Vascular abnormalities encountered during musculoskeletal ultrasound examinations encompass a broad spectrum of entities, including vascular tumors, vascular malformations, inflammatory hyperemia, traumatic vascular injuries, and several non-vascular lesions that may mimic vascular pathology. Accurate characterization is essential to avoid diagnostic errors and inappropriate management. This review is supplemented by illustrative ultrasound and Doppler images from our clinical experience, selected to demon-strate the characteristic imaging features of vascular lesions and their principal mimickers. Lesions were analyzed based on morphology, vascularity, compressibility, flow characteristics, and clinical presentation. Characteristic ultrasound patterns allow most vascular findings to be categorized into four major groups: true vascular lesions, hypervascular tumors, hemorrhagic lesions, and inflammatory processes. High-resolution ultrasound combined with Doppler evaluation enables differentiation between low-flow and high-flow vascular abnormalities and provides valuable information about lesion extent, hemodynamic behavior, and relationships with adjacent structures. Particular attention is given to subtle findings that may overlap among different entities, as well as to practical clues that can help guide further imaging or clinical management when ultrasound findings remain indeterminate. Dynamic assessment and clinical history significantly improve diagnostic confidence. This educational review presents a practical ultrasound-based approach to evaluating vascular and vascular-like soft-tissue lesions, emphasizing imaging features and clinical correlation.
Cystic lesions are common around the knee joint. They include joint recesses, arthrosynovial cysts, gan -glion cysts, bursae, and cystic tumors. The clinical presentation is predominantly determined by lesion location, volume, and mass effect on adjacent structures. Cysts are easily detected on both ultrasound (US) and magnetic resonance imaging (MRI). Most superficially located cystic lesions around the knee can be confidently characterized using Doppler US without the need for further imaging. US can also guide cyst aspiration or therapeutic injection of corticosteroids and local anesthetics. MRI may be helpful for delin-eating complex anatomy and is particularly useful for evaluating deeply located cystic masses and intraos-seous cysts. Certain benign and malignant masses exhibit high signal intensity on T2-weighted images and can mimic true cysts. Whenever there is doubt about the cystic nature of a visualized mass, administration of a contrast agent is mandatory to rule out solid tumors with cystic degeneration or myxoid contents.
Soft-tissue masses and pseudotumoral lesions are commonly assessed in routine ultrasonography, either because they represent the primary indication for imaging or because they are discovered incidentally during examinations performed for unrelated clinical reasons. Ultrasound is particularly well suited for their assessment, offering several advantages, including real-time correlation with physical findings and clinical history, low cost, excellent spatial and contrast resolution, Doppler evaluation, and direct comparison with the contralateral side. The annual incidence of soft-tissue tumors is estimated at approximately 3 per 1,000 inhabitants, with benign lesions accounting for nearly 99% of cases and lipomas being the most frequent. In many patients, ultrasonography enables a confident diagnosis and helps determine whether further evaluation with magnetic resonance imaging or percutaneous biopsy is required. The predominantly superficial anatomy of the foot and ankle makes these regions especially accessible to high-frequency ultrasound. The technique is particularly valuable for assessing superficial masses smaller than 5 cm. Familiarity with the sonographic appearance of the different soft-tissue tumors, together with an understanding of the advantages and limitations of ultrasonography, is essential for radiologists. Accurate interpretation improves diagnostic precision and reduces the risk of inadequate management, particularly when potentially malignant lesions are encountered.
Ultrasound is an essential imaging modality for evaluating soft-tissue lesions, particularly when clinical suspicion arises for firm swellings. Although imaging techniques such as radiographs and cross-sectional imaging are foundational, ultrasound assesses lesion size, location, margins, internal echotexture, cystic or solid nature, vascularity, compressibility, and relation to adjacent structures. It provides critical insights into potential osseous involvement and the identification of aggressive extraosseous components. Swelling/mass in the hand and wrist may represent either true soft-tissue tumors or pseudomasses. Pseudomasses, which are non-neoplastic masses such as ganglion cysts, constitute the majority of soft-tissue tumors of the hand and wrist. Osseous tumors may also present as masses in the hand, and ultrasound may aid in detection of the lesion and guide further management with other appropriate modalities. Ultrasound helps categorize the type of vascular malformation, which range from slow-flow to high-flow types. Additionally, anomalous anatomical variants, such as accessory muscles and osseous abnormalities, can mimic soft-tissue masses, complicating diagnosis. Ultrasound effectively distinguishes these entities. Ultrasound facilitates diagnosis and enables image-guided tissue sampling for histopathology, thereby supporting accurate diagnosis and guiding management decisions. Overall, the integration of ultrasound into clinical practice significantly enhances the evaluation of soft-tissue lesions in the hand and wrist.
This scoping review aimed to evaluate the feasibility and diagnostic accuracy of contrast-enhanced ultrasound, shear-wave elastography, and strain elastography in the assessment of pediatric soft-tissue masses. Across the existing literature, the diagnostic performance of these advanced ultrasound techniques remains inconsistent. Substantial methodological heterogeneity was identified, including variability in reporting standards, differences in preset elasticity color scales, divergent shear-wave velocity thresholds, and inconsistent interpretation of strain ratios, all of which significantly limit inter-study comparability. Importantly, the applicability of the current evidence base to pediatric practice is limited, as studies including exclusively pediatric cohorts are scarce, with most investigations conducted in adult or mixed-age populations. Furthermore, few studies provided a detailed evaluation of real-world feasibility, such as acquisition time, patient compliance, or failure rates, which are critical considerations in children. Among the included studies, contrast-enhanced ultrasound and strain elastography demonstrated more consistent diagnostic trends, whereas shear-wave elastography yielded heterogeneous and often conflicting results. In particular, strain elastography showed a recurring association between increased tissue stiffness and malignant lesions, suggesting potential clinical utility. Overall, the findings support a multiparametric ultrasound approach that integrates contrast-enhanced ultrasound and elastography with conventional B-mode and Doppler imaging as the most promising strategy for improving diagnostic confidence and potentially reducing reliance on invasive diagnostic procedures in the pediatric population.
