serum blood urea nitrogen (BUN). These tests give us clues about both normal function and etiologies of pathology. Examples of how the three tests help us begin abound: too much protein in the urine in the shape of a glomerulus (called “casts”) may indicate immune-mediated glomerulonephritis, too-high creatinine alone may indicate diffuse renal failure and intravascular fluid overload, and an altered creatinine-BUN ratio may indicate intravascular fluid depletion.', '1af6b45f-cc53-4158-a3b9-ce6da84e45a8': 'In a typical ultrasound fashion, we will look at the end anatomic result of renal function and formulate a theory of a patient’s condition. Figure 9-1 shows an ultrasonography scan of the longitudinal view of the usual left kidney.', '4ee7dc40-e07a-4002-9723-16304e36c6e4': 'Although it might be challenging to view a nephron or its functional parts on ultrasound, we can observe the results of renal malfunction with our gross anatomic view and make some rapid observations that may help a patient. The fascia is the outer fibrous covering of many organs, and Gerota’s fascia is the one that surrounds the kidneys and adrenal glands. This fascia is particularly dense and hyperechoic, most often producing a bright reflection (white) back onto the screen in the B-mode. From this distinct outline, we can determine the size, shape, location, and consistency of the surrounding structures near the kidney. The kidney measures approximately 11–14 cm in length, 6 cm in width, and 4 cm in thickness. You may measure these at first, but you may soon only estimate the size visually. Other hyperechoic structures typically surround the kidney. The liver is located superior to the right kidney, and the spleen is located superior to the left kidney. The kidneys are retroperitoneal, or behind the peritoneal cavity. Difficulties in visualizing a kidney are due to the presence of air-filled lungs superior to it as well as the ribs. Air, of course, disperses the ultrasound waves so that reflection is complex. Ribs cause shadowing, which may completely prohibit your initial viewing attempts. Because the liver does not fully extend to the left side, the left kidney is often partially covered by the thoracic cavity and more challenging to visualize.', '6fb9dba2-7f71-4324-9224-043f32d51c0c': 'Other than size and shape, a general clinician ultrasound exam may include lobules, evaluation of cortex thickness, evaluation of the renal pelvis, a survey to evaluate hyperechoic renal calculi (kidney stones), and observation of the vessels entering and leaving the renal pelvis (renal arteries, renal veins, and ureters). If atrophy is noted or a patient has marked hypertension, renal artery blood flow velocity is calculated via Doppler technology to determine if there is renal artery stenosis. This latter exam is usually outside the realm of general clinical ultrasound. It may be best for the general ultrasound clinician to refer this exam to those who do the exam often.', '9952ffed-02e2-4753-a6a9-9b590efebbf5': 'Large kidneys, or hydronephrosis, may be due to congenital variation, but this most often is a condition due to distal obstruction. Figure 9-2 shows an ultrasound image of end-stage hydronephrosis. Most often, there is only unilateral obstruction of the ureter. As the kidney continues to make urine in the presence of ureteral obstruction, there is backflow pressure and renal swelling. This is often seen in patient care with ureteral calculi obstructing a ureter. Hematuria (blood in the urine), unilateral pain, and unilateral hydronephrosis are diagnostic of ureteral calculi, even if a calculus is too small to be seen (usually less than 3 mm). Treatment is begun based on this clinical presumption.', '28bcd32e-af5d-4d70-b78d-c0d899dc808c': 'Choices to diagnose kidney and ureteral stones include intravenous pyelogram (IVP), plain radiographs, CT scans (which allow the synthesis of a 3D picture from multiple radiologic views), and ultrasound. Plain radiography, or shooting an X-ray through the abdomen, is the oldest evaluation method but is still used. Often hydronephrosis and occasionally an actual stone may be visualized. This method is often used to follow a visible stone over several days. IVP production involves injecting dye into a patient’s vein and taking serial plain X-rays to observe the flow of dye through the kidney and ureter. This method has lost great popularity due to the dye load on the kidney occasionally causing renal malfunction and less accuracy in diagnosis. CT technology is fast, does not require dye in this particular study, and is most accurate. The clarity of this technology is evident to the most inexperienced patient. Even a very small stone with a typical size of 1 mm may be measured more accurately. The stone may be more easily seen even if it does not contain calcium to reflect ultrasound waves. CT is used most often, but ultrasound is becoming more popular due to cost and the lack of ionizing radiation. Figure 9-3 shows an ultrasound image of a renal stone located at the pyeloureteral junction.', 'e6681785-c04e-4f7c-bd54-0d1710fc83e1': 'Over 70 million CT scans are performed in the United States every year.[1] The malignant potential of CT scans was most famously brought to the forefront in 2007 by David Brenner and Eric Hall in the New England Journal of Medicine.[2] Determining the medical cost of a CT scan is also a complex issue. There is a wide range of costs for CT imaging, typically running from $900 to $3,000. It is conceded by most that clinician-generated ultrasound avoids both of these menacing issues.', '9a6fd7a4-f37f-48b5-b16e-7a0e07269571': 'Clinically, significantly small bilateral kidneys with a thin cortex may indicate chronic renal disease from a diffuse process such as glomerulonephritis or chronic urinary tract infections causing scarring. This condition is distinct from a single small kidney and indicates a localized problem, such as decreased blood flow to only one kidney, known as renal artery stenosis.'}"
+Figure 9-3,ultrasound/images/Figure 9-3.jpg,"Figure 9-3: Ultrasound scan of renal stone located at the pyeloureteral junction. Renal stone located at the pyeloureteric junciton with accompanying hydronephrosis by Hansen KL, Nielsen MB, Ewertsen C licensed under CC BY 4.0","Choices to diagnose kidney and ureteral stones include intravenous pyelogram (IVP), plain radiographs, CT scans (which allow the synthesis of a 3D picture from multiple radiologic views), and ultrasound. Plain radiography, or shooting an X-ray through the abdomen, is the oldest evaluation method but is still used. Often hydronephrosis and occasionally an actual stone may be visualized. This method is often used to follow a visible stone over several days. IVP production involves injecting dye into a patient’s vein and taking serial plain X-rays to observe the flow of dye through the kidney and ureter. This method has lost great popularity due to the dye load on the kidney occasionally causing renal malfunction and less accuracy in diagnosis. CT technology is fast, does not require dye in this particular study, and is most accurate. The clarity of this technology is evident to the most inexperienced patient. Even a very small stone with a typical size of 1 mm may be measured more accurately. The stone may be more easily seen even if it does not contain calcium to reflect ultrasound waves. CT is used most often, but ultrasound is becoming more popular due to cost and the lack of ionizing radiation. Figure 9-3 shows an ultrasound image of a renal stone located at the pyeloureteral junction.","{'fa16e870-67a3-4f62-9870-23f6aaeab1d9': 'Kidneys are interesting because understanding renal function and disease involves several disciplines, including chemistry, biology, and physics. In clinical medicine, we often analyze renal function using standard lab tests such as urinalysis, serum creatinine, and serum blood urea nitrogen (BUN). These tests give us clues about both normal function and etiologies of pathology. Examples of how the three tests help us begin abound: too much protein in the urine in the shape of a glomerulus (called “casts”) may indicate immune-mediated glomerulonephritis, too-high creatinine alone may indicate diffuse renal failure and intravascular fluid overload, and an altered creatinine-BUN ratio may indicate intravascular fluid depletion.', '1af6b45f-cc53-4158-a3b9-ce6da84e45a8': 'In a typical ultrasound fashion, we will look at the end anatomic result of renal function and formulate a theory of a patient’s condition. Figure 9-1 shows an ultrasonography scan of the longitudinal view of the usual left kidney.', '4ee7dc40-e07a-4002-9723-16304e36c6e4': 'Although it might be challenging to view a nephron or its functional parts on ultrasound, we can observe the results of renal malfunction with our gross anatomic view and make some rapid observations that may help a patient. The fascia is the outer fibrous covering of many organs, and Gerota’s fascia is the one that surrounds the kidneys and adrenal glands. This fascia is particularly dense and hyperechoic, most often producing a bright reflection (white) back onto the screen in the B-mode. From this distinct outline, we can determine the size, shape, location, and consistency of the surrounding structures near the kidney. The kidney measures approximately 11–14 cm in length, 6 cm in width, and 4 cm in thickness. You may measure these at first, but you may soon only estimate the size visually. Other hyperechoic structures typically surround the kidney. The liver is located superior to the right kidney, and the spleen is located superior to the left kidney. The kidneys are retroperitoneal, or behind the peritoneal cavity. Difficulties in visualizing a kidney are due to the presence of air-filled lungs superior to it as well as the ribs. Air, of course, disperses the ultrasound waves so that reflection is complex. Ribs cause shadowing, which may completely prohibit your initial viewing attempts. Because the liver does not fully extend to the left side, the left kidney is often partially covered by the thoracic cavity and more challenging to visualize.', '6fb9dba2-7f71-4324-9224-043f32d51c0c': 'Other than size and shape, a general clinician ultrasound exam may include lobules, evaluation of cortex thickness, evaluation of the renal pelvis, a survey to evaluate hyperechoic renal calculi (kidney stones), and observation of the vessels entering and leaving the renal pelvis (renal arteries, renal veins, and ureters). If atrophy is noted or a patient has marked hypertension, renal artery blood flow velocity is calculated via Doppler technology to determine if there is renal artery stenosis. This latter exam is usually outside the realm of general clinical ultrasound. It may be best for the general ultrasound clinician to refer this exam to those who do the exam often.', '9952ffed-02e2-4753-a6a9-9b590efebbf5': 'Large kidneys, or hydronephrosis, may be due to congenital variation, but this most often is a condition due to distal obstruction. Figure 9-2 shows an ultrasound image of end-stage hydronephrosis. Most often, there is only unilateral obstruction of the ureter. As the kidney continues to make urine in the presence of ureteral obstruction, there is backflow pressure and renal swelling. This is often seen in patient care with ureteral calculi obstructing a ureter. Hematuria (blood in the urine), unilateral pain, and unilateral hydronephrosis are diagnostic of ureteral calculi, even if a calculus is too small to be seen (usually less than 3 mm). Treatment is begun based on this clinical presumption.', '28bcd32e-af5d-4d70-b78d-c0d899dc808c': 'Choices to diagnose kidney and ureteral stones include intravenous pyelogram (IVP), plain radiographs, CT scans (which allow the synthesis of a 3D picture from multiple radiologic views), and ultrasound. Plain radiography, or shooting an X-ray through the abdomen, is the oldest evaluation method but is still used. Often hydronephrosis and occasionally an actual stone may be visualized. This method is often used to follow a visible stone over several days. IVP production involves injecting dye into a patient’s vein and taking serial plain X-rays to observe the flow of dye through the kidney and ureter. This method has lost great popularity due to the dye load on the kidney occasionally causing renal malfunction and less accuracy in diagnosis. CT technology is fast, does not require dye in this particular study, and is most accurate. The clarity of this technology is evident to the most inexperienced patient. Even a very small stone with a typical size of 1 mm may be measured more accurately. The stone may be more easily seen even if it does not contain calcium to reflect ultrasound waves. CT is used most often, but ultrasound is becoming more popular due to cost and the lack of ionizing radiation. Figure 9-3 shows an ultrasound image of a renal stone located at the pyeloureteral junction.', 'e6681785-c04e-4f7c-bd54-0d1710fc83e1': 'Over 70 million CT scans are performed in the United States every year.[1] The malignant potential of CT scans was most famously brought to the forefront in 2007 by David Brenner and Eric Hall in the New England Journal of Medicine.[2] Determining the medical cost of a CT scan is also a complex issue. There is a wide range of costs for CT imaging, typically running from $900 to $3,000. It is conceded by most that clinician-generated ultrasound avoids both of these menacing issues.', '9a6fd7a4-f37f-48b5-b16e-7a0e07269571': 'Clinically, significantly small bilateral kidneys with a thin cortex may indicate chronic renal disease from a diffuse process such as glomerulonephritis or chronic urinary tract infections causing scarring. This condition is distinct from a single small kidney and indicates a localized problem, such as decreased blood flow to only one kidney, known as renal artery stenosis.'}"
+Figure 9-4,ultrasound/images/Figure 9-4.jpg,Figure 9-4: Ultrasound image of gallbladder stone. Ultrasound image of gallbladder stone Gallstone 091937515 by Nevit Dilmen licensed under CC BY-SA 3.0,"Gallbladder ultrasounds are standard diagnostic investigations that can be done by primary care and emergency providers. The capsule of the gallbladder, with its fluid-filled contents, often makes a very clearly defined reflective surface. Figure 9-4 shows an ultrasound image of a gallbladder stone. Calculi, often called “gallstones,” may be seen within the gallbladder because of the high density and reflectivity of the discrete objects sitting in often clear fluid. Another feature called “shadowing” is helpful in diagnosis. Shadowing refers to the sharply demarcated darkness that is under the gallstone. Not all gallstones cause disease or need to be addressed. Other features that can be noted on ultrasound and can indicate pathology or a diseased state in a patient include the location of the calculi, the size of the gallbladder, inflammation of the gallbladder, and acute cholecystitis.","{'2c2bf2a1-ff3a-407f-a2cd-a009445f05d4': 'Gallbladder ultrasounds are standard diagnostic investigations that can be done by primary care and emergency providers. The capsule of the gallbladder, with its fluid-filled contents, often makes a very clearly defined reflective surface. Figure 9-4 shows an ultrasound image of a gallbladder stone. Calculi, often called “gallstones,” may be seen within the gallbladder because of the high density and reflectivity of the discrete objects sitting in often clear fluid. Another feature called “shadowing” is helpful in diagnosis. Shadowing refers to the sharply demarcated darkness that is under the gallstone. Not all gallstones cause disease or need to be addressed. Other features that can be noted on ultrasound and can indicate pathology or a diseased state in a patient include the location of the calculi, the size of the gallbladder, inflammation of the gallbladder, and acute cholecystitis.'}"
+Figure 9-5,ultrasound/images/Figure 9-5.jpg,Figure 9-5: Acute cholecystitis as seen on the ultrasound axial view. Acute cholecystitis as seen on ultrasound axial view by Cerebisae licensed under CC BY-SA 4.0,"Surrounding a thickened wall can also be inflammatory fluid, indicating an acute inflammatory response or “acute cholecystitis.” This inflammatory fluid will be seen as a dark area outside the (usually thickened) gallbladder wall, as shown in Figure 9-5.","{'d0d1c926-85d0-48f5-9894-61bd047f5d46': 'Surrounding a thickened wall can also be inflammatory fluid, indicating an acute inflammatory response or “acute cholecystitis.” This inflammatory fluid will be seen as a dark area outside the (usually thickened) gallbladder wall, as shown in Figure 9-5.'}"
+Figure 9-6,ultrasound/images/Figure 9-6.jpg,Figure 9-6: Abdominal ultrasound showing the right lobe of the liver and right kidney. Ultrasound liver right lobe and right kidney by Ptrump16 licensed under CC BY-SA 4.0,"Figure 9-6 is an abdominal ultrasound showing the right lobe of the liver and right kidney. Compared to the gallbladder, kidney, intestine, or bladder, the liver’s thin covering makes it less distinctive. Distinctive features include the following:","{'6e41a2d8-cd4c-46c4-8da0-547a50cecee8': 'Figure 9-6 is an abdominal ultrasound showing the right lobe of the liver and right kidney. Compared to the gallbladder, kidney, intestine, or bladder, the liver’s thin covering makes it less distinctive. Distinctive features include the following:'}"
+Figure 8-1,ultrasound/images/Figure 8-1.jpg,"Figure 8-1: Ultrasound image of the intercostal space with the ribs shown by the vertical arrows. Rib shadows are displayed below. The upper horizontal arrows represent the pleural line, and the lower horizontal arrows represent the artifact of the pleural line, called the A-line. Normal lung surface by Daniel A. Lichtenstein licensed under CC BY 2.0","In many ways, pulmonary ultrasound is the antithesis of cardiac ultrasound. The motion cycle of the lungs is less dramatic and less frequent, and the “snow patterns” on the screen caused by a lung consolidation or other conditions allow health care providers to make rapid, critical, and often lifesaving decisions about patients who are most ill. The total picture of the reflections of an ultrasound beam that is received from the same beam-emitting probe is often blurred. The “artifacts” are often distracting and even prohibitive in making the exact measurements. Figure 8-1 shows an ultrasound image of the intercostal space. Daniel Lichtenstein, known by many as the father of critical care ultrasound, was one of the first experts to recognize that the artifacts emitted in the lungs were not the problem but part of the solution in determining the pulmonary and vascular status of the patient.[3] The notion of lung ultrasound was possible and pertinent through Dr. Lichtenstein and his colleagues’ recognition and hard work.","{'a88c93dc-e581-4a7e-b203-eaf04b6b551f': 'While both systems are housed in the thorax, pulmonary and cardiac ultrasound approaches and findings can be strikingly different. As briefly discussed in the previous chapter, cardiac ultrasound has specific measures used for valves, blood velocity, and cardiac muscle contractility. The operators’ abilities can adversely affect measurement accuracy on such subtle issues as the angle at which the probe is held and, subsequently, the angle at which measurements are obtained. One of the productive uses of artificial intelligence in the ultrasound field allows the operator to know when the best angle of insonation is obtained before the image is captured. Clear imaging is partially achieved by filtering raw images and removing portions of the images that are confusing to obtain the measurements. These measurements then determine important treatment routes, including choosing medication for the patient and even deciding if cardiac surgery is necessary.', '1e9c197f-655a-46c3-8f3d-1cba7b24cc13': 'In many ways, pulmonary ultrasound is the antithesis of cardiac ultrasound. The motion cycle of the lungs is less dramatic and less frequent, and the “snow patterns” on the screen caused by a lung consolidation or other conditions allow health care providers to make rapid, critical, and often lifesaving decisions about patients who are most ill. The total picture of the reflections of an ultrasound beam that is received from the same beam-emitting probe is often blurred. The “artifacts” are often distracting and even prohibitive in making the exact measurements. Figure 8-1 shows an ultrasound image of the intercostal space. Daniel Lichtenstein, known by many as the father of critical care ultrasound, was one of the first experts to recognize that the artifacts emitted in the lungs were not the problem but part of the solution in determining the pulmonary and vascular status of the patient.[3] The notion of lung ultrasound was possible and pertinent through Dr. Lichtenstein and his colleagues’ recognition and hard work.'}"
+Figure 8-2,ultrasound/images/Figure 8-2.jpg,"Figure 8-2: Pleural line with A-lines similar to Figure 8-1, indicating gas below the pleural line. Pneumothorax and the stratosphere sign by Daniel A. Lichtenstein licensed under CC BY 2.0","What have been named “A-lines” are the results of a reverberation artifact from the pleura or recurrent mirror images of the pleura that appear under the pleural lining at regular intervals, as shown in Figure 8-2. Disruption of the interstitium of the pleura changes the entire pleural reflection. Because the beam is prevented from uniformly penetrating the pleura, the areas that are disrupted are now seen as “B-lines,” as shown in Figure 8-3. There is no longer a reverberation artifact or A-lines when there are B-lines in motion.","{'c4b0b8cf-8273-4965-88f4-28c2ba437e94': 'What have been named “A-lines” are the results of a reverberation artifact from the pleura or recurrent mirror images of the pleura that appear under the pleural lining at regular intervals, as shown in Figure 8-2. Disruption of the interstitium of the pleura changes the entire pleural reflection. Because the beam is prevented from uniformly penetrating the pleura, the areas that are disrupted are now seen as “B-lines,” as shown in Figure 8-3. There is no longer a reverberation artifact or A-lines when there are B-lines in motion.', '608a8e3f-e51b-4804-a7cc-6cc986c20841': 'B-lines representing pleural interstitial disruption often represent pulmonary edema or vascular overload, as shown in the right diagram of Figure 8-3. The edema, which collects on the pleural surface, causes “comet tail” artifacts that account for the lines extending the lungs’ entire length. It is often in the realm of intensivists or pulmonologists to ascertain a patient’s intravascular volume. Dr. Lichtenstein was an original contributor to the direct visualization of the inferior vena cava to determine intravascular blood volume. He later discovered that B-lines might more accurately represent intravascular volume overload.'}"
+Figure 8-3,ultrasound/images/Figure 8-3.jpg,Figure 8-3: The image on the left shows four or five B-lines. The image on the right shows twice as many B-lines with two examples of pulmonary edema. Interstitial syndrome and the lung rockets by Daniel A. Lichtenstein licensed under CC BY 2.0,"B-lines representing pleural interstitial disruption often represent pulmonary edema or vascular overload, as shown in the right diagram of Figure 8-3. The edema, which collects on the pleural surface, causes “comet tail” artifacts that account for the lines extending the lungs’ entire length. It is often in the realm of intensivists or pulmonologists to ascertain a patient’s intravascular volume. Dr. Lichtenstein was an original contributor to the direct visualization of the inferior vena cava to determine intravascular blood volume. He later discovered that B-lines might more accurately represent intravascular volume overload.","{'c4b0b8cf-8273-4965-88f4-28c2ba437e94': 'What have been named “A-lines” are the results of a reverberation artifact from the pleura or recurrent mirror images of the pleura that appear under the pleural lining at regular intervals, as shown in Figure 8-2. Disruption of the interstitium of the pleura changes the entire pleural reflection. Because the beam is prevented from uniformly penetrating the pleura, the areas that are disrupted are now seen as “B-lines,” as shown in Figure 8-3. There is no longer a reverberation artifact or A-lines when there are B-lines in motion.', '608a8e3f-e51b-4804-a7cc-6cc986c20841': 'B-lines representing pleural interstitial disruption often represent pulmonary edema or vascular overload, as shown in the right diagram of Figure 8-3. The edema, which collects on the pleural surface, causes “comet tail” artifacts that account for the lines extending the lungs’ entire length. It is often in the realm of intensivists or pulmonologists to ascertain a patient’s intravascular volume. Dr. Lichtenstein was an original contributor to the direct visualization of the inferior vena cava to determine intravascular blood volume. He later discovered that B-lines might more accurately represent intravascular volume overload.'}"
+Figure 8-4,ultrasound/images/Figure 8-4.jpg,"Figure 8-4: B-line artifacts arising from an apparently thickened pleural line. B-line artifacts by Buda N, Cylwik J, Mróz K, Rudzińska R, Dubik P, Malczewska A, Oraczewska A, Skoczyński S, Suska A, Górecki T, Mendrala K, Piotrkowski J, Gola W, Segura-Grau E, Zamojska A, and Wełnicki M licensed under CC BY 4.0","Returning to the earlier chapters, we recall that degrees of brightness represent specific tissue characteristics, such as density. Pleura is one of those highly reflective densities. As the acute phase of COVID-19 disease progresses, distinctive changes may be observed first on lung ultrasound, which warns the clinician that the patient may be quickly worsening. Initially, COVID-19 may begin to change the pleura and cause the patient’s condition to worsen due to pleural thickening and focal fluid collection in some areas. Pleural thickening can be relatively easily seen on lung ultrasound, as shown in Figure 8-4.","{'77438786-bc1e-4e74-bcab-7e34f1ec3447': 'Due to many factors, it is a slippery slope to write anything about COVID-19. The disease is widespread, the actual effectiveness of isolation is unknown, testing has been inaccurate for the most part, supplies to even care for patients have been limited to an unprecedented extent in most developed countries, and the treatment theories change almost daily.', 'a89ad325-338e-4f78-a57f-3c8b40fec1f8': 'Far too many patients diagnosed with COVID-19 have had a rapid downhill course and go on to have a painfully long critical care course with a high mortality rate. For the first time in the world, there have been several considerations brought to the forefront. There has been a common consensus that COVID-19 has caused significant shortages of medical supplies both in the United States and worldwide, including those in testing capacity, ICU and hospital bed supply, hospital staff, personal protective equipment (PPE), and mechanical ventilators for affected regions.[5] There is greatly magnified attention on the safety of caretakers of the most critically ill patients. The mental health and well-being of health care professionals have been the focus of increased attention, with persistent evidence of high burnout, psychosocial stress, and mortality rates.[6] There has been a realization of how the increased vulnerability of our underserved population will perhaps impact how medical care is distributed in the future. The prevalence of COVID-19 has had a disproportionate impact on the poor, minorities, and a broad range of vulnerable populations due to its inequitable spread in areas of dense population and limited mitigation capacity resulting from a high prevalence of chronic conditions or poor access to high-quality public health and medical care.[7] There has been a growing need for more research on health equity in order to increase global knowledge and allow cross-national learning of what works for those most in need due to the direct and collateral effects of COVID-19. It has also been demonstrated that a pandemic can quickly destroy many characteristics of our society, affecting the economic, social, and personal habits of people in all countries. The World Health Organization has warned of a mental health burden related to the spread of COVID-19 infection through the global population: stress, worry, fear, and changes in our daily lives (working from home, temporary unemployment, homeschooling, etc.) are all challenging people’s mental and physical health as well as the global health care system and economy.[8]', '7bc2a51d-280e-4918-b0c6-3d16bf932d13': 'COVID-19 has been a very humbling condition to deal with for any health care professional. Many patients do well even with a positive COVID test. Many patients found to be COVID-positive on routine screening remain asymptomatic. On the other end of the care spectrum, too many people without major risk factors are experiencing significant acute and chronic symptoms from the virus. Many have died, and a handful of them have been health care workers. The objective predictors of who will do well, such as lab tests and plain X-rays, have been inaccurate in too many cases. Especially in developed countries, diagnosticians can usually rely on numerous pieces of data to arrive at a reasonable treatment plan. At the time of this writing, COVID-19 remains a disease where the outcome can be unpredictable in a most painful manner. Patients with comorbidities are indeed at far greater risk of doing poorly, up to the point of having a much higher mortality rate. Age, congestive heart failure, chronic obstructive pulmonary disease, and dementia significantly increase the chance of doing poorly. The realization that an extensive ICU run for patients with limited life expectancy may not be in the best interest of the patient or a society where ICU resources are limited has been a most painful reality for medical workers to consider.', '41aa6553-4191-4b6f-8406-207225b7981c': 'Lung ultrasound with handheld machines has developed into the most useful serial evaluator of the progression of COVID-19 lung disease. One of the challenges during the COVID-19 pandemic is was that several patients had to undergo ultrasound examinations within a limited amount of time, and those ultrasound tests needed to be completed on easily transportable machines. It was imperative for these machines to have the least number of knobs and small unreachable parts or spaces so that they can be sterilized quickly for immediate use with other COVID-19 patients.', '2fcc663c-369b-4692-b4e0-88b5ab0a18a4': 'Returning to the earlier chapters, we recall that degrees of brightness represent specific tissue characteristics, such as density. Pleura is one of those highly reflective densities. As the acute phase of COVID-19 disease progresses, distinctive changes may be observed first on lung ultrasound, which warns the clinician that the patient may be quickly worsening. Initially, COVID-19 may begin to change the pleura and cause the patient’s condition to worsen due to pleural thickening and focal fluid collection in some areas. Pleural thickening can be relatively easily seen on lung ultrasound, as shown in Figure 8-4.', '3b6dfbe8-78cb-4f4e-a815-5eb562a493ef': 'As the thickened pleura from COVID-19 becomes even more inflamed, adhesions can develop in specific areas of the lungs. These adhesions may also be focal so that there may be focal areas of impaired ventilation even on the same side of the lung. As COVID-19 disease progresses, there can be focal infiltrates in the posterior and inferior portions of the lung, which are unique and can be identified on an ultrasound as gray areas (these regions appear anechoic on the normal lungs) commonly referred to as “ground glass”. The nature of the infiltrates with “ground glass” is present. The “ground glass” is from inflammation of the bronchioles and alveoli. This type of inflammation is characteristic of COVID-19.', '9b2f3549-7eb8-4bb8-8472-dfac231d1569': 'It has been suggested that the ultrasound or CT findings of infiltrates in certain distributions can also be used as a diagnostic test suggesting the need for imploring further specific COVID-19-influenced testing. CT almost always presents a more precise view of the anatomic effects of the COVID virus on a patient. Handheld ultrasound is more accurate in evaluating the physiological effects of COVID-19 on ventilation, especially when considering the sliding lung sign. CT is more expensive and delivers more radiation. It may not be as practical to clean thoroughly to prevent droplet transmission of infection.', 'a3572532-9bb2-4ac1-ab16-3630c27c6ab3': 'As opposed to other serious systemic diseases, progressive lung findings may remain focal or become more diffuse in the lungs. As the disease progresses, a more diffuse systemic condition from adhesions and inflammation may develop. This is known as acute respiratory distress syndrome (ARDS), which often leads to the need for ventilator support for several weeks. Several characteristics of COVID-19 have forced ethical discussions of patient care to very different levels from those for patients with other conditions.', 'c04c198c-b11f-4bf8-ae64-cb3903964fff': 'Given the dismal results of cardiopulmonary resuscitation (CPR) in treating patients with COVID and the genuine risk to presumably healthy medical professionals, modifications to CPR have been suggested by many institutions that influence health care actions. These include the following:[9]', '1175afac-cde2-4d92-9d11-94acba8877ae': 'Some of the humbling parts of COVID-19 can be seen in the personal experiences of clinicians who have authentic discussions with patients with COVID-19 and the statistics of their success or failure in helping the most ill:'}"
+Figure 7-1,ultrasound/images/Figure 7-1.jpg,Figure 7-1: Parasternal long-axis view of the heart.,"The position of the heart in the thorax is much more variable than often expected. The heart may be in a more superior or lateral placement in the thoracic cavity due to abdominal anatomical abnormalities. Lung conditions, such as emphysema, may present a heart in a vertical orientation due to chronic lung overdistension. In most healthy individuals, the heart may be best seen in a view called the parasternal long axis, where the probe is held at the second or third intercostal space immediately left of the sternum, as shown in Figure 7-1. Directly below the palpated area will be the chamber walls of the left atrium and the left ventricle.","{'47158f00-ca4f-45c7-b571-0f2ed470caa5': 'The position of the heart in the thorax is much more variable than often expected. The heart may be in a more superior or lateral placement in the thoracic cavity due to abdominal anatomical abnormalities. Lung conditions, such as emphysema, may present a heart in a vertical orientation due to chronic lung overdistension. In most healthy individuals, the heart may be best seen in a view called the parasternal long axis, where the probe is held at the second or third intercostal space immediately left of the sternum, as shown in Figure 7-1. Directly below the palpated area will be the chamber walls of the left atrium and the left ventricle.', '32120b99-a474-4b9c-a1d6-b170d2a95158': 'With optimal health, the heart contracts and expands synchronously. The circulation of the blood in the heart is shown in Figure 7-2. Blood enters the right atrium from the inferior vena cava and the superior vena cava. Blood then flows through the tricuspid valve to the right ventricle during cardiac expansion or diastole; this is mostly a passive flow. Blood is then expelled from the right ventricle during systole (or cardiac contraction) through the pulmonary artery and into the progressively smaller pulmonary arteries, pulmonary arterioles, and finally, pulmonary capillaries. Carbon dioxide and oxygen exchange occurs between the pulmonary capillaries and alveolar sacs of the lungs. Freshly oxygenated blood then returns via the pulmonary veins to the left atrium. Blood flows mostly passively from the left atrium, through the mitral valve, and into the left ventricle during diastole. Blood is finally propelled during systole through the aortic valve into the aorta and the body. The heart adapts to different behavioral and physiological stressors.'}"
+Figure 7-2,ultrasound/images/Figure 7-2.jpg,Figure 7-2: Blood circulation in the heart. Blood Circulation by Wapcaplet licensed under CC BY-SA 3.0,"With optimal health, the heart contracts and expands synchronously. The circulation of the blood in the heart is shown in Figure 7-2. Blood enters the right atrium from the inferior vena cava and the superior vena cava. Blood then flows through the tricuspid valve to the right ventricle during cardiac expansion or diastole; this is mostly a passive flow. Blood is then expelled from the right ventricle during systole (or cardiac contraction) through the pulmonary artery and into the progressively smaller pulmonary arteries, pulmonary arterioles, and finally, pulmonary capillaries. Carbon dioxide and oxygen exchange occurs between the pulmonary capillaries and alveolar sacs of the lungs. Freshly oxygenated blood then returns via the pulmonary veins to the left atrium. Blood flows mostly passively from the left atrium, through the mitral valve, and into the left ventricle during diastole. Blood is finally propelled during systole through the aortic valve into the aorta and the body. The heart adapts to different behavioral and physiological stressors.","{'47158f00-ca4f-45c7-b571-0f2ed470caa5': 'The position of the heart in the thorax is much more variable than often expected. The heart may be in a more superior or lateral placement in the thoracic cavity due to abdominal anatomical abnormalities. Lung conditions, such as emphysema, may present a heart in a vertical orientation due to chronic lung overdistension. In most healthy individuals, the heart may be best seen in a view called the parasternal long axis, where the probe is held at the second or third intercostal space immediately left of the sternum, as shown in Figure 7-1. Directly below the palpated area will be the chamber walls of the left atrium and the left ventricle.', '32120b99-a474-4b9c-a1d6-b170d2a95158': 'With optimal health, the heart contracts and expands synchronously. The circulation of the blood in the heart is shown in Figure 7-2. Blood enters the right atrium from the inferior vena cava and the superior vena cava. Blood then flows through the tricuspid valve to the right ventricle during cardiac expansion or diastole; this is mostly a passive flow. Blood is then expelled from the right ventricle during systole (or cardiac contraction) through the pulmonary artery and into the progressively smaller pulmonary arteries, pulmonary arterioles, and finally, pulmonary capillaries. Carbon dioxide and oxygen exchange occurs between the pulmonary capillaries and alveolar sacs of the lungs. Freshly oxygenated blood then returns via the pulmonary veins to the left atrium. Blood flows mostly passively from the left atrium, through the mitral valve, and into the left ventricle during diastole. Blood is finally propelled during systole through the aortic valve into the aorta and the body. The heart adapts to different behavioral and physiological stressors.'}"
+Figure 6-1,ultrasound/images/Figure 6-1.jpg,Figure 6-1: Some examples of commonly used transducers in musculoskeletal ultrasound assessment.,"Image optimization is obtained by selecting the proper transducer with appropriate frequencies. In general, a high-frequency linear transducer (10 MHz or higher) will be the appropriate selection for the evaluation of most joints. However, sometimes a curvilinear transducer gives better imaging in larger joints and in the evaluation of most adult hips, which usually require deeper penetration for visualization. Another exception would be the evaluation of superficial detailed structures such as the pulley system of the digits in the hand. A hockey stick transducer (>10 MHz) would be more appropriate for better resolution. Figure 6-1 shows some commonly used transducers in musculoskeletal ultrasound assessment. When evaluating a joint, it is helpful to start by directing your angle of insonation to the bony cortex, which is usually the most distal and hyperechoic structure, to avoid anisotropy.[3]","{'5c221601-b7a3-4e59-b718-5266208b8ecf': 'In general, transverse and longitudinal planes (also called sagittal planes) should be obtained of all key anatomic structures and pathologies when performing a diagnostic evaluation. It is always important to know your orientation when visualizing the images. Transducers usually have an indicator on one side at the end of the probe, such as a light, knob, or notch corresponding to the right side of the screen’s image. If you are unsure, just touch one edge of the probe with your finger, and look at the screen to see if you are on the right or left side before imaging. During the evaluation, compare static images, dynamic images, Doppler evaluation, and possible contralateral evaluation. Also, document any masses or fluid collections, such as bursal distension, by indicating the location, size, shape, echotexture, compressibility, and presence or absence of flow with Doppler.[2]', '7dd1c996-580c-4581-ae03-1e6dd86d49c2': 'Image optimization is obtained by selecting the proper transducer with appropriate frequencies. In general, a high-frequency linear transducer (10 MHz or higher) will be the appropriate selection for the evaluation of most joints. However, sometimes a curvilinear transducer gives better imaging in larger joints and in the evaluation of most adult hips, which usually require deeper penetration for visualization. Another exception would be the evaluation of superficial detailed structures such as the pulley system of the digits in the hand. A hockey stick transducer (>10 MHz) would be more appropriate for better resolution. Figure 6-1 shows some commonly used transducers in musculoskeletal ultrasound assessment. When evaluating a joint, it is helpful to start by directing your angle of insonation to the bony cortex, which is usually the most distal and hyperechoic structure, to avoid anisotropy.[3]'}"
+Figure 6-2,ultrasound/images/Figure 6-2.jpg,Figure 6-2: Anterior view of shoulder anatomy.,"Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-3,ultrasound/images/Figure 6-3.jpg,Figure 6-3: Structure of the biceps tendon viewed in the transverse and longitudinal planes.,"The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-4,ultrasound/images/Figure 6-4.jpg,Figure 6-4: Examination of the subscapularis tendon in the sagittal plane.,"After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-5,ultrasound/images/Figure 6-5.jpg,Figure 6-5: Examination of the acromioclavicular joint in the sagittal plane.,"The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-6,ultrasound/images/Figure 6-6.jpg,Figure 6-6: Supraspinatus in the longitudinal (sagittal) view showing the bird’s beak appearance.,"The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-7,ultrasound/images/Figure 6-7.jpg,Figure 6-7: The infraspinatus in the longitudinal (sagittal) plane.,"Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-8,ultrasound/images/Figure 6-8.jpg,Figure 6-8: The posterior glenohumeral joint on ultrasound.,"Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.","{'fb051694-bf0e-46e7-afd8-aff8ec5caa1c': 'Figure 6-2 shows the anterior view of the shoulder anatomy. The shoulder is one of the most accessible joints to perform a comprehensive ultrasound evaluation. An ultrasound evaluation can be as reliable as an MRI for a rotator cuff tear. A complete shoulder evaluation should include the rotator cuff’s tendons and muscles, including the subscapularis, supraspinatus, infraspinatus, and teres minor. Also, examine the biceps brachii (with dynamic maneuvers, if indicated for subluxation, dislocation, or impingement), the acromioclavicular joint, the suprascapular nerve (in the suprascapular notch and the spinoglenoid notch), and the posterior glenohumeral joint.[4] Evaluating each anatomic structure in the transverse and longitudinal planes is essential.', '397a225b-7f03-4991-9b96-a7b1fdc47894': 'For examination of the patient’s shoulder, developing an approach that allows for the best visualization with dynamic maneuvers is helpful. One approach would be to start by standing in front of the seated patient with their arm at their side, the elbow at 90 degrees flexion, the forearm in supination, and the ultrasound machine on one side of the patient for exam visualization.', '1ba3dc4c-f546-4069-9472-bfdfff5d1e55': 'The long-head biceps tendon is the first structure to be evaluated, and it works as a good reference point for the anterior shoulder evaluation. The origin of the long-head biceps is the supraglenoid tubercle of the scapula, and the insertion is the radial tuberosity and bicipital aponeurosis. It is innervated by the musculocutaneous nerve. Its action is flexion and supination of the forearm at the elbow joint and flexion of the arm at the shoulder joint. First, look at the transverse position within the bicipital groove of the humeral head with a linear transducer.', '7b04ce25-19d5-4539-8bb1-08094a8e79eb': 'The biceps tendon should have a bright, dense, ovoid, and bristle-like appearance. It should be assessed from proximal to distal in the transverse and longitudinal planes, as shown in Figure 6-3. It is essential to evaluate the most proximal area where the biceps tendon courses over the humeral head because this is a common site for pathology. Also, fluid distension within the bicipital tendon sheath often indicates shoulder pathology, since part of it communicates with the shoulder joint. Continue the evaluation distally until the fibrous-appearing band of the pectoralis major inserted into the proximal humerus is visualized. This is sometimes where a bicipital tendon tear can be found separated from the muscle after an injury. Dynamic maneuvers, both active and passive, can be very helpful in the evaluation.', 'd4ad118c-a2b4-4553-aab0-33a419a2c9da': 'After looking at the bicipital tendon/muscle, return to the point of reference within the bicipital groove of the humerus in the transverse plane. Next, evaluate the subscapularis, which originates at the subscapular fossa and inserts into the lesser tubercle of the humerus. It is innervated by the upper superior and lower inferior subscapular nerves, and the action is for internal rotation of the humeral head. It prevents anterior displacement of the humerus. First, start by moving the transducer medially to the lesser tuberosity to evaluate the rotator interval, which is the space between the anterior margin of the supraspinatus tendon and the superior margin of the subscapularis tendon. The subscapularis tendon/muscle is evaluated by a passive range of motion with external rotation, as shown in Figure 6-4. This brings the subscapularis into the longitudinal (sagittal) plane as it rotates over the humerus. During this dynamic maneuver, also evaluate for coracoid impingement. A limited view of the anterior glenohumeral joint can also be evaluated in this position. The probe is then rotated 90 degrees clockwise in the transverse plane. In this view, the subscapularis will have a characteristic vertical hypoechoic segmented appearance secondary to the musculoskeletal junction, which is usually normal anatomy and not a tear. The evaluation should again include any evidence of effusion, synovial hypertrophy, or tearing.[5],[6]', '8298e819-4749-4713-a101-0a312bb0343e': 'The next anatomic structure to evaluate in the anterior position of the patient is the acromioclavicular (AC) joint, shown in Figure 6-5. The most straightforward approach is to palpate the AC joint and place the linear transducer on top of it in the transverse plane. Evaluate for widening, such as in a tear or effusion, which is sometimes indicative of rotator cuff pathology.', '9c174bd1-5d63-476c-8fdf-5d2cb3da399f': 'The next rotator cuff to be evaluated is the supraspinatus, which originates in the supraspinatus fossa and is inserted on the superior facet of the greater tubercle of the humerus. Innervation is by the suprascapular nerve; its action is the abduction of the arm and stabilization of the glenohumeral joint. The best position for the patient to be in is called the modified crass position. In this position (which involves extension, adduction, and internal rotation), the patient is sitting upright with the palm of their hand on the ipsilateral hip and the elbow flexed and pointed posteriorly. This brings the supraspinatus out from under the cover of the acromion. Over 90% of rotator cuff injuries involve the supraspinatus.[7],[8] First, evaluate the supraspinatus tendon in the longitudinal plane, as shown in Figure 6-6. This image is the most essential view and should have a bird’s beak appearance. Next, include the transverse plane view. Evaluate the bony cortex, hyaline cartilage, supraspinatus tendon/muscle, peribursal fat, and the subacromial bursa. Pooling of fluid within the subacromial bursa or restrictive motion of the supraspinatus tendon could indicate subacromial impingement.[9]', '810d7bbd-4356-49dc-9916-c3501fd35601': 'It is vital to evaluate the tears of the supraspinatus with the correct description. First, determine if it is a full-thickness tear extending from the articular to the bursal surface or a partial-thickness tear. Partial-thickness tears involve the articular or bursal surface or are localized within the tendon, not extending to either surface. This is called an intrasubstance tear. When evaluating the diameter of the tear, measure along the long and short axis.', '88bfd4f9-b0ba-4d82-9429-7398bbf24370': 'Posterior cuff imaging is evaluated next by facing the posterior shoulder, palpating the scapular spine, and placing the transducer below it in an oblique axial plane angled superiorly toward the humeral head. A curvilinear probe is sometimes needed for better penetration, since the posterior shoulder is a deeper structure. The infraspinatus and teres minor tendons are first evaluated in the longitudinal plane from the scapular fossa’s origin to the humerus’s greater tuberosity, as shown in Figure 6-7. The origin of the infraspinatus is the infraspinatus fossa of the scapula, and the insertion is on the middle facet of the greater tuberosity of the humerus. The suprascapular nerve innervates it, and its action is for external rotation and abduction of the arm at the shoulder joint with stabilization of the shoulder joint. The teres minor originates on the lateral border of the scapula and inserts onto the inferior facet of the greater tuberosity of the humerus. It is innervated by the axillary nerve and functions similarly to the infraspinatus.', '6ea029f0-bcd2-44fb-a0ad-57d5b21e21a1': 'Next, evaluate the suprascapular nerve in the suprascapular notch and the spinoglenoid notch. Sometimes, turning on the Doppler to better visualize the suprascapular artery is helpful, and right next to it is the suprascapular nerve.', 'b30a3821-b75a-4627-99ec-2e3f9bdd1bb7': 'Finally, evaluate the posterior glenohumeral joint, as shown in Figure 6-8. Look for joint effusion, cortical irregularities, and osteophytes, and evaluate the posterior labrum for cysts or tears. Also, this is a good approach for intra-articular glenohumeral joint injections using a posterior approach. This completes the shoulder evaluation.'}"
+Figure 6-11,ultrasound/images/Figure 6-11.jpg,"Figure 6-11: Side-by-side pictures of the transducer position on the elbow and anterior transverse elbow imaging of the anterior recess (AR), radial nerve (RN), brachial artery (BA), median nerve (MN), biceps (BI), and brachialis (BR) just proximal to the elbow crease. The abbreviations given here and labeled on the ultrasound images represent the corresponding structures.","Anteriorly, look at the joint space for narrowing, cortical and cartilage irregularities, synovial hypertrophy, and effusion. Also evaluate the brachialis, biceps, median and radial nerves, and the brachial artery, as shown in Figure 6-11.","{'437ee1cb-dd32-486c-9a28-c7568c7b1a1e': 'The entire elbow examination is usually accomplished with a linear transducer. Like all the other joints, the elbow is best evaluated in a quadrant approach: anterior, medial, lateral, and posterior. Figures 6-9 and 6-10 show the anatomical structures of the elbow.', 'cc785d45-d3a5-4eaa-9e8a-ecad96c7601c': 'Anteriorly, look at the joint space for narrowing, cortical and cartilage irregularities, synovial hypertrophy, and effusion. Also evaluate the brachialis, biceps, median and radial nerves, and the brachial artery, as shown in Figure 6-11.', '5a3f3656-284d-4854-a00f-846b35ab211c': 'Next, the medial elbow evaluation is performed with the elbow in partial extension and the probe in a longitudinal axis, as shown in Figure 6-12. Evaluate the anterior band of the ulnar collateral ligament (UCL). It will have a characteristic triangular homogenous appearance as it spans from its attachment proximally to the humeral trochlea and distally to the olecranon. The common flexor tendon is superficial to the UCL and evaluated carefully at the insertion point of the medial epicondyle, since this is the site of medial epicondylitis. The pronator teres should also be examined for any evidence of tears, effusion, or synovial hypertrophy.[10],[11]', 'b6c7d8fd-5af9-4382-b818-8018dfcc11c6': 'The lateral elbow is next approached with the elbow flexed at 90 degrees and the ipsilateral hand resting in pronation, as shown in Figure 6-13. A longitudinal probe placement is performed to evaluate the bony margins of the capitulum of the humerus and the radial head. Evaluate the radial collateral ligament complex and the common extensor tendon (CET). Closely evaluate the attachment of the CET to the lateral epicondyle, the site of lateral epicondylitis.', 'f89fcac1-24df-49f8-9c52-e4d65001c6c2': 'Finally, the posterior evaluation is performed with the elbow at approximately 90 degrees of flexion, as shown in Figure 6-14. Evaluate the triceps muscle and tendon, olecranon bursa, and the ulnar nerve within the groove between the medial epicondyle and the olecranon of the ulna. This can be a site for entrapment of the ulnar nerve, which should have an area of 7 mm or less.[12],[13]'}"
+Figure 6-12,ultrasound/images/Figure 6-12.jpg,Figure 6-12: Side-by-side pictures of the transducer position and a longitudinal image of the medial elbow showing the common flexor tendon (CFT).,"Next, the medial elbow evaluation is performed with the elbow in partial extension and the probe in a longitudinal axis, as shown in Figure 6-12. Evaluate the anterior band of the ulnar collateral ligament (UCL). It will have a characteristic triangular homogenous appearance as it spans from its attachment proximally to the humeral trochlea and distally to the olecranon. The common flexor tendon is superficial to the UCL and evaluated carefully at the insertion point of the medial epicondyle, since this is the site of medial epicondylitis. The pronator teres should also be examined for any evidence of tears, effusion, or synovial hypertrophy.[10],[11]","{'437ee1cb-dd32-486c-9a28-c7568c7b1a1e': 'The entire elbow examination is usually accomplished with a linear transducer. Like all the other joints, the elbow is best evaluated in a quadrant approach: anterior, medial, lateral, and posterior. Figures 6-9 and 6-10 show the anatomical structures of the elbow.', 'cc785d45-d3a5-4eaa-9e8a-ecad96c7601c': 'Anteriorly, look at the joint space for narrowing, cortical and cartilage irregularities, synovial hypertrophy, and effusion. Also evaluate the brachialis, biceps, median and radial nerves, and the brachial artery, as shown in Figure 6-11.', '5a3f3656-284d-4854-a00f-846b35ab211c': 'Next, the medial elbow evaluation is performed with the elbow in partial extension and the probe in a longitudinal axis, as shown in Figure 6-12. Evaluate the anterior band of the ulnar collateral ligament (UCL). It will have a characteristic triangular homogenous appearance as it spans from its attachment proximally to the humeral trochlea and distally to the olecranon. The common flexor tendon is superficial to the UCL and evaluated carefully at the insertion point of the medial epicondyle, since this is the site of medial epicondylitis. The pronator teres should also be examined for any evidence of tears, effusion, or synovial hypertrophy.[10],[11]', 'b6c7d8fd-5af9-4382-b818-8018dfcc11c6': 'The lateral elbow is next approached with the elbow flexed at 90 degrees and the ipsilateral hand resting in pronation, as shown in Figure 6-13. A longitudinal probe placement is performed to evaluate the bony margins of the capitulum of the humerus and the radial head. Evaluate the radial collateral ligament complex and the common extensor tendon (CET). Closely evaluate the attachment of the CET to the lateral epicondyle, the site of lateral epicondylitis.', 'f89fcac1-24df-49f8-9c52-e4d65001c6c2': 'Finally, the posterior evaluation is performed with the elbow at approximately 90 degrees of flexion, as shown in Figure 6-14. Evaluate the triceps muscle and tendon, olecranon bursa, and the ulnar nerve within the groove between the medial epicondyle and the olecranon of the ulna. This can be a site for entrapment of the ulnar nerve, which should have an area of 7 mm or less.[12],[13]'}"
+Figure 6-13,ultrasound/images/Figure 6-13.jpg,"Figure 6-13: Side-by-side pictures of the transducer position and a longitudinal image of the lateral elbow showing the common extensor tendon (CET), lateral epicondyle (LE), and radial head (RH). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.","The lateral elbow is next approached with the elbow flexed at 90 degrees and the ipsilateral hand resting in pronation, as shown in Figure 6-13. A longitudinal probe placement is performed to evaluate the bony margins of the capitulum of the humerus and the radial head. Evaluate the radial collateral ligament complex and the common extensor tendon (CET). Closely evaluate the attachment of the CET to the lateral epicondyle, the site of lateral epicondylitis.","{'437ee1cb-dd32-486c-9a28-c7568c7b1a1e': 'The entire elbow examination is usually accomplished with a linear transducer. Like all the other joints, the elbow is best evaluated in a quadrant approach: anterior, medial, lateral, and posterior. Figures 6-9 and 6-10 show the anatomical structures of the elbow.', 'cc785d45-d3a5-4eaa-9e8a-ecad96c7601c': 'Anteriorly, look at the joint space for narrowing, cortical and cartilage irregularities, synovial hypertrophy, and effusion. Also evaluate the brachialis, biceps, median and radial nerves, and the brachial artery, as shown in Figure 6-11.', '5a3f3656-284d-4854-a00f-846b35ab211c': 'Next, the medial elbow evaluation is performed with the elbow in partial extension and the probe in a longitudinal axis, as shown in Figure 6-12. Evaluate the anterior band of the ulnar collateral ligament (UCL). It will have a characteristic triangular homogenous appearance as it spans from its attachment proximally to the humeral trochlea and distally to the olecranon. The common flexor tendon is superficial to the UCL and evaluated carefully at the insertion point of the medial epicondyle, since this is the site of medial epicondylitis. The pronator teres should also be examined for any evidence of tears, effusion, or synovial hypertrophy.[10],[11]', 'b6c7d8fd-5af9-4382-b818-8018dfcc11c6': 'The lateral elbow is next approached with the elbow flexed at 90 degrees and the ipsilateral hand resting in pronation, as shown in Figure 6-13. A longitudinal probe placement is performed to evaluate the bony margins of the capitulum of the humerus and the radial head. Evaluate the radial collateral ligament complex and the common extensor tendon (CET). Closely evaluate the attachment of the CET to the lateral epicondyle, the site of lateral epicondylitis.', 'f89fcac1-24df-49f8-9c52-e4d65001c6c2': 'Finally, the posterior evaluation is performed with the elbow at approximately 90 degrees of flexion, as shown in Figure 6-14. Evaluate the triceps muscle and tendon, olecranon bursa, and the ulnar nerve within the groove between the medial epicondyle and the olecranon of the ulna. This can be a site for entrapment of the ulnar nerve, which should have an area of 7 mm or less.[12],[13]'}"
+Figure 6-14,ultrasound/images/Figure 6-14.jpg,Figure 6-14: Side-by-side pictures of the transducer position and a posterior longitudinal image of the elbow showing the triceps tendon (TT) and the olecranon fossa (F). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.,"Finally, the posterior evaluation is performed with the elbow at approximately 90 degrees of flexion, as shown in Figure 6-14. Evaluate the triceps muscle and tendon, olecranon bursa, and the ulnar nerve within the groove between the medial epicondyle and the olecranon of the ulna. This can be a site for entrapment of the ulnar nerve, which should have an area of 7 mm or less.[12],[13]","{'437ee1cb-dd32-486c-9a28-c7568c7b1a1e': 'The entire elbow examination is usually accomplished with a linear transducer. Like all the other joints, the elbow is best evaluated in a quadrant approach: anterior, medial, lateral, and posterior. Figures 6-9 and 6-10 show the anatomical structures of the elbow.', 'cc785d45-d3a5-4eaa-9e8a-ecad96c7601c': 'Anteriorly, look at the joint space for narrowing, cortical and cartilage irregularities, synovial hypertrophy, and effusion. Also evaluate the brachialis, biceps, median and radial nerves, and the brachial artery, as shown in Figure 6-11.', '5a3f3656-284d-4854-a00f-846b35ab211c': 'Next, the medial elbow evaluation is performed with the elbow in partial extension and the probe in a longitudinal axis, as shown in Figure 6-12. Evaluate the anterior band of the ulnar collateral ligament (UCL). It will have a characteristic triangular homogenous appearance as it spans from its attachment proximally to the humeral trochlea and distally to the olecranon. The common flexor tendon is superficial to the UCL and evaluated carefully at the insertion point of the medial epicondyle, since this is the site of medial epicondylitis. The pronator teres should also be examined for any evidence of tears, effusion, or synovial hypertrophy.[10],[11]', 'b6c7d8fd-5af9-4382-b818-8018dfcc11c6': 'The lateral elbow is next approached with the elbow flexed at 90 degrees and the ipsilateral hand resting in pronation, as shown in Figure 6-13. A longitudinal probe placement is performed to evaluate the bony margins of the capitulum of the humerus and the radial head. Evaluate the radial collateral ligament complex and the common extensor tendon (CET). Closely evaluate the attachment of the CET to the lateral epicondyle, the site of lateral epicondylitis.', 'f89fcac1-24df-49f8-9c52-e4d65001c6c2': 'Finally, the posterior evaluation is performed with the elbow at approximately 90 degrees of flexion, as shown in Figure 6-14. Evaluate the triceps muscle and tendon, olecranon bursa, and the ulnar nerve within the groove between the medial epicondyle and the olecranon of the ulna. This can be a site for entrapment of the ulnar nerve, which should have an area of 7 mm or less.[12],[13]'}"
+Figure 6-15,ultrasound/images/Figure 6-15.jpg,Figure 6-15: Schematic of the wrist and hand anatomy.,"The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-17,ultrasound/images/Figure 6-17.jpg,Figure 6-17: Schematic of the cross-sectional view of the wrist.,"Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-17,ultrasound/images/Figure 6-17.jpg,Figure 6-17: Schematic of the cross-sectional view of the wrist.,"Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-18,ultrasound/images/Figure 6-18.jpg,Figure 6-18: Dorsal wrist image of the scapholunate ligament (SCL).,"After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-19,ultrasound/images/Figure 6-19.jpg,Figure 6-19: Side-by-side pictures of the transducer position and volar wrist showing the median nerve (MN) and flexor carpi radialis (FCR). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.,"Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-20,ultrasound/images/Figure 6-20.jpg,Figure 6-20: Side-by-side pictures of the transducer position and sagittal volar hand imaging of the metacarpal phalangeal joint (MCP) and the flexor tendon (FT). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.,"Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]","{'3f8f509f-f991-4857-857d-3520d9fe56e9': 'The wrist and hand anatomy involve superficial structures; therefore, the best approach is to use a high-frequency hockey stick transducer for better resolution. Figure 6-15 shows the anatomical structure of the wrist and hand.', 'a628bb34-f0b1-4427-9f29-70ab1bd78309': 'Start with the palm of the hand facing down. Identify Lister’s tubercle (see Figure 6-17) on the dorsum of the distal radius by digital palpation, and place the transducer on top of it in a transverse plane, as shown in Figure 6-16. This bony prominence separates the second and third extensor tendon compartments of the six in the wrist and helps with identification and orientation. Just radial to Lister’s tubercle is the second compartment containing the extensor carpi radialis brevis and the extensor carpi radialis longus.', '584de14e-d711-4c77-9a9f-6956272be08e': 'With further radial movement, the first compartment on the side of the wrist is identified, which contains extensor pollicis brevis and abductor pollicis longus tendons. The first compartment is the site of de Quervain’s tenosynovitis. Evaluate each compartment from proximal to distal in both planes with active and passive dynamic maneuvers depending on the clinical concerns. Superficial to the compartments is the extensor retinaculum.', '370de007-9a12-47c6-80ca-af329ecff6a1': 'The third compartment is on the ulnar aspect of Lister’s tubercle and contains the extensor pollicis longus, as shown in Figure 6-17. Moving further toward the ulna, next to the third compartment, is the fourth compartment, which contains multiple extensor digitorum tendons and extensor indicis. Compartment five contains the extensor digiti minimi, and the sixth compartment contains the extensor carpi ulnaris, as shown in Figure 6-17. Evaluate each for any pathology.', 'bc0c05fb-ff3a-4ae9-87f2-48922564f601': 'After evaluating each compartment, return to Lister’s tubercle in the transverse plane, and move the probe distally to the radiocarpal joint. The bone just distal to the radius is the scaphoid, and the lunate bone is next to the scaphoid in the ulnar direction. Between the dorsal aspects of both bones is a triangular area that represents the scapholunate ligament, which has a compact hyperechoic fibrillar echotexture, as shown in Figure 6-18. This is a common site for injuries from falls involving extended wrists that could result in a tear of the scapholunate ligament. It is also a common site for ganglion cysts.', '713b8385-c361-453d-ae19-664116b78afc': 'Now rotate the hand to evaluate the volar aspect, as shown in Figure 6-19. Evaluate the median nerve, flexor tendons, volar joint recesses, flexor carpi radialis, palmaris longus, and radial artery and the flexor tendons, pulleys, volar plates, collateral ligaments, and joint recesses of the fingers as clinically indicated. The median nerve is found between the flexor carpi radialis and palmaris longus. Place the transducer between these two tendons in the distal wrist crease in the transverse plane, and move the probe proximally as the honeycomb appearance of the median nerve courses radial to the flexor tendons and then moves ulnar and deep between the flexor digitorum superficialis and profundus. If the median nerve has a cross-sectional area of 12 mm2 or greater, this suggests carpal tunnel syndrome. Also, a 2 mm2 or greater difference in the cross-sectional area of the median nerve measured proximally at the level of the pronator quadratus and distally at the level of carpal tunnel has a 99% accuracy for carpal tunnel syndrome.[14]', 'f2567925-2688-4770-b776-a7a35919fef4': 'Finally, individual digits should be evaluated in the transverse and longitudinal planes using dynamic maneuvers as clinically indicated for the evaluation of pathology. There are five flexor tendon pulleys in the fingers, which are named A1–A5 and consist of annular ligament pulleys and cruciate pulleys—that is, the flexor tendon pulley system. The thumb only has two pulleys, which are labeled A1 and A2. When evaluating the pulley system in the digits, the A2 and A4 pulleys are most important in the sagittal plane, as shown in Figure 6-20. If pathology is present, this may demonstrate bowstringing and hypoechoic edema.[15]'}"
+Figure 6-21,ultrasound/images/Figure 6-21.jpg,Figure 6-21: Anterior schematic of the skeletal structure and tendons of the hip.,"Figure 6-21 shows a schematic of the skeletal structure and tendons of the hip. The low-frequency curvilinear transducer is most appropriate for hip evaluation. Start with the anterior evaluation by having the patient supine with the ipsilateral leg in full extension and with slight external rotation, as shown in Figure 6-22.","{'22aca1c1-1504-4acb-84e5-3e9979c51c2e': 'Figure 6-21 shows a schematic of the skeletal structure and tendons of the hip. The low-frequency curvilinear transducer is most appropriate for hip evaluation. Start with the anterior evaluation by having the patient supine with the ipsilateral leg in full extension and with slight external rotation, as shown in Figure 6-22.', 'cdb9e49a-d342-40d9-acc6-b55c5a42d0cf': 'Superficial to the capsule is the potential space between the capsule and the iliopsoas muscle, which is the iliopsoas bursa. This is the largest bursa in the human body, and an iliopsoas bursitis would be considered an extracapsular effusion. Like hip capsulitis, iliopsoas bursitis can be approached with an injection—but more superficial. The iliopsoas tendon is then evaluated by placing the transducer in the longitudinal plane in line with the femoral shaft and medial. The iliopsoas is a conjoined muscle composed of the iliacus and the psoas major muscles, which attach to the intertrochanteric line of the femur. This is evaluated from proximal to distal in the longitudinal and transverse planes. Also, consider evaluating the femoral vessels and nerve, sartorius muscle, tensor fascia lata tendons and muscles, lateral femoral cutaneous nerve, and rectus femoris tendon and muscles. Dynamic hip maneuvers may also help evaluate for tears, subluxation, or dislocation.[16]', 'c77d6dd7-4d5f-44b4-b714-beae6b996bd9': 'Now have the patient in the lateral decubitus position with the hip to be evaluated up in a flexed 20–30 degree position to examine the gluteus muscles and tendons, as shown in Figures 6-23 through 6-25. The gluteus minimus, which is deep to the gluteus medius, originates from the ilium between the inferior and anterior gluteal lines. It inserts onto both the anterior aspect of the capsule and via its long head onto the anterior surface of the greater trochanter. The gluteus minimus and gluteus medius work together to abduct and internally rotate the hip. Finally, the gluteus maximus starts in the posterior iliac crest and sacrum/coccyx, crosses over the posterior facet, and inserts into the proximal femur, as Figure 6-25 shows. It extends and laterally rotates the hip.', '0c0d884d-e832-424b-ada8-a45a7074335b': 'To visualize the tendons in the sagittal plane, rotate the probe 90 degrees and angle the beam anterior to posterior to visualize the gluteus minimus and posterior to anterior to visualize the gluteus medius, as shown in Figure 6-24, and the gluteus maximus, as shown in Figure 6-25.', '799095d3-ea8c-42e1-8e69-ac0488656125': 'To evaluate the hamstrings, first identify the ischial tuberosity to locate the origins of the semimembranosus, biceps femoris, and semitendinosus tendons. Locate the conjoined tendons of the biceps femoris and semitendinosus, as shown in Figure 6-26. The semimembranosus lies deep and usually slightly inferior to the conjoined tendons.'}"
+Figure 6-25,ultrasound/images/Figure 6-25.jpg,Figure 6-25: Side-by-side pictures of the transducer position and image of the gluteus maximus (GMAX) in the sagittal plane.,"Now have the patient in the lateral decubitus position with the hip to be evaluated up in a flexed 20–30 degree position to examine the gluteus muscles and tendons, as shown in Figures 6-23 through 6-25. The gluteus minimus, which is deep to the gluteus medius, originates from the ilium between the inferior and anterior gluteal lines. It inserts onto both the anterior aspect of the capsule and via its long head onto the anterior surface of the greater trochanter. The gluteus minimus and gluteus medius work together to abduct and internally rotate the hip. Finally, the gluteus maximus starts in the posterior iliac crest and sacrum/coccyx, crosses over the posterior facet, and inserts into the proximal femur, as Figure 6-25 shows. It extends and laterally rotates the hip.","{'22aca1c1-1504-4acb-84e5-3e9979c51c2e': 'Figure 6-21 shows a schematic of the skeletal structure and tendons of the hip. The low-frequency curvilinear transducer is most appropriate for hip evaluation. Start with the anterior evaluation by having the patient supine with the ipsilateral leg in full extension and with slight external rotation, as shown in Figure 6-22.', 'cdb9e49a-d342-40d9-acc6-b55c5a42d0cf': 'Superficial to the capsule is the potential space between the capsule and the iliopsoas muscle, which is the iliopsoas bursa. This is the largest bursa in the human body, and an iliopsoas bursitis would be considered an extracapsular effusion. Like hip capsulitis, iliopsoas bursitis can be approached with an injection—but more superficial. The iliopsoas tendon is then evaluated by placing the transducer in the longitudinal plane in line with the femoral shaft and medial. The iliopsoas is a conjoined muscle composed of the iliacus and the psoas major muscles, which attach to the intertrochanteric line of the femur. This is evaluated from proximal to distal in the longitudinal and transverse planes. Also, consider evaluating the femoral vessels and nerve, sartorius muscle, tensor fascia lata tendons and muscles, lateral femoral cutaneous nerve, and rectus femoris tendon and muscles. Dynamic hip maneuvers may also help evaluate for tears, subluxation, or dislocation.[16]', 'c77d6dd7-4d5f-44b4-b714-beae6b996bd9': 'Now have the patient in the lateral decubitus position with the hip to be evaluated up in a flexed 20–30 degree position to examine the gluteus muscles and tendons, as shown in Figures 6-23 through 6-25. The gluteus minimus, which is deep to the gluteus medius, originates from the ilium between the inferior and anterior gluteal lines. It inserts onto both the anterior aspect of the capsule and via its long head onto the anterior surface of the greater trochanter. The gluteus minimus and gluteus medius work together to abduct and internally rotate the hip. Finally, the gluteus maximus starts in the posterior iliac crest and sacrum/coccyx, crosses over the posterior facet, and inserts into the proximal femur, as Figure 6-25 shows. It extends and laterally rotates the hip.', '0c0d884d-e832-424b-ada8-a45a7074335b': 'To visualize the tendons in the sagittal plane, rotate the probe 90 degrees and angle the beam anterior to posterior to visualize the gluteus minimus and posterior to anterior to visualize the gluteus medius, as shown in Figure 6-24, and the gluteus maximus, as shown in Figure 6-25.', '799095d3-ea8c-42e1-8e69-ac0488656125': 'To evaluate the hamstrings, first identify the ischial tuberosity to locate the origins of the semimembranosus, biceps femoris, and semitendinosus tendons. Locate the conjoined tendons of the biceps femoris and semitendinosus, as shown in Figure 6-26. The semimembranosus lies deep and usually slightly inferior to the conjoined tendons.'}"
+Figure 6-24,ultrasound/images/Figure 6-24.jpg,Figure 6-24: Side-by-side pictures of the transducer position and image of the gluteus medius (GMED) in the sagittal plane.,"To visualize the tendons in the sagittal plane, rotate the probe 90 degrees and angle the beam anterior to posterior to visualize the gluteus minimus and posterior to anterior to visualize the gluteus medius, as shown in Figure 6-24, and the gluteus maximus, as shown in Figure 6-25.","{'22aca1c1-1504-4acb-84e5-3e9979c51c2e': 'Figure 6-21 shows a schematic of the skeletal structure and tendons of the hip. The low-frequency curvilinear transducer is most appropriate for hip evaluation. Start with the anterior evaluation by having the patient supine with the ipsilateral leg in full extension and with slight external rotation, as shown in Figure 6-22.', 'cdb9e49a-d342-40d9-acc6-b55c5a42d0cf': 'Superficial to the capsule is the potential space between the capsule and the iliopsoas muscle, which is the iliopsoas bursa. This is the largest bursa in the human body, and an iliopsoas bursitis would be considered an extracapsular effusion. Like hip capsulitis, iliopsoas bursitis can be approached with an injection—but more superficial. The iliopsoas tendon is then evaluated by placing the transducer in the longitudinal plane in line with the femoral shaft and medial. The iliopsoas is a conjoined muscle composed of the iliacus and the psoas major muscles, which attach to the intertrochanteric line of the femur. This is evaluated from proximal to distal in the longitudinal and transverse planes. Also, consider evaluating the femoral vessels and nerve, sartorius muscle, tensor fascia lata tendons and muscles, lateral femoral cutaneous nerve, and rectus femoris tendon and muscles. Dynamic hip maneuvers may also help evaluate for tears, subluxation, or dislocation.[16]', 'c77d6dd7-4d5f-44b4-b714-beae6b996bd9': 'Now have the patient in the lateral decubitus position with the hip to be evaluated up in a flexed 20–30 degree position to examine the gluteus muscles and tendons, as shown in Figures 6-23 through 6-25. The gluteus minimus, which is deep to the gluteus medius, originates from the ilium between the inferior and anterior gluteal lines. It inserts onto both the anterior aspect of the capsule and via its long head onto the anterior surface of the greater trochanter. The gluteus minimus and gluteus medius work together to abduct and internally rotate the hip. Finally, the gluteus maximus starts in the posterior iliac crest and sacrum/coccyx, crosses over the posterior facet, and inserts into the proximal femur, as Figure 6-25 shows. It extends and laterally rotates the hip.', '0c0d884d-e832-424b-ada8-a45a7074335b': 'To visualize the tendons in the sagittal plane, rotate the probe 90 degrees and angle the beam anterior to posterior to visualize the gluteus minimus and posterior to anterior to visualize the gluteus medius, as shown in Figure 6-24, and the gluteus maximus, as shown in Figure 6-25.', '799095d3-ea8c-42e1-8e69-ac0488656125': 'To evaluate the hamstrings, first identify the ischial tuberosity to locate the origins of the semimembranosus, biceps femoris, and semitendinosus tendons. Locate the conjoined tendons of the biceps femoris and semitendinosus, as shown in Figure 6-26. The semimembranosus lies deep and usually slightly inferior to the conjoined tendons.'}"
+Figure 6-26,ultrasound/images/Figure 6-26.jpg,Figure 6-26: Sagittal hip image of the conjoined tendons (CT) of the biceps femoris and semitendinosus into the ischial tuberosity (IT). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.,"To evaluate the hamstrings, first identify the ischial tuberosity to locate the origins of the semimembranosus, biceps femoris, and semitendinosus tendons. Locate the conjoined tendons of the biceps femoris and semitendinosus, as shown in Figure 6-26. The semimembranosus lies deep and usually slightly inferior to the conjoined tendons.","{'22aca1c1-1504-4acb-84e5-3e9979c51c2e': 'Figure 6-21 shows a schematic of the skeletal structure and tendons of the hip. The low-frequency curvilinear transducer is most appropriate for hip evaluation. Start with the anterior evaluation by having the patient supine with the ipsilateral leg in full extension and with slight external rotation, as shown in Figure 6-22.', 'cdb9e49a-d342-40d9-acc6-b55c5a42d0cf': 'Superficial to the capsule is the potential space between the capsule and the iliopsoas muscle, which is the iliopsoas bursa. This is the largest bursa in the human body, and an iliopsoas bursitis would be considered an extracapsular effusion. Like hip capsulitis, iliopsoas bursitis can be approached with an injection—but more superficial. The iliopsoas tendon is then evaluated by placing the transducer in the longitudinal plane in line with the femoral shaft and medial. The iliopsoas is a conjoined muscle composed of the iliacus and the psoas major muscles, which attach to the intertrochanteric line of the femur. This is evaluated from proximal to distal in the longitudinal and transverse planes. Also, consider evaluating the femoral vessels and nerve, sartorius muscle, tensor fascia lata tendons and muscles, lateral femoral cutaneous nerve, and rectus femoris tendon and muscles. Dynamic hip maneuvers may also help evaluate for tears, subluxation, or dislocation.[16]', 'c77d6dd7-4d5f-44b4-b714-beae6b996bd9': 'Now have the patient in the lateral decubitus position with the hip to be evaluated up in a flexed 20–30 degree position to examine the gluteus muscles and tendons, as shown in Figures 6-23 through 6-25. The gluteus minimus, which is deep to the gluteus medius, originates from the ilium between the inferior and anterior gluteal lines. It inserts onto both the anterior aspect of the capsule and via its long head onto the anterior surface of the greater trochanter. The gluteus minimus and gluteus medius work together to abduct and internally rotate the hip. Finally, the gluteus maximus starts in the posterior iliac crest and sacrum/coccyx, crosses over the posterior facet, and inserts into the proximal femur, as Figure 6-25 shows. It extends and laterally rotates the hip.', '0c0d884d-e832-424b-ada8-a45a7074335b': 'To visualize the tendons in the sagittal plane, rotate the probe 90 degrees and angle the beam anterior to posterior to visualize the gluteus minimus and posterior to anterior to visualize the gluteus medius, as shown in Figure 6-24, and the gluteus maximus, as shown in Figure 6-25.', '799095d3-ea8c-42e1-8e69-ac0488656125': 'To evaluate the hamstrings, first identify the ischial tuberosity to locate the origins of the semimembranosus, biceps femoris, and semitendinosus tendons. Locate the conjoined tendons of the biceps femoris and semitendinosus, as shown in Figure 6-26. The semimembranosus lies deep and usually slightly inferior to the conjoined tendons.'}"
+Figure 6-28,ultrasound/images/Figure 6-28.jpg,"Figure 6-28: Side-by-side pictures of the transducer position and transverse image of rectus femoris (RF), vastus medialis (VM), vastus lateralis (VL), and vastus intermedius (VI). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.","Start the evaluation by using a high-frequency linear transducer and having the patient in the supine position. The anterior evaluation starts in the suprapatellar area with the probe in line with the femur, as shown in Figure 6-28.","{'3d24aaee-cd0a-4cd4-85dc-0620ac5282a6': 'Start the evaluation by using a high-frequency linear transducer and having the patient in the supine position. The anterior evaluation starts in the suprapatellar area with the probe in line with the femur, as shown in Figure 6-28.', 'da240aa9-8e4f-4c96-8b89-37d8277a0932': 'Evaluate the following structures from deep to superficial, starting with the bony cortex of the femur, the quadriceps muscles and fascial planes, the femoral trochlea, the prefemoral fat pad, the suprapatellar bursa, and the suprapatellar fat pad. Evaluate proximally from the quadriceps muscle to the distal area over the patella in the longitudinal and transverse planes, looking for any pathology such as effusion or tears, as shown in Figures 6-29 and 6-30. It is sometimes helpful to perform toggling and heel-to-toe maneuvers to fine-tune the anatomy and avoid anisotropy.', '1ed09168-b376-4337-9334-24ba2090fabf': 'Next, slide the transducer medially, and evaluate the medial aspect of the knee joint from the femoral to the tibial condyles in the sagittal and transverse planes, as shown in Figures 6-31 and 6-32. Also, evaluate the medial collateral ligament and the medial meniscus in the joint space. As you move the transducer distally, evaluate the pes anserine complex for any evidence of injury or inflammation, such as pes anserine bursitis.', 'b3a13ade-c40e-4f20-a4cb-b8b6db876029': 'Next, slide the probe to the lateral aspect of the knee joint, and evaluate the joint space of the distal femur and fibular head, as shown in Figure 6-33. In the longitudinal and transverse planes, evaluate the peripheral margin of the lateral meniscus and the lateral collateral ligament from proximal to distal.', 'e08d1f5a-66a6-4ea0-82d9-c34dbbf988b2': 'Next, scan the infrapatellar area in the longitudinal plane with the bony landmarks proximally of the femur and tibia joint space and distally of the proximal tibia, as shown in Figure 6-34. Keep light pressure on the probe to avoid compressing any possible fluid within the bursa. There are two bursae superficial to the patellar tendon near the patella and one deep to the patellar ligament in the area of the proximal tibia. Evaluate the patellar ligament, sometimes called the patellar tendon, which is the portion of the quadriceps femoris tendon that continues from the patella to the tibial tuberosity.', '16a00555-ca8f-47d5-8314-ffece92b88ab': 'Finally, the posterior view of the knee is evaluated with the knee slightly flexed at 10–20 degrees, as shown in Figure 6-35. Many structures can be seen in the popliteal fossa, including the popliteal artery and vein. One important area to evaluate is the area between the medial head of the gastrocnemius muscle and the semimembranosus tendon, which is the usual site of a Baker’s cyst. This completes the knee evaluation.'}"
+Figure 6-33,ultrasound/images/Figure 6-33.jpg,"Figure 6-33: Side-by-side pictures of the transducer position and image of the lateral meniscus (LM), lateral collateral ligament (LCL), and popliteus (P). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.","Next, slide the probe to the lateral aspect of the knee joint, and evaluate the joint space of the distal femur and fibular head, as shown in Figure 6-33. In the longitudinal and transverse planes, evaluate the peripheral margin of the lateral meniscus and the lateral collateral ligament from proximal to distal.","{'3d24aaee-cd0a-4cd4-85dc-0620ac5282a6': 'Start the evaluation by using a high-frequency linear transducer and having the patient in the supine position. The anterior evaluation starts in the suprapatellar area with the probe in line with the femur, as shown in Figure 6-28.', 'da240aa9-8e4f-4c96-8b89-37d8277a0932': 'Evaluate the following structures from deep to superficial, starting with the bony cortex of the femur, the quadriceps muscles and fascial planes, the femoral trochlea, the prefemoral fat pad, the suprapatellar bursa, and the suprapatellar fat pad. Evaluate proximally from the quadriceps muscle to the distal area over the patella in the longitudinal and transverse planes, looking for any pathology such as effusion or tears, as shown in Figures 6-29 and 6-30. It is sometimes helpful to perform toggling and heel-to-toe maneuvers to fine-tune the anatomy and avoid anisotropy.', '1ed09168-b376-4337-9334-24ba2090fabf': 'Next, slide the transducer medially, and evaluate the medial aspect of the knee joint from the femoral to the tibial condyles in the sagittal and transverse planes, as shown in Figures 6-31 and 6-32. Also, evaluate the medial collateral ligament and the medial meniscus in the joint space. As you move the transducer distally, evaluate the pes anserine complex for any evidence of injury or inflammation, such as pes anserine bursitis.', 'b3a13ade-c40e-4f20-a4cb-b8b6db876029': 'Next, slide the probe to the lateral aspect of the knee joint, and evaluate the joint space of the distal femur and fibular head, as shown in Figure 6-33. In the longitudinal and transverse planes, evaluate the peripheral margin of the lateral meniscus and the lateral collateral ligament from proximal to distal.', 'e08d1f5a-66a6-4ea0-82d9-c34dbbf988b2': 'Next, scan the infrapatellar area in the longitudinal plane with the bony landmarks proximally of the femur and tibia joint space and distally of the proximal tibia, as shown in Figure 6-34. Keep light pressure on the probe to avoid compressing any possible fluid within the bursa. There are two bursae superficial to the patellar tendon near the patella and one deep to the patellar ligament in the area of the proximal tibia. Evaluate the patellar ligament, sometimes called the patellar tendon, which is the portion of the quadriceps femoris tendon that continues from the patella to the tibial tuberosity.', '16a00555-ca8f-47d5-8314-ffece92b88ab': 'Finally, the posterior view of the knee is evaluated with the knee slightly flexed at 10–20 degrees, as shown in Figure 6-35. Many structures can be seen in the popliteal fossa, including the popliteal artery and vein. One important area to evaluate is the area between the medial head of the gastrocnemius muscle and the semimembranosus tendon, which is the usual site of a Baker’s cyst. This completes the knee evaluation.'}"
+Figure 6-34,ultrasound/images/Figure 6-34.jpg,Figure 6-34: Side-by-side pictures of the sagittal image of the patellar ligament (PL).,"Next, scan the infrapatellar area in the longitudinal plane with the bony landmarks proximally of the femur and tibia joint space and distally of the proximal tibia, as shown in Figure 6-34. Keep light pressure on the probe to avoid compressing any possible fluid within the bursa. There are two bursae superficial to the patellar tendon near the patella and one deep to the patellar ligament in the area of the proximal tibia. Evaluate the patellar ligament, sometimes called the patellar tendon, which is the portion of the quadriceps femoris tendon that continues from the patella to the tibial tuberosity.","{'3d24aaee-cd0a-4cd4-85dc-0620ac5282a6': 'Start the evaluation by using a high-frequency linear transducer and having the patient in the supine position. The anterior evaluation starts in the suprapatellar area with the probe in line with the femur, as shown in Figure 6-28.', 'da240aa9-8e4f-4c96-8b89-37d8277a0932': 'Evaluate the following structures from deep to superficial, starting with the bony cortex of the femur, the quadriceps muscles and fascial planes, the femoral trochlea, the prefemoral fat pad, the suprapatellar bursa, and the suprapatellar fat pad. Evaluate proximally from the quadriceps muscle to the distal area over the patella in the longitudinal and transverse planes, looking for any pathology such as effusion or tears, as shown in Figures 6-29 and 6-30. It is sometimes helpful to perform toggling and heel-to-toe maneuvers to fine-tune the anatomy and avoid anisotropy.', '1ed09168-b376-4337-9334-24ba2090fabf': 'Next, slide the transducer medially, and evaluate the medial aspect of the knee joint from the femoral to the tibial condyles in the sagittal and transverse planes, as shown in Figures 6-31 and 6-32. Also, evaluate the medial collateral ligament and the medial meniscus in the joint space. As you move the transducer distally, evaluate the pes anserine complex for any evidence of injury or inflammation, such as pes anserine bursitis.', 'b3a13ade-c40e-4f20-a4cb-b8b6db876029': 'Next, slide the probe to the lateral aspect of the knee joint, and evaluate the joint space of the distal femur and fibular head, as shown in Figure 6-33. In the longitudinal and transverse planes, evaluate the peripheral margin of the lateral meniscus and the lateral collateral ligament from proximal to distal.', 'e08d1f5a-66a6-4ea0-82d9-c34dbbf988b2': 'Next, scan the infrapatellar area in the longitudinal plane with the bony landmarks proximally of the femur and tibia joint space and distally of the proximal tibia, as shown in Figure 6-34. Keep light pressure on the probe to avoid compressing any possible fluid within the bursa. There are two bursae superficial to the patellar tendon near the patella and one deep to the patellar ligament in the area of the proximal tibia. Evaluate the patellar ligament, sometimes called the patellar tendon, which is the portion of the quadriceps femoris tendon that continues from the patella to the tibial tuberosity.', '16a00555-ca8f-47d5-8314-ffece92b88ab': 'Finally, the posterior view of the knee is evaluated with the knee slightly flexed at 10–20 degrees, as shown in Figure 6-35. Many structures can be seen in the popliteal fossa, including the popliteal artery and vein. One important area to evaluate is the area between the medial head of the gastrocnemius muscle and the semimembranosus tendon, which is the usual site of a Baker’s cyst. This completes the knee evaluation.'}"
+Figure 6-35,ultrasound/images/Figure 6-35.jpg,"Figure 6-35: Side-by-side pictures of the transducer position and transverse image of the posterior knee viewing of the medial head of the gastrocnemius muscle (MHG), popliteal artery (PA), and the popliteal vein (PV). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.","Finally, the posterior view of the knee is evaluated with the knee slightly flexed at 10–20 degrees, as shown in Figure 6-35. Many structures can be seen in the popliteal fossa, including the popliteal artery and vein. One important area to evaluate is the area between the medial head of the gastrocnemius muscle and the semimembranosus tendon, which is the usual site of a Baker’s cyst. This completes the knee evaluation.","{'3d24aaee-cd0a-4cd4-85dc-0620ac5282a6': 'Start the evaluation by using a high-frequency linear transducer and having the patient in the supine position. The anterior evaluation starts in the suprapatellar area with the probe in line with the femur, as shown in Figure 6-28.', 'da240aa9-8e4f-4c96-8b89-37d8277a0932': 'Evaluate the following structures from deep to superficial, starting with the bony cortex of the femur, the quadriceps muscles and fascial planes, the femoral trochlea, the prefemoral fat pad, the suprapatellar bursa, and the suprapatellar fat pad. Evaluate proximally from the quadriceps muscle to the distal area over the patella in the longitudinal and transverse planes, looking for any pathology such as effusion or tears, as shown in Figures 6-29 and 6-30. It is sometimes helpful to perform toggling and heel-to-toe maneuvers to fine-tune the anatomy and avoid anisotropy.', '1ed09168-b376-4337-9334-24ba2090fabf': 'Next, slide the transducer medially, and evaluate the medial aspect of the knee joint from the femoral to the tibial condyles in the sagittal and transverse planes, as shown in Figures 6-31 and 6-32. Also, evaluate the medial collateral ligament and the medial meniscus in the joint space. As you move the transducer distally, evaluate the pes anserine complex for any evidence of injury or inflammation, such as pes anserine bursitis.', 'b3a13ade-c40e-4f20-a4cb-b8b6db876029': 'Next, slide the probe to the lateral aspect of the knee joint, and evaluate the joint space of the distal femur and fibular head, as shown in Figure 6-33. In the longitudinal and transverse planes, evaluate the peripheral margin of the lateral meniscus and the lateral collateral ligament from proximal to distal.', 'e08d1f5a-66a6-4ea0-82d9-c34dbbf988b2': 'Next, scan the infrapatellar area in the longitudinal plane with the bony landmarks proximally of the femur and tibia joint space and distally of the proximal tibia, as shown in Figure 6-34. Keep light pressure on the probe to avoid compressing any possible fluid within the bursa. There are two bursae superficial to the patellar tendon near the patella and one deep to the patellar ligament in the area of the proximal tibia. Evaluate the patellar ligament, sometimes called the patellar tendon, which is the portion of the quadriceps femoris tendon that continues from the patella to the tibial tuberosity.', '16a00555-ca8f-47d5-8314-ffece92b88ab': 'Finally, the posterior view of the knee is evaluated with the knee slightly flexed at 10–20 degrees, as shown in Figure 6-35. Many structures can be seen in the popliteal fossa, including the popliteal artery and vein. One important area to evaluate is the area between the medial head of the gastrocnemius muscle and the semimembranosus tendon, which is the usual site of a Baker’s cyst. This completes the knee evaluation.'}"
+Figure 6-36,ultrasound/images/Figure 6-36.jpg,"Figure 6-36: Anatomical view of the foot (Lateral collateral ligament of ankle joint by Laboratiores Servier licensed under CC BY-SA 4.0) and ankle (Dorsal superficial muscles of the right foot (lateral view) by Betts JG, Young kA, Wise JA, Johnson E, Poe B, Kruse DH, Korol O, Johnson JE, Womble M, and DeSaix P licensed under CC BY 4.0).","Figure 6-36 shows the anatomical view of the foot and ankle. The ankle and foot can be challenging to evaluate, since many structures require anatomic familiarity and detailed imaging. However, in general, a systematic approach is helpful. As with the other joint evaluations, a quadrant approach works best. Start with the anterior/dorsal evaluation by flattening the foot with an anterior longitudinal plane of the probe across the joint space of the tibia and talus, as shown in Figure 6-37. This provides an excellent focal point to sweep across the ankle joint to evaluate the muscles from medial to lateral: tibialis anterior, extensor hallucis longus, and extensor digitorum longus, as shown in Figure 6-38.","{'741724c3-e1d1-4bb8-9d0c-128300453a67': 'Figure 6-36 shows the anatomical view of the foot and ankle. The ankle and foot can be challenging to evaluate, since many structures require anatomic familiarity and detailed imaging. However, in general, a systematic approach is helpful. As with the other joint evaluations, a quadrant approach works best. Start with the anterior/dorsal evaluation by flattening the foot with an anterior longitudinal plane of the probe across the joint space of the tibia and talus, as shown in Figure 6-37. This provides an excellent focal point to sweep across the ankle joint to evaluate the muscles from medial to lateral: tibialis anterior, extensor hallucis longus, and extensor digitorum longus, as shown in Figure 6-38.', '1c297f72-5a65-4f1d-a53c-aec2a8b9c3f6': 'The subtalar joint is often of interest for evaluation and injection purposes. It is found in the longitudinal plane just medial to the lateral malleolus in the talus and calcaneus joint space.', '5da60c3e-f921-4f75-8a00-218b4487096e': 'Evaluate from the proximal muscle to the tendon insertion points in the transverse and longitudinal planes as clinically indicated.[17] Dynamic imaging is helpful to evaluate the integrity of the ligament. Now place the probe behind the lateral malleolus in the longitudinal plane with a posterior to anterior angle of insonation to evaluate the peroneus longus, which is superficial to the peroneus brevis. Evaluate both the longitudinal and transverse planes proximally and distally to their insertion points, as shown in Figures 6-39 and 6-40.', 'f5488363-d170-479f-86dd-3dacb517ae48': 'Place the probe in the transverse plane behind the medial malleolus to evaluate the medial side of the ankle and foot, as shown in Figure 6-41. Now we can evaluate the cross-sectional area of the structures in the tarsal tunnel. From medial to lateral, we have the Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery/Vein/Nerve, and flexor Hallucis longus tendon. Tom, Dick, And Very Nervous Harry is a commonly used mnemonic to recall these anatomical structures. This is important to evaluate for tarsal tunnel syndrome if clinically indicated.[18]', '97cfe372-c879-4c4a-98f3-863e5bd5b459': 'To complete the evaluation, look at the Achilles tendon in the transverse and sagittal planes from the proximal gastrocnemius and soleus muscles to the insertion into the calcaneus, as shown in Figures 6-42 and 6-43.', '21c1bdb5-b568-47d2-9745-e8afd7657f1f': 'Finally, evaluate the foot’s plantar fascia in the longitudinal plane, as shown in Figure 6-44. The thickness at the insertion to the calcaneus should not be more than 4 mm, which would be suggestive of plantar fasciitis.'}"
+Figure 6-41,ultrasound/images/Figure 6-41.jpg,"Figure 6-41: Side-by-side pictures of the transducer position and transverse image of the medial ankle, including the medial malleolus (MM), tibialis posterior tendon (PTT), flexor digitorum longus tendon (FDL), posterior tibial vein (V) and artery (A), tibial nerve (N), and flexor hallucis longus tendon (FHL). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.","Place the probe in the transverse plane behind the medial malleolus to evaluate the medial side of the ankle and foot, as shown in Figure 6-41. Now we can evaluate the cross-sectional area of the structures in the tarsal tunnel. From medial to lateral, we have the Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery/Vein/Nerve, and flexor Hallucis longus tendon. Tom, Dick, And Very Nervous Harry is a commonly used mnemonic to recall these anatomical structures. This is important to evaluate for tarsal tunnel syndrome if clinically indicated.[18]","{'741724c3-e1d1-4bb8-9d0c-128300453a67': 'Figure 6-36 shows the anatomical view of the foot and ankle. The ankle and foot can be challenging to evaluate, since many structures require anatomic familiarity and detailed imaging. However, in general, a systematic approach is helpful. As with the other joint evaluations, a quadrant approach works best. Start with the anterior/dorsal evaluation by flattening the foot with an anterior longitudinal plane of the probe across the joint space of the tibia and talus, as shown in Figure 6-37. This provides an excellent focal point to sweep across the ankle joint to evaluate the muscles from medial to lateral: tibialis anterior, extensor hallucis longus, and extensor digitorum longus, as shown in Figure 6-38.', '1c297f72-5a65-4f1d-a53c-aec2a8b9c3f6': 'The subtalar joint is often of interest for evaluation and injection purposes. It is found in the longitudinal plane just medial to the lateral malleolus in the talus and calcaneus joint space.', '5da60c3e-f921-4f75-8a00-218b4487096e': 'Evaluate from the proximal muscle to the tendon insertion points in the transverse and longitudinal planes as clinically indicated.[17] Dynamic imaging is helpful to evaluate the integrity of the ligament. Now place the probe behind the lateral malleolus in the longitudinal plane with a posterior to anterior angle of insonation to evaluate the peroneus longus, which is superficial to the peroneus brevis. Evaluate both the longitudinal and transverse planes proximally and distally to their insertion points, as shown in Figures 6-39 and 6-40.', 'f5488363-d170-479f-86dd-3dacb517ae48': 'Place the probe in the transverse plane behind the medial malleolus to evaluate the medial side of the ankle and foot, as shown in Figure 6-41. Now we can evaluate the cross-sectional area of the structures in the tarsal tunnel. From medial to lateral, we have the Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery/Vein/Nerve, and flexor Hallucis longus tendon. Tom, Dick, And Very Nervous Harry is a commonly used mnemonic to recall these anatomical structures. This is important to evaluate for tarsal tunnel syndrome if clinically indicated.[18]', '97cfe372-c879-4c4a-98f3-863e5bd5b459': 'To complete the evaluation, look at the Achilles tendon in the transverse and sagittal planes from the proximal gastrocnemius and soleus muscles to the insertion into the calcaneus, as shown in Figures 6-42 and 6-43.', '21c1bdb5-b568-47d2-9745-e8afd7657f1f': 'Finally, evaluate the foot’s plantar fascia in the longitudinal plane, as shown in Figure 6-44. The thickness at the insertion to the calcaneus should not be more than 4 mm, which would be suggestive of plantar fasciitis.'}"
+Figure 6-44,ultrasound/images/Figure 6-44.jpg,Figure 6-44: Side-by-side pictures of the transducer position and plantar sagittal view with plantar fascia (PF) insertion into the calcaneus (C). The abbreviations given here and labeled on the ultrasound image represent the corresponding structures.,"Finally, evaluate the foot’s plantar fascia in the longitudinal plane, as shown in Figure 6-44. The thickness at the insertion to the calcaneus should not be more than 4 mm, which would be suggestive of plantar fasciitis.","{'741724c3-e1d1-4bb8-9d0c-128300453a67': 'Figure 6-36 shows the anatomical view of the foot and ankle. The ankle and foot can be challenging to evaluate, since many structures require anatomic familiarity and detailed imaging. However, in general, a systematic approach is helpful. As with the other joint evaluations, a quadrant approach works best. Start with the anterior/dorsal evaluation by flattening the foot with an anterior longitudinal plane of the probe across the joint space of the tibia and talus, as shown in Figure 6-37. This provides an excellent focal point to sweep across the ankle joint to evaluate the muscles from medial to lateral: tibialis anterior, extensor hallucis longus, and extensor digitorum longus, as shown in Figure 6-38.', '1c297f72-5a65-4f1d-a53c-aec2a8b9c3f6': 'The subtalar joint is often of interest for evaluation and injection purposes. It is found in the longitudinal plane just medial to the lateral malleolus in the talus and calcaneus joint space.', '5da60c3e-f921-4f75-8a00-218b4487096e': 'Evaluate from the proximal muscle to the tendon insertion points in the transverse and longitudinal planes as clinically indicated.[17] Dynamic imaging is helpful to evaluate the integrity of the ligament. Now place the probe behind the lateral malleolus in the longitudinal plane with a posterior to anterior angle of insonation to evaluate the peroneus longus, which is superficial to the peroneus brevis. Evaluate both the longitudinal and transverse planes proximally and distally to their insertion points, as shown in Figures 6-39 and 6-40.', 'f5488363-d170-479f-86dd-3dacb517ae48': 'Place the probe in the transverse plane behind the medial malleolus to evaluate the medial side of the ankle and foot, as shown in Figure 6-41. Now we can evaluate the cross-sectional area of the structures in the tarsal tunnel. From medial to lateral, we have the Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery/Vein/Nerve, and flexor Hallucis longus tendon. Tom, Dick, And Very Nervous Harry is a commonly used mnemonic to recall these anatomical structures. This is important to evaluate for tarsal tunnel syndrome if clinically indicated.[18]', '97cfe372-c879-4c4a-98f3-863e5bd5b459': 'To complete the evaluation, look at the Achilles tendon in the transverse and sagittal planes from the proximal gastrocnemius and soleus muscles to the insertion into the calcaneus, as shown in Figures 6-42 and 6-43.', '21c1bdb5-b568-47d2-9745-e8afd7657f1f': 'Finally, evaluate the foot’s plantar fascia in the longitudinal plane, as shown in Figure 6-44. The thickness at the insertion to the calcaneus should not be more than 4 mm, which would be suggestive of plantar fasciitis.'}"
+Figure 5-2,ultrasound/images/Figure 5-2.jpg,"Figure 5-2: Ultrasound image at 23 weeks showing fetus, amniotic fluid, and normal fetal morphology. Ultrasonography picture at 23 weeks showing fetus, amniotic fluid and normal fetal morphology by Dahab AA, Aburass R, Shawkat W, Babgi R, Essa O, and Mujallid RH licensed under CC BY 2.0","The volume of amniotic fluid is calculated by what is called the amniotic fluid index. Even debris (represented by diffuse abnormal reflections in the amniotic fluid) is a harbinger of difficulties. At first glance, the ease of clarity and measurement is heavily influenced by the amount of amniotic fluid. As discussed in the earlier chapters, media, especially fluid, influences the quality of ultrasound wave transmission and reflection. Figure 5-2 shows an ultrasound image at 23 weeks of the fetus, amniotic fluid, and normal fetal morphology. A clear initial view is not necessarily a good sign, since excess amniotic fluid (a condition referred to as polyhydramnios) may make the images easy to obtain but may, more importantly, indicate problems. It has been noted that polyhydramnios represents a high-risk obstetric condition as much as 20% of the time.[2],[3]","{'de30f12f-eaeb-4caf-ae51-cc29e74c4811': 'The volume of amniotic fluid is calculated by what is called the amniotic fluid index. Even debris (represented by diffuse abnormal reflections in the amniotic fluid) is a harbinger of difficulties. At first glance, the ease of clarity and measurement is heavily influenced by the amount of amniotic fluid. As discussed in the earlier chapters, media, especially fluid, influences the quality of ultrasound wave transmission and reflection. Figure 5-2 shows an ultrasound image at 23 weeks of the fetus, amniotic fluid, and normal fetal morphology. A clear initial view is not necessarily a good sign, since excess amniotic fluid (a condition referred to as polyhydramnios) may make the images easy to obtain but may, more importantly, indicate problems. It has been noted that polyhydramnios represents a high-risk obstetric condition as much as 20% of the time.[2],[3]'}"
+Figure 5-3,ultrasound/images/Figure 5-3.jpg,"Figure 5-3: The figure on the left shows the internal view of the cardiac right chambers, and the one on the right is the echocardiographic image showing the ventricular septal defect. Internal view of cardiac right chambers by Muñoz-Castellanos L, Espinola-Zavaleta N, Kuri-Nivón M, and Keirns C. licensed under CC BY 2.0","There is a division of a single atrium and a single ventricle by the growth of a septal wall from the wall of the single cavity in all directions toward the middle. This is a gradual and persistent hole in the septum that grows abnormally, leading to the septum closing, which results in a septal defect. Fortunately, one can detect both an atrial septal defect and/or a ventricular septal defect using ultrasound, as shown in Figure 5-3. Color flow ultrasound Doppler is often helpful, as one can view the flow from one side of the dividing atrial atrium or ventricle to the other side.","{'4f266643-0c87-453e-8714-f22a30c49faa': 'Fetal cardiac development (the development of the four chambers) is fascinating. The normal opening between the two upper chambers of the fetus’s heart, the right and left atria, is called the foramen ovale (FO). The FO permits blood flow to bypass the lungs before the infant is born (a fetus gets its oxygen from the placenta, not the lungs). As a result, the heart does not have to work as hard to pump blood where it is not needed. The FO typically closes six months to a year after the infant is born. A patent foramen ovale (PFO) occurs when the FO remains open after birth. A PFO often does not cause any issues.[4] When an infant is born with congenital heart abnormalities, the FO is more likely to remain open.', '2854845e-0e28-4025-bb1d-e67db181292e': 'There is a division of a single atrium and a single ventricle by the growth of a septal wall from the wall of the single cavity in all directions toward the middle. This is a gradual and persistent hole in the septum that grows abnormally, leading to the septum closing, which results in a septal defect. Fortunately, one can detect both an atrial septal defect and/or a ventricular septal defect using ultrasound, as shown in Figure 5-3. Color flow ultrasound Doppler is often helpful, as one can view the flow from one side of the dividing atrial atrium or ventricle to the other side.'}"
+Figure 5-4,ultrasound/images/Figure 5-4.jpg,"Figure 5-4: An ectopic pregnancy adjacent to the left ovary. Ectopicleftmass by James Heilman, MD licensed under CC BY-SA 3.0","The other common peril in the first trimester of pregnancy is ectopic pregnancy, or pregnancy outside the uterus. As with intrauterine pregnancies, ectopic pregnancies grow and develop at very fast rates. Figure 5-4 shows an ectopic pregnancy adjacent to the left ovary. Most ectopic pregnancies are in the ovaries, fallopian tubes, or uterine horn. In either event, the pregnancies can “outgrow their blood supply,” rupturing and leading to maternal hemorrhage and potential death.","{'e216b56c-aa11-433a-9405-1fcc5aa371af': 'The first trimester of pregnancy is when there is the most danger of mishap. Due to the rapid cell division and differentiation of the embryo in unbelievable numbers, even minor “errors” in cellular division may cause the very common event of spontaneous abortion. In the emergency department, it is often an unhappy task for a health professional to explain this issue to patients and their families. It is essential to be careful in doing so due to the tendency of many patients to wonder why a tragedy has occurred and to cast blame on themselves. Without careful explanation, patients who experience spontaneous abortion, or expulsion of an unsuccessful pregnancy through the vagina, may feel that they were at fault when this is not the case.', 'a0267643-fbdb-4851-aa9e-cecbf9e3bde5': 'One can evaluate the earliest pregnancies with many parameters. The serial evaluation of the lab value of the “pregnancy hormone,” beta human chorionic gonadotropin (BHCG), over a few days gives an indication of developmental health. Early in pregnancy, the BHCG should double every 2–3 days. If there is a decrease or no increase in the value, this is a most worrisome sign for embryologic death. Often, early fetal demise will not be 100% certain, and the ultrasound and BHCG evaluation are done serially over a few days. Two ultrasounds without a heartbeat at the appropriate fetal age and an inappropriately declining BHCG are often considered diagnostic for intrauterine fetal death and likely spontaneous abortion.', 'f34e29b5-1eec-4c39-bba0-c2f640f59b99': 'Ultrasound evaluation can most accurately begin in early pregnancy with a longer, higher-frequency transvaginal probe. Returning to the knowledge of ultrasound physics from earlier chapters, it is crucial to realize why a higher-frequency probe is placed through the vagina and near the cervix. The accuracy of the higher-frequency probe allows a marked improvement in resolution when the reflection is only a short distance. At four to five weeks gestation, we first see the fetal yolk sac, fetal pole, gestational sac, and fetal heartbeat. An irregularly shaped gestational sac or lack of a fetal heartbeat when the embryologic or crown-rump length is greater than five weeks are ominous signs of possible embryological death. It is estimated that up to 50% of pregnancies end in spontaneous abortion, often so early in development that the patient does not recognize the pregnancy.', 'b8272123-5204-4770-b380-1dfe736ccd30': 'The other common peril in the first trimester of pregnancy is ectopic pregnancy, or pregnancy outside the uterus. As with intrauterine pregnancies, ectopic pregnancies grow and develop at very fast rates. Figure 5-4 shows an ectopic pregnancy adjacent to the left ovary. Most ectopic pregnancies are in the ovaries, fallopian tubes, or uterine horn. In either event, the pregnancies can “outgrow their blood supply,” rupturing and leading to maternal hemorrhage and potential death.', '73e720f9-46e9-4e5c-9498-383e5f0aab12': 'Sonographic signs of an intact ectopic pregnancy include enlargement in the area of implantation (even a functioning fetal heartbeat) and an “empty uterus” or lack of an intrauterine pregnancy when the BHCG is greater than 1500 international units. A patient with a ruptured ectopic pregnancy classically presents with sudden-onset unilateral pelvic pain and possibly signs of hemorrhagic shock. On the ultrasound, free fluid may be noted most commonly not only in the pouch of Douglas but also in the paracolic gutters or Morrison’s pouch. This is often a surgical emergency; the bleeding must be stopped before maternal death occurs from hemorrhage.', 'c17a52ba-633f-4d94-887b-2a10e94f6971': 'Gestational dating refers to the estimation of the gestation of the pregnancy. This is somewhat helpful when the medical provider evaluates issues such as whether to try to delay a patient in preterm labor or if induction of a patient who continues pregnancy more than 10 days after the estimated date of confinement (EDC) is indicated. Both of these issues have several determining factors. For preterm labor, infant mortality significantly decreases as delivery is delayed in many cases. For postterm situations, having a healthy term fetus more than 10 days after the EDC may pose unnecessary risks. These are complex decisions based on such data. To further complicate the issue, gestational dating may have variable accuracies. Some individuals have little or no prenatal care (i.e., some show up only to the emergency department when they are about to deliver or deliver at home without ever being evaluated by a medical provider). If one does have prenatal care and prenatal ultrasound, gestational dating accuracy remains variable. The facet that introduces the most variability is the gestational age at which the scan is performed. It has been traditionally noted that gestational dating accuracy has an 8% variability of the maturity of the pregnancy.[5] An example is that a 45-day gestation would have an accuracy of ±days, and a pregnancy of approximately 250 days would have an accuracy of ±20 days. This variability may decrease as ultrasound machines become more sophisticated. The principle, however, continues to make sense that as pregnancies mature, the genetic and environmental issues that make us all different have a greater influence on growth.'}"
+Figure 5-5,ultrasound/images/Figure 5-5.jpg,Figure 5-5 Ultrasound image of fetal hydrocephalus. Aorta duplication artifact 131206105958250c by Nevit Dilmen licensed under CC BY-SA 3.0,"The head measurement is first determined by the biparietal diameter and occipital-frontal circumference. There is a flow pattern of cerebrospinal fluid (CSF) through the brain’s ventricular system and into the spinal cord through the foramen of Magendie and the foramen of Luschka. An obstruction of this flow causes increased back pressure, dilation of the ventricles, and pathologic pressure of the surrounding brain tissue. Many other conditions other than stenosis of the foramina cause hydrocephalus. This abnormality may be seen on prenatal ultrasound first as an increased head size and then as an increased ventricular size. Figure 5-5 shows an ultrasound image of fetal hydrocephalus. Hydrocephalus intervention is most often treated with postdelivery shunt placement, which involves placing a tube in the cerebral ventricles to bypass the obstruction and drain the excess fluid into other body cavities, such as the abdomen, where the fluid may be reabsorbed.","{'d68afd6d-98df-44fc-a8b5-44d094c36b60': 'The head measurement is first determined by the biparietal diameter and occipital-frontal circumference. There is a flow pattern of cerebrospinal fluid (CSF) through the brain’s ventricular system and into the spinal cord through the foramen of Magendie and the foramen of Luschka. An obstruction of this flow causes increased back pressure, dilation of the ventricles, and pathologic pressure of the surrounding brain tissue. Many other conditions other than stenosis of the foramina cause hydrocephalus. This abnormality may be seen on prenatal ultrasound first as an increased head size and then as an increased ventricular size. Figure 5-5 shows an ultrasound image of fetal hydrocephalus. Hydrocephalus intervention is most often treated with postdelivery shunt placement, which involves placing a tube in the cerebral ventricles to bypass the obstruction and drain the excess fluid into other body cavities, such as the abdomen, where the fluid may be reabsorbed.', '98e1ad28-0210-4e83-b51a-42a511c01439': 'Other than abnormalities in CSF flow, there may be other abnormalities that are represented by an abnormal prenatal head ultrasound. These abnormalities have a wide range of etiologies, including genetic abnormalities, congenital abnormalities, and abnormal growth in an otherwise normal fetus. Genetic abnormalities have to do with abnormal chromosomes primarily due to mutation. Congenital abnormalities usually begin in the prenatal period and are evident at birth.', '84295ea5-b29c-460c-8de2-163ff1bf86e1': 'Cardiac ultrasound accurately predicts congenital abnormalities for many more subtle conditions. The most common congenital heart disease is patent ductus arteriosus, where the fetal ductus arteriosus that diverts the circulation away from the prenatal lungs and into the aorta does not close upon birth. This, of course, is never diagnosed prenatally. Rare but hazardous and sometimes fatal conditions such as transposition of the great vessels or defects of the central cardiac wall (called the septal wall) may be undetected by screening ultrasound exams. The complexity increases when there are combinations of heart defects such as tetralogy of Fallot, including pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect, and an aorta that receives blood from both the right and left ventricle. In developed countries, when a fetal cardiac ultrasound is suspected from a routine prenatal ultrasound, a targeted ultrasound using more specialized machines and more specialized operators is subsequently performed. There may also be noncardiac prenatal ultrasound signs of heart disease, such as fetal hydrops (swelling) for fetal congestive heart failure.'}"
+Figure 5-6,ultrasound/images/Figure 5-6.jpg,Figure 5-6: Ultrasound images of a fetus’s face and arms during week 20.,"In first discussing the more common screening prenatal ultrasound exams, we have made mention of more targeted exams. Thoracic measurements, measurement of bones other than the femur, more targeted cardiac exams, more central nervous system ventricular evaluations, and fetal neck skin thickness measurements are made. For example, Figure 5-6 shows ultrasound images of a fetus’s face and arms during week 20.","{'aa646de5-dff3-4f80-a2e5-f63dfde9bedd': 'In first discussing the more common screening prenatal ultrasound exams, we have made mention of more targeted exams. Thoracic measurements, measurement of bones other than the femur, more targeted cardiac exams, more central nervous system ventricular evaluations, and fetal neck skin thickness measurements are made. For example, Figure 5-6 shows ultrasound images of a fetus’s face and arms during week 20.', '39d5ac62-2eca-4ad0-86ba-73ea5ee2376d': 'More specific investigation of suspected abnormalities may indicate some conditions that can be corrected prenatally by thrilling advanced treatments such as umbilical cord blood transfusions, correction of amniotic fluid abnormalities, relief of posterior ureteral valve abnormality, or other intrauterine surgeries. As discussed earlier, almost all of these procedures are initiated by the targeted ultrasound.', 'bc575a2b-2457-49bc-9fd9-6b04c0411a13': 'In 2023, as in every other year in the history of humanity, it remains true that the results of the most sophisticated events in fetal development can be influenced by some of the simplest yet sometimes neglected measures: receiving good prenatal care, ceasing maternal smoking or other substance use, and taking prenatal vitamins. We believe that it is important for future clinicians reading this to never tire of reminding patients to optimize their developing infants’ likelihood of being healthy.', '1cea81f8-42d4-4fab-9537-f809b8fda57e': 'When using ultrasound, risks must be minimized to ensure patient safety. There are two basic rules of medical ethics:[1]', '749dd97a-d7e8-45e7-94e8-b6d903cb6d04': 'In that case, a procedure is deemed ethical only when it benefits the patient.', '5555e979-37b2-48f4-8eb8-1dac202bd685': 'Ultrasound is generally considered safe if used properly. While there is no evidence it will physically affect the patient long-term, it should still be noted that it is a form of energy, and even at low levels, some studies suggest that overexposure to ultrasound can lead to potential undesirable effects such as', '50c67ea3-ad36-432c-b6b7-6721a7b39efe': 'The damage type and extent mainly depend on the ultrasound wave characteristics such as frequency, intensity level, and exposure time, among other factors.'}"
+Figure 4-1,ultrasound/images/Figure 4-1.jpg,Figure 4-1: Ultrasound image showing the thermal index and mechanical index of a carotid exam in the top right corner.,"Nevertheless, tissue viscosity is 100 times greater than that of water such that bubble oscillations are greatly limited. A typical display of soft tissue TI and MI values for a carotid exam is shown in the top right corner of the Doppler image in Figure 4-1.","{'ffbb7405-88d1-43c4-95b0-cd26d0baa25f': 'Oscillations of gas bubbles (cavitation) occur inside tissue due to ultrasound pressure waves. The cavitation effect happens due to the excitation of a stable gas bubble by an acoustic field (noninertial cavitation—the formed bubble oscillates in the acoustic field), and streaming effects result from the movement of complex fluids due to radiation force pressures (inertial, or transient, cavitation—the formed bubble rapidly collapses and produces a shock wave that can be capable of causing biological damage).[6],[7] Bubbles are formed in a liquid when the local pressure falls (rarefaction part of the ultrasound wave) below the vapor pressure of the liquid. This cavitation effect is dependent on the fluid inertia, viscosity, and surface tension. Therefore, it is important to shorten the exposure time to minimize cavitation. Another critical point is that cavitation is likely to occur at lower transducer frequencies. However, cavitation-related bioeffects require the presence of cavitation nuclei (or bubbles) close to cells and physical or chemical interaction between bubbles and cells.', '47a30129-3979-4fcf-b0b3-e2ce3d6ad97a': 'The use of the MI as an indicator is based on the assumption that sound induces oscillations of microbubbles, which can cause an increase in the internal temperature of a water gas bubble.', '093cf76e-6ca5-409b-a371-cc1f2aa2bd0a': 'Nevertheless, tissue viscosity is 100 times greater than that of water such that bubble oscillations are greatly limited. A typical display of soft tissue TI and MI values for a carotid exam is shown in the top right corner of the Doppler image in Figure 4-1.', '2a82aad0-f946-48a1-a631-d4d5e95c41f1': 'The risk of cavitation increases with increasing MI values. Other studies suggest that high MI values are associated with the induction of premature ventricular contractions in echocardiography.3 The potential for nonthermal biohazards is likely to increase if the equipment is not used correctly. Such biohazards have been observed in animal tissues with gas bubbles at MI values greater than .[8]3 The bioeffects associated with MI values of or less have been reported in skeletal muscle, fat, myocardia, kidneys, livers, and intestines.[9]', '794a8933-d75b-4d93-a500-5f548635fd76': 'Consequently, unnecessary exposure to tissues such as the neonatal lungs should be avoided. Ultrasound operators should keep the MI values as low as possible when carrying out a diagnosis.'}"
+Figure 3-1,ultrasound/images/Figure 3-1.jpg,Figure 3-1: Orthogonal planes of the uterus.,"Three-dimensional ultrasound is based on the same principles of operation as 2D ultrasound but has an added position-sensing component to produce the effect of a 3D image, as illustrated in Figure 3-1. In 3D ultrasound imaging, echoes are used to form real-like realistic volume images.","{'f7fa6317-d215-4aff-8142-90fcabf80e20': 'Two-dimensional ultrasound is considered a standard or conventional imaging technique. In 2D scanning, a series of thin slices make up an image, and only one slice can be seen at a time.', 'd6355d00-b714-496c-b0e0-21b99b62f4dc': 'Three- and four-dimensional clinical ultrasounds have been around for nearly 25 years. However, their use has lagged behind that of computerized tomography (CT) and magnetic resonance imaging (MRI) due to the difficulty in rendering the data in 3D.[1] However, ultrasound equipment’s increasing computing power has helped resolve complex signal processing tasks needed to render 3D ultrasound data.', '474f61cc-6d35-45b2-9a84-bdf103cb2750': 'Three-dimensional ultrasound is based on the same principles of operation as 2D ultrasound but has an added position-sensing component to produce the effect of a 3D image, as illustrated in Figure 3-1. In 3D ultrasound imaging, echoes are used to form real-like realistic volume images.', '6d3d705e-c3c4-47e6-ba8a-c016c343a5fb': 'A 4D ultrasound shows 3D ultrasound images in motion. Two-dimensional ultrasound images are commonly used because they are less expensive than 3D or 4D. However, many centers now use 3D/4D ultrasound. The most common area of use has been fetal cardiovascular scanning. The 3D/4D technology offers real-time motion-gated cardiac scanning.', '7f017ea0-029b-4fe5-bd1c-3e16b1283c66': 'A 3D/4D ultrasound offers expecting parents a memorable lifetime opportunity to see the features of their unborn babies. Figure 3-2 shows 2D grayscale and 3D colored images.'}"
+Figure 3-2,ultrasound/images/Figure 3-2.jpg,Figure 3-2: 2D grayscale image on the left (Scan20semanas1 by Guimi licensed under CC BY-SA 2.5) and 3D colored image on the right (4215.600×450 by Clayuyu licensed under CC BY-SA 4.0).,A 3D/4D ultrasound offers expecting parents a memorable lifetime opportunity to see the features of their unborn babies. Figure 3-2 shows 2D grayscale and 3D colored images.,"{'f7fa6317-d215-4aff-8142-90fcabf80e20': 'Two-dimensional ultrasound is considered a standard or conventional imaging technique. In 2D scanning, a series of thin slices make up an image, and only one slice can be seen at a time.', 'd6355d00-b714-496c-b0e0-21b99b62f4dc': 'Three- and four-dimensional clinical ultrasounds have been around for nearly 25 years. However, their use has lagged behind that of computerized tomography (CT) and magnetic resonance imaging (MRI) due to the difficulty in rendering the data in 3D.[1] However, ultrasound equipment’s increasing computing power has helped resolve complex signal processing tasks needed to render 3D ultrasound data.', '474f61cc-6d35-45b2-9a84-bdf103cb2750': 'Three-dimensional ultrasound is based on the same principles of operation as 2D ultrasound but has an added position-sensing component to produce the effect of a 3D image, as illustrated in Figure 3-1. In 3D ultrasound imaging, echoes are used to form real-like realistic volume images.', '6d3d705e-c3c4-47e6-ba8a-c016c343a5fb': 'A 4D ultrasound shows 3D ultrasound images in motion. Two-dimensional ultrasound images are commonly used because they are less expensive than 3D or 4D. However, many centers now use 3D/4D ultrasound. The most common area of use has been fetal cardiovascular scanning. The 3D/4D technology offers real-time motion-gated cardiac scanning.', '7f017ea0-029b-4fe5-bd1c-3e16b1283c66': 'A 3D/4D ultrasound offers expecting parents a memorable lifetime opportunity to see the features of their unborn babies. Figure 3-2 shows 2D grayscale and 3D colored images.'}"
+Figure 3-3,ultrasound/images/Figure 3-3.jpg,"Figure 3-3: A schematic of the formation of a 4D ultrasound image. Figure 1 by Yagel S, Cohen SM, Shapiro I, and Valsky DV licensed under CC BY 2.0","A 3D ultrasound uses a series of 2D images covering a volume of a particular area. This allows the images to be rotated and displayed in different orientations. When displayed in real time, or live, they form a 4D ultrasound. Volume acquisition is achieved by using an array of transducers consisting of many 2D frames, one behind the other. Automated mathematical algorithms are then used to process the volume data to produce the desired image, as illustrated in Figure 3-3.","{'a0e9c8b5-6faa-449b-b169-b1880310eb9d': 'A 3D ultrasound uses a series of 2D images covering a volume of a particular area. This allows the images to be rotated and displayed in different orientations. When displayed in real time, or live, they form a 4D ultrasound. Volume acquisition is achieved by using an array of transducers consisting of many 2D frames, one behind the other. Automated mathematical algorithms are then used to process the volume data to produce the desired image, as illustrated in Figure 3-3.', 'ccbafe67-7027-4c66-b261-682f81e07550': 'The reconstruction in Figure 3-3 occurs in a matter of seconds such that the spatio-temporal imaging correlation (STIC) acquisition is completed in the presence of the patient. The STIC acquisition mode can be combined with B-mode, color, and power Doppler. From a good STIC acquisition, a sequential plane may be viewed in corresponding transverse and longitudinal planes at any time point, simultaneously.', 'e50f981e-d828-49c6-bb2d-e9a49534d80e': 'The B-flow image is a live grayscale depiction of blood flow and cardiac chambers. When applied to 3D fetal echocardiography, the B-flow image shows blood flow in the heart and great vessels in real time.[4]'}"
+Figure 3-3,ultrasound/images/Figure 3-3.jpg,"Figure 3-3: A schematic of the formation of a 4D ultrasound image. Figure 1 by Yagel S, Cohen SM, Shapiro I, and Valsky DV licensed under CC BY 2.0","A 3D ultrasound uses a series of 2D images covering a volume of a particular area. This allows the images to be rotated and displayed in different orientations. When displayed in real time, or live, they form a 4D ultrasound. Volume acquisition is achieved by using an array of transducers consisting of many 2D frames, one behind the other. Automated mathematical algorithms are then used to process the volume data to produce the desired image, as illustrated in Figure 3-3.","{'a0e9c8b5-6faa-449b-b169-b1880310eb9d': 'A 3D ultrasound uses a series of 2D images covering a volume of a particular area. This allows the images to be rotated and displayed in different orientations. When displayed in real time, or live, they form a 4D ultrasound. Volume acquisition is achieved by using an array of transducers consisting of many 2D frames, one behind the other. Automated mathematical algorithms are then used to process the volume data to produce the desired image, as illustrated in Figure 3-3.', 'ccbafe67-7027-4c66-b261-682f81e07550': 'The reconstruction in Figure 3-3 occurs in a matter of seconds such that the spatio-temporal imaging correlation (STIC) acquisition is completed in the presence of the patient. The STIC acquisition mode can be combined with B-mode, color, and power Doppler. From a good STIC acquisition, a sequential plane may be viewed in corresponding transverse and longitudinal planes at any time point, simultaneously.', 'e50f981e-d828-49c6-bb2d-e9a49534d80e': 'The B-flow image is a live grayscale depiction of blood flow and cardiac chambers. When applied to 3D fetal echocardiography, the B-flow image shows blood flow in the heart and great vessels in real time.[4]'}"
+Figure 2-1,ultrasound/images/Figure 2-1.jpg,Figure 2-1: A typical ultrasound machine. ALOKA SSD-3500SV by Kitmondo Marketplace licensed under CC BY 2.0,"As shown in Figure 2-1, an ultrasound machine includes the following major components:","{'ac6528b8-b0ab-4fa4-907b-daab138b866c': 'As shown in Figure 2-1, an ultrasound machine includes the following major components:', '7560208e-8c9a-43b0-b384-92670a326c40': 'Figure 2-2 shows a generalized schematic of ultrasound machines’ mode of operation.', '1d7e4f44-13c3-41e6-8914-b6b85de0ad71': 'More details about the operations of the components of the ultrasound machine are discussed in the sections below.'}"
+Figure 2-2,ultrasound/images/Figure 2-2.jpg,Figure 2-2: Schematic of the mode of operation of ultrasound machines.,Figure 2-2 shows a generalized schematic of ultrasound machines’ mode of operation.,"{'ac6528b8-b0ab-4fa4-907b-daab138b866c': 'As shown in Figure 2-1, an ultrasound machine includes the following major components:', '7560208e-8c9a-43b0-b384-92670a326c40': 'Figure 2-2 shows a generalized schematic of ultrasound machines’ mode of operation.', '1d7e4f44-13c3-41e6-8914-b6b85de0ad71': 'More details about the operations of the components of the ultrasound machine are discussed in the sections below.'}"
+Figure 2-3,ultrasound/images/Figure 2-3.jpg,Figure 2-3: An illustrative diagram of the behavior of piezoelectric materials used in ultrasound probes.,"In the 19th century, Pierre and Jacques Curie discovered that some materials generate electric potentials in response to mechanical deformation (material shrinks or expands) or stress (the substance is squeezed or stretched)—a phenomenon called the piezoelectric effect, which is illustrated in Figure 2-3. Conversely, the same materials change their shapes when an electric field is applied.","{'eae5b0c6-a3cc-480e-a256-25fb867d830a': 'In the 19th century, Pierre and Jacques Curie discovered that some materials generate electric potentials in response to mechanical deformation (material shrinks or expands) or stress (the substance is squeezed or stretched)—a phenomenon called the piezoelectric effect, which is illustrated in Figure 2-3. Conversely, the same materials change their shapes when an electric field is applied.', '3f5a0f7f-0dbf-4c0e-876b-374b57ccf6f2': 'Examples of such materials include silicon oxide, potassium sodium tartrate, barium titanate, and lithium niobate. Bones, tendons, skin, and some man-made polymeric materials can also exhibit the piezoelectric effect. These materials bend in different ways depending on the frequency and their shape, which can result in different vibration modes. The modes are the basis for developing transducers that operate at different frequencies.'}"
+Figure 2-4,ultrasound/images/Figure 2-4.jpg,Figure 2-4: Components of an ultrasound probe.,"A typical ultrasound probe with its components is shown in Figure 2-4. The vibration of crystals in an ultrasound machine’s transducer generates ultrasound, and the transducer can detect the echoes and convert them to electrical signals. A transducer is composed of piezoelectric crystals, which respond to pressure to generate an electric current. The alternating current causes the piezoelectric crystals to vibrate at a desired frequency corresponding to ultrasound waves. The produced ultrasound beam is directed into the tissues by moving the transducer and changing the angle of incidence of the ultrasonic beam. Conversely, when an electric current is applied to the crystals, its shape changes with polarity, producing electrical signals from echoes that are processed to generate a display. Hence the crystals act as transmitters (for a short time) and receivers (most of the time).","{'21ea2cce-2b35-49d2-b305-ec9206d1a049': 'A typical ultrasound probe with its components is shown in Figure 2-4. The vibration of crystals in an ultrasound machine’s transducer generates ultrasound, and the transducer can detect the echoes and convert them to electrical signals. A transducer is composed of piezoelectric crystals, which respond to pressure to generate an electric current. The alternating current causes the piezoelectric crystals to vibrate at a desired frequency corresponding to ultrasound waves. The produced ultrasound beam is directed into the tissues by moving the transducer and changing the angle of incidence of the ultrasonic beam. Conversely, when an electric current is applied to the crystals, its shape changes with polarity, producing electrical signals from echoes that are processed to generate a display. Hence the crystals act as transmitters (for a short time) and receivers (most of the time).', '94811f99-172d-4f5b-b147-104bc6827fcf': 'Since the air between the tissue and the transducer inhibits the propagation of the ultrasound beam, a conducting gel is usually applied between them.'}"
+Figure 2-5,ultrasound/images/Figure 2-5.jpg,Figure 2-5: Block diagram of an ultrasound imaging system.,"Figure 2-5 shows a block diagram of an ultrasound imaging system. Two modes are essential in the formation of an ultrasound image. These are the transmission modes that convert an alternating current into mechanical pressure waves. The backscattered pressure waves are picked up by the receiving mode, which converts them into electrical signals. The ultrasound waves that get fully transmitted through any tissues or structures do not produce echoes and appear dark. For example, all fluids appear echo-free and black on the ultrasound image.","{'630d92c7-dc16-4dc5-9257-db9e15ba9009': 'Figure 2-5 shows a block diagram of an ultrasound imaging system. Two modes are essential in the formation of an ultrasound image. These are the transmission modes that convert an alternating current into mechanical pressure waves. The backscattered pressure waves are picked up by the receiving mode, which converts them into electrical signals. The ultrasound waves that get fully transmitted through any tissues or structures do not produce echoes and appear dark. For example, all fluids appear echo-free and black on the ultrasound image.'}"
+Figure 2-6,ultrasound/images/Figure 2-6.jpg,Figure 2-6: An illustration of the pulse-echo imaging operation.,"The transducer generates pulses and detects backscattered energy from the tissue boundaries, as shown in Figure 2-6. The length of delay between the transmitted and received pulses is used to determine the depth of the tissue boundary or organ under examination.","{'e1884315-5857-43d0-8267-a013b09efebe': 'The transducer generates pulses and detects backscattered energy from the tissue boundaries, as shown in Figure 2-6. The length of delay between the transmitted and received pulses is used to determine the depth of the tissue boundary or organ under examination.', 'e1cb142a-d659-48b4-be24-15b5df92ded4': 'These piezoelectric signals from the crystals are amplified and converted into a gray or white color on the ultrasound image via a computer program. The difference in tissue reflectivity allows us to see individual structures. When ultrasound hits a dense object, it is wholly reflected, forming a posterior acoustic shadow (a bright and echogenic image). This is because no ultrasound is transmitted, creating an echo void. The computer can calculate the tissue’s depth by measuring the time between when the wave was sent and when an echo was detected.'}"
+Figure 2-7,ultrasound/images/Figure 2-7.jpg,"Figure 2-7: The stones in gallbladders are very bright, and they cast an acoustic shadow posterior to the stones. Ultrasonography of sludge and gallstones, annotated by Kitmondo Marketplace licensed under CC0 2.0","Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.","{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-8,ultrasound/images/Figure 2-8.jpg,Figure 2-8: A mirror image artifact appears as a symmetric image with less intensity than the actual image on the opposite side of the baseline. The mirror image artifact is apparently outside the liver. Leberhaemangiom mit Spiegelartefakt 56M – US – 001 by Hellerhoff licensed under CC BY-SA 4.0,"Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.","{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-9,ultrasound/images/Figure 2-9.jpg,Figure 2-9a: One of the assumptions of ultrasound imaging is that the beam travels in a straight line.,Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.,"{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-9,ultrasound/images/Figure 2-9.jpg,Figure 2-9b: Schematic of the formation of a ghost artifact.,Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.,"{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-9,ultrasound/images/Figure 2-9.jpg,Figure 2-9a: One of the assumptions of ultrasound imaging is that the beam travels in a straight line.,Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.,"{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-9,ultrasound/images/Figure 2-9.jpg,Figure 2-9b: Schematic of the formation of a ghost artifact.,Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.,"{'0d70a4c7-b6cc-4419-8c2e-149cc2c06a7b': 'Highly reflective or attenuating tissues reduce the ultrasound beam intensity inside the tissues, leading to obscured images close to or behind them. This shadowing artifact results from refraction that causes echoes to appear darker, like a shadow, due to the ultrasound beam’s decreased amplitude, intensity, and power.', 'ee3a1fe3-d05c-4493-9e30-24eba25f7416': 'Shadows occur when an ultrasound beam cannot pass through an area deeply due to the presence of a strongly reflecting or attenuating tissue. Figure 2-7 shows acoustic shadowing caused by the stones in the gallbladder. The shadows occur in regions of high acoustic impedance mismatch, such as soft tissue / gas or soft tissue / bone interfaces. These shadowing artifacts prevent visualization of the accurate anatomy on a scan by covering it with an anechoic shadow. This may cause misdiagnosis of the tissue anatomy.', '9d5452c2-6a31-477b-b3a8-0d54d6033e57': 'Other causes of shadowing artifacts are improper scanning techniques, improper settings, or poor ultrasound systems.', 'd59d7b0a-9152-49a1-936f-218e5bb1b28a': 'Some possible ways to reduce these artifacts include taking images from several angles, changing the lateral resolution, or decreasing the frequency to avoid missing information.', '3daef67e-2dd5-434e-8fbb-d719d1d0e989': 'Mirror Image Artifact (a.k.a. Ghost Artifact)', 'cfd32dde-14b6-413f-abe5-2a7983530f65': 'Multiple reflections (reverberation) often occur in regions with high impedance mismatches, such as air/fluid or flesh/bone interfaces. The multiple reflections duplicate a true reflector when the waves from a highly reflective surface are redirected toward a second structure. The redirected waves form a replica of the original structure, which appears on the image as a second structure.', 'fa3de6bb-03e5-41e5-ad9d-ba85b8fb9acd': 'Mirror image artifacts occur in both grayscale and color Doppler imaging. The true reflector and the artifact are equidistant from the mirror plane located between the two, as shown in Figure 2-8. This violates the assumptions that (1) ultrasound waves travel in a straight line and (2) waves travel directly to a reflecting tissue and are reflected directly back to the transducer.', 'bc9f6cb0-1004-4468-aab7-0e672923c67e': 'A ghost artifact can develop on a color Doppler image when multiple reflections occur beyond borders. Ghost or mirror image artifacts can be reduced by decreasing the overall gain or changing the beam angle. During diagnosis, mirror images should be clearly separated from actual anatomy, especially in guided needle biopsy, where samples must be taken from a specific location.', 'ada9e603-3ce4-4713-994e-dfb8d56493ce': 'Two possible ways by which mirror image artifacts can be formed are illustrated in Figure 2-9a.', 'cc2c1ae8-6ab7-4ecf-8051-2e78c5a3a6e3': 'Circular structures such as cysts can cause refraction, which produces shadows on the object’s edge due to a mismatch in acoustic impedance at the boundary or interface. The change in direction (bending) results from the change in the propagation velocity of the ultrasound waves. A schematic of this process is illustrated in Figure 2-9b.'}"
+Figure 2-10,ultrasound/images/Figure 2-10.jpg,Figure 2-10: Image illustration of a side lobe effect.,"Beams generated from the edges of a single-element transducer tend to spread from the primary beam, as shown in Figure 2-10. These lobe beams can be reflected into the primary beam, adding energy to the beam’s main axis. These artifacts violate the assumption that all reflections occur in the path of the beam’s main axis.","{'4d97ebad-4bee-4604-b21f-5ddc8384d31c': 'Beams generated from the edges of a single-element transducer tend to spread from the primary beam, as shown in Figure 2-10. These lobe beams can be reflected into the primary beam, adding energy to the beam’s main axis. These artifacts violate the assumption that all reflections occur in the path of the beam’s main axis.', '1c900944-be4e-450f-b1a0-54daa93a46a2': 'This duplication of the true anatomy with false reflection results from strong reflections that return to the transducer. Since the machine assumes all echoes to be coming from a true anatomic structure, incorrect images are displayed together with the correct ones.', '2b379c11-63fb-4f56-b869-704a39fcbd36': 'A rapidly oscillating ultrasound beam produces multiple side lobe echoes that appear on the display as a curved line equidistant from the transducer. The two most important features that distinguish a side lobe artifact from an anatomical structure are that it is equidistant to the transducer along its length and it passes through anatomical structures.', '27f37706-d7b9-4367-b0a0-988d39cea73c': 'The side lobe artifact is corrected by imaging the structure in multiple directions. The artifact will not appear in all viewing directions.'}"
+Figure 2-11,ultrasound/images/Figure 2-11.jpg,"Figure 2-11: An ultrasound energy beam that deviates from the central beam results in side or grating lobes, which, upon encountering a reflector, can produce echoes that return to the transducer. The machine erroneously assumes the echoes are due to reflection from the main beam axis and displays the image in the wrong location.","While the assumption is that all reflections are in the path of the beam’s main axis, as the beam is projected from the transducer into the tissue, some of the ultrasound waves spread outward, as shown in Figure 2-11. The presence of a strong reflector along the path of the diffracted waves produces echoes that are misinterpreted as being along the beam’s main axis. The grating lobe artifact generally appears weaker than the true reflector. This obscures the actual anatomy with a false reflection.","{'63766a7f-154b-4ca2-bd3e-d8382ee385ee': 'While the assumption is that all reflections are in the path of the beam’s main axis, as the beam is projected from the transducer into the tissue, some of the ultrasound waves spread outward, as shown in Figure 2-11. The presence of a strong reflector along the path of the diffracted waves produces echoes that are misinterpreted as being along the beam’s main axis. The grating lobe artifact generally appears weaker than the true reflector. This obscures the actual anatomy with a false reflection.', 'aa308a33-07c8-4c1d-9c15-751fe342404d': 'The artifact is corrected by taking multiple views of the structure under examination. An artifact will not appear in all views.'}"
+Figure 2-12,ultrasound/images/Figure 2-12.jpg,Figure 2-12: A schematic of multiple reflections from two surfaces.,"The echo from the secondary reflector takes a longer path and hence longer time to get back to the transducer. Since ultrasound machines measure the depth based on the time between the transmitted signal and the received echo, the machine will perceive a longer time and depth and position the image on the wrong spot, as shown in Figure 2-12.","{'89a3c4a4-7ee1-4eec-a2c7-3c65998214f6': 'Multipath artifacts occur when the primary ultrasound beam reflects off anatomy at an angle such that a part of the echo returns to the transducer and at the same time, another echo also reaches the transducer after reflecting off a second boundary.', 'b0893dbc-2290-4b33-9095-15bfee75e847': 'The echo from the secondary reflector takes a longer path and hence longer time to get back to the transducer. Since ultrasound machines measure the depth based on the time between the transmitted signal and the received echo, the machine will perceive a longer time and depth and position the image on the wrong spot, as shown in Figure 2-12.', 'eb05a650-d111-4586-9a2f-f556bd3e67da': 'In this case, the assumption that the ultrasound beam travels directly to the reflector and back to the transducer is violated. This phenomenon creates what is called a propagation path error. These artifacts give rise to the incorrect axial location of an object due to longer path lengths.', 'd70fe753-ba13-41fd-bfda-39453da25d9d': 'Multipath reflections may form images that appear deeper or misplaced. The problem can be reduced by taking multiple views at different angles.'}"
+Figure 2-13,ultrasound/images/Figure 2-13.jpg,Figure 2-13: Reflections from an oblique surface.,Figure 2-13 illustrates the possible reflections from an oblique surface in various directions. This observation contradicts the assumption that an ultrasound pulse travels directly to a reflecting boundary surface and back to the transducer.,"{'c3b89cb6-99a0-435c-a5b9-4ebd9973dfa5': 'An ultrasound beam incident on a curved or oblique boundary is reflected in various directions. Some of the reflected waves are directed away from the transducer. This reflection is similar to the scattering process. In this case, reflectors do not appear on the image due to longer path lengths and increasing attenuation.', 'e7144c72-2e7c-4383-8ee3-f202651df621': 'Figure 2-13 illustrates the possible reflections from an oblique surface in various directions. This observation contradicts the assumption that an ultrasound pulse travels directly to a reflecting boundary surface and back to the transducer.', '5ee7cfc8-ea64-4c90-9a79-437958123325': 'The strength of the echo received by the transducer is less than the expected intensity, which gives false brightness, missing reflections, or an improper location of the anatomic structure. These artifacts are associated with weak, too-bright echoes or improperly located structures. This artifact can be reduced by changing the transducer angle or by using a large footprint.'}"
+Figure 2-14,ultrasound/images/Figure 2-14.jpg,Figure 2-14: Beam width artifact can cause an image to appear in the wrong location due to side echoes that are erroneously interpreted by the machine as part of the central beam.,"While it may be convenient to assume that the beam width stays approximately equal to the transducer size, the ultrasound beam actually spreads out as it moves away from the transducer, as Figure 2-14 shows. Due to this divergence, the echoes generated from the edge of the beam appear to be coming from the center of the beam. The artifacts are most apparent when most of the beam travels through the fluid and part of it interacts with adjacent soft tissue, as shown in Figure 2-14.","{'5766d62f-5c35-4771-a717-6d1ecdbf4667': 'While it may be convenient to assume that the beam width stays approximately equal to the transducer size, the ultrasound beam actually spreads out as it moves away from the transducer, as Figure 2-14 shows. Due to this divergence, the echoes generated from the edge of the beam appear to be coming from the center of the beam. The artifacts are most apparent when most of the beam travels through the fluid and part of it interacts with adjacent soft tissue, as shown in Figure 2-14.'}"
+Figure 2-15,ultrasound/images/Figure 2-15.jpg,"Figure 2-15: Reverberation artifacts are characterized as multiple horizontal lines that are equidistant from one another, and they are more pronounced as the intensity decreases with the depth. Ultrasonography of diastasis recti – annotated by Mikael Häggström, M.D. licensed under CC0 1.0","Figure 2-15 shows an image with multiple reflections, indicated by arrows at the top. The first bright line at the top close to the transducer is the only real line image. The other bright images below the actual reflector are artifacts. Another way reverberation artifacts can occur is when the transducer behaves as another reflecting surface such that the returning echoes are rereflected back into the tissue-reflecting structure, resulting in the formation of an identical artifact located at twice the distance from the transducer.","{'f9ece966-5d13-4881-8761-a7e58a5198a2': 'While the ultrasound machine is based on the assumptions that (1) sound travels in a straight line, (2) all echoes are parallel to the transducer axis, and (3) sound waves travel at 1540 m/s in soft tissue, the ultrasound echoes may be reflected repeatedly between two highly reflective surfaces that are parallel to the primary ultrasound beam. This causes reflections that oscillate between the tissue and the transducer. The artifacts appear on the image as multiple stairways that are equally spaced apart from one another and tend to increase with increasing tissue depth.', 'dcb36d76-cd1b-4bf5-ada0-35b02c45ee00': 'Figure 2-15 shows an image with multiple reflections, indicated by arrows at the top. The first bright line at the top close to the transducer is the only real line image. The other bright images below the actual reflector are artifacts. Another way reverberation artifacts can occur is when the transducer behaves as another reflecting surface such that the returning echoes are rereflected back into the tissue-reflecting structure, resulting in the formation of an identical artifact located at twice the distance from the transducer.', 'ebda50ab-c188-4a6b-9587-1ce34803f63f': 'Because of attenuation, each image formed due to subsequent echoes is weaker than the first, as shown in Figure 2-15. The artifact can be prevented by moving the transducer probe at various angles to see an area covered by the artifact.'}"
+Figure 2-15,ultrasound/images/Figure 2-15.jpg,"Figure 2-15: Reverberation artifacts are characterized as multiple horizontal lines that are equidistant from one another, and they are more pronounced as the intensity decreases with the depth. Ultrasonography of diastasis recti – annotated by Mikael Häggström, M.D. licensed under CC0 1.0","Figure 2-15 shows an image with multiple reflections, indicated by arrows at the top. The first bright line at the top close to the transducer is the only real line image. The other bright images below the actual reflector are artifacts. Another way reverberation artifacts can occur is when the transducer behaves as another reflecting surface such that the returning echoes are rereflected back into the tissue-reflecting structure, resulting in the formation of an identical artifact located at twice the distance from the transducer.","{'f9ece966-5d13-4881-8761-a7e58a5198a2': 'While the ultrasound machine is based on the assumptions that (1) sound travels in a straight line, (2) all echoes are parallel to the transducer axis, and (3) sound waves travel at 1540 m/s in soft tissue, the ultrasound echoes may be reflected repeatedly between two highly reflective surfaces that are parallel to the primary ultrasound beam. This causes reflections that oscillate between the tissue and the transducer. The artifacts appear on the image as multiple stairways that are equally spaced apart from one another and tend to increase with increasing tissue depth.', 'dcb36d76-cd1b-4bf5-ada0-35b02c45ee00': 'Figure 2-15 shows an image with multiple reflections, indicated by arrows at the top. The first bright line at the top close to the transducer is the only real line image. The other bright images below the actual reflector are artifacts. Another way reverberation artifacts can occur is when the transducer behaves as another reflecting surface such that the returning echoes are rereflected back into the tissue-reflecting structure, resulting in the formation of an identical artifact located at twice the distance from the transducer.', 'ebda50ab-c188-4a6b-9587-1ce34803f63f': 'Because of attenuation, each image formed due to subsequent echoes is weaker than the first, as shown in Figure 2-15. The artifact can be prevented by moving the transducer probe at various angles to see an area covered by the artifact.'}"
+Figure 2-16,ultrasound/images/Figure 2-16.jpg,Figure 2-16: Comet tail artifact seen in the intercostal space.  Interstitial syndrome adn the lung rockers by Daniel A Lichtenstein licensed under CC BY 2.0,"The artifact typically appears as one or multiple solid bright “tails” parallel to the axis of the primary sound beam, as shown in Figure 2-16. The pattern may differ depending on the size, shape, and composition of the reflecting tissue structure and the scan orientation and distance from the transducer.","{'f4f08bee-1006-479e-8555-5bf233191066': 'There are various possible causes of comet tail artifacts. These are', '62489a39-bb87-4cf0-b21e-1fcbd1ba1f21': 'The artifact typically appears as one or multiple solid bright “tails” parallel to the axis of the primary sound beam, as shown in Figure 2-16. The pattern may differ depending on the size, shape, and composition of the reflecting tissue structure and the scan orientation and distance from the transducer.', '810990c2-3e79-4255-9e23-c117c5babc64': 'This artifact helps diagnose or rule out pneumothorax. If the pneumothorax is present, the air within the pleural space hinders the propagation of ultrasound waves, thereby preventing the formation of comet tail artifacts.', '180e878e-3c2e-4353-a7d5-632009269397': 'The major problem is that the tails cause significant attenuation such that the beam becomes significantly weak and cannot reach deeper regions of the tissue. These tails prevent the scan from imaging the underside of the reflecting structure. The artifact can be prevented by performing multiple scans at different angles to view the area obscured by the tail.'}"
+Figure 2-17,ultrasound/images/Figure 2-17.jpg,"Figure 2-17: Schematics of the different types of transducer arrays: (a) linear sequential, (b) curvilinear, and (c) linear phased.","Transducers are available in various shapes and sizes depending on users’ needs. As discussed earlier, a transducer consists of piezoelectric crystals—not one crystal but an array of multiple crystal elements. The various arrays and transducers are discussed below, and their schematics are shown in Figure 2-17.","{'ad3c8a13-f0ef-4424-b20b-216b46bca33a': 'Transducers are available in various shapes and sizes depending on users’ needs. As discussed earlier, a transducer consists of piezoelectric crystals—not one crystal but an array of multiple crystal elements. The various arrays and transducers are discussed below, and their schematics are shown in Figure 2-17.'}"
+Figure 2-18,ultrasound/images/Figure 2-18.jpg,"Figure 2-18: The vertical position is expressed as a voltage signal amplitude, indicating the relative amplitude of the echoes.","In the B-mode, the echoes are represented by bright dots. A shade of gray is assigned to each echo. The brightness of the dots indicates the strength of the echoes. The position of a dot on the screen represents the reflector distance and is determined by the transducer-reflector time relationship. Many diagnoses are made in the B-mode (in black and white) with a relatively simple probe and protocol. It finds use in the study of both stationary and moving structures. The B-mode is an electronic conversion of the A-mode and A-line information into brightness-modulated dots on the display screen, as illustrated in Figure 2-18.","{'8073b444-59b6-4428-9550-ef2281091677': 'In the B-mode, the echoes are represented by bright dots. A shade of gray is assigned to each echo. The brightness of the dots indicates the strength of the echoes. The position of a dot on the screen represents the reflector distance and is determined by the transducer-reflector time relationship. Many diagnoses are made in the B-mode (in black and white) with a relatively simple probe and protocol. It finds use in the study of both stationary and moving structures. The B-mode is an electronic conversion of the A-mode and A-line information into brightness-modulated dots on the display screen, as illustrated in Figure 2-18.', '10e60eb9-e3f7-44c5-900a-a8b33e64cc3a': 'The B-mode display can be used for the M-mode and 2D grayscale imaging. Modern B-mode ultrasound uses both the fundamental and the second harmonic frequencies. Harmonic imaging is most useful in patients with thick and complicated body wall structures. Figure 2-19 shows anatomical structures in the B-mode.', '0b113810-32c1-4c9c-9916-922056c7b34c': 'The B-mode is also used for early intima-media thickness analysis of the carotid arteries (located in the neck) to determine the potential for lethal cardiac events. Abnormal thickening of the arterial walls of the carotid arteries is an early indicator of vascular disease throughout the body. The thicker the arterial wall, the greater the risk of heart attack or stroke.'}"
+Figure 2-19,ultrasound/images/Figure 2-19.jpg,Figure 2-19: The B-mode displays anatomic structures by utilizing different gray brightness in a 2-dimensional space. Scan20semanas1 by Guimi licensed under CC BY-SA 2.5,The B-mode display can be used for the M-mode and 2D grayscale imaging. Modern B-mode ultrasound uses both the fundamental and the second harmonic frequencies. Harmonic imaging is most useful in patients with thick and complicated body wall structures. Figure 2-19 shows anatomical structures in the B-mode.,"{'8073b444-59b6-4428-9550-ef2281091677': 'In the B-mode, the echoes are represented by bright dots. A shade of gray is assigned to each echo. The brightness of the dots indicates the strength of the echoes. The position of a dot on the screen represents the reflector distance and is determined by the transducer-reflector time relationship. Many diagnoses are made in the B-mode (in black and white) with a relatively simple probe and protocol. It finds use in the study of both stationary and moving structures. The B-mode is an electronic conversion of the A-mode and A-line information into brightness-modulated dots on the display screen, as illustrated in Figure 2-18.', '10e60eb9-e3f7-44c5-900a-a8b33e64cc3a': 'The B-mode display can be used for the M-mode and 2D grayscale imaging. Modern B-mode ultrasound uses both the fundamental and the second harmonic frequencies. Harmonic imaging is most useful in patients with thick and complicated body wall structures. Figure 2-19 shows anatomical structures in the B-mode.', '0b113810-32c1-4c9c-9916-922056c7b34c': 'The B-mode is also used for early intima-media thickness analysis of the carotid arteries (located in the neck) to determine the potential for lethal cardiac events. Abnormal thickening of the arterial walls of the carotid arteries is an early indicator of vascular disease throughout the body. The thicker the arterial wall, the greater the risk of heart attack or stroke.'}"
+Figure 2-20,ultrasound/images/Figure 2-20.jpg,Figure 2-20: Typical example of the M-mode showing a four-chamber view of the heart. Echokardiographie M-Mode 4KB TAPSE by Wolff-BI licensed under CC BY-SA 3.0,"Imaging the pattern of moving cardiac structures over time constitutes M-mode echocardiography, as Figure 2-20 shows.","{'064bc4e5-84f7-4fd9-94d8-2232a5daf1d0': 'In the M-mode, the motion of an object points along the transducer axis and is revealed by a bright trace moving up and down across the image. This display is commonly used to evaluate the morphology, movement, and velocity of cardiac valves and walls.', '30945be5-7e9f-422c-a5a3-de482ea1a956': 'Imaging the pattern of moving cardiac structures over time constitutes M-mode echocardiography, as Figure 2-20 shows.'}"
+Figure 2-21,ultrasound/images/Figure 2-21.jpg,Figure 2-21: Ultrasound image of the right common carotid artery and the corresponding Doppler waveform.,"Three modalities are currently used in Doppler echocardiography, and these are pulsed wave (PW) Doppler, continuous wave (CW) Doppler, and color flow (CF) Doppler imaging. Color flow imaging evaluates the Doppler flow information for its direction toward or away from the transducer based on the color display. A commonly used acronym for remembering the color and direction is BART—blue away, red toward. The PW Doppler does not continuously transmit and receive the ultrasound pulse. Multiple crystals in the transducer are excited in a quick burst, producing ultrasound waves. This transmission burst is then followed by a “listening” period during which the crystals detect the reflected signals. Signals from more superficial structures are received sooner than those from deeper structures with more extended “listening” periods. This feature allows signals only from specific depths to be processed, thereby controlling sample size and range resolution. Therefore, two vessels located above each other can be evaluated separately, and vessels can also be followed as their courses change. The PW Doppler wave is site-specific and can only measure low-flow velocities—it cannot correctly measure high velocities (above –m/s). The CW Doppler uses two piezoelectric crystals, one to emit ultrasound continuously and the other to receive the reflected waves continuously. This results in a fixed sample size and no range resolution or ability to place the sample volume at a specific depth. It also cannot create anatomic images. It is used for precise settings such as very high peak systolic velocities.1 The CW Doppler measures very high blood flow velocities, and the color flow CF Doppler is a PW Doppler with multiple gates that allow it to measure the flow velocity through the heart on the two-dimensional echocardiographic image. Physicians often use Doppler imaging to detect blockages to the blood flow (due to clots), constriction of vessels or tumors, and congenital vascular malformations. Figure 2-21 shows an ultrasound image of the right common carotid artery and the corresponding Doppler waveform.","{'362d7398-42f5-449e-b00a-4c0d75a8e077': 'Doppler imaging is based on the Doppler effect, which shows the relationship between velocity and frequency shift. This imaging system is mainly used to measure blood flow velocity to determine any narrowing of the arteries and assess the risk of stroke occurrence.', '55fd43cd-276d-493d-a15c-91302ae9c8f7': 'In the sonographic application of the Doppler effect, a typical moving source would be flowing blood, and a typical receiver would be a stationary transducer. When the source is moving away, the detected frequency is lower. Conversely, a source moving closer to the receiver would have a higher detected frequency.', '0d3dcee4-dea9-44e8-b849-a498a15f6f52': 'For a stationary source (transducer) and a receiver (target) moving with velocity (v) at an angle (θ) relative to the direction of the incident wave of frequency (fs) from the transducer, the Doppler frequency is given by', '6c0ed5c0-28c1-46b3-875a-fad1aee8cd80': 'where c is the speed of sound in the tissue, which is 1540 m/s.', '0a003347-99e4-4348-8313-3006fad1bfa4': 'The transducer transmits and receives sound waves in the form of sinusoidal signal waves. The magnitude of the Doppler shift is related to the velocity of the blood cells or moving tissue, and the polarity of the shift reflects the direction of blood flow. The blood flowing toward the transducer is positive, and the blood flowing away from the transducer is negative.', '6d10fb6c-9939-4ab2-a3e2-27f26ba93666': 'The Doppler shift (Δf) is directly proportional to the velocity (v) of the blood cells, the transducer frequency (fs), and the cosine of the angle of incidence (θ) and is inversely proportional to the velocity of sound in tissue (c = 1540 m/s). In cardiac applications, the angle of incidence in the Doppler equation is assumed to be 0 or 180 degrees.', '5773a07e-047e-4b1a-b1c2-d42d868a174c': 'Three modalities are currently used in Doppler echocardiography, and these are pulsed wave (PW) Doppler, continuous wave (CW) Doppler, and color flow (CF) Doppler imaging. Color flow imaging evaluates the Doppler flow information for its direction toward or away from the transducer based on the color display. A commonly used acronym for remembering the color and direction is BART—blue away, red toward. The PW Doppler does not continuously transmit and receive the ultrasound pulse. Multiple crystals in the transducer are excited in a quick burst, producing ultrasound waves. This transmission burst is then followed by a “listening” period during which the crystals detect the reflected signals. Signals from more superficial structures are received sooner than those from deeper structures with more extended “listening” periods. This feature allows signals only from specific depths to be processed, thereby controlling sample size and range resolution. Therefore, two vessels located above each other can be evaluated separately, and vessels can also be followed as their courses change. The PW Doppler wave is site-specific and can only measure low-flow velocities—it cannot correctly measure high velocities (above –m/s). The CW Doppler uses two piezoelectric crystals, one to emit ultrasound continuously and the other to receive the reflected waves continuously. This results in a fixed sample size and no range resolution or ability to place the sample volume at a specific depth. It also cannot create anatomic images. It is used for precise settings such as very high peak systolic velocities.1 The CW Doppler measures very high blood flow velocities, and the color flow CF Doppler is a PW Doppler with multiple gates that allow it to measure the flow velocity through the heart on the two-dimensional echocardiographic image. Physicians often use Doppler imaging to detect blockages to the blood flow (due to clots), constriction of vessels or tumors, and congenital vascular malformations. Figure 2-21 shows an ultrasound image of the right common carotid artery and the corresponding Doppler waveform.', '23f187ae-5ac9-4a60-8f06-0fdaf128cca5': 'Duplex ultrasonography combines physiologic information based on Doppler shift frequencies with anatomic information from real-time, high-resolution B-mode imaging.'}"
+Figure 2-22,ultrasound/images/Figure 2-22.jpg,Figure 2-22: Physiological features of the pulmonary and systemic circuits. Diagram of the pulmonary and systemic circuits by Colorado Community College System licensed under CC BY-NC-SA 4.0,"Understanding blood flow dynamics is important in the study of vascular disease development, such as atherosclerosis, thrombosis, or aneurysms. The circulation system transports nutrients and waste around the body (delivering oxygen and nutrients to the cells and removing cellular wastes and carbon dioxide). Its other function is to maintain a constant temperature and potential or power of hydrogen (pH) in all organs of the body. The circulation system comprises the heart (the pump that drives the blood to all body tissues), blood vessels (delivery routes), and blood (the medium that transports the food and the waste materials). The blood flows continuously through two separate loops that originate and terminate at the heart: the pulmonary circulation and systemic circulation loops, as shown in Figure 2-22. Pulmonary circulation carries blood between the heart and lungs, and systemic circulation carries blood between the heart and the body’s organs and tissues. At any time, about 84% of the entire blood volume is in systemic circulation, 7% is in the heart, and 9% is in the pulmonary vessels.","{'0e394c39-0d2b-4b29-abef-8056d4cb667d': 'Understanding blood flow dynamics is important in the study of vascular disease development, such as atherosclerosis, thrombosis, or aneurysms. The circulation system transports nutrients and waste around the body (delivering oxygen and nutrients to the cells and removing cellular wastes and carbon dioxide). Its other function is to maintain a constant temperature and potential or power of hydrogen (pH) in all organs of the body. The circulation system comprises the heart (the pump that drives the blood to all body tissues), blood vessels (delivery routes), and blood (the medium that transports the food and the waste materials). The blood flows continuously through two separate loops that originate and terminate at the heart: the pulmonary circulation and systemic circulation loops, as shown in Figure 2-22. Pulmonary circulation carries blood between the heart and lungs, and systemic circulation carries blood between the heart and the body’s organs and tissues. At any time, about 84% of the entire blood volume is in systemic circulation, 7% is in the heart, and 9% is in the pulmonary vessels.', '51405623-d214-4853-b606-938a4cb827bb': 'Under normal conditions, the average resting heart rate of an adult between the ages of 18 and 80 is about 75 beats/min, with a stroke volume of 70 mL/beat (cardiac output of L/min). For vigorous-intensity physical activity, the heart rate can increase to as high as 200 beats/min, with a stroke volume of up to 150 mL/beat (cardiac output of about 25 L/min).[1] The arteries respond to varying pressure conditions by dilating or shrinking to accommodate the hemodynamic demands.', 'd5568f5d-f20f-4b4a-8909-4d37b92f15e5': 'The presence of a pressure gradient between the aorta and the veins ensures the blood keeps moving to the peripherals. In mathematical form, the volume per unit time (Q) can be expressed using Dacy’s law: Q = ΔP/R, where ΔP is the pressure differential and R is the resistance. Figure 2-23 shows the systemic blood pressure throughout different paths of the body.', '10a4dfdd-37b2-41c3-aa17-e7916d895767': 'As the heart pumps the blood, the pressure varies between systolic pressure (pressure peak after ventricular systole) and diastolic pressure (pressure drop during ventricular diastole). In the aorta, the systolic average pressure is about 120 mm of Hg, while the diastolic average pressure is about 80 mm of Hg.', 'd1131fa2-7f21-4a8e-9b7c-e1f99a7c26a9': 'The velocity of the flow is mainly determined by three critical variables: radius (r), vessel length (λ), and viscosity (η), which are related to one another by Poiseuille’s equation:', '2a516815-4417-42e8-9523-0256cccb3fb4': 'where ΔP is the pressure differential and resistance is given by', 'b34dbb50-c5fb-403b-8248-86303d6eec8e': 'This shows that since the radius changes with vasoconstriction and vasodilation, the effect will be a dramatic change in the resistance and flow of blood.', '9e6e0d61-2435-4834-ac88-e507ef8ab58a': 'The blood flow through straight, long, and smooth vessels is almost linear, with each layer of blood remaining the same distance from the walls of the vessels. These different layers flow at different velocities. Speed is dependent on both the axial distance and pressure. At high pressure, the velocity is high, whereas at low pressure, the velocity is low. This leads to a decrease in pressure and velocity from the heart to peripheral circulation.', '77aeca56-7f5b-4342-9d53-744e268d9004': 'Due to the difference in systolic and diastolic pressures, pulse pressure is generated during systole. A pulsatile blood flow is created down the pressure gradient into systemic circulation. The pulse pressure is ~ 40 mm of Hg, the difference between systolic and diastolic pressures.'}"
+Figure 2-23,ultrasound/images/Figure 2-23.jpg,"Figure 2-23: Systemic blood pressure throughout different paths of the body. Systemic Blood Pressure by Betts JG, Young KA, Wise JA, Johnson E, Poe B, Kruse DH, Korol O, Johnson JE, Womble M, and DeSaix P. licensed under CC BY 4.0","The presence of a pressure gradient between the aorta and the veins ensures the blood keeps moving to the peripherals. In mathematical form, the volume per unit time (Q) can be expressed using Dacy’s law: Q = ΔP/R, where ΔP is the pressure differential and R is the resistance. Figure 2-23 shows the systemic blood pressure throughout different paths of the body.","{'0e394c39-0d2b-4b29-abef-8056d4cb667d': 'Understanding blood flow dynamics is important in the study of vascular disease development, such as atherosclerosis, thrombosis, or aneurysms. The circulation system transports nutrients and waste around the body (delivering oxygen and nutrients to the cells and removing cellular wastes and carbon dioxide). Its other function is to maintain a constant temperature and potential or power of hydrogen (pH) in all organs of the body. The circulation system comprises the heart (the pump that drives the blood to all body tissues), blood vessels (delivery routes), and blood (the medium that transports the food and the waste materials). The blood flows continuously through two separate loops that originate and terminate at the heart: the pulmonary circulation and systemic circulation loops, as shown in Figure 2-22. Pulmonary circulation carries blood between the heart and lungs, and systemic circulation carries blood between the heart and the body’s organs and tissues. At any time, about 84% of the entire blood volume is in systemic circulation, 7% is in the heart, and 9% is in the pulmonary vessels.', '51405623-d214-4853-b606-938a4cb827bb': 'Under normal conditions, the average resting heart rate of an adult between the ages of 18 and 80 is about 75 beats/min, with a stroke volume of 70 mL/beat (cardiac output of L/min). For vigorous-intensity physical activity, the heart rate can increase to as high as 200 beats/min, with a stroke volume of up to 150 mL/beat (cardiac output of about 25 L/min).[1] The arteries respond to varying pressure conditions by dilating or shrinking to accommodate the hemodynamic demands.', 'd5568f5d-f20f-4b4a-8909-4d37b92f15e5': 'The presence of a pressure gradient between the aorta and the veins ensures the blood keeps moving to the peripherals. In mathematical form, the volume per unit time (Q) can be expressed using Dacy’s law: Q = ΔP/R, where ΔP is the pressure differential and R is the resistance. Figure 2-23 shows the systemic blood pressure throughout different paths of the body.', '10a4dfdd-37b2-41c3-aa17-e7916d895767': 'As the heart pumps the blood, the pressure varies between systolic pressure (pressure peak after ventricular systole) and diastolic pressure (pressure drop during ventricular diastole). In the aorta, the systolic average pressure is about 120 mm of Hg, while the diastolic average pressure is about 80 mm of Hg.', 'd1131fa2-7f21-4a8e-9b7c-e1f99a7c26a9': 'The velocity of the flow is mainly determined by three critical variables: radius (r), vessel length (λ), and viscosity (η), which are related to one another by Poiseuille’s equation:', '2a516815-4417-42e8-9523-0256cccb3fb4': 'where ΔP is the pressure differential and resistance is given by', 'b34dbb50-c5fb-403b-8248-86303d6eec8e': 'This shows that since the radius changes with vasoconstriction and vasodilation, the effect will be a dramatic change in the resistance and flow of blood.', '9e6e0d61-2435-4834-ac88-e507ef8ab58a': 'The blood flow through straight, long, and smooth vessels is almost linear, with each layer of blood remaining the same distance from the walls of the vessels. These different layers flow at different velocities. Speed is dependent on both the axial distance and pressure. At high pressure, the velocity is high, whereas at low pressure, the velocity is low. This leads to a decrease in pressure and velocity from the heart to peripheral circulation.', '77aeca56-7f5b-4342-9d53-744e268d9004': 'Due to the difference in systolic and diastolic pressures, pulse pressure is generated during systole. A pulsatile blood flow is created down the pressure gradient into systemic circulation. The pulse pressure is ~ 40 mm of Hg, the difference between systolic and diastolic pressures.'}"
+Figure 2-24,ultrasound/images/Figure 2-24.jpg,"Figure 2-24: Diagram representing laminar flow on the left and turbulent flow on the right. Turbulent pipe flow by Ryan Toomey, University of South Florida licensed under CC BY-SA 4.0","In a laminar flow, the motion of the fluid is very orderly, with all particles moving in straight lines parallel to the walls of the tube, as shown on the left of Figure 2-24. The velocity profile across the tube is parabolic, with the fluid’s highest velocity at the tube’s center, as shown in Figure 2-25. The parabolic profile arises because the fluid molecules touching the walls experience more resistance than those at the center.","{'ce337dc4-0ce0-4e1c-a177-337ef22b27e3': 'In a laminar flow, the motion of the fluid is very orderly, with all particles moving in straight lines parallel to the walls of the tube, as shown on the left of Figure 2-24. The velocity profile across the tube is parabolic, with the fluid’s highest velocity at the tube’s center, as shown in Figure 2-25. The parabolic profile arises because the fluid molecules touching the walls experience more resistance than those at the center.', '2a03ea6b-4511-428a-ba83-a3f23b8f2229': 'When the velocity of the blood becomes too high as it passes through a constricted vessel or a rough surface, the flow may become irregular, resulting in random fluctuations in position and time, leading to turbulent flow.', '9c30835e-8403-4c0f-bf3d-eaabd9de8074': 'The tendency for turbulent flow is measured using the Reynolds number, which depends on the velocity of the flow, the diameter of the vessel, and the density of the blood:', 'a91336d1-9659-4b2a-bd81-b43c69d5f781': 'where ν is the average blood flow velocity (in cm/s), d is the vessel diameter (in cm), ρ is density, and η is the viscosity of the blood. In these units, turbulence occurs when Re > 200, resulting in the formation of eddies. Turbulence can occur in regions of stenosis with increased flow velocity. This type of flow is not common in healthy vessels.'}"
+Figure 1-1,ultrasound/images/Figure 1-1.jpg,Figure 1-1: Characteristics of a longitudinal wave on a slinky.,"A mechanical wave requires a material medium (such as a solid, liquid, or gas) to propagate through; its speed depends on the properties of that medium. Mechanical waves fall into two classes: longitudinal and transverse waves. For a transverse wave, the displacement of the medium is perpendicular to the direction of the motion of the wave. In a longitudinal wave, the displacement of the medium is in the same direction as wave motion. One example of a longitudinal wave is sound. These waves are similar to the motion of a pulse on a slinky, as illustrated in Figure 1-1.","{'ff14df7c-f49d-4cfa-ad03-37f14f428a6b': 'A mechanical vibration is a back-and-forth motion. When vibrations affect the media around them, waves are generated. These waves transport energy from one point to another. If a single vibratory disturbance moves from one point to the other, it is called a pulse. A back-and-forth motion that occurs repeatedly is called a periodic motion.', '06708e13-5f36-4588-ba5c-826e48f9dde8': 'A mechanical wave requires a material medium (such as a solid, liquid, or gas) to propagate through; its speed depends on the properties of that medium. Mechanical waves fall into two classes: longitudinal and transverse waves. For a transverse wave, the displacement of the medium is perpendicular to the direction of the motion of the wave. In a longitudinal wave, the displacement of the medium is in the same direction as wave motion. One example of a longitudinal wave is sound. These waves are similar to the motion of a pulse on a slinky, as illustrated in Figure 1-1.'}"
+Figure 1-2,ultrasound/images/Figure 1-2.jpg,Figure 1-2: Characteristics of a longitudinal wave.,"A sound wave comprises alternating regions of low and high pressures. The waveform is a sinusoidal wave function in which the crests and troughs represent high- and low-pressure regions, respectively, as shown in Figure 1-2.","{'b613c9ab-3917-44dd-8e75-231d25383637': 'A sound wave comprises alternating regions of low and high pressures. The waveform is a sinusoidal wave function in which the crests and troughs represent high- and low-pressure regions, respectively, as shown in Figure 1-2.'}"
+Figure 1-3,ultrasound/images/Figure 1-3.jpg,Figure 1-3: Transverse wave characteristics.,"The maximum displacement or height from the horizontal axis, the equilibrium position, is the amplitude (A) of the wave. The distance between two successive points in the same phase is the wavelength (λ). For example, the wavelength is the distance between neighboring peaks, neighboring troughs, or any two points where the wave returns to the same shape, as shown in Figure 1-3.","{'41928900-1660-4888-9c70-5f340af2a1a9': 'The maximum displacement or height from the horizontal axis, the equilibrium position, is the amplitude (A) of the wave. The distance between two successive points in the same phase is the wavelength (λ). For example, the wavelength is the distance between neighboring peaks, neighboring troughs, or any two points where the wave returns to the same shape, as shown in Figure 1-3.'}"
+Figure 1-4,ultrasound/images/Figure 1-4.jpg,Figure 1-4: The intensity of a wave decreases inversely with the square of the distance from its source.,"The acoustic power of an ultrasound wave is the quantity of energy generated per unit of time. The standard unit of acoustic power is the watt (W), and 1 watt = 1 joule per second. Therefore, the unit of sound intensity is W/m2. The intensity equation shows that sound intensity decreases as the square of the distance from the point source. We all know that sound loudness (ear perception of sound intensity level) decreases as we move away from the source, as illustrated in Figure 1-4.","{'c7719661-e564-4a35-878b-acf0773a12ad': 'The amount of sound energy flux per unit of time is called the sound intensity (I). For a point source generating sound with acoustic power (P), the intensity (I) at distance (r) from the source obeys the inverse square law:', '1df58a7b-8cfc-4918-9045-c2748bffb08b': 'The acoustic power of an ultrasound wave is the quantity of energy generated per unit of time. The standard unit of acoustic power is the watt (W), and 1 watt = 1 joule per second. Therefore, the unit of sound intensity is W/m2. The intensity equation shows that sound intensity decreases as the square of the distance from the point source. We all know that sound loudness (ear perception of sound intensity level) decreases as we move away from the source, as illustrated in Figure 1-4.', 'd1bdb2eb-eb39-4dfe-ba83-ad28757e16b1': 'The sound intensity level (also called the sound acoustic level) is commonly measured relative to the standard threshold of hearing intensity (Io) in decibels. A decibel is a dimensionless quantity (no units) represented as dB, which is based on the logarithmic scale. In mathematical form, the sound intensity level (ß) is expressed as', '25adb5cb-cf9c-4894-b816-311292508c5b': 'where Io = 10-12 W/m2, which is the faintest audible sound intensity.'}"
+Figure 1-5,ultrasound/images/Figure 1-5.jpg,Figure 1-5. Ultrasound reflection at the boundary between two tissues with different acoustic impedances.,"Like any wave, ultrasound waves are reflected at tissue boundaries and interfaces. The transducer detects these reflected waves, and piezoelectric signals are generated and processed into an image form via a computerized processing unit. These signals form the basis of all ultrasound imaging. The number of reflected waves detected by the transducer depends on the angle of incidence at the band boundary and the difference in acoustic impedance between the two tissues traversed by the beam. More details about the acoustic impedance will be discussed later. However, it represents the resistance of a tissue to the passage of ultrasound. Typically, a propagating ultrasound wave is split into two components, as Figure 1-5 illustrates.","{'507c54b7-ef71-413e-8958-ce867bb566d4': 'Like any wave, ultrasound waves are reflected at tissue boundaries and interfaces. The transducer detects these reflected waves, and piezoelectric signals are generated and processed into an image form via a computerized processing unit. These signals form the basis of all ultrasound imaging. The number of reflected waves detected by the transducer depends on the angle of incidence at the band boundary and the difference in acoustic impedance between the two tissues traversed by the beam. More details about the acoustic impedance will be discussed later. However, it represents the resistance of a tissue to the passage of ultrasound. Typically, a propagating ultrasound wave is split into two components, as Figure 1-5 illustrates.', '30ab11aa-78ca-47bd-85f2-45b1f8ec6bb1': 'If the wave traverses from medium 1 (with acoustic impedance Z1) to medium 2 (with acoustic impedance Z2), the reflection coefficient is', 'ca26653d-2041-42e6-b877-bfdea1dd4355': 'where θi is the angle of incidence, θr is the reflected angle, and θt is the angle of transmission. Pr and Pi represent the reflection and incident probability amplitudes, respectively.', '0392caf1-c857-45ac-8e02-b4474259e8e5': 'Reflections can also be classified into two categories: specular and diffuse, as illustrated in Figure 1-6.', 'f13ec0d4-918a-44d2-b9f3-597ce06a9387': 'The ultrasound beam that succeeds in penetrating the boundary layers or interface is called the transmitted wave. The transmission coefficient is mathematically expressed in the following form (refer to Figures 1-5 and 1-7):[2]'}"
+Figure 1-6,ultrasound/images/Figure 1-6.jpg,Figure 1-6: Different types of ultrasound reflections.,"Reflections can also be classified into two categories: specular and diffuse, as illustrated in Figure 1-6.","{'507c54b7-ef71-413e-8958-ce867bb566d4': 'Like any wave, ultrasound waves are reflected at tissue boundaries and interfaces. The transducer detects these reflected waves, and piezoelectric signals are generated and processed into an image form via a computerized processing unit. These signals form the basis of all ultrasound imaging. The number of reflected waves detected by the transducer depends on the angle of incidence at the band boundary and the difference in acoustic impedance between the two tissues traversed by the beam. More details about the acoustic impedance will be discussed later. However, it represents the resistance of a tissue to the passage of ultrasound. Typically, a propagating ultrasound wave is split into two components, as Figure 1-5 illustrates.', '30ab11aa-78ca-47bd-85f2-45b1f8ec6bb1': 'If the wave traverses from medium 1 (with acoustic impedance Z1) to medium 2 (with acoustic impedance Z2), the reflection coefficient is', 'ca26653d-2041-42e6-b877-bfdea1dd4355': 'where θi is the angle of incidence, θr is the reflected angle, and θt is the angle of transmission. Pr and Pi represent the reflection and incident probability amplitudes, respectively.', '0392caf1-c857-45ac-8e02-b4474259e8e5': 'Reflections can also be classified into two categories: specular and diffuse, as illustrated in Figure 1-6.', 'f13ec0d4-918a-44d2-b9f3-597ce06a9387': 'The ultrasound beam that succeeds in penetrating the boundary layers or interface is called the transmitted wave. The transmission coefficient is mathematically expressed in the following form (refer to Figures 1-5 and 1-7):[2]', 'd286f5ba-57f3-498e-a7f6-78df26c4f4f1': 'The ratio of the speed of the transmitted wave (v2) to that of the incident wave (v1) is related to the ratio of the sines of the angles of transmission and incidence, a relationship called Snell’s law:', '37d19691-6b2d-4a46-a792-cf49522e0d3e': 'When the waves are reflected from a perfectly flat surface or boundary, the reflected waves tend to be uniformly parallel to each other. In contrast, they tend to be diffuse for rough surfaces. This phenomenon is commonly observed as a “mirage” when driving on a hot summer day, and the road appears to have a wet surface that disappears as one gets closer. This leads to two different kinds of reflections, specular and diffuse, which are illustrated in Figure 1-6.', '36a37054-51f5-43fb-8012-6d2db5dfd122': 'The transducer picks up the reflected waves and converts the echoes into images. The strength of the echoes depends on the acoustic impedance between the two tissues through which the waves pass. Typically, boundary reflections occur on blood vessel walls and organ boundaries.'}"
+Figure 1-6,ultrasound/images/Figure 1-6.jpg,Figure 1-6: Different types of ultrasound reflections.,"Reflections can also be classified into two categories: specular and diffuse, as illustrated in Figure 1-6.","{'507c54b7-ef71-413e-8958-ce867bb566d4': 'Like any wave, ultrasound waves are reflected at tissue boundaries and interfaces. The transducer detects these reflected waves, and piezoelectric signals are generated and processed into an image form via a computerized processing unit. These signals form the basis of all ultrasound imaging. The number of reflected waves detected by the transducer depends on the angle of incidence at the band boundary and the difference in acoustic impedance between the two tissues traversed by the beam. More details about the acoustic impedance will be discussed later. However, it represents the resistance of a tissue to the passage of ultrasound. Typically, a propagating ultrasound wave is split into two components, as Figure 1-5 illustrates.', '30ab11aa-78ca-47bd-85f2-45b1f8ec6bb1': 'If the wave traverses from medium 1 (with acoustic impedance Z1) to medium 2 (with acoustic impedance Z2), the reflection coefficient is', 'ca26653d-2041-42e6-b877-bfdea1dd4355': 'where θi is the angle of incidence, θr is the reflected angle, and θt is the angle of transmission. Pr and Pi represent the reflection and incident probability amplitudes, respectively.', '0392caf1-c857-45ac-8e02-b4474259e8e5': 'Reflections can also be classified into two categories: specular and diffuse, as illustrated in Figure 1-6.', 'f13ec0d4-918a-44d2-b9f3-597ce06a9387': 'The ultrasound beam that succeeds in penetrating the boundary layers or interface is called the transmitted wave. The transmission coefficient is mathematically expressed in the following form (refer to Figures 1-5 and 1-7):[2]', 'd286f5ba-57f3-498e-a7f6-78df26c4f4f1': 'The ratio of the speed of the transmitted wave (v2) to that of the incident wave (v1) is related to the ratio of the sines of the angles of transmission and incidence, a relationship called Snell’s law:', '37d19691-6b2d-4a46-a792-cf49522e0d3e': 'When the waves are reflected from a perfectly flat surface or boundary, the reflected waves tend to be uniformly parallel to each other. In contrast, they tend to be diffuse for rough surfaces. This phenomenon is commonly observed as a “mirage” when driving on a hot summer day, and the road appears to have a wet surface that disappears as one gets closer. This leads to two different kinds of reflections, specular and diffuse, which are illustrated in Figure 1-6.', '36a37054-51f5-43fb-8012-6d2db5dfd122': 'The transducer picks up the reflected waves and converts the echoes into images. The strength of the echoes depends on the acoustic impedance between the two tissues through which the waves pass. Typically, boundary reflections occur on blood vessel walls and organ boundaries.'}"
+Figure 1-8,ultrasound/images/Figure 1-8.jpg,Figure 1-8: Ultrasound refraction at surface boundaries.,"When an ultrasound beam strikes a tissue boundary obliquely, the transmitted component of the beam undergoes a change in direction. This change is due to the differences in the velocities of the incident and transmitted beams. This bending process, called refraction, is illustrated in Figure 1-8 and is often related to the formation of artifacts during ultrasound image acquisition.","{'c8108331-7bdd-41ac-b939-e7c33b58961a': 'When an ultrasound beam strikes a tissue boundary obliquely, the transmitted component of the beam undergoes a change in direction. This change is due to the differences in the velocities of the incident and transmitted beams. This bending process, called refraction, is illustrated in Figure 1-8 and is often related to the formation of artifacts during ultrasound image acquisition.', '555c47cc-52c6-40bf-9753-e9bacd216566': 'In ultrasound imaging, refraction can result in the formation of artifacts such as double image artifacts, as shown in Figure 1-9. This artifact is caused by the differential refraction of the ultrasound beam while passing through the relatively different echogenic tissues, such as muscle and fat tissues, and the difference in velocities in those tissues.'}"
+Figure 1-9,ultrasound/images/Figure 1-9.jpg,"Figure 1-9: The figure on the left illustrates how a double image artifact is formed, and the one on the right is the actual double image artifact of an aorta on an ultrasound image. Aorta duplication artifact by Nevit Dilmen licensed under CC BY-SA 3.0","In ultrasound imaging, refraction can result in the formation of artifacts such as double image artifacts, as shown in Figure 1-9. This artifact is caused by the differential refraction of the ultrasound beam while passing through the relatively different echogenic tissues, such as muscle and fat tissues, and the difference in velocities in those tissues.","{'c8108331-7bdd-41ac-b939-e7c33b58961a': 'When an ultrasound beam strikes a tissue boundary obliquely, the transmitted component of the beam undergoes a change in direction. This change is due to the differences in the velocities of the incident and transmitted beams. This bending process, called refraction, is illustrated in Figure 1-8 and is often related to the formation of artifacts during ultrasound image acquisition.', '555c47cc-52c6-40bf-9753-e9bacd216566': 'In ultrasound imaging, refraction can result in the formation of artifacts such as double image artifacts, as shown in Figure 1-9. This artifact is caused by the differential refraction of the ultrasound beam while passing through the relatively different echogenic tissues, such as muscle and fat tissues, and the difference in velocities in those tissues.'}"
+Figure 1-10,ultrasound/images/Figure 1-10.jpg,Figure 1-10: An illustration of attenuation at multiple tissue boundaries.,"As the ultrasound moves through tissues, some of the ultrasound energy is lost due to absorption through heat, reflection, refraction, and scattering. The beam weakens with increased depth into the tissue, increasing acoustic impedance mismatch. Another factor is the presence of air bubbles inside the tissue, which tend to form virtually impenetrable barriers to ultrasound. Attenuation becomes higher not only with increasing distance from the transducer but also because of the heterogeneity caused by acoustic impedance mismatch as well as the higher frequency of the transducer, as illustrated in Figure 1-10. This is because air has a higher resistance to ultrasound propagation than fluids.","{'e48d8b65-e273-4ca6-8293-358568497be2': 'As the ultrasound moves through tissues, some of the ultrasound energy is lost due to absorption through heat, reflection, refraction, and scattering. The beam weakens with increased depth into the tissue, increasing acoustic impedance mismatch. Another factor is the presence of air bubbles inside the tissue, which tend to form virtually impenetrable barriers to ultrasound. Attenuation becomes higher not only with increasing distance from the transducer but also because of the heterogeneity caused by acoustic impedance mismatch as well as the higher frequency of the transducer, as illustrated in Figure 1-10. This is because air has a higher resistance to ultrasound propagation than fluids.', '3551265a-ac1d-4650-9080-3f5abe8b263d': 'The intensity (Ix) of an ultrasound beam at tissue depth x can be estimated using Beer’s law:', '0c1c38e1-0b08-434e-ad2d-139905d2b955': 'where Io is the incident intensity at the tissue surface and μ is the intensity attenuation coefficient. Of this attenuation, absorption contributes about 60–80%.[4]', '5ddc7f54-7db6-49ee-8dad-28b20ea4c22e': 'Attenuation increases with increasing gas and fat. The higher the tissue density (or impedance), the lower the reflection. For example, blood has an attenuation coefficient value closer to dB/MHz.cm, while the typical value for bone is around dB/MHz.cm.2', '8500b2fc-db8e-48ed-b345-fc0ec1eba0c0': 'Attenuation generally increases linearly with increasing frequency among different body tissues. Fluid-filled structures have much lower attenuation than solid structures. Hence the transmitted pulse from a fluid-filled structure is usually more substantial than that from passing through an equivalent amount of solid tissue.'}"
+Figure 1-11,ultrasound/images/Figure 1-11.jpg,Figure 1-11: Schematic of an ultrasound diffraction.,"The ultrasound beam spreads out with distance from the transducer as it passes through the tissue, causing diffraction, as shown in Figure 1-11. This results in the reduction of beam intensity.","{'99d34e43-ff9b-4b27-8e61-1f7df5832e24': 'The ultrasound beam spreads out with distance from the transducer as it passes through the tissue, causing diffraction, as shown in Figure 1-11. This results in the reduction of beam intensity.', '0877934c-afb8-4fd9-a5e9-bfcdbb2ed4a6': 'This diffraction pattern is highly dependent on the shape and size of the transducer relative to the wavelength of ultrasound. This phenomenon causes a decrease in the intensity of the ultrasound beam. To achieve a parallel beam, the diameter of the crystal face is designed to be approximately 10 to 20 times the wavelength of ultrasound.'}"