Ultrasound Imaging of the Fascial Layers: You See (Only) What You Know

Fascial plane blocks: from microanatomy to clinical applications

PURPOSE OF REVIEW

In the last 20 years, advancements in the understanding of fasciae have significantly transformed anaesthesia and surgery. Fascial plane blocks (FPBs) have gained popularity due to their validated safety profile and relative ease. They are used in various clinical settings for surgical and nonsurgical indications. Growing evidence suggests a link between the microscopic anatomy of fasciae and their mechanism of action. As a result, knowledge of these aspects is urgently needed to better optimise pain management. The purpose of this review is to summarise the different microscopic aspects of deep/muscular fascia to expand our understanding in the performance of FPBs.

RECENT FINDINGS

There is ample evidence to support the role of FPBs in pain management. However, the exact mechanism of action remains unclear. Fasciae are composed of various structural elements and display complex anatomical characteristics at the microscopic level. They include various cell types embedded within an extracellular matrix abundant in collagens and hyaluronan. Increasingly, numerous studies demonstrated their innervation that contributes to their sensory functions and their role in proprioception, motor coordination and pain perception. Lastly, the diversity of the cellular and extracellular matrix, with their viscoelastic properties, is essential to understanding the FPBs' mechanism of action.

SUMMARY

Physicians must be aware of the role of fascial microscopic anatomy and better understand their properties to perform FPBs in a conscious manner and enhance pain management.

Sonographic measurement of deep fascia parameters - Interrater reliability

PURPOSE

The deep fascia has recently been a current topic in many medical fields, including rehabilitation. Some research has already focused on assessing deep fascia, however results of individual authors differ in certain aspects. This study focuses on the inter-rater reliability of ultrasound (US) measurement of the thickness of deep fascia and loose connective tissue (LCT). The aim was to define the causes of any discrepancies in measurement that could contribute to the unification of management of evaluating fascia.

METHODS

An observational study was performed including 20 healthy individuals in whom fascia lata of the anterior thigh was examined by US imaging and then measured in Image J software. Three raters participated in this study: the first with 6 years of US imaging experience, other two were newly trained. The measurement of fascial parameters was conducted in two phases with special consultation between them resulting in an agreement of the research team on the more precise way of measurement.

RESULTS

Results revealed the value of inter-rater reliability ICC3,1 = 0.454 for deep fascia thickness and ICC3,1 = 0.265 for LCT thickness in the first phase and any significant difference in the second phase. This poor inter-rater reliability led to a search for possible causes of discrepancies, which authors subsequently highlighted.

CONCLUSION

The findings of the study show the main pitfalls of deep fascia measurement that should contribute to the unification of evaluation.

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block Combined with Port-Site Infiltration (PSI) for Laparoscopic Sleeve Gastrectomy in an ERABS Pathway: A Randomized, Prospective, Double-Blind, Placebo-Controlled Trial

PURPOSE

Patients undergoing laparoscopic sleeve gastrectomy (LSG) commonly experience moderate to severe postoperative pain. We conducted a randomized, prospective double-blind placebo-controlled study to evaluate the analgesic effect of laparoscopic-guided TAP (LG-TAP) block after LSG in a high-volume bariatric center, applying an enhanced recovery after bariatric surgery (ERABS) pathway.

MATERIAL AND METHODS

One hundred ten patients were randomly allocated to receive LG-TAP block with local anesthetic (LA) or saline solution (placebo), both combined with port-site infiltration with LA (LA-PSI). Primary outcome was pain score measured in post-anesthesia care unit (PACU) and at 6, 12, and 24 h after surgery. Secondary outcomes included postoperative nausea and/or vomiting (PONV), analgesic requirement, time to walking, time to flatus, length of hospital stay (LOS), and surgical complications.

RESULTS

No significant differences were observed between LG-TAP and placebo groups in postoperative analgesia, with a median (IQR) NRS of 2 (4.75-0) vs. 2 (5.25-0) in PACU, 5.5 (7-3) vs. 6 (7-4) at 6 h, 2 (6-0) vs. 3 (5.25-1.75) at 12 h, and 2 (3.75-0) vs. 1 (2-0) at 24 h; all p > 0.05. A significant difference was found in PONV in PACU (LG-TAP, 46%; placebo, 25%, p-value, 0.019) and at 6 h postoperatively (LG-TAP, 69%, placebo, 41%, p-value, 0.003). No differences were observed as regards other secondary outcomes.

CONCLUSION

Our results suggest that LG-TAP block is not related to more effective postoperative analgesia compared to placebo when LA-PSI is performed.

Crural and Plantar Fasciae Changes in Chronic Charcot Diabetic Foot: A Cross-Sectional Ultrasound Imaging Study-An Evidence of Fascial Continuity

Crural fascia (CF) and plantar fascia (PF) are biomechanically crucial in the gait and in the proprioception, particularly in the propulsion phase of the foot during the gait cycle and in the dissipation of forces during weight-bearing activities. Recent studies have revealed an association between increases in PF thickness and diabetes. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the CF and PF at different regions/levels in chronic Charcot diabetic foot patients (group 1) and in healthy volunteers (group 2). A cross-sectional study was performed using US imaging to measure the CF with Pirri et al.'s protocol and PF with a new protocol in a sample of 31 subjects (15 patients and 16 healthy participants). The findings for CF and PF revealed statistically significant differences in the poster region of CF (Post 1: group 1 vs. group 2: p = 0.03; Post 2: group 1 vs. group 2: p = 0.03) and in PF at two different levels (PF level 1: group 1 vs. group 2: p < 0.0001; PF level 2: group 1 vs. group 2: p < 0.0001). These findings suggest that chronic Charcot diabetic foot patients have CF and PF thicker compared to healthy volunteers. The US examination suggests that fascial thicknesses behavior in these patients points out altered fascial remodeling due to diabetes pathology and biomechanical changes.

Ultrasound Imaging of Thoracolumbar Fascia Thickness: Chronic Non-Specific Lower Back Pain versus Healthy Subjects; A Sign of a "Frozen Back"?

The thoracolumbar fascia (TLF) plays an important role in lower back pain (LBP). Recent studies have revealed an association between increases in TLF thickness and reduced TLF gliding in patients with LBP. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the TLF at the bilateral L3 level of the lumbar spine in the longitudinal and transverse axes in chronic non-specific LBP and in healthy subjects. A cross-sectional study was performed using US imaging to measure the longitudinal and transverse axes with a new protocol in a sample of 92 subjects: 46 chronic non-specific LBP patients and 46 healthy participants. The findings for TLF thickness revealed statistically significant differences (p < 0.05) in the longitudinal and transverse axes between the two groups. Moreover, in the healthy group, a statistically significant difference was found between the longitudinal and transverse axes (p = 0.001 for left and p = 0.02 for right), which was not evident in the LBP patients. These findings suggest that the LBP patients lost anisotropy of the TLF, with it becoming homogeneously thicker and losing adaptability in the transversal direction. The US imaging evaluation suggests that TLF thickness behavior points out altered fascial remodelling compared to healthy subjects, a sort of "frozen back".

The relationship between clinical examination measures and ultrasound measures of fascia thickness surrounding trunk muscles or lumbar multifidus fatty infiltrations: An exploratory study

Patients with chronic low back pain (CLBP) exhibit remodelling of the lumbar soft tissues such as muscle fatty infiltrations (MFI) and fibrosis of the lumbar multifidus (LuM) muscles, thickness changes of the thoracolumbar fascia (TLF) and perimuscular connective tissues (PMCT) surrounding the abdominal lateral wall muscles. Rehabilitative ultrasound imaging (RUSI) parameters such as thickness and echogenicity are sensitive to this remodelling. This experimental laboratory study aimed to explore whether these RUSI parameters (LuM echogenicity and fascia thicknesses), hereafter called dependent variables (DV) were linked to independent variables (IV) such as (1) other RUSI parameters (trunk muscle thickness and activation) and (2) physical and psychological measures. RUSI measures, as well as a clinical examination comprising physical tests and psychological questionnaires, were collected from 70 participants with LBP. The following RUSI dependent variables (RUSI-DV), measures of passive tissues were performed bilaterally: (1) LuM echogenicity (MFI/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1); (2) TLF posterior layer thickness, and (3) PMCT thickness of the fasciae between subcutaneous tissue thickness (STT) and external oblique (PMCT_STT/EO ), between external and internal oblique (PMCT_EO/IO ), between IO and transversus abdominis (PMCT_IO/TrA ) and between TrA and intra-abdominal content (PMCT_TrA/IA ). RUSI measures of trunk muscle's function (thickness and activation), also called measures of active muscle tissues, were considered as independent variables (RUSI-IV), along with physical tests related to lumbar stability (n = 6), motor control deficits (n = 7), trunk muscle endurance (n = 4), physical performance (n = 4), lumbar posture (n = 2), and range of motion (ROM) tests (n = 6). Psychosocial measures included pain catastrophizing, fear-avoidance beliefs, psychological distress, illness perceptions and concepts related to adherence to a home-based exercise programme (physical activity level, self-efficacy, social support, outcome expectations). Six multivariate regression models (forward stepwise selection) were generated, using RUSI-DV measures as dependent variables and RUSI-IV/physical/psychosocial measures as independent variables (predictors). The six multivariate models included three to five predictors, explaining 63% of total LuM echogenicity variance, between 41% and 46% of trunk superficial fasciae variance (TLF, PMCT_STT/EO ) and between 28% and 37% of deeper abdominal wall fasciae variance (PMCT_EO/IO , PMCT_IO/TrA and PMCT_TrA/IA ). These variables were from RUSI-IV (LuM thickness at rest, activation of IO and TrA), body composition (percent fat) and clinical physical examination (lumbar and pelvis flexion ROM, aberrant movements, passive and active straight-leg raise, loaded-reach test) from the biological domain, as well as from the lifestyle (physical activity level during sports), psychological (psychological distress-cognitive subscale, fear-avoidance beliefs during physical activities, self-efficacy to exercise) and social (family support to exercise) domains. Biological, psychological, social and lifestyle factors each accounted for substantial variance in RUSI-passive parameters. These findings are in keeping with a conceptual link between tissue remodelling and factors such as local and systemic inflammation. Possible explanations are discussed, in keeping with the hypothesis-generating nature of this study (exploratory). However, to impact clinical practice, further research is needed to determine if the most plausible predictors of trunk fasciae thickness and LuM fatty infiltrations have an effect on these parameters.

Detection of Lymphatic Vessels in the Superficial Fascia of the Abdomen

Recently, the superficial fascia has been recognized as a specific anatomical structure between the two adipose layers-the superficial adipose tissue (SAT) and the deep adipose tissue (DAT). The evaluation of specific characteristics of cells, fibers, blood circulation, and innervation has shown that the superficial fascia has a clear and distinct anatomical identity, but knowledge about lymphatic vessels in relation to the superficial fascia has not been described. The aim of this study was to evaluate the presence of lymphatic vessels in the hypodermis, with a specific focus on the superficial fascia and in relation to the layered subdivision of the subcutaneous tissue into SAT and DAT. Tissue specimens were harvested from three adult volunteer patients during abdominoplasty and stained with D2-40 antibody for the lymphatic endothelium. In the papillary dermis, a huge presence of lymphatic vessels was highlighted, parallel to the skin surface and embedded in the loose connective tissue. In the superficial adipose tissue, thin lymphatic vessels (mean diameter of 11.6 ± 7.71 µm) were found, close to the fibrous septa connecting the dermis to the deeper layers. The deep adipose tissue showed a comparable overall content of lymphatic vessels with respect to the superficial layer; they followed the blood vessel and had a larger diameter. In the superficial fascia, the lymphatic vessels showed higher density and a larger diameter, in both the longitudinal and transverse directions along the fibers, as well as vessels that intertwined with one another, forming a rich network of vessels. This study demonstrated a different distribution of the lymphatic vessels in the various subcutaneous layers, especially in the superficial fascia, and the demonstration of the variable gauge of the vessels leads us to believe that they play different functional roles in the collection and transport of interstitial fluid-important factors in various surgical and rehabilitation fields.

Acute Effects of Percussive Massage Therapy on Thoracolumbar Fascia Thickness and Ultrasound Echo Intensity in Healthy Male Individuals: A Randomized Controlled Trial

Percussive massage therapy (PT) has been widely used by therapists and the fitness population to treat myofascial-related conditions. However, there is no evidence to confirm the effects of PT on the fascia. This study aimed to investigate the effects of PT on thoracolumbar fascia (TLF) morphology and other related outcomes.

METHODS

Sixty-six healthy males participated and were randomly allocated into a percussive massage group (PT group) and a control group. The PT group received 15 min of back percussion massage, while the control group rested prone lying in the same environment for 15 min. Thoracolumbar fascia (TLF) thickness and echo intensity, perceived stiffness, lumbar flexibility, and skin temperature were measured in both groups before and immediately after the intervention.

RESULT

TLF thickness and lumbar flexibility did not change when compared in the two groups. However, the echo intensity (left side, difference -3.36, 95% CI -5.1 to -1.6; right side, difference -4.39, 95% CI -6.1 to -2.7) and perceived stiffness (difference, -1.18, 95% CI -1.84 to -0.52) in the TLF region were significantly lower in the PT group than in the control group and were accompanied by increased skin temperature (difference 0.29, 95% CI 0.11 to 0.48).

CONCLUSION

We suggest that a 15 min PT with 30 Hz on the back region could reduce TLF echo intensity and perceived stiffness and increase skin temperature in healthy men individual.

Ultrasound Imaging of the Superficial Fascia in the Upper Limb: Arm and Forearm

The superficial fascia has received much attention in recent years due to its important role of compartmentalizing the subcutaneous tissue. Ultrasound (US) imaging, owing to its high definition, provides the possibility of better visualizing and measuring its thickness. The aim of this study was to measure and compare, with US imaging, the thickness of superficial fascia in the arm and forearm in different regions/levels. An observational study has been performed using US imaging to measure superficial fascia thickness in the anterior and posterior regions at different levels in a sample of 30 healthy volunteers. The results for superficial fascia thickness revealed statistically significant differences (p < 0.0001) in the arm between the anterior and posterior regions; in terms of forearm, some statistically significant differences were found between regions/levels. However, in the posterior region/levels of the arm, the superficial fascia was thicker (0.53 ± 0.10 mm) than in the forearm (0.41 ± 0.10 mm); regarding the anterior regions/levels, the superficial fascia of the arm (0.40 ± 0.10 mm) was not statistically different than the forearm (0.40 ± 0.12 mm). In addition, the intra-rater reliability was good (ICC2,k: 0.88). US helps to visualize and assess the superficial fascia inside the subcutaneous tissue, improving the diagnosis of fascial dysfunction, and one of the Us parameters to reliably assess is the thickness in different regions and levels.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Shoulder

ABSTRACT

In this dynamic protocol, ultrasound examination of the shoulder using different maneuvers is described for several/relevant shoulder problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine]) will help musculoskeletal physicians perform a better and uniform/standard approach.

Ultrasound Imaging of Head/Neck Muscles and Their Fasciae: An Observational Study

Background: Masticatory muscle thickness provides objective measurements of the temporomandibular motor function, which may change in patients with oral myofascial pain. Moreover, they are considered as being part of the craniocervical unit by a crucial relationship with cervical muscles and their fasciae. In this study, we aimed to assess by ultrasound (US) imaging the fasciae of the masseter, temporal, and sternocleidomastoid muscles to understand their mean thickness and eventual variation in relationship with the muscles, sides, and sex.

Methods: We studied 16 healthy volunteers without temporomandibular joint dysfunction. Concerning each subject were evaluated the range of motion of the temporomandibular joint and of the neck, the thickness of muscles and their fasciae of both sides, and the delta of muscle thickness.

Results: All the motor evaluations of the subjects showed normal ranges. The US results showed that the fasciae have a mean thickness of 0.50 ± 0.1 mm, which did not change during muscle contraction. The evaluated muscles presented a symmetry between right and left (p > 0.05), even if the delta of muscle (US) thickness had a huge range between different subjects, for example in the masseter muscle from 0.7 to 4.2 mm.

Conclusions: Ultrasound imaging is a suitable and reliable tool to study the muscles and fasciae of the head and neck region, permitting also the evaluation of the ability of the muscles to contract. Finally, identifying functional asymmetry that could become symptomatic, US imaging could allow an early rehabilitation treatment.

Ultrasound Imaging of Brachial and Antebrachial Fasciae

Knowledge about fasciae has become increasingly relevant in connection to regional anesthesiology, given the growing interest in fascial plane, interfascial, and nerve blocks. Ultrasound (US) imaging, thanks to high definition, provides the possibility to visualize and measure their thickness. The purpose of this study was to measure and compare, by US imaging, the thickness of deep/muscular fasciae in different points of the arm and forearm. An observational study has been performed using US imaging to measure brachial and antebrachial fasciae thickness at anterior and posterior regions, respectively, of the arm and forearm at different levels with a new protocol in a sample of 25 healthy volunteers. Results of fascial thickness revealed statistically significant differences (p < 0.0001) in the brachial fascia between the anterior and the posterior regions; in terms of the antebrachial fascia, no statistically significant difference was present (p > 0.05) between the regions/levels. Moreover, regarding the posterior region/levels, the brachial fascia had a greater thickness (mean 0.81 ± 0.20 mm) than the antebrachial fascia (mean 0.71 ± 0.20 mm); regarding the anterior region/levels, the antebrachial fascia was thicker (mean 0.70 ± 0.2 mm) than the brachial fascia (mean 0.61 ± 0.11 mm). In addition, the intra-rater reliability reported good reliability (ICC_2,k: 0.88). US imaging helps to improve grading of fascial dysfunction or disease by revealing subclinical lesions, clinically invisible fascial changes, and one of the US parameters to reliably evaluate is the thickness in the different regions and levels.

An Investigation of the Association between Transversus Abdominis Myofascial Structure and Activation with Age in Healthy Adults using Ultrasound Imaging

BACKGROUND

Because of their importance in core stability, training the deep abdominal muscles, fascial structures and particularly the transversus abdominis, is a key component of many sport and physical therapy programs. However, there are gaps in knowledge about age-related changes in the structure and activation capacity of these muscles.

HYPOTHESIS/PURPOSE

This study investigated the association between deep abdominal muscles and fascial structures and transversus abdominis activation with age in healthy adults.

STUDY DESIGN

A cross-sectional study.

METHODS

Eighty-six adults aged 18 to 77 participated in this study. An ultrasound image of their transversus abdominis, internal oblique, external oblique and associated fasciae was first captured at rest, then during a contraction of the transversus abdominis. Bivariate correlation analyses and hierarchical analyses were performed (significance level: p < 0.05).

RESULTS

The thickness of these three muscles decreases with age ( ρ = -0.66 for external oblique, -0.51 for internal oblique and -0.58 for transversus abdominis), whereas the thickness of their fasciae increases ( ρ = 0.39 for the fascia of external oblique, 0.54 for the fascia between internal oblique and external oblique, and 0.74 for the fascia between internal oblique and transversus abdominis). Transversus abdominis activation decreases with age (r =-0.44). Age accounts for 19.5% of the variance in transversus abdominis activation.

CONCLUSION

These results demonstrate that normal aging is associated with changes in deep abdominal myofascial structures and transversus abdominis activation. Assessment of these metrics can provide valuable baseline information for physical therapists involved in rehabilitation and strengthening programs targeting older individuals.

LEVEL OF EVIDENCE

Level 2.

Compartments of the antebrachial fascia of the forearm: clinically relevant ultrasound, anatomical and histological findings

PURPOSE

Acute compartment syndrome is defined as a limb-threatening condition caused by bleeding or oedema in a closed muscle compartment surrounded by fascia or bone. It is most commonly encountered in the forearm, which has three compartments: posterior, anterior and lateral. These are surrounded and closed in by the antebrachial fascia, formed by dense connective tissue that facilities their study on ultrasound and is key to fasciotomy treatment. The purpose of this study was to broaden existing ultrasound, anatomical and histological knowledge of the fascia of the forearm to facilitate their identification on ultrasound, with possible clinical and therapeutic applications.

METHODS

The study was performed in 50 cryopreserved upper limbs from adult cadavers from the dissection room of the Faculty of Medicine and Health Sciences. They were examined on ultrasound and subsequent anatomical dissection and microscopy to study the fascia and its relationship with different muscles of the forearm compartments.

RESULTS

Distinct anatomical relationships were observed on ultrasound and dissection between the fascia and the extensor carpi ulnaris, extensor digiti minimi, and anconeus muscle in the posterior compartment, and the flexor carpi radialis and flexor carpi ulnaris in the anterior compartment. They were isolated by the antebrachial fascia and had distinct relationships with the neurovascular structures.

CONCLUSION

These results demonstrate that high-definition ultrasound enables us to locate the antebrachial fascia and particular muscles with a distinct relationship with neurovascular structures. This helps better identify these structures, facilitating diagnosis of any pathology in the area, with potential therapeutic and clinical applications.

A Closer Look at the Cellular and Molecular Components of the Deep/Muscular Fasciae

The fascia can be defined as a dynamic highly complex connective tissue network composed of different types of cells embedded in the extracellular matrix and nervous fibers: each component plays a specific role in the fascial system changing and responding to stimuli in different ways. This review intends to discuss the various components of the fascia and their specific roles; this will be carried out in the effort to shed light on the mechanisms by which they affect the entire network and all body systems. A clear understanding of fascial anatomy from a microscopic viewpoint can further elucidate its physiological and pathological characteristics and facilitate the identification of appropriate treatment strategies.

Ultrasound Imaging of Crural Fascia and Epimysial Fascia Thicknesses in Basketball Players with Previous Ankle Sprains Versus Healthy Subjects

Background: Fascial layers may play an important role in locomotor mechanics. Recent researches have revealed an association between increases of fascia thickness and reduced joint flexibility in patients with chronic pain. The purpose of this study was to measure and compare, through the use of ultrasound imaging, the thickness of the deep/crural fascia in different points of the leg as well as the epimysial fascia thickness at level 2 of anterior compartment of leg, in male basketball players with history of recurrent ankle sprain and in healthy participants. Methods: A cross-sectional study has been performed using ultrasound imaging to measure deep/crural fascia thickness of anterior, lateral and posterior compartment of the leg at different levels with a new protocol in a sample of 30 subjects, 15 basketball players and 15 healthy participants. Results: Findings of fascial thickness revealed statistically significant differences (p < 0.01) in epimysial fascia thickness and in deep/crural fascia thickness between levels/compartments of the same group and between two groups. Moreover, Post 3 deep/crural fascia thicknesses (p < 0.001) were decreased showing statistically significant difference for the basketball players group respect the healthy participants group. Conclusions: These findings suggested that the posterior compartment was thicker than anterior compartment, probably due to a postural reason in both groups. Moreover, they showed an increase of thickness of the epimysial fascia in basketball players with previous ankle sprains. This variability underlines the importance to assess the fasciae and to make results comparable.

An anatomical comparison of the fasciae of the thigh: A macroscopic, microscopic and ultrasound imaging study

Although the number of Ultrasound (US) imaging studies investigating the fascial layers are becoming more numerous, the majority tend to use different reference points and terminology to describe their findings. The current work set out to compare macroscopic and microscopic data of specimens of the fascial layers of the thigh with US imaging findings. Specimens of the different fascial layers of various regions of the thigh were collected for macroscopic and histological analyses from three fresh cadavers and compared with in vivo US images of the thighs of 20 healthy volunteers. The specimens showed that the subcutaneous tissue of the thigh is made up of three layers: a superficial adipose layer, a membranous layer/superficial fascia, and a deep adipose layer. The deep fascia is composed of an aponeurotic fascia, which envelops all the thigh muscles and is laterally reinforced by the iliotibial tract and an epimysial fascia, which is specific for each muscle. The morphometric measurements of the thickness of the superficial fascia were different (anterior: 153.2 ± 39.3 µm; medial: 128.4 ± 24.7 µm; lateral: 154 ± 28.9 µm; and posterior: 148.8 ± 33.2 µm) as were those of the deep fascia (anterior: 556.8 ± 176.2 µm; medial: 820.4 ± 201 µm; lateral: 1112 ± 237.9 µm; and posterior: 730.4 ± 186.5 µm). The US scans showed a clear picture of the superficial adipose tissue, the superficial fascia, and the deep adipose tissue, as well as the deep fasciae. The epimysial and aponeurotic fasciae of only some topographic areas could be independently identified. The US imaging findings confirmed that the superficial and deep fascia have different thicknesses, and they showed that the US measurements were always larger with respect to those produced by histological analysis (p < 0.001) probably due to shrinkage during the processing. The posterior region (level 1) of the superficial fascia had, for example, a mean thickness of 0.56 ± 0.12 mm at US, while the histological analysis showed that it was 148.8 ± 33.2 µm. Showing a similar pattern, the thickness of the deep fascia was as follows: 1.64 ± 0.85 mm versus 730.4 ± 186.5 µm. Study results have confirmed that US can be considered a valid, non-invasive instrument to evaluate the fascial layers. In any event, there is a clear need for a set of standardised protocols since the thickness of the fascial layers of different parts of the human body varies and the data obtained using inaccurate reference points are not reproducible or comparable. Given the inconsistent terminology used to describe the fascial system, it would also be important to standardise the terminology used to define its parts. The difficulty in distinguishing between the epimysial and aponeurotic/deep fascia can also impede data interpretation.

Sonographic characteristics of pilomatricomas and their association with symptom duration

This study aimed to investigate the associations between the sonographic findings and duration of symptoms in children with pilomatricoma.This study included 86 children with 95 lesions confirmed to be pilomatricoma after pathological examination. The associations between symptom duration and sonographic observations, including the presence or absence of peritumoral hyperechogenicity, calcification, and vascularity were investigated. The internal echogenicity of each pilomatricoma was scored using a 5-point scale based on echogenic spots and calcification with posterior acoustic shadowing. The Mann-Whitney U and Kruskal-Wallis tests were used for statistical analysis.We found that the absence of peritumoral hyperechogenicity and severity of calcification were associated with increased symptom duration. Calcification, (present, 19.19 ± 18.99 months vs absent, 4.31 ± 3.24 months; P < .01) and peritumoral hyperechogenicity (present, 5.02 ± 5.80 months vs absent, 16.17 ± 18.24 months; P < .01), and grade of internal echogenicity (grade 0/1/2/3/4 = 3 months [1 patient]/4.33 ± 3.26 months [range, 1-12]/4.57 ± 3.46 months [range, 2-12]/10.89 ± 9.17 months [range, 3-28]/35.27 ± 19.16 months [range, 9-60], respectively; P = .01 and <.01) were associated with significant differences in symptom duration. There were no significant between-group differences in vascularity (6.01 ± 7.24 months; range, 1-48 vs 15.50 ± 19.12 months; range, 1-60; P = .08).Pilomatricomas with a relatively short symptom duration were more likely to exhibit peritumoral hyperechogenicity and calcification with less severe posterior acoustic shadowing compared to lesions with a longer symptom duration. These sonographic findings provided useful information that facilitated the correct and rapid diagnosis of pilomatricoma.

Ultrasound imaging of a scar on the knee: Sonopalpation for fascia and subcutaneous tissues

Persistent scar pain associated with healed surgical incisions after a trauma is a common and potentially debilitating type of fascial pain. At present, there is no universally effective treatment for persistent surgical or post-trauma scar pain. Herein we describe the successful objective diagnosis of debilitating scar pain by Ultrasound (US) imaging. The sonopalpation of the fasciae and subcutaneous tissues seems to be relevant to diagnose the real cause of the pain and why not to monitor the treatment.