 Hi everyone, I am Dr. Vankrishna. Today I will be discussing an approach to superficial soft tissue swellings. So, etiologies of the superficial soft tissue swellings are extremely varied. They can range from non-neoplastic to benign or malignant neoplastic conditions. Chronital characterization of these lesions continue to be a challenge. High resolution ultrasound with the access to top per evaluation is often the first line screening modality that is used to evaluate these soft tissue swellings. It is widely available cost-effective and a real-time tool which allows for both static and dynamic evaluation of the swelling. The goal is in the next 10 minutes I would like to propose an algorithmic approach to characterize to the extent of possible some of these soft tissue swellings which we commonly encounter in our day-to-day practice. This will help the need for further imaging or to perform invasive procedures and also we can identify potentially aggressive lesions which will require further imaging in the form of an MRI or a biopsy. So, a general checklist which I do before performing an ultrasound evaluation of a soft tissue swelling is to ask for the detailed history. I would like to look for multiplicity, the duration, the rate of growth. Is there any pain, any trauma, any symptoms of infection? Is there any pre-existing systemic illness or malignancy in the patient or is the patient on any kind of medication or anticoagulation? The physical examination of the swelling also needs to be performed. I look at the size, the firmness, the mobility, the tenderness and the overlying skin changes. When performing a high-resolution ultrasound of a soft tissue swelling, use a high frequency linear ray transducer. Evaluate the lesion in at least two perpendicular planes using both grayscale and color Doppler ultrasound. It is always recommended to use copious amount of jelly and very light pressure that removes the compression of small vessels and missing minimal blood flow. Minimize the color box and use low PRF and low or no wall fitter settings. Of course, you can use techniques which are available in certain machines like extended field of ursine images, which are used to be useful to document large masses and certain dynamic conditions within the masses. So broadly, if you look at a soft tissue swelling, the first thing you need to note down is whether it is solid or cyst. If it is a cystic swelling, if the swelling is thick or thin-walled, it is abascular, it shows some kind of communication with the joint or adjacent tendon, you're probably dealing with a ganglion cyst. If the swelling has a thick irregular wall, it is abascular, showing floating internal echoes and the patient has constitutional symptoms like fever, then you're dealing with probably an abscess. This swelling shows a lot of vascularity and may show continuity with the artery or the vein, and you may be dealing with the pseudonyism or Avina varix respectively. If there are multiple channels and there are calcific lesions within the swelling, which roughly represent turbulence, always perform the compression release maneuver to show the retrograde filling of these channels, then it could be a vascular malformation, probably venous malformation. Always remember to ask the history of trauma, and if there is a history of trauma and the swelling is overlying the boning prominence, if it shows septations and fat globules within, then it's probably a moral level lesion. So the first case which I have here is a firm swelling with the dorsal aspect of the wrist, and that is the swelling which is quite an echoic and it has a hyper-echoic internal separation. This is the distal end of the radius, this is the lunate, and this is the capitinic. You can see the neck of the swelling which is extending almost into the radiocapitate joint, and that is the neck of the swelling. Compression and release maneuver was showing you a lot of debris within the floating debris within the swelling. So this was a ganglion cyst. Most of the dorsal ganglion cysts at the wrist originate from the dorsal scapulonate ligament. They may extend with a thin neck into the joint space and may show echogenic debris. The important point here which I would like to emphasize is the ganglion cysts show no internal vascularity. If they do show any kind of internal vascularity, an alternative diagnosis should be sought. This is a four month old child who presented with a painful soft tissue swelling over the chest wall. Child was not doing very well, had repetitive episodes of fever. That is a soft tissue swelling and someone had tried to aspirate it and that's the small puncture wound that was there. Ultra sound is showing a very thick walled swelling. It is not fully an echoic, it has got this floating internal debris. And on the posterior aspect of the swelling we can clearly see an effect in the rib through which the swelling is communicating to. Doppler shows there is no internal vascularity in the swelling, but rather there is more vascularity around the periphery of the swelling. And if you notice the subcutaneous fat also appears quite echo-genic and inflamed. CD3D image clearly demonstrating the erosion in the rib in which the swelling is communicating. So this was a case of rib osteomyelitis with a subcutaneous abscess in the chest wall. There is a thick wall around the collection with floating internal debris surrounding hyper-echoic area of inflammation and erosions in the underlying rib. The lesion per se itself is quite abracular and clinical history also comes to our aid in the diagnosis of this condition. A 24-year-old male who presented with history of trauma to the wrist following which he developed a slightly painful pulsatile swelling over the hypothenar remnants. He had undergone treatment outside and someone had actually nicked the swelling and when it bled profusely they had sutured it. So the swelling was not progressively increasing size and the patient had pain. So this is a classical pseudo-aneurysm we are able to see even on grayscale the aneurysm is communicating with the ulnar artery that is the neck. And obviously color Doppler shows the characteristic yin-yang sign which is associated with pseudo-aneurysm. A 30-year-old who presented with a painless swelling which becomes prominent on valsalva so as you can see this is the rest phase and this is the valsalva phase where the swelling over the neck is becoming very prominent. Ulrasound clearly demonstrated the swelling was just an expansion of the external jugular vein and this is when patient was performing valsalva we are able to see the swelling was actually the flow into the swelling was actually seizing up. So whenever he performs valsalva this flow is stopping and when he releases the pressure this flow is back. MR was also done for this patient because the technician wanted it and here we are able to compare both sides of the external jugular vein really demonstrating that this was a vena varix. A 22-year-old who presented with multiple soft tissue swellings which are painless and present since childhood and they are gradually progressively increasing in size. A high-resolution ultrasound during the unequivoc channels with a hyper-equipped flabellet within and the dynamic maneuver compression release shows the retrograde filling of this swelling. So this was a venous malformation you can clearly demonstrate the flabellets and the vascularity. A 22-year-old with history of trauma over the knee joint with the soft tissue swelling that was slightly painful. So this is the soft tissue swelling I have used the extended field of view as I had told for larger swellings you can use it to beautifully demonstrate the extent of the lesion. So extending all the way from the patella to the level of the tibia and you have multiple internal separations. The inching point however are these flat globules which are floating inside the swelling. This was a moral level lesion it develops in close de-gloving injuries it is a hemolymphatic mass it is often anechoic or hypoechoic with internal debris or separations and the flat globules which appear as this echogenic foci with them. Coming to the solid swellings they are homogeneous or heterogeneous. The homogeneous soft tissue swellings which are often hyper-equic and located in the subcutaneous region and usually avascular or usually lipomers. If they are hypoechoic swellings they can be well or ill-defined. Well-defined swellings which show continuity with the tendon sheet and show market vascularity within are usually chance and tumor of the tendon sheet. If they show continuity with the fascia they are fibromatosis. Continuity with the nerve is neuroma. Well or ill-defined swelling which show anarchic internal vascularity. This word is quite important. If the vascularity is not regular and very irregular then you are probably dealing with an indeterminate mass. This has a wide differential and there is definitely a concern for malignancy. Such lesions definitely need to undergo an MRI or biopsy. So this is a soft painless soft tissue swelling. As you can see here well-defined in the subcutaneous plane color Doppler showing no internal vascularity. This is a lipoma. Lipomers need not have a definitive capsule. Lipomers can show this ill-defined area hypoechoic areas with no internal vascularity. So this is unencapsulated lipomers. Lipomers can also occur within the muscle. This is inside the deltoid muscle and again no internal vascularity hypoechoic swelling. So this is an example of an intramuscular lipoma. For 26 year old firm painless slow growing swelling over the plantar aspect of the foot and the screen over the swelling is absolutely normal hypoechoic swelling which is seen here marked internal vascularity and the swelling is along the plantar fascia. So that is the clenching point here. It is growing along the fascia as a case of plantar fibromatosis. Another lesion which is showing gradually progressive firm swelling over the arm and when tapping the swelling it produces sharp radiation pain in the forearm and the wrist. So that is seen in the MRI as spindle shaped swelling with slight internal vascularity. You can see the median nerve is entering and exiting this swelling and that's the median nerve. This is the bracheal artery. So this is a median nerve stretch neuroma. On asking for the history the patient said he had a stretch injury and following that he has developed a neuroma in continuity. So this is a 27 year old quite an interesting case who presented with a hard slightly tender soft tissue swelling over the lumbar region. So this is what I was telling. The swelling is quite well defined located in the subcutaneous plane. We attempted to call it as a benign lesion. Doppler showed a lot of chaotic vascularity as you can see very anarchy vascularity not a smooth vascularity within. So it was grouped into an indeterminate lesion with a concern for malignancy and the patient underwent first an FNAC followed by a wide local excision and the histopathology came out to be a pleomorphic and differentiated sarcoma. So always pay attention to the vascularity of the lesion. Heterogeneous soft tissue swellings with a history of trauma and showing peripheral calcifications are usually myosidious ossificants. Always compare your diagnosis with a radiograph. While an ill-defined necrotic lesion with an archic vascularity again has a wide differential. Patient with left hemiplegia underwent native massage to improve the strength now presented with a tender enlarging mass. That's the ultrasound image showing peripheral calcified or hyperequic lines with strong posterior acoustic shadowing within the muscle muscle. That's the biceps muscle. X-ray is very convincing sheets of calcification is there around the underlying bone is absolutely normal. So this is a case of myosidious ossificants and it is more common in patients with hemiplegia. A 52-year-old with firm tender, mildly tender soft tissue swelling in the gluteal region that is progressively enlarging. So as you can see a large swelling that is noted in the in the muscular plane and this swelling is heterogeneous, hyperequic. But what is quite interesting is the vascularity, very anarchic vascularity. Very irregular vascularity within the lesion. Very suspicious and biopsy came out to be a spindle cell sarcoma. So the take-off message is what I would like to say is if you do a meticulous sonographic technique and follow an algorithmic approach you probably can accurately characterize most of the lesions, not all of them. Understand the limitations of ultrasound and if the lesion cannot be characterized as a benign entity based on all the examples I have shown you above do not report it as a benign lesion, rather report it as an indeterminate lesion with concern for malignancy and then you should either image further or do a biopsy and be wary of lesions having an anarchic internal vascularity because most of more often than thought these are more sinister. Thank you very much for your kind attention.