Ultrasound Fundamentals: An Evidence-Based Guide

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 Jinlei Li
Robert Ming-Der Chow
Nalini Vadivelu
Alan David Kaye
Editors

Ultrasound
Fundamentals
An Evidence-Based Guide for Medical
Practitioners

123
Ultrasound Fundamentals
Jinlei Li • Robert Ming-Der Chow
Nalini Vadivelu • Alan David Kaye
Editors

Ultrasound Fundamentals
An Evidence-Based Guide for Medical
Practitioners
Editors
Jinlei Li Robert Ming-Der Chow
Department of Anesthesiology Department of Anesthesiology
Yale University School of Medicine Yale University School of Medicine
New Haven New Haven
CT CT
USA USA

Nalini Vadivelu Alan David Kaye

Department of Anesthesiology Department of Anesthesiology and Pharmacology
Yale University Toxicology and Neurosciences
New Haven LSU Health Shreveport
CT Shreveport
USA LA
USA

Department of Anesthesiology
Department of Pharmacology
Louisiana State University School of Medicine
Louisiana State University Health Sciences
Center
New Orleans
LA
USA

ISBN 978-3-030-46838-5    ISBN 978-3-030-46839-2 (eBook)

https://doi.org/10.1007/978-3-030-46839-2

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
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computer software, or by similar or dissimilar methodology now known or hereafter developed.
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imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Dr. Jinlei Li, M.D., Ph.D., F.A.S.A: I want to thank my mother Shuzhen Zang,
M.D., father Lin Li, husband Yong, and children Claire and Alex for their
unconditional love and continuous support.

Robert Ming-Der Chow, M.D.: I want to thank my parents Nina and KC

Chow as well as my sister Sonya and brother-in-law Marc for their
unwavering support in all that I do. I also wish to thank my uncle Curtis Hsu
and aunt Ann Hsu for believing in me since I was a child. Lastly, I wish to
thank Robert Jason Yong, M.D., M.B.A., Andrew Vaclavik, M.D., and Milan
Stojanovic, M.D., for their invaluable teaching and mentorship.

Dr. Nalini Vadivelu, M.D.: I wish to thank my husband Thangamuthu

Kodumudi and our sons Dr. Gopal Kodumudi and Vijay Kodumudi for their
unwavering support. I wish to thank my brother Dr. Amarender Vadivelu for
his unconditional care. I wish to thank my mentors, colleagues, residents, and
students from all over the world who constantly inspire me to reach greater
heights.

Dr. Alan David Kaye, M.D., Ph.D.: I want to thank my mother Florence and
wife Dr. Kim Kaye, M.D., for their unwavering support and love. I wish to
thank Dr. Matthew, Eng, M.D., for his excellent teaching of ultrasound to our
department and myself. Finally, I wish to thank Dr. Charles Fox, M.D., for his
amazing support and friendship over the past 30 years, since we met the first
day of intern orientation back in 1989.
Foreword

Ultrasound has radically changed the way we practice medicine. This modality gives us diag-
nostic possibilities in so many situations. It is also used to provide insight into pathological
conditions. Ultrasound use, in combination with diagnostic procedures, makes them easier and
safer as well as improves patient satisfaction. The benefits of its use are too numerous to name.
During my 35-year career in obstetrics and maternal fetal medicine, I have seen the vast
benefit of this modality. For my patients, it provides a window into the womb to view their
unborn child, but its benefits do not stop there. Ultrasound is used to diagnose, treat, and care
for the unborn child. It truly has allowed us to treat a new patient category, the fetus.
The book Ultrasound Fundamentals: An Evidence-Based Guide to Medical Practitioners
encompasses many of the uses of ultrasound in modern medicine. This extensive evaluation
tackles the basic physics of ultrasound, progressing its active use in practices across the spec-
trum of medicine. The editors have assembled a wide range of authorities that reflect upon their
vast experiences using this modality. This text touches on almost all specialties and provides
state-of-the-art techniques that should afford our patients better outcomes.
Ultrasound has truly revolutionized medicine. It has become an inexpensive, highly accu-
rate, and portable imaging modality that we can take to the patient in the clinic, operating
room, critical care areas, hospital floor, or in our radiology suites. This imaging modality has
truly changed medicine, and I believe the reader will find this textbook very helpful. More
importantly, our patients will benefit from the presentations.

David F. Lewis, MD, MBA

Chairman, Obstetrics & Gynecology, Dean, School of Medicine
LSU Health Science Center – Shreveport, Shreveport
LA, USA

vii
Preface

As a physician, I am certainly not the only one who can appreciate the increasingly important
role that ultrasound plays in education and patient care. Some consider ultrasound to be the
new stethoscope, which is certainly not an overstatement in my mind. As a matter of fact, I
personally feel ultrasound techniques supply us with a third eye to look deep into the human
anatomy, physiology, and pathology, from top to bottom. Training to effectively use this third
eye should start in medical school, which is one of the reasons why I wanted to create an intro-
ductory ultrasound book for medical students, the future of medicine. In addition, there are
many healthcare workers, including practicing physicians, physician assistants, nurses,
advanced nurse practitioners, and physical therapists, who need to use ultrasound at work, but
did not have adequate training in the past. Therefore, a visual tool that would allow healthcare
workers to learn on the job effectively and efficiently is desirable. These considerations are the
motivation behind this book, along with the hopes of empowering learners and practitioners
with the ability to visualize the body from head to toe via ultrasound. Unique and pragmatic,
Ultrasound Fundamentals is a back to basics manual on normal and pathologic sonoanatomy
of the head and neck, upper and lower extremities, chest, abdomen, and other major organ
systems.
In this book, every chapter has been written by expert physicians who actively practice in a
variety medical fields while using ultrasound. This concise and evidence-based ultrasound text
includes key topics ranging from the head and neck to the upper and lower extremities, cover-
ing all the clinically relevant sonoanatomy. In addition, this 33-chapter book emphasizes the
practical use of ultrasound for the diagnosis and treatment of a multitude of conditions in vari-
ous specialty areas such as airway management, cardiovascular disease assessment, pulmo-
nary status evaluation, orthopedics, gynecology, and pediatrics. The optimal techniques and
the step-by-step interpretation of normal and pathologic sonoanatomy are discussed in detail.
This text can be used as a starting point for the study of ultrasound-guided diagnosis and treat-
ment, a refresher manual for sonoanatomy on major organ systems, or a last-minute guide
before a bedside procedure. There is a great breadth of material that is covered in a comprehen-
sive manner, making it a great resource for board review and exam preparation for various
medical, surgical, and allied specialties.

Jinlei Li, M.D., Ph.D., F.A.S.A.

Associate Professor
Program Director, Regional Anesthesia and Acute Pain Medicine Fellowship
Department of Anesthesiology, Yale University School of Medicine
Director of Regional Anesthesia Service, Yale New Haven Health
New Haven, CT, USA

ix
Contents

Part I Ultrasound Basics


Ultrasound Physics & Overview���������������������������������������������������������������������������������������   3
Atin Saha and Mahan Mathur

Ultrasound Probe Selection, Knobology and Optimization of Image Quality ������������� 17
Marcelle Blessing
Basic Ultrasound Needling Techniques����������������������������������������������������������������������������� 25
Benjamin Portal, Karina Gritsenko, and Melinda Aquino
Practical US Guided Vascular Access������������������������������������������������������������������������������� 29
Sean P. Clifford and Jiapeng Huang

Part II Head and Neck Ultrasound


Ultrasound for Head Assessment: Diagnosis and Treatment����������������������������������������� 47
Alan David Kaye, Matthew Brian Novitch, and Jennifer Kaiser
Ultrasound-Guided Neck Assessment������������������������������������������������������������������������������� 55
Andrew Brunk, Erik Helander, and Alan David Kaye

The Utility of Ultrasound in Airway Management ��������������������������������������������������������� 61
Amit Prabhakar, Babar Fiza, Natalie Ferrero, and Vanessa Moll
 ltrasound Technique for Common Head and Neck Blocks ����������������������������������������� 65
U
Avijit Sharma, Praba Boominathan, and Robert Ming-Der Chow

Part III Upper and Lower Extremity Ultrasound


The Techniques and Merit of Ultrasound in Orthopaedics ������������������������������������������� 79
Cristina Terhoeve, Robert Zura, John Reach, and Andrew King

Shoulder Joint Sonoanatomy and Ultrasound-Guided Shoulder Joint Injection��������� 87
Allan Zhang and George C. Chang Chien

Elbow Joint Sonoanatomy and Ultrasound-Guided Elbow Joint Injection ����������������� 99
Allan Zhang and George C. Chang Chien

Wrist Joint Sonoanatomy and Ultrasound-Guided Wrist Joint Injection ������������������� 109
Jason Kajbaf and George C. Chang Chien

Ultrasound Guided Brachial Plexus Block����������������������������������������������������������������������� 121
Jinlei Li, Avijit Sharma, Ellesse Credaroli, Nalini Vadivelu, and Henry Liu

Hip Joint Sonoanatomy and Ultrasound-Guided Hip Joint Injection��������������������������� 129
Jason Kajbaf and George C. Chang Chien

xi
xii Contents


Knee Joint Sonoanatomy and Ultrasound-Guided Knee Joint Injection ��������������������� 135
Jason Kajbaf and George C. Chang Chien

Ankle Sonoanatomy and US Guided Joint Blocks����������������������������������������������������������� 143
Soo Yeon Kim, Chaiyaporn Kulsakdinun, and Jung H. Kim

Ultrasound Guided Nerve Blocks for Lower Extremity������������������������������������������������� 149
Christopher M. Harmon, Kelly S. Davidson, Erik Helander, Matthew R. Eng,
and Alan David Kaye

Part IV Chest and Abdomen Ultrasound


The Role of Ultrasound in the Management of Cardiac Patients ��������������������������������� 163
Alan David Kaye, Cody M. Koress, O. Morgan Hall, Mitchell C. Fuller,
Matthew Brian Novitch, Jinlei Li, and Henry Liu

Ultrasound for Chest: Heart and TTE����������������������������������������������������������������������������� 171
Paula Trigo Blanco

Ultrasound for Chest: Lung and Pleural Examination and Diagnosis ������������������������� 185
You Shang, Xiaojing Zou, and Hong Wang

Ultrasound-Guided Nerve Blocks for Chest��������������������������������������������������������������������� 193
Kaitlin Crane, Ibrahim N. Ibrahim, Elliott Thompson, Monica W. Harbell,
Elyse M. Cornett, and Alan David Kaye

Ultrasound Guided Nerve Blocks for Abdomen��������������������������������������������������������������� 205
Shilpa Patil, Anusha Kallurkar, Yury Rapoport, Pankaj Thakur,
Andrew P. Bourgeois, Elyse M. Cornett, Matthew R. Eng, and Alan David Kaye

Part V Ultrasound in Specialty Care


The Role of Ultrasound in the Critical Care Setting������������������������������������������������������� 221
Alan David Kaye, Cody M. Koress, Amir O. Elhassan, Caroline Galliano,
Nicholas S. Moore, Christina J. Pollock, Matthew Brian Novitch, Krish D. Sekar,
and Amit Prabhakar

Clinical Utilization of Ultrasound in Vascular Disease��������������������������������������������������� 227
Matthew Brian Novitch, Anna J. Sudbury, Mitchell C. Fuller, Jennifer J. Dennison,
Cody M. Koress, Amit Prabhakar, Vanessa Moll, Elyse M. Cornett,
and Alan David Kaye
Pediatric Ultrasound����������������������������������������������������������������������������������������������������������� 239
Allan Brook, Einat Blumfield, and Andrew Brook

Fundamentals of Gynecologic Ultrasound����������������������������������������������������������������������� 251
Barry Hallner, Nia Thompson, and Lisa Peacock

Ultrasound for Spine and Nerve Blocks��������������������������������������������������������������������������� 271
Chiedozie C. Uwandu, Emily Bouley, Timothy Montet, Mark R. Jones,
and Alan David Kaye
Use of Ultrasound in Urology��������������������������������������������������������������������������������������������� 285
Hemangini Thakkar, Patil Bhushan, Jamil S. Syed, and Sujata Patwardhan
Ultrasound Guided Interventions������������������������������������������������������������������������������������� 307
Junaid Raja, Igor Latich, and Mahan Mathur
Contents xiii


Ultrasound Application in Dermatologic Conditions ����������������������������������������������������� 317
Chang Ye Wang, Kavita Darji, Felipe Aluja Jaramillo, Ximena Wortsman,
and A. Mary Guo

Part VI Emergency Ultrasound


Fundamentals of Point of Care Ultrasound Applications
in Perioperative Settings����������������������������������������������������������������������������������������������������� 337
Sonya Bohaczuk and Yan Lai

Ultrasound for Abdomen and FAST: Evaluation and Diagnosis����������������������������������� 351
Christopher L. Moore, Jacob Avila, and John W. Combs

Practicality of Ultrasound in Emergency Medicine��������������������������������������������������������� 365
Jason Arthur, Scott Bomann, and Christopher L. Moore

Index������������������������������������������������������������������������������������������������������������������������������������� 373
Contributors

Melinda Aquino, MD Montefiore Medical Center, Bronx, NY, USA

Jason Arthur, MD/MPH University of Arkansas for Medical Sciences, Department of
Emergency Medicine, Little Rock, AR, USA
Jacob Avila, MD, RDMS University of Kentucky, Emergency Medicine, Lexington, KY,
USA
Patil Bhushan Department of Urology, KEM Hospital, Mumbai, India
Paula Trigo Blanco, MD Southern New Hampshire Medical Center, Anesthesiology, Nashua, NH,
USA
Marcelle Blessing, MD Yale University School of Medicine, Department of Anesthesiology,
New Haven, CT, USA
Einat Blumfield, MD Children’s Hospital of Montefiore, Albert Einstein College of Medicine,
Radiology, Bronx, NY, USA
Sonya Bohaczuk, MD Mount Sinai West and St. Luke’s Hospitals, Department of
Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai
Medical Center, New York, NY, USA
Scott Bomann, MD, MPH, DO, FACEP, FACEM Wellington Regional Hospital,
Department of Emergency Medicine, Wellington, New Zealand
Praba Boominathan, MD Department of Anesthesiology, Yale University School of
Medicine, New Haven, CT, USA
Emily Bouley, MD Harvard Medical School, Beth Israel Deaconess Medical Center,
Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA, USA
Andrew P. Bourgeois, MD Department of Anesthesiology, LSU Health Sciences Center,
New Orleans, LA, USA
Andrew Brook, BA Albert Einstein College of Medicine class of 2024, Bronx, NY, USA
Allan Brook, MD, FACR, FSIR Montefiore Medical Center, Radiology, Bronx, NY, USA
Andrew Brunk, MD Department of Anesthesiology, LSUHSC, New Orleans, LA, USA
George C. Chang Chien, DO GCC Institute, Newport Beach, CA, USA
Ventura County Medical Center, Ventura, CA, USA
Robert Ming-Der Chow, MD Department of Anesthesiology, Yale University School of
Medicine, New Haven, CT, USA
Sean P. Clifford, MD Department of Anesthesiology & Perioperative Medicine, University
of Louisville, Louisville, KY, USA
John W. Combs, MD Jackson Memorial Hospital, Emergency Medicine, Miami, FL, USA

xv
xvi Contributors

Elyse M. Cornett, PhD Department of Anesthesiology, LSU Health Shreveport, Shreveport,

LA, USA
Kaitlin Crane Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
Ellesse Credaroli, MD Department of Anesthesiology, Yale University, New Haven, CT, USA
Kavita Darji, MD Department of Dermatology, Saint Louis University School of Medicine,
St. Louis, MO, USA
Kelly S. Davidson, MD Department of Anesthesiology, LSU-HSC, New Orleans, LA, USA
Jennifer J. Dennison, BS Medical College of Wisconsin, Wauwatosa, WI, USA
Amir O. Elhassan, MD Ohio State University Health Sciences Center, Department of
Anesthesiology, Columbus, OH, USA
Matthew R. Eng, MD Department of Anesthesiology, LSU Health Sciences Center, New
Orleans, LA, USA
LSU-HSC New Orleans, Anesthesiology, New Orleans, New Orleans, LA, USA
Natalie Ferrero Emory University Hospital Midtown, Department of Anesthesiology,
Division of Critical Care, Atlanta, GA, USA
Babar Fiza, MD Emory University Hospital Midtown, Department of Anesthesiology,
Division of Critical Care, Atlanta, GA, USA
Mitchell C. Fuller, BS Medical College of Wisconsin, Wauwatosa, WI, USA
Caroline Galliano, BS Louisiana State University Health Sciences Center, Department of
Anesthesiology, New Orleans, LA, USA
Karina Gritsenko, MD Montefiore Medical Center, Bronx, NY, USA
A. Mary Guo, MD Department of Dermatology, Saint Louis University School of Medicine,
St. Louis, MO, USA
O. Morgan Hall, BS Department of Anesthesiology, LSU School of Medicine, New Orleans,
LA, USA
Barry Hallner, MD Female Pelvic Medicine and Reconstructive Surgery, Louisiana State
University Health, New Orleans, LA, USA
Monica W. Harbell, MD Department of Anesthesiology and Perioperative Medicine, Mayo
Clinic Arizona, Phoenix, AZ, USA
Christopher M. Harmon, MD Department of Anesthesiology, Thomas Jefferson University
Hospital, Sidney Kimmel Medical College, Philadelphia, PA, USA
Erik Helander, MBBS Department of Anesthesiology, University of Florida-Gainesville,
Gainesville, FL, USA
Jiapeng Huang, MD, PhD, FASA, FASE Department of Anesthesiology & Perioperative
Medicine, University of Louisville, Louisville, KY, USA
Ibrahim N. Ibrahim Department of Anesthesiology, LSU Health Shreveport, Shreveport,
LA, USA
Felipe Aluja Jaramillo, MD Department of Radiology, Fundación Universitaria Sanitas,
Country Scan, Bogotá, Colombia
Mark R. Jones, MD Harvard Medical School, Beth Israel Deaconess Medical Center,
Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA, USA
Jennifer Kaiser Medical College of Wisconsin, Milwaukee, WI, USA
Contributors xvii

Jason Kajbaf, DO University of California, Los Angeles, Department of PM&R, Los

Angeles, CA, USA
Anusha Kallurkar, MD Department of Anesthesiology, LSU Health Shreveport, Shreveport,
LA, USA
Alan David Kaye, MD, PhD Departments of Anesthesiology and Pharmacology, Toxicology,
and Neurosciences, Lousiana State University Health Sciences Center, Shreveport, LA, USA
Department of Anesthesiology, Department of Pharmacology Louisiana State University School
of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
Soo Yeon Kim, MD Department of Physical Medicine and Rehabilitation, Montefiore
Medical Center, Bronx, NY, USA
Jung H. Kim, MD Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn
School of Medicine at Mt. Sinai St. Luke’s and Mt. Sinai West Hospitals, New York, NY, USA
Andrew King, MD Department of Orthopaedic Surgery, Louisiana State University Health
Sciences Center, New Orleans, LA, USA
Cody M. Koress, BS, MD Department of Anesthesiology, LSU School of Medicine, Louisiana
State University Health Sciences Center, New Orleans, LA, USA
Chaiyaporn Kulsakdinun, MD Department of Orthopedics, Montefiore Medical Center,
Bronx, NY, USA
Yan Lai, MD, MPH, FASA Mount Sinai West and St. Luke’s Hospitals, Department of
Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai
Medical Center, New York, NY, USA
Igor Latich Department of Radiology and Biomedical Imaging, Yale School of Medicine,
New Haven, CT, USA
Jinlei Li, MD, PhD Department of Anesthesiology, Yale University School of Medicine, New
Haven, CT, USA
Henry Liu, MD Department of Anesthesiology & Perioperative Medicine, Hahnemann
University Hospital Drexel University College of Medicine, Philadelphia, PA, USA
Department of Anesthesiology & Perioperative Medicine, Penn State Milton S. Hershey
Medical Center, Hershey, PA, USA
Mahan Mathur, MD Department of Radiology and Biomedical Imaging, Yale School of
Medicine, New Haven, CT, USA
Vanessa Moll, MD, PhD, DESA Emory University School of Medicine, Department of
Anesthesiology, Division of Critical Care Medicine, Atlanta, GA, USA
Timothy Montet Lousiana State University Health Science Center, Department of
Anesthesiology, New Orleans, LA, USA
Nicholas S. Moore, BA Harvard Medical School, Boston, MA, USA
Christopher L. Moore, MD Yale School of Medicine, Department of Emergency Medicine,
New Haven, CT, USA
Matthew Brian Novitch, MD University of Washington School of Medicine, Department of
Anesthesiology, Seattle, WA, USA
Shilpa Patil, MD Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA,
USA
Sujata Patwardhan, MS (Surg), Mch Urology Department of Urology, KEM Hospital,
Mumbai, India
xviii Contributors

Lisa Peacock, MD Louisiana State University Health, Department of Obstetrics and

Gynecology, New Orleans, LA, USA
Christina J. Pollock, MD University of Arizona School of Medicine, Department of
Anesthesiology, Tucson, AZ, USA
Benjamin Portal, MD Montefiore Medical Center, Bronx, NY, USA
Amit Prabhakar, MD, MS Emory University School of Medicine, Department of
Anesthesiology, Division of Critical Care, Atlanta, GA, USA
Junaid Raja Department of Radiology and Biomedical Imaging, Yale School of Medicine,
New Haven, CT, USA
Yury Rapoport, MD Department of Anesthesiology, LSU Health Shreveport, Shreveport,
LA, USA
John Reach, MD Department of Orthopaedic Surgery, Yale School of Medicine, New Haven,
CT, USA
Atin Saha, MD, MS Department of Radiology and Biomedical Imaging, Yale School of
Medicine, New Haven, CT, USA
Krish D. Sekar, MD Louisiana State University Health Sciences Center, Department of
Anesthesiology, New Orleans, LA, USA
You Shang, MD Institute of Anesthesiology and Critical Care Medicine, Union Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Avijit Sharma, MD Department of Anesthesiology, Yale University School of Medicine,
New Haven, CT, USA
Anna J. Sudbury, BS Medical College of Wisconsin, Wauwatosa, WI, USA
Jamil S. Syed, BS Department of Urology, Yale University School of Medicine, New Haven,
CT, USA
Cristina Terhoeve, DNB, DMRD, DMRE Department of Orthopaedic Surgery, Louisiana
State University Health Sciences Center, New Orleans, LA, USA
Hemangini Thakkar, MD Department of Urology, KEM Hospital, Mumbai, India
Pankaj Thakur, MD Department of Anesthesiology, LSU Health Shreveport, Shreveport,
LA, USA
Elliott Thompson, BS Department of Anesthesiology, LSU Health Shreveport, Shreveport,
LA, USA
Nia Thompson, MD, MPH Female Pelvic Medicine and Reconstructive Surgery, Louisiana
State University Health, New Orleans, LA, USA
Chiedozie C. Uwandu, MD Harvard Medical School, Beth Israel Deaconess Medical Center,
Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA, USA
Nalini Vadivelu, MD Department of Anesthesiology, Yale University, New Haven, CT, USA
Hong Wang, MD, PhD, FASE, FASA Department of Anesthesiology, West Virginia
University, Morgantown, WV, USA
Chang Ye Wang, MD Department of Dermatology, Saint Louis University School of
Medicine, St. Louis, MO, USA
Contributors xix

Ximena Wortsman, MD Department of Dermatology, University of Chile and Pontifical

Catholic University of Chile, Santiago, Chile
Allan Zhang, DO Department of Radiology, University of Connecticut Health Center,
Farmington, CT, USA
Xiaojing Zou, MD Institute of Anesthesiology and Critical Care Medicine, Union Hospital,
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Robert Zura, MD Department of Orthopaedic Surgery, Louisiana State University Health
Sciences Center, New Orleans, LA, USA
 Part I
Ultrasound Basics
 Ultrasound Physics & Overview

Atin Saha and Mahan Mathur

1 Introduction wave propagate, a peak followed by a trough; the time it

takes for the complete cycle to pass is defined as the wave’s
This chapter will elucidate the basic physics principles upon period and is expressed in seconds per cycle. It is often easier
which ultrasound imaging is based. In addition, ultrasound to work with the inverse of the period, which is also known
transducer instrumentation will be reviewed and common as a wave’s frequency, represented as cycles/second.
ultrasound artifacts will be discussed. Basic knowledge of Ultrasound transducers (devices that generate and acquire
how a system produces and acquires ultrasound waves will ultrasound waves) are categorized by the frequency of sound
enhance understanding of the perceived anatomy. A compre- they utilize. The speed of sound (velocity) in a medium is
hensive grasp of ultrasound physics is vital for both the defined by the wavelength multiplied by its frequency.
proper interpretation and acquisition of ultrasound images.

2.2 Strength of a Wave

2 What Is Ultrasound?
There are three parameters that describe the strength of a
To understand ultrasound, we must first understand sound. A wave: amplitude, power and intensity. Amplitude is the size
sound wave is generated by the propagation of “vibrational of the wave and is defined graphically as the difference
energy” through a medium (gas, liquid or solid); in other between the average and maximum values of the wave
words, molecules striking other molecules [1]. If measured (Fig. 1). Power is the energy generated per unit time (Joules/
from a single location, the molecular movements are detected second) and is expressed in Watts. As a sonographer, the out-
as pressure waves alternating between rarefaction (decreased put power may be altered to generate brighter images. This
pressure in a medium) and compression (increased pressure occurs by increasing the voltage to the piezoelectric crystals
in a medium) with each repetition of a pressure wave referred of the transducer, resulting in increased force of vibration
to as a cycle [1, 2]. Basic sound wave properties are described which subsequently leads to stronger soundwaves transmit-
by its wavelength and frequency. Ultrasound is named as ted to the body [1]. Intensity represents the concentration of
such to reflect the fact that sound waves utilized in this form energy in a cross-section of a sound beam and is mathemati-
of imaging have frequencies above the range of human hear- cally defined as the power divided by the cross-sectional area
ing (that is, greater than 20 kHz) [3]. of the sound wave.

2.1 Wavelength & Frequency 3 Ultrasound Image Generation

Wavelength (λ) can be defined as the distance between two It is important to highlight that ultrasound does not strictly
similar points on a wave occurring in a cycle (for example depict tissue structures, but rather the interfaces between tis-
the distance between two peaks or troughs) (Fig. 1). Imagine sues of differing acoustic impedances. This concept helps
you are standing in a stationary position and observing a one to understand fundamentally how ultrasound images are
generated.
A. Saha (*) · M. Mathur An ultrasound pulse is emitted from the transducer, and
Department of Radiology and Biomedical Imaging, the echoes returning to the transducer from differing depths
Yale School of Medicine, New Haven, CT, USA
within the body are processed to generate a two-dimen-
e-mail: [email protected]

© Springer Nature Switzerland AG 2021 3

J. Li et al. (eds.), Ultrasound Fundamentals, https://doi.org/10.1007/978-3-030-46839-2_1
4 A. Saha and M. Mathur

b
λ

Amplitude
Pressure

Time

Fig. 1 Sound waves consist of varying pressures through a medium. values of a wave is defined as the amplitude. A region of decreased
The distance between similar pressure points on a curve is classified as pressure in a medium is defined as rarefaction (a) while a region of
a wavelength (λ) and the distance between the average and maximum increased pressure is defined as compression (b)

sional image. The time delay between the emission of an When a wave passes through the medium changing the direc-
ultrasound pulse and the return of the reflected sound wave tion of travel, it is described as a refracted wave (Fig. 2) [9].
is known as the round-trip time [5]. Reflection of the sound The difference in acoustic impedance between two tissues
wave occurs due to differing sound propagation properties forming an interface determines the amount of reflection and
at the boundaries of differing media. For example, this can refraction of an incident beam. The reflection gradient (R)
be seen at the interface between the renal cortex and its sur- describes this mathematically for incident angles perpendic-
rounding fat [6, 7]. ular to a tissue interface [9].
The following is an analogous example that illustrates this 2
 Z1  Z 2 
concept: imagine you had a basketball and decided to bounce R  , where Z1 and Z2 are the acoustic
it off of three different types of backboards - glass, concrete  Z1  Z 2 
and steel. Think of the basketball as a sound wave. If you impedances of respective tissues at an interface.
were to use the same force and transmit the basketball The greater the difference between the acoustic imped-
(“sound wave”) towards the different backboards you would ances, the greater the amount of energy from an incident
expect the ball to be reflected differently off the backboards ultrasound wave is reflected back. As discussed previously,
towards you given differing intrinsic properties of the glass, acoustic impedance is a function of the density of the
concrete and steel. medium. Therefore, the greater the difference in densities of
the tissue interface, the bigger the reflection and smaller the
refraction component of an incident ultrasound wave.
3.1 I ntrinsic Features Influencing Inserting acoustic impedances into this formula, one can
Ultrasound Studies begin to understand the appearance of ultrasound images at
different interfaces. For example, at the interface of renal tis-
Before discussing the concept of image generation, it is sue (Z1 = 1.65 × 106) and muscle (Z2 = 1.68 × 106) [10],
important to define acoustic impedance (Z). Acoustic imped- R = 0.0014. This means that the kidney-muscle interface
ance is the frequency-dependent resistance that an ultrasound reflects approximately 0.1% of the incident energy.
beam encounters as it passes through a tissue [8, 9]. On the other hand, at the interface of renal tissue
Z = ρ ∙ c, where Z = acoustic impedance, ρ = density of (Z1 = 1.65 × 106) and air (Z2 = 0.0004 × 106) [10], R = 0.999,
the medium, c = speed of sound in the medium. which means that the kidney-air interface reflects approxi-
Tissues within the body have differing densities (ρ) and mately 99.9% of the incident energy, allowing approximately
thus different impedances. At tissue interfaces, an incident 0.1% of the energy to travel into the tissues. This explains
ultrasound beam is partially reflected and partially refracted. why air and soft-tissue interfaces obscure evaluation of
Ultrasound Physics & Overview 5

a b
Beam perpendicular to interface
Interface
Reflection
Refraction

α'
α'

Reflection Transmission
Impedance mismatch
Stronger when the impedance Stronger when the impedance
mismatch is large mismatch is small
Z1 Z2
Sonar and medical ultrasound rely on:
difference in acoustic impedance between two
tissues/media

Fig. 2 (a) Generation of an ultrasound image: reflection versus transmission. (b) Interaction of ultrasound with interfaces in the body according
to the laws of wave optics. (Diagram and adapted caption courtesy of Schäberle et.al 2018 Springer)

deeper structures and why lungs and air-filled bowel loops interferences is responsible for the visual appearance of an
are sub-optimally examined via ultrasound. ultrasound image. The way that sound waves interfere with
It is rare to find smooth interfaces between tissues in the each other can alter the amplitude and subsequently the
body and often, the interfaces will be rough. A sound wave image brightness [15].
hitting a rough surface will scatter in multiple directions in
the form of a spherical wave instead of along a single path
[11]. Therefore, in the clinical setting, ultrasound images are 3.2 Ultrasound Modes
generated from a mixture of reflected and scattered sound
waves. When an ultrasound beam is perpendicular to a struc- There are three basic ultrasound modes that enable clinicians
ture it appears clearly delineated and bright, as the to extract desired information from the target organs of
information utilized to generate the image is primarily
­ interest.
derived from reflected sound waves [9]. If the ultrasound Amplitude-Mode: This mode has limited applications. As
beam interacts with the target tissue in a tangential manner, an example, this can be utilized to measure the corneal thick-
then only diffusely reflected echoes are available for image ness in ophthalmology. A line through the target is scanned,
generation, and the image will appear less clearly delineated after which amplitudes of the ultrasound wave echoes are
and less bright (even though the acoustic impedances may be returned to the transducer, and are subsequently converted
the same in the above-mentioned examples). and displayed as a function of round-trip time. This one-­
As a sound beam travels through the human body, the beam dimensional information can be utilized to infer depth of a
undergoes attenuation (loses energy) through a process called structure [16, 17].
scatter. The loss of energy of an ultrasound beam occurs Brightness-Mode: This mode is utilized to detect static
through the conversion to heat [12]. A higher transmitted fre- structures and appreciate anatomy. Amplitudes from a return-
quency leads to increased attenuation and limits the depth pen- ing ultrasound wave are displayed as points with differing
etration of an ultrasound beam [13]. The increased attenuation brightness. The brightness of a point represents the strength
can be compensated to a degree by adjusting the time-gain of the return wave. Once all the echoes from the subsequent
compensation parameter [14]. Time-­gain compensation allows transmitted pulses have returned, a complete 2D Brightness-­
for the increase in gain as time passes which results in equally mode image is displayed [16–18].
echogenic tissues appearing similar regardless of tissue depth. Motion-Mode: This mode is utilized to image rapidly
Interference is an important concept to understand as it moving structures such as cardiac valves or vessel walls.
can affect the ultrasound image. As discussed previously, a Unlike the brightness mode, the motion mode utilizes
sound wave has a compression phase and a rarefaction phase. repeated emission of an ultrasound beam in a stationary
When multiple sounds waves are superimposed, they can be location to gain information from moving structures at dif-
out-of-phase thus canceling each other out, (destructive ferent time points. Information is displayed along a time
interference) or can be in-phase (constructive interference). axis which describes the motion of the structure at varying
The spatial distribution of both destructive and constructive time points [16, 17].
6 A. Saha and M. Mathur

4 Resolution 5.1 Types of Transducers

The minimum distance between two structures that still There are four main types of transducers utilized to image
allows for discernibility as separate structures is known the body: curvilinear, phased array, linear array and endo-
as the image resolution. This applies to all imaging cavitary. Having a good understanding of the advantages and
modalities including computed tomography and mag- limitations of each transducer will assist in obtaining the best
netic resonance imaging. In ultrasound, image resolution image possible.
is specifically defined as the spatial discrimination Curvilinear transducers (Fig. 3) are ideal for abdominal
between two structures that have differing acoustic imaging. They have excellent tissue penetration which allows
impedance [9]. for imaging of deeper structures. Typical frequency range is
Axial resolution is the ability to separate two closely from 2–5 MHz [4].
spaced echoes that lie in a plane parallel to the direction of Phased array transducers (Fig. 4) are best utilized to
the sound wave [14, 17]. In other words, helping to dis- image through small regions, particularly in more difficult
criminate between structures that lie anterior/posterior to areas, such as between ribs. They are commonly used in car-
each other. The shorter the wavelength (and therefore, the diac imaging. A pie-shaped field of view is created utilizing
higher the frequency) of the excitation pulse, the better the electronic beam steering. Typical frequency range is from
axial resolution. However, as discussed previously, the 2–7 MHz [4].
higher the frequency, the more the wave is attenuated. Thus, Linear array transducers (Fig. 5) are best for imaging
high frequency limits the maximum depth from which the superficial structures such as muscles, nerves, vasculature or
echoes can be reflected. The best achievable axial resolu- soft tissues. They produce a rectangular image. Typical fre-
tion is 0.5λ [20]. quency range is from 5–10 MHz [4].
Lateral resolution is the ability to separate two closely Endocavitary transducers (Fig. 6) are placed inside a body
spaced echoes that are in the perpendicular plane to the cavity and are primarily used for obstetric, gynecologic or
direction of the incident wave. The smaller the width of the otolaryngology applications. They produce wide angle
ultrasound beam, the better the lateral resolution of the images up to 180 degrees. Typical frequency range is from
image. 8–13 MHz [4].

5 Ultrasound Transducer 5.2 Transducer Position

Piezoelectric crystals within most modern ultrasound All transducers have a position indicator which corresponds
transducers are the most important components for ultra- to the marker on the image screen. This allows the sonogra-
sonography. These crystals function sequentially: first, to pher to identify the image orientation being displayed on the
generate ultrasound waves by altering the crystal length screen (Fig. 7).
when subjected to an electrical current and second, to Standard ultrasound imaging planes include the trans-
receive ultrasound waves and convert changes in deforma- verse (also known as axial), sagittal and coronal planes. In
tion of the crystal to electrical current which allows for the transverse plane, the transducer marker is pointed to the
formation of an image. Quartz, lithium niobate and tour- patient’s right (Fig. 8) In the sagittal plane (imaging anterior
maline are a few materials that possess piezoelectric prop-
erties [21].
An ultrasound transducer contains multiple individual
piezoelectric elements that allow it to produce an image by
shifting the functional elements in a systematic manner. As
an example, take a transducer with 9 elements. To generate
the first scan line, elements 1–4 may be activated to pro-
duce the first incident wave. For the second scan line, a one
element shift is made, resulting in activation of elements
2–5. For the third scan line, another one element shift is
made, resulting activation in elements 3–6. This continues
in a similar fashion, until a total of 6 scan lines are pro-
duced. The number of scan lines can also be altered by
adjusting the number of elements being activated to gener- Fig. 3 Curvilinear Transducer. (Diagram and adapted caption courtesy
ate a scan line [9, 14]. of Creditt et al. 2017 Springer)
Ultrasound Physics & Overview 7

Fig. 4 Phased Array Transducer. (Diagram and adapted caption cour- Fig. 5 Linear Array Transducer (Diagram and adapted caption cour-
tesy of Creditt et al. 2017 Springer) tesy of Creditt et al. 2017 Springer)
8 A. Saha and M. Mathur

6 Doppler Sonography

Doppler sonography provides crucial information about the

flow of blood within the body, including both direction and
velocity. The Doppler effect was first described by Austrian
physicist Christian Doppler in the 1840s [19]. It states that a
sound wave that is reflected from a moving object undergoes
a change or shift in frequency. More specifically, if an object
is moving towards the transducer the incident wave will have
a lower frequency than the reflected sound wave and vice-­
versa for objects moving away from the transducer. In medi-
cal imaging, this effect can be harnessed to calculate blood
velocity, utilizing sound waves that are reflected by the trav-
eling red blood cells (Fig. 11). The blood flow velocity is
calculated as a function of incident angle, emitted and
received frequencies based on the following equation:
 c 
V   Fr  F0     , where V is the blood flow
 cos   2 F0 
velocity, Fr is received frequency, F0 is the transmitted fre-
quency, c is the speed of sound in the soft tissue, α is the
angle between the transmitted beam and the direction of
blood flow [9].
As velocity is a function of the cosine of the incident
angle, special attention is required to ensure the Doppler
angle is at or below 60 degrees. Even minor deviations
greater than 60 degrees will lead to inaccurate velocity cal-
culations given the properties of a cosine curve.

6.1 Pulsed Wave Doppler

Pulsed wave doppler is utilized to further characterize and

quantify changes in flow over time. Similar to gray-scale
brightness-mode image generation, pulsed wave Doppler
systems operate by transmitting a short pulse, switching
off for a time interval, and then switching back on.
Reflected waves arriving during the switched off time
period are not evaluated. By controlling the Doppler gate
or “listening time” we can interrogate a vessel of a par-
ticular depth. The Doppler gate is defined by the time
interval that the system is actively “listening” to the
returning echoes [22].
Imagine you are a rubber ball that is so elastic that it
always bounces back to exactly where it was thrown from.
Now see yourself as “the ball” cocked in a sling shot on a
Fig. 6 Endocavitary transducer (Diagram and adapted caption cour- racquetball court which is then subsequently launched.
tesy of Creditt et al. 2017 Springer) Before you are launched, two things are known: one is
that you will be traveling at a constant velocity through
to posterior), the marker should be pointed towards the sound, while the second is that the distance between the
patient’s head or cephalad (Fig. 9). In the coronal plane launch and the racquetball court wall is fixed. The time it will
(transducer lateral to the patient’s body) the marker should take from you to come back or in physics terms the “round-­
point towards the patient’s head by convention (Fig. 10). trip time” can be calculated. This can be obtained by dividing
Ultrasound Physics & Overview 9

Fig. 7 The small bump (arrow) on the left side of the transducer corresponds to the blue box on the left side of the image screen (dashed arrow).
(Diagram and adapted caption courtesy of Creditt et al. 2017 Springer)

a b

Right

Fig. 8 Transverse plane: (a) The transducer marker is directed towards kidney. (Diagram and adapted caption courtesy of Creditt et al. 2017
the patient’s right side (b) Corresponding ultrasound image: Ao Aorta, and Xu et al. 2018 Springer)
SMA superior mesenteric artery, LRV left renal vein, S Spine, LK left
10 A. Saha and M. Mathur

a b

Head

Fig. 9 Sagittal plane: (a) The transducer marker is directed towards the QL quadrate hepatic lobe, CL caudate hepatic lobe, CBD common bile
patient’s head with the transducer positioned at the midline of the abdo- duct, PV portal vein, IVC inferior vena cava. (Diagram and adapted cap-
men (b) Corresponding ultrasound image: MHV middle hepatic vein, tion courtesy of Creditt et al. 2017 and Zang 2018 Springer)

the distance between the wall and launch site by the velocity
a of the rubber ball traveling in air.
This concept allows the sonographer to selectively listen
to certain vascular structures by “turning on” the transducer
during the time interval we expect the signal from a vessel to
be coming back while ignoring the other signals. To “turn
Head on” the transducer we can create what is called a time-filter.
This process allows for selectively interrogating a particular
vessel at a certain depth. The combination of 2D-real time
gray scale imaging and pulsed Doppler sonography is called
Duplex Doppler Sonography. This is the standard technique
utilized to evaluate for deep venous thrombosis.
b

6.2 Color Doppler

Color Doppler ultrasound displays flow data in color for a

defined area, superimposed on a 2D gray scale image. As
discussed, in standard duplex ultrasound, a sample volume is
outlined in the real time gray scale image for which Doppler
shift frequencies are obtained by interpreting separate scan
lines. In regards to color Doppler, simultaneously measuring
flow velocities at different vessel sites requires multiple sam-
ple volumes to be placed along adjacent beam paths.
However, this data cannot be interpreted by Fourier trans-
form due to time constraints and the copious amount of data
acquired. Instead, a technique called autocorrelation is uti-
lized. This technique compares two consecutive reflected
Fig. 10 Coronal plane: (a) The transducer marker is directed towards beams from the sampled sites for a given color scan line to
the patient’s head with the transducer positioned on the lateral side of identify phase shifts in order to estimate mean Doppler shift
the abdomen. (b) Corresponding ultrasound image: RL right hepatic
lobe, RK right kidney, B Bowel, IVC inferior vena cava, Ao abdominal
frequency [23].
aorta (Diagram and adapted caption courtesy of Creditt et al. 2017 and The mean frequency shift is utilized to determine the
Xu et al. 2018 Springer) color shade. Low frequency shifts are assigned a darker color
Ultrasound Physics & Overview 11

a b
Dopper Effect

Stationary source Moving source

cos α
∆F = Fr − F0 = 2·F0·v
c

T
R
0
F

r
F
f0 − Df f0 + Df α
f0 f0

∆f ≈ f0 v
c Vessel

Fig. 11 Doppler effect. (a) Dependence of the Doppler shift (change in drawing illustrates the effect of the angle of incidence on the Doppler
frequency between source and receiver) on the velocity of the moving measurement. In the equation for calculating the Doppler shift, the
source and its direction of motion relative to the reflector. (b) Diagram cosine of this angle is utilized. The Doppler shift increases with the
of Doppler interrogation of a vessel with laminar blood flow. The acuity of the angle (cosine of 90° = 0) (T transmitter, R receiver, F0,
arrows in the vessel are vectors representing different flow velocities. emitted frequency, Fr reflected frequency). (Diagram and adapted cap-
Blood flow is fastest in the center and decreases toward the wall. The tion courtesy of Schäberle et.al 2018 Springer)

while high-frequency shifts are assigned a lighter color. In 7.1 Shadowing

addition, based on the phase shift away or towards the trans-
ducer, a blue or red color is assigned respectively (Fig. 12). Shadowing is a common artifact utilized to characterize
structures (Fig. 13). It occurs when sound waves are predom-
inantly reflected off the tissue interface and/or absorbed. As
6.3 Power Doppler discussed in the previous sections, shadowing occurs behind
air secondary to increased reflection at air-tissue interfaces.
Unlike color Doppler which utilizes frequency shifts to An incident sound wave will be predominantly reflected,
determine blood flow, power Doppler utilizes the amplitude although some will interact with interfaces in front of the air,
of the Doppler signal. Differing hues of a single color reflect- producing secondary reflections that travel back to the air
ing the total energy of the received wave are utilized to rep- surface. This results in secondary reflections which are
resent blood flow. Power Doppler does not provide received by the transducer manifesting as low-level echoes
information regarding directionality of blood flow, however behind an air interface. This accounts for the “dirty shadow-
it is superior in detecting slow flow and is largely indepen- ing” appearance which is often a sign that a structure con-
dent of the Doppler angle [24]. tains air [25].
Shadowing also occurs secondary to increased absorption
by osseous structures and calcifications [26], as can be seen
7 Artifacts with gallstones (Fig. 13). This limits the energy available for
the generation of secondary reflections, with associated
The generation of ultrasound images is based on several shadows appearing more anechoic posterior to the c­ alcified/
assumptions. These assumptions include that the only source ossified structures. This creates a “clean shadowing”
of sound wave generation is the ultrasound transducer, that appearance.
sound waves travel in a linear fashion and at a constant veloc-
ity, that attenuation is uniform within a scan plane, and that
each reflector in the body will produce a single echo. Any 7.2 Posterior Enhancement
deviation from these assumptions results in artifacts, which
can provide important diagnostic information on tissue com- Posterior acoustic enhancement is helpful in identifying cys-
position. Artifacts can often be distinguished by physically tic structures that contain fluid. Sound waves are much less
shifting the transducer. Actual tissue structures will remain attenuated by fluid-filled structures than by solids and there-
visible, while artifacts will change position or may even fore possess greater strength after passing through a fluid
disappear. structure. As a result, structures deep to fluid-filled struc-
12 A. Saha and M. Mathur

a b c

Fig. 12 Liver vessels: (a) Hepatic veins, bidirectional undulating flow vein flow on color Doppler (red color signals) (d) Duplex-Doppler flow
demonstrated by color doppler signal (either red or blue signals, indi- profile confirms appropriate directionality of portal flow, where +1 indi-
cating two flow directions during the respiratory cycle) with cardiac and cates maximum velocity. (Diagram and adapted caption courtesy of
respiratory modulation also demonstrated by spectral flow analysis. (b) Riccabona 2014 Springer)
Main portal vein entering liver on gray-scale imaging (c) Main portal

tures, such as a cyst, will produce stronger reflections and

appear brighter (also known as increased through transmis-
sion) (Fig. 14) [25, 26].

7.3 Mirror Images

If we think about a mirror, it is a highly reflective surface that

is smooth. Air is the best acoustic mirror in the human body as
it is a highly reflective surface for sound waves (see Sect. 3.1).
Thus, the interfaces between air and soft tissue are prone to
producing mirror images. The base of the right lung can often
serve as a mirror on abdominal ultrasounds, duplicating the
liver, diaphragm or other right upper quadrant structures
(Fig. 15). The trachea also provides a smooth air-­soft tissue
interface, acting as a mirror for neck structures [25, 27].

Fig. 13 Gallstone shadowing: Posterior acoustic shadowing (arrow)

helps properly identify gallstones (dashed arrow) within the gallblad- 7.4 Reverberation
der and can help distinguish stones from other structures such as pol-
yps. (Diagram and adapted caption courtesy of Vitto et.al 2018 Reverberation artifact (Fig. 16) occurs when there is a strong
Springer)
reflective surface in the near field. A highly reflective surface
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