MEASUREMENT

IN
ULTRASOUND
A practical handbook

Paul 8. SidhU BSc MB BS MRCP FRCR DTM&H

Consultant Radiologist
Department of Radiology
King's College Hospital
London, UK

Wui K. Chong MB ss MRCP FRCR

Assistant Professor
University of North Carolina Hospital
Department of Radiology
Chapel Hill
North Carolina. USA

~'
ARNOLD
A Memtlel of lhe HOOtfer Headline Group
Lonllon
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MEASUREMENT
IN
ULTRASOUND
 CONTENTS
LN of conrrihuror'
f-oreword hy D.wid 0 . ( "'~rmc
"'
1-orcwnrd h~ C1rol A. Mrtrd~r.wdt
l'rd.u.:t·
A.:l-m•w ledgemcnr'

1 ABDOMEN (LIVER . GAllBLADDER AND SPLEEN) 1

)
I in:r (.tdultl
I m:r {pcdi.Hnc l 4
( ,,,flhl.lddcr {adult) 6
C .lllhl.1ddcr ( pedi.un.:) H
( ;,,IJhl.tdtler (neoru ul l 10
( ,,,llhl.lddcr w.1ll 12
( ommon h1lc du,·r (.ldulr) 14
Common hilc duct (pcdi.unc) I~
Ht·p.Hrc du.:t (adult) 20
~plt..-n (.1dulr .md pt'tli.un.:) 22
1>i.tphr.l)!m.uic motion 1ft

2 ABDOMEN (VASCULAR) 29

Rc11.1l .uter~ ~0
r \",\IU,ltiOll ot .lCUtt' r.·n.ll "'"lrucrion with intr.trt"ll.ll I )opplcr .>4
Porr,1l \'t"lll 36
Hcp,Uic \'ein~ 3H
Ht·p~w,· artery 40
Cl'li.K .tnd ~uperior rne~enreric arrene~ 4.:!
Doppler ultr.t~ounJ m.-.l,uremcm of postpr.tndial intt•.,rin,ll
blood tlcm 46
lnkrrnr me~enreri,· .lrtery 4H

3 RETROPERITONEUM 51

"-1dney' {.tdult I 5.?.

"-•dney ~ite {ped•:nrid 56
& Contents

II.Jdn£>y size (infant and m:on.ual) 60

Rc:nal pelviC di<tmetc:r {neonatal :md fetal) 64
Adrc:nal gbnds (adult) 6(,
Adn·nal 1-\l.mds (infanrl 67
Adrcn.tl glands (nconat.tll 6R
I'.:mcreas (adult) -o
J>.Jnc:re<nic duct (adult) -2
I'.1m:rc:a~ (pediatric) -4
p,o.1s muscle 7€.
Retroperitoneal!}' mph node:~ 7!{

4 ORGAN TRANSPLANTATION 81
·It II. I \111 .md I' wl ~ '>1dhu

l\1dne) transplanmtion 82
Rcn.1l arter}' steno~i' in tr.m,plamation 86
l.i\•c:r tr.msplamarion 81:l
J>,uKrc:a~ tr.mspl.mtarion 92

5 PELVIS 95
Bladder
1-,,·,hthJ.t '·"~·hrrh.lftlll.I.J. /..l.n.1 ' " ' .md l'.tul '>. \nlhu

Bladder volume and f<'Sidu.JI volume 96

~l.tddn wall I00
Urererovesic,tl jets (pcdi.um: .111d infant) 102

Male genital tract 104

\111. f.-,., 1tl11 1 \.u. huh.m.md.t "d I' .. " ". ''"
T<·~tes 104
Epididvmis 108
Prost.H<' - tr<Jnsrecral ~ono~rarhy 110
~emin.tl vesicles- rransrcc:ral sonogr.1phy 111
l'<·nis I 14

Female urogenital tract 118

"· "' / ,1(,"" .... J \\ '" "- ~ h•·ll.
Ov;try- transv~tginal sonop.raphy llH
Ov.trian follicles- rransvagin;JI sonography 120
Cen·ix - transvagin.ll sonogr.1phy 122
Uterus - rransvagin.1l sonogr<tphy 124
 Cootcnts B

lndom\:tri.ll stripe- transv.t~nal <,ono~raph~ llf.

llrl·thr.t llX
ll·n~th of th\: ~:nvi' .md 0:\:n·~~;,tl~:an,tl in pr~n.mcy HO

6 SUPERFICIAL STRUCTURES 133

l'.tr.uhnoid gl,t111.b I \4
\uhm.wdihul.u ,,,livar)' ).:l.tnd\ I 16
l'.wmd "'livary ).:l.wJ, I Hl
r h} rmd gland 140
1 nnph node~ in thl· lll'lk 144
Orlnt~- extr.10cul.tr mu-o:k' 14X
( )rh•t' - optio: nern I'll

7 NEONATAL BRAIN 153

Vcnrrindar si7t.· I 'i4

Doppler studies of intt·rn.llli,tl hlnml llcm I ~X

8 GASTROINTESTINAL TRACT 161

I'~ Inn.: '1\:llll\i' II'>!

Appendix IM
llpp.:r ~.tstroillll.,t in.t l rr.tc.:r w.tll - endcN:opi.: ulrr.t,ound IM-.
nowd wall- tr:m~thdonun.tl ultr:t\lllllld II'>X
An.tl endosonu~-:raph) n1
9 MUSCULOSKELETAL SYSTEM 173
' '

General considerations 174

Upper limb - shoulder 176
I ong h.:,td of hin•po; l..,f,
'>uh'l:,tpulan' t\:ndon ~-~~

'>upr.t,pmatu~ r.:ndon ISO

lnfr.t,pinaru' t.:mlon IlL!
Upper limb - elbow 184
Allll'nor 10inr !>pa.:e 1!14
Olco:r:uton foss.t I H6
B Contents

I ,lferal elhow 188

Mrdial dhow 190
Upper limb - wrist 192
l>or..a I tt'ndon' 192
C:1rpal tunnel I<J4

lower limb - hips 196

Hip eifusion 196
De,·elopmenr.tl Jyspl.1si.t oi the hip l'ill

l ower limb - knee 200

l ower limb - ankle 202
Amerior. mt•d•.tl, l.ueral tendon' l()l
A.:hilles tendon 204
l ower limb - fool 206
I'Lmt.lr f.1s.:i.t 206
lmerdigiral wch .. pa.:es 208

10 PERIPHERAL VASCULAR SYSTEM (ARTERIAL) 211

"I I'.

Upper limh' - pcriph..:ral .mcrin 212

Ahdominal aort.l and common iliac arrerit:~ 214
I ower limh.;- peripheral arreri"'~ l iH
Lower limh~- peripheral arrcne~ for stenos1" 220
fxrra.:rani.1l artt·ric' 222
E"cra.:rani;ll ;trlt:nt"- m<:;hurcnll'nt of inrern;ll .:.trottd
arrc:r\ ~tc:no~i., 226
rranscrania I Dopplt·r ultrasound BO
11 PERIPHERAL VASCULAR SYSTEM (VENOUS) 235

Inferior vena .:.w.1 2.ll'i

N.:.:k vei1h .DH
I q: vein' 240

12 OBSTETRICS 243

Comp.trison of '>crurn P-hCG levels .md ultrasound

landm.Hh to J!:C~t.uional .1ge on tr.msv.tgin.ll ~onowaphy
{first trimc,tc:r) 244
 Contents -

Gcst.ltlnnal s.K (tirst trinll'l>tcr) 246

Fet.tl heartht·;u (hr~t trimester) .250
Crown-rump len~th 252
Nu.:ha l fold thi.:kness lS4
Nuchal tr;tn~lu.:en.:y th~.:knc~~ 256
Bipa ri~tt,t l J i,unetcr lS8
Head .:in:umkrcn.:e 2.62
Alxlominal drcumtercncc 266
Multiple fer,tl p,t r,m1C'tcrs in the .t~ses.<>menr ot ~esrational .tgc 270
Ratio of head to abdomen circumference 2~4
Estimated icml weight ha~cd on biparietal diameter and
.thdominal t:in.:umit•rt·n.:e 176
Fet.tl femur lcn~rh 186
Fetal humerus length 290
Sysrolic/diastolil- r.uio in the umhili.:al artery 294
Cerebral ventride\- lateral ventricle transverse arnal
mcao;un·mcnr 29t!
Cisterna m.tgn.t .~01)
Thor;tcic cir.:umteren.:c .~02
Renal pelvis diameter 304
~1ean ren;tl len~th~ for gesmrion;tl ages .l06
Ourer orhiral diameter 30!!
Feral 'roma.:h di.Jmt•tt·r 312
fer a I ~ma II howe! JI4
fetal colon 116
Predic.:red fetal wei~ht percentiles throughout prc)!.nanc.:\' ll X
Amnioti.: fluid HO
 CONTRIBUTORS
Kcllc\' Z. AIJi,nn .\Ill
D•o~gnosric R.1dmlogy.
Mnli..:al College of Virgima Hmpnal,,
Virg ini,1 Commonwealth Uniwr~ity,
VirginiJ. liS.\

7 elena A. Aziz II'.. \IR I!' \IIH P Hu M

lkpJrtmenr ol R.uliolugy.
King\ College: llo~p•r.ll,
London, ll 1--

\Vui K. Ch ong \IIIII' \IMI ••ttu K

llniwrsiry of 1\:orth Carolin.t llmpit.ll,
DqlMUlH: nt oi Ro~ diology.
C h.1pd Hill. North Carolin.1, liSA

David Elia~ \I IIII\ MKl t'ttH I<

Dl·parrmcnr o i Radllllogy,
Ktng'!> Collq.?.t' Ho,pit.ll,
I ondon. UK

Janice Nc\\\omc \Ill

l'oromac R.1diology. Ale .....llldri.l,
Virgin ia. ll~A

J.- c,hthra Satchithananda '''" ''" '", \IP.II' HH , Hu 11

lkp.unnc:nt of R.1dio logy.
i--u1g\ Collegt· Hmplfa l.
I omlon, ll"

M.1ria E.K. Sdl:tr~ \IK< hll ~KI K

Department oi R.lllinlogv,
1--mg's College Hmplf.ll.
I ondon. L'K

Paul ~- ~idhu R.,.lllllll,\IRI I' IIHR 111111~>.11

Dt•p:trrnwnr nf Radiology.
King's ( ollq.~c Ho,p•ra I,
london. UK
a Contributors

Anthony E. Swartz. RToR RUM'

Department of Obs rcrn.:~ .111J G} ncxology,
Univcrsitr of North Carolin.1 llospit.JI,
Chapel Hill, North Carolin.1, USA
 FOREWORD BY
DAVID 0. COSGROVE
(\ k:tsun·mcnt~ arc nel·dcd for .til nna~inJ! rechn iquc\ to lil·monstrare
that ~rrucwre\ of tntcn~!>t arl·norm.tl or .thnorm.tl and wllocument the
dl'J!ree ut an~ ahnormahtv. All roo otren, howe\·er. the norm.tl value'
.tn: huried in rcferl'llCl' tl''-thooJ..., .tnd m.ty he .twkw.trd to lind when
thl·y .trc nccdl·d during a hu,~ 'c;uutm~ li .. r. Thi~ pocket hook l'orrcct<>
thi~ defect by providing, in cump.tct f<•rm ••1 .:omprd1t: n~in- ~l't ot
norm.tlultr;hound meJsurt:ml·nt' hoth for paedrarn.:' .tnd ;tdulrs. The
dcarl~ ordcrccl ~ection' should m.tke it ~imple and qurck ro locate the
rde\·,tnr iniomt.uion requtrl·J .wJ, for those who nl'l'd to know more,
,cJc.:nve reference~ .md ~UAAl'\llun' for iurrher readin~ .tre provided.
~lu.:h of the normJI \·,tllll: dat,t i~ prt:~ented .ts .:onn·nienr tables.
parricul.ulv in tht• p.u:dratric' 'l'Cttnn~.
Till' .turhor!> .trc wdl J...nown n:,c.Hcher~ in im.t~lll~ and p.trri-
cul.uly m ultra,ounJ, Dr ~iJhu 111 the liJ... .tnd Dr Chon~ in the l iSA.
Thi' hooJ... '' highly comml·ndcJ ro all worl...mJ! m the fidd ol
ulrra,ound: it will prm·ide J \·.tlu.thlt· companion to murmc dinical
pract Kl'.
();n 1d 0. C:osj!rnvc
Profe~sorof Clini .:a l ll lrr.t~otnlll
Imaging ~cicnn·~ lkp;trtmenr
1-=.tl' lllt\' of f\ted~t:ine
lmpl·n;tl Colley.e
H.tlllllll'r\lllll h I ~OSpl£.11
London
UK
 FOREWORD BY
CAROL A.
MITTELSTAEDT
Tht· tt·chnology .tml applicJtions of di.tgnn-.tic ulrr.t'>numl h:nc '>hown
rcm.trkable growth ,ince ultra~ounJ w.l'.. lir-;t u-.cd ,1, a diagno~tic im::tg·
ing modJiity. Along wirh this expan~10n h.m: hccn ,ruJic'i ~tknnfying
.tppropriatt' ultr.t:.ound tt:chnique' .mJ me.tsurcment!>. Though there hJve
lll:c:n numerou:. .uriclt·, .md book' 111 the: field of ultr::t:.ound. tht· rc:.tders
of the~e must ferret out the mea<Ouremcnt' from the \"::tnou~ puhlic.mon:..
linn I now thcrt: h.h hccn no 'llllld. · ulrr."'Hmd measurement gmdt·.
Meusurt'lll£'111 111 lJitrusmmd i~ .111 n..:dknt n::sourcc for thn'>e per-
lorming and inrt·rprt·rmg ultrasouml ot .til tYf>l::.. Nor onlr :liT v.triou:.
mc,tsurement' li,tt·d for ;t numher of organ' .md ~rrucrurt·, for hoth
lll:di.ttric and .tdult p.tticnt~. hut the ulrra'>otmd tcchmqm•, employed
to uhtain the<Oe mea~urt·ment' .lrl' .tl", dc,cnhed. Doppla p.~r.uneter~
for .t number of org.m,, 'u..:h ,,... tr.tn,pl.mt~ and vanou:. \l'\\eb. ,lfe
dl·lined .tlong wtth the re..:hnique to oht.tin the'ie.
1 his puhlic;trion encompas:.e~ thl· .thdomen (parc:nchnnal organs
.md ,·essels), rctropcrironeum, org,ut tran~pl::tnr.uion, nuk ,tnd iem.tle
gl'll tt.JI tr.Jcts, :.upnti..:i.tl 'itructUfl'' ('u..:h :to; thrroid,l) mph nmJt.,, ,ali-
\ MY gland:.), neon.tt.tl hr.tin, g,t,trointl'<;tinal tr::tct. nnt ....culo,kdetal
~~ 'tl'lll, pc:nphcral ,·,t,.;ular ~ntl'lll (hoth arrerial and ,·enous). Jllll
oh,tc:tric~. f.11.:h ~pccilic ~ection de:..:rihc::. thl· prc:p.tr.uion. pnsinon,
1r.tn:.Juccr, method, .tppc:.tr:mcc, .md me.huremctl! v,1 ri.1hil•<; involved.
\X'ith rc:~pect to oh~rerrics. thi' mc::hurt·ml·nt handbook •~ .1 quick rd-
nc:nn· li~rin~ ,u..:h vanahle!> ·" gt·~t.uiwul sac siLe, rel.uion~hip to
he.trthcat, gl·~t.Hion~tl .tgc, .tnJ mon·. J\t ulriple measurt'llll'nts and
Doppler paramc:ter!> .trc: provided lor tlw oh,tetric panc:nr.
:\ly congrarulationl> go to the .lllrltor' of .\fe,J:wrcmcntmllltr,,smmd,
.tnJ I would ht~hll· recommend tht' hook ·" .1 <Jlllck nt<:.l,urcmt•nt rd-
t•rc:nct" lor .tlltho!>t: interprc:ring .md J"ll:donuing ultr.bmmJ S<..tn:..
C::trol A. f\lml·l,t:wJt. J\11>
Profcl>,Or ol R .1diolo~y
J>ep.trrmcnt of R.tdiology
llni\'er~iry ()i Norrh ( Jrt>lin.t
School ol :\ lnlicmc
( "h,tpel Hill. Norrh ( .trolina
l 'SA
•
 PREFACE
Anatomical measuremems .1re made frequenrly during rhe course of an
ultrasound examination. Measurements enable us to distinguish
normal trom abnormal. Many measurements are common knowledge
for expenenced sonographers; others are encountered less trequenrly,
necessitating referral w texrhooks. Standard ultrasound rexrhooks
comprehensively cover the 'normal' me,tsuremenrs; but this inform.t-
tion is likel) to he buried in the texr. Other hooks deal wirh all radio-
log.ical measurement, including ultra:.ound, but locating the relevant
infonn.Jtion quickly may be cumbersome.
We recognized rhe need for a succinct, easy-ro-use pocket text ot
ultrasound measuremenr when we witnessed residents, sonographers
.md experienced pra1.:tirioners reaching for a textbook to look up .t
measurc:menr. \Ve have attempted to construct a 'pocket' textbook
with easy-to-read text and good qu.tliry images to .tllov. anyone prac-
tising ultrasound to make an accu rate measurement of a normal struc-
ture. Of course many of the!>e measurements will be frequently used in
pr.1ctice. while others will nor. W~.· have mduded the most commonly
usc:d measuremems con.•ring abdominal. pelvic. obstetric & gynaeco-
logic.tl. pediatric, v.1scular, small parts and transplant im~tging. This is
nor meant to cover all measurements used in ultrasound, hut should
indude all those likely ro he in everyday use by general sonographer~
or radiologist~. Those requiring more ~peci,Jli7cd measurement~ will
need to refer to the .tppropriate textbook~. We have nor included a
se..-rion on echocardiography. as this is ofren a .-.rec•ali7ed rracrice in
the remit of the c.trdiologist.
\Ve hope rhar this tt."Xt will be of ..ome use ro radiology residents,
sonographers in training and 10 the mon: e'periencni practitioner
requiring .1 quick 'update' on <I les~ practi'>ed meao;uremem.
Paul S. Sidhu and Wui K. Chong
 ACKNOWLEDGEMENTS
A~ with any hook, a lar~e number of people mak~: conrrihution~. which
,lrl' often unacknowledged in rhe tinal manuscript. Without their con-
trihution ~ succcs~ would nm be guaranreed.
Wl· wi~h ro thank Mrs. Philippa Warren for her hdp with typing
tht• manuscript and offering advice as ro the gl·nc:ral l.tyour. Special
thanh to P.tt 1-=.trranr tor reviewing the m:muscripr :md pomting our
afl·a~ where improvem~:rns could he made.
On any hook on norm:\ I mea.,uremcm-;, ,, whole host of volunteer..
arc required in order to oht;lin image~ ot norm.tl an:uomy. To thi~
effect we w1sh to thank Joanne Poole DCRIR l, Oert·k Sv:l~ti-~alcc M 0.
l:ln ~t anron 1\ID, Jason Wilkms :'\10, Sue Rowe l\ID. A~h l ey Shaw
l\11>, ~ue Ri'cpk.J ROI\1~ a nd ~crg1o Khomyak RO\IS. In addition,
thanks ~o to Vicky ~oh's then unnamed and unhorn child!
Finally (PSI. th.tnks musr go to my wife. ~tonica and children,
(,ianluca and Francesca for their rcm.uk.thk mkran~·c.
ABDOMEN (LIVER,
GALLBLADDER AND
SPLEEN)

Keshthra Satchithananda,
Zelena A. Aziz,
Maria E.K. Sellars and
Paul S. Sidhu

Liver (adult)
.,
Li ver ( pcdi.uric) 4
Gallhladdcr (adult) 6
Gallbladder (pediatric) 8
G allbladder (neonatal) 10
Gallbladder wall 12
Common bile duct (adult) 14
Common bile duct (pediatric) IH
Hepatic duct (adult) 20
Spleen (adult and pediatric) 12
Diaphragmatic motion 26
 Abdomen (liver, gallbladder and spleen)

Liver (adult)

PREPARAT IO N
None.
POSIT ION
Supine, ri14ht antcrio•· ohlique w d~:mon:.tr:ltl· the porta hcpatis.
PROHE
2.0-4.0 :-.tHz curvilinear transducer.
M ETHOD
longitudinal views .1rc taken in the middavicular and midline pmi-
tions, ,md measurements obtained. Anteroposterior diameters .ue ab1•
measured ar rhe midpoint of the longirudin.1l d1ameter!>. All mea,urc-
mc:nt~ .trc taken on deep inspiration.

APPFARANCE
Uniform panern of medium ~rren,;rh cchoe~.

MEASUREM ENTS

Diameter Mean ± SO (em)

~liddavkulilr long•tudinal I 0.5 ± l.S

M iddavicul.1 r anteropmtcrior 8. 1 ± 1.9

;\1 idline longitudinal !U ± 1.7

Midline ..mteroposterior 5.7 ± 1.5

In rhe transverse plane, the normal caudat<: lobe should he l~:~s than 2/J
of the si.te of the right lohe.
FUR I HER READIN G
Harhin WP. Rohcrt N.J. ferrucci JT. Diagnosis of cir.-hmi!> ha~cd on
regi011.11 chan14es in hc:patic morphology: a radiolo14ic;ll and
pathological Jll;t l ~)i,.. RtJditilogY 1980; 13 .5:r~-183 .
N icder.m C. Sonncnhcrg A. ~tulk-r Jl:.. Erckenhrechr Jt. C.,l·holren T.
hit'>l:h WP. Sonographic llll':t!.Urrmcnts of the normal liver.
~plccn, pancreas. and p()rt.tl vein. Radiology 1983; 149:537-540.
 Liver (adult) . .

Figure 1a longitudinal view through the left lobe of the 11ver obtamed m 111e
midline. Cursor 1, anteroposterior diameter: cursor 2. midline longitudinal diameter

Figure 1b
Longitudinal VJew
through the right
lobe of the liver in
the midclavicular
line. Cursor 1.
mldclaVJcular
anteroposterior
diameter: cursor 2.
midclavicular
longitudinal
diameter
 Abdomen (liver. gallbladder and spleen}

Liver (pediatric)

PR EI'ARATIOI'.
None.
POSITIO N
~upinc, right anrerior ohliquc po~itions ro demon~trarc the porta hepar is.

PROBF.
4.0- 10.0 M l lz curvilinear transducer.
M ETHOD
I on.;tudinal images of the right lobe are taken 111 the middavicular or
midaxillary position~. The length of the liver is measured from the
upperrnmt portion of rhe dome oi tht: diaphragm tu the interior rip.
APPEARANCE
Uniform pattern of medium sm:ngrh cchoc~.
M t' ASU RtMENT~

Age length of right lobe of liver

(months) (mean ± SO, mm)
1-3 64 ± 10.4
4-6 73± 10.8
7-9 79 ± 8.0
12-30 l\S ± I 0.0
36-59 86 ±I U!
60-lB IOU ± U.6
H4-107 105 ± 10.6
108-131 I 05 ± 12.5
132- 155 115±14.0
156-179 ll8 ± 14.6
180-200 111 ± 11.7

FURT HER REAOING

J...onus OL, Ozdemir A, Akk.ly.1 :\, Erhas G, C'dik H, lsik S. Normal
liver, spleen, and kidney Jiml·nsion~ in neonate~. int,mh, and
children: evaluation with :.ono~raphy. Americ,m juumLII of
Rocntg<'llolugy J9<,1!l;17 1: 16<,1.3- 1698.
 Uver (pediatric) B

Figure 2a longitudinal vrews of the right lobe in the midclavicular position wrth
the length measured from the dome of the diaphragm to the inferior tip of the liver

Figure 2b Longitudinal views of lhe right lobe in the midaxillary position wrth the
length measured from the dome of the diaphragm to the rnferior trp of tile liver
D Abdomen (liver, gallbladder and spleen)

Gallbladder (adult)

l' REI'ARAT ION

P.ment should be fasted for 6-8 hours heforc examin.uion.
POSIT IO N
The g.tllbladder is initially cx;tmined in the supine position. Then the
patient is turned to the right anterior oblique position to ensure ;my
small mobile stones are not missed.
l'RO Bf.
2.0-4.0 Mllz curvilinear transducer.
MET HO D
Longicudinal and transverse images are taken trom a suhcmral or an
imercostal approach on deep inspiration in the supine and right ante-
rior ohliqm· positions.
AI'PEARANCE
On a longitudinal image the gallbladder appears as .1n echo-tree pear-
shaped srrucrurc. The gallhhHidcr wall is smooth and is seen <lS a line
of high n:tlcnivity.
M FA~ U RfMt:.NTS
There is .:ons1derable variation in the siLe and shape of the gallbladder.
bur .:ert.1in reference values do exi!>t.

Length (mm) Width (mm)

~ewhorn 30-32 1/3 of length
Adult I 00 (range 80-120) 40-50

FURTHER READING
Carroll BA, Oppenheimer DA. Muller HH. lligh-frei.Juenq• real-nme
ultrasound of the neonara I hi!i.tr~ system. R<1dmlogy
19H2; 1-45:437-440.
Dodds WJ, Groh W.J, Darwel.,;h R~l, l •.1\vson Tl , Kishk ~M. 1\em
MK. Sonogr.tphi.: measurement of ~allhladdcr volume Americ,m
Joumal of Rocll!Kl'IIOiogy !985; 145:1009-1011.
finherg HJ, Bimholz .I C. lJirra,ound ev.tluation of the gallbladder
wall. Radiology 1979; 133:693-698.
 Gallbladder (adult) B

Figure Ja Longitudinal aspect of the gallbladder

Figure 3b
Transverse dtameter
at the mid aspect of
the gallbladder
- Abdomen (liver, gallbladder and spleen)

Gallbladder (pediatric)

PREPAR ATIO N
Youn).\cr patients should fast for 3 hours; older children should fast for
6-8 hours before examimuion.
PO~ITION
The gallhl.1dder is initially ex..1mined in the supine position, and then
rhe patient is turned to right anterior oblique position.
J>KOlU;
4.0--6.0 ~1 H7 curvilinear rran~ducer.

M f T HO D
Longuudmal and transverse images are ohtJined from a subcostal or
intercosta l .1pproach in the supine .md right anterior oblique position~.
APPEAKANCE
On a lonJ,\itudinal image the gJIIhl..1dder .1ppears as an echo-free pear-
shaped structure.
M EASUREMENT S

Age (years) Length . mean and Width, mean and

range (mm) range (mm)
-
2-5 41 (29-52} 17 ( 14-23 )

6-H S6 (44-74} 18 ( 10-24)

9- 11 55 (34-65) 19(12-32)
12-16 61 (38-80) 20 ( 13-281

FUKT H EK KEAOING
l'vkG.than .JP. Phillips HE, Cox KL. Sonography of the normal
pediatric gallbladder and biliary rr.tcr. R.Jdivlvgy
1982;144:873-875.
 Gallbladder (pediatric) B

(a)

(b)

Figure 4
Longitudinal (a) and
transverse (b)
images are taken
from a subcostal or
intercostal approach
on deep inspiration
B Abdomen (liver, gallbladder and spleen)

Gallbladder (neonatal)

PREPARAT ION
Patient should not he fasted before examination.
PO SIT ION
The gallbl.tdder is initially examined in the supine position. Thl·n the
patient is turned to righ t anterior ohlique position.
PROBE
8.0-U.O MHz curvilinear transducer.
M ETHOD
Longitudinal .md transverse images are obtained from a subcosr.tl or
inren.:o~till appro.Kh in the supine and right anterior ohlique po,irimh.

APPEARANCE
On .1 lon~itudin.tl im.tge the gallbladder appear!> as an echo-free pc.lr
shaped structure. The gallbladder wall is ~mooth anll i' 'ecn ,,., .1 line:
o f high reflectiviry.
MEASUREM EJ'\'TS
Length 30-32 mm; w1dth l/3 of length.
FURT HFR RF ADING
Curoll BA, Oppenheimer OA, Muller HH. High-frequency real-time
ultrasound of the neonatal biliary system. R,ufiology
l '1H2; 14.'i:4 37-440.
 Gallbladder (neonatal) D

(a)
(b)

Figure 5
Long1tudinal (a) and
transverse (b)
1mages are taken
from a subcostal or

- 1ntercostal approach
on deep msp1rahon
B Abdomen (fiver, gallbladder and spleen)

Gallbladder wall

PREPARATION
Patient should he f;tsted for 6-8 hours oefore examination.
POSITION
Supine or left lateral decubitus positions. l ma~in~; is performed m
either the longitudinal or transverse plane.
PROBE
2.0-4.0 MHz curvihne,u transducer.
METHOD
Longitudinal and transverse images are taken from a suhcostal or an
imercosral approach on deep inspir.uion in the o;upint• and left lateral
decubitus positions.
APPEARANCE
On a longitudinal image the gallbladder appears as ,m echo-tree pear-
sh.lped strucrure. The gallbladder w.tll io; smooth and is seen as a line
of high reflectivity.
MEASUREMI:'Nn
!\tcasuremenr of the galloladdcr wall is made alon~ the .txis of the
ultrasound beam using the portion oi the gallbladder .:omiguous with
the liver and induding all idcntifiahlc layers. A'·eragc w.tll thickn~' i!>
2- 3 mm. Wall thickness greater than .LS mm is highly suggestive ot
dise;tse. A wall thickness of 3 mm or less docs nor ruk out cholecystitis.
FURTHER REAOING
fngel j.M. Deitch EA. Sikkema W. Gallbladder wall thickness:
sonographic .tccuracy and n:l,nion to disease. AmcriL·ull joumal of
Roe11tgeno/ogy 1980; 134 :907-909.
Finberg H.J. Birnholz .JC. Ultrasound evaluation of tht.: g.tllbladder
wall. R,1dmlugy 1979;13:693-698.
 Gallbladder wall 1111

Figure 6 The
thickness of the
gallbladder wall is
measured along the
long axis of the
ultrasound beam in
an area where the
gallbladder is
contiguous With the
liver
B Abdomen (liver, gallbladder and spleen)

Common bile duct (adult)

PREPARATION
Patu.:nt should he fasted for 6-8 hours before ex.unin<mon.
POSITION
Initially supine, then turn to the right ctnterior oblique or lateral dn:u-
bitis positions to demonstrate the common duct.
l'ROBl
2.0-4.0 M I-ll curvilinear transducer.
METHOD
Patient is imaged from a sulxostal position, in the longitudin.1l pbne
or from an intercostal position. The common dm.< is measured at .1
point that passes anrenor to the right portal vein, often with the
hepatic artery seen in cross-se~<ion herween the duct and the vein. The
measurement is raken from the inner wall to the inner wall and shouiJ
he perpendicular to the course o f the duct.
APPEARANCE
The extrahepatic hile dua may be divic.kd into thrn· !>egmcnrs: the
hilar segment in front of the main portal vein, the supr:1p:mcrcaric and
the inrrapancreatic ~cgmenr which is venrral ro the inferior vena cava
and passes throu~h thl· pancreatic he.1d. The m,n:im31 ameroposterior
diameter of the cxtr,thepatic bile duct is m~:asurl·d.
M EASU RFM ENTS
Avera~e measurement for '' normal adult i ~ 4 mm, though up ro 6 mm
is aco..:~:ptcd as normal. The mean o..:ommon duct diaml·tcr following
cholecystectomy is 7.7 ± 2. 1 mm. Afrcr cholecy~reaomy R- I O mm can
he norn1:1 L There is an age-Jqx·ndenr change in the di;lmeter of the
o..:ommon duct and it can he up to I 0 mm in the \'Cf\' elderly.
 Common bile duct (adult) 1111

Figure 7 The
common duct is
measured at a point
(between cursors)
where it passes
antercor to the right
portal vem with the
hepatic artery seen
in cross-section
between the duct
and the vein
8 Abdomen (liver, gallbladder and spleen)

Location Anteroposterior diameter (mean ± SO, mm)

Proximal 2.9 ± 1.1
Middle 3.5 ± 1.2
Distal 3.S ± 1.2
Rq>rndu.:ed .-.oth perm"""" irom Horrnw ~1~1. Hnrruw IC. ;-.;,Jku..m \, 1\orlw Cl.
Ru~nl>erg Ht-.. h ~I(~ a~..:•~ ted wuh ~11c ot ~dult rxtrnhcpati.: hilr duct: '"nogr~phu.:
\tilth·. H.Jdmlogy 200 I ;221 :4 I 1-414.

Age (years) Common bile duct size' (mean ± SO, mm)

Male Female
<2 1 3.3 ± 1.1 3.3 ± 1. 1
2 1-30 4.7 ± 1.3 4.7 ± 1.2

31~0 5.0 ± 1.5 4.6 ± 1.4

4 1-50 5.4 ± lA 5 ..1 ± 1.2
51-60 6.1± 1.<1 5.3±1.X

>60 6. I ± 2.0 6.8 ± 1.7

The extmhepatic duct mav he ml·asured at three loc.ltaon~: in the

porta hepatis (proximal), in thl· most di~t.JI aspect of the he;td of the
pancreas (distal) .tnd midway hctwccn the'e measurement~. ·
 Common bile duct (adutt) &

R EFERf NU \
I . l lorrow .\viM, l lorrnw J C, f\;iakosari t\ , f.: irby C L, Ro~enlx·rg
HK. Is a~e a~~oci.tted with 'iize of adult extrahepatic bile du~o:t:
c;onograph ic stud y. R.t~diolog)' 200 I ;21 1:4 I 1-4 14.
2. \X!u CC, Ho Yll, Cht·n CY. Efit·.:r of .t~e on ~:ommon hile Ju.:r
di:tnwter: a real-tillll' ultr;l~tmogrJphic ~ruJ y. Jnum.ll n{ Clmic.ll
l 'ltr<~soml<l 19!<4; 1 2 :4~3-4~8.

FURT HER RFA DINC

Ft·ng R, Song Q. Ones the common hile Jucr dil.tte after
cbok·cy~tn·romy? Amcric.m /uum.d of Rocutg£'1m/og'·
1995; 165:H59-Hf> I.
Hunt DR, S~:ou A.J. Ch .m~e~ in bik dun diameter a trer
cholecy!>tccromy: A 5-ye.tr prospecrivc srud y. Gustrocuterologv
19XI.J:97: 1485- 148X.
Pa ru lek.tr SG. Ultrasound evaluation of common bile duct sin:.
R.1dwlugy 197'1;133:~03-~o7.
B Abdomen (liver, gallbladder and spleen)

Common bile duct (pediatric)

------------------
PREPARAT IO N
None.
POSITJO I'.
Initially supine, then turn ro the right anr...·rior oblique position to
demonstrate the ~ommon duct.
PROBE
4.0-6.0 l'v11 ~ L curvilinear transducer.
M ETH O D
Patient is imaged from,, subcostal position in the longirudin.tl phtn<.' or
from an inr...·n:ost.tl position. The ~ummon bile duct m<ty lx- identified
by means of the anatomtc course within the gastroduoJcnal ligamenr,
<.' oursing distally to the head of th<.· pancrca<> .md <thse111:e of flow with
Doppler interrogation. The inrernal di.uneter of the exrr.thep.u ic duct
is measured from innn wall to inner wall.
APPEARANCE
\X'ith high resolutton imaging normalmtrahcp.ui~ Ju~t!> can he vt~u.tl­
iz<.·J as ruhular stru~tures with thin high - rctl e~tive walls. The term
·~ommon Ju~t· is u:.ed. since it is not po~sible on ultrasound to demon·
srr.ue the entran<.:l' ot rhe cysti.: duct, and rhu~ dtfferentiate the .:om·
mon hepatic duct from the ~ommon bile du~L
M f AS UREMF.NT S
The common dm:t ol neonates .tnd children younger than I year
should be l.n mm or less in di.unctcr from inner wall to inner wall. The
stzc increases slowly wuh <lgl' . The common duc..< during c hildhood .tnd
t·.trly adolesn·nce should not mca~ure more rhan 2.5-3.0 mm in dio:~m·
erl·r. lr i:. a di~tensihle ~tructurc that Jemonsrr:ues $mall hut c;mristiC<lllv
si~nitic.ult changes in size dunng d.tily fluctu.uions in the hilc tluw.

FURTHER Rl:.AI>ING
Hcrnanz-~chuhnan :...1. Ambrosino ~1~:1, freeman PC, Quinn CB.
Common bile Jucr in children. Sono~raphic dimensions.
Radmlogy 1995; 195:193-195.
 Common bile duct (pediatric)

Figure 8 The
common duct is
measured at a point
where it passes
anterior to the nght
portal vein with the
hepatic artery seen
in cross-section
between the duct
and the vein
IEJI Abdomen (liver. gallbladder and spleen)

Hepatic duct (adult)

PREPARATION
Panenr should be fasted tor 6-H hou rs hefore examination.
POSITION
Initially supine. then wrn to the right anterior oblique po~ition to
demonstrate the common uuct.
PROBE
2.0-4.0 J\tllz curvilinear tr:m,Jucer.
M ETHOD
Patient is ima~ed from a sulxnsml plane, in tht' longitudinal Jirl'Ction
or from an inrerco~ral plane:.
APPEARANCE
W1th high re~olution ima~ing normal intrahep<ltic duct' can hl'
vi~ua l ized as tuhubr structun·s with thin high-rdle.:rive walls.

M EAS UREM ENTS

:-..lormal hepatic duct is mca~ureJ .11 3 mm inremal Jiametl:r (normal
hepatic duct~ 3H' under half the 'IZC of rhc corresponding port.tl vein
and h.tH· a 'rr~tight cour,c).
FU RT H ER R EADING
Oewhury KC. Visualisation of normal biliary dtKts with ulrr.t~ounu.
Brlllsh Juum,ll of R,u/iolog\' I ':180;53:774-780.
 Hepatic duct (adult) Ell

figure 9 A dilated
peripheral hepatic
duct (between
cursors) in the left
lobe of the liver
EJI Abdomen (liver, gallbladder and spleen}

Spleen (adult and pediatric)

JlREJ>ARATIOl\
None.
POSIT ION
1 eft upper Jhdomen in the midaxillary line, then turn patient to ldt
,mterior o hlique position as necessary to view rhe spleen.
PRO BE
2.0-5.0 MHz curvilinear transducer.
MET HOD
Splenic length mc01sured durin~ quiet breathin~. Qbt;~ined from ;l .:oro·
nal plane that incl udes the hilum. The greatest longitudinal d istance
between the sple nic dome a nd the tip (splenic length) is mca, u rcJ.
Transverse, longitudinal ,md di.tgonal di;uneters .ue measure<.! from
the image showing maximum cro,,·scction.tl ar<.•a in a coron,tl pl.mc.
APPEARANCE
Spleen should show a uniform homogeneoul> echo parrern. It is slighth·
le~s rdlcctive than the li ve r.

MEASURFMF.NTS
I ength: A mca~urement oi length :tnd diameter can he made in the
ohlique plane at the I Oth and lith intcn.:mra l ,p,lCI.', throug h tht·
splenic hilum !length S I Z e m, diameter S7 <.:m ). ~pken si?<· corrcl.ttes
with height ra thc.·r than age.
 Spleen (adult and pediatric) &

Figure 1Oa The

greatest longilu!llnal
diStance between
the splentc dome
and the ttp is
measured as the
splenic length
(between cursors)

Figure 1Db Three

measurements are
obtained (cursors 1.
2 and 3) tn order to
calculate splemc
area
IDJ Abdomen (liver, gallbladder and spleen)

Age Splenic length in children (em)

(North American population)'
(months) Median (10th-90th cenlile) Suggested upper hmtt
0-3 4.5 (3.3-5.8) 6.0
3-6 S.3 (4.9-6.4) 6.5
6- 12 6.2 (5.2-6.8) 7.0
(years)
1-2 6.9 (5.4-7.5) ~.0
2-4 7.4 (6.4-8.6) 9.0
4-6 7.8 (6.9-8.8) 9.5
6-8 S.2 (7.0-9.6) 10.0
H- 10 9.2 (7.9-10.5) I 1.0
10-12 9.9 (8.6-10.9) 11.5
12- l.S 10.1 (8.7-11.4 ) 12.0
15-20 (m,llt!) I 0.0 (9.0- 11. 7) 13.0
15-10 (female) 11.2 (10.1 -12.6) 12.0

Age Normal splenic lengths (Chinese population)

(years)
(mean ± SO, em)
Male Female
0-4 5. 94 ± 1.18 5.77 ± 1.2 1
5-9 7.8 1 ± 1.18 7.48 ± 1.21
10- 14 9. 10± 1.41 ~.76± 1.1 0
I S- 19 I0.04 ± 1.29 8.6 1 ± 1.03
20-29 9.57 ± 1.0 9.08 ± 1.26
30-39 9.52 ± 1.29 8.88 ± 1.2H
40-49 9.38 ± 1.48 8.92 ± 1.54
50-59 1Uil± 1..B X.l5 ± I.J9
60-69 8.99 ± 1.61 8.66 ± 1.50
70-79 !L60 ± 1.62 lU5 ± 1.54
RO-H9 7.90 ± l.H5 7.59 ± 1.53
 Spleen (adult and pediatric) lEI

Area: View the -;plecn in thc longituJin<tl a x i~. in decp inspiration. The
inreriace herween lung and spleen serve!. .1~ the transverse di.Hnerer and
the longitudinal diameter is measured from here to the !-.picnic tip. The
diagonal di.1merer is measured from this lateral splct>n-lung interface
to the med1al spleen margin. The cross-sectional area is calculated: '

diagonal/" (transverse"+ longirudinal')/2

Normal Diameter (mean ± SO. em)

Tmnsverse di.1meter 5.5 ± I .4
Longitudinal di.uncter S.H ± 1 .~
Diagonal diameter 3.7±1.0

REFERENCE~
I. Ro~enberg HK, MarkowirL. Rl. Kolberg H. Park C. Hubhard A.
Bdl RD. Normal ~plenic ~i7e in infant~ and childrl·n: ~onugrapllic
me..tsuremenrs. A mcrictm /olfllttli o{ Roentgenology
1991;157:119- 12 I.
2. Loftus WK. Mctrcweli C. Norm.tl splt>nic size in a Chinc!>l'
population. Journal of Ultrasomt1i in Medicine 1997; 16:345-34 7.
3. Niederau C. Sonnenberg A. Muller JE. En:kenhrecht Jt. Scholten
T. Fritsch WP. Sonographic measurements of the normal liver.
spleen. pancreas••md portal vein. Radiology 1983;149:537- 540.
- Abdomen (liver, gallbladder and spleen)

Diaphragmatic motion

PREPARAT ION
None.
POSITIO N
Supine.
PROBE
3.5-5.0 ).1Hz ~un·ilinear tr.msdu~er.
M ETHOD
Performed from a l.Uh~osra l posmon. m a l<>nJ.drudinal plane. A wrsor
is pl:lced at the position of the dome of either the left or ri~hr hemi -
diaphr.tgm at end tid.tl volume••tnd then m.uked ar full inspir.Hion. If
forced expiration is lt~ed. the dome ot the diaphragm may not he
visihle.
APPFARANCF
The thin high-rdlcctiw diaphra~matic cum: i!> rcaJil)' idl•ntifit•ll.
M EASUREM ENTS
The estimated diaphragmatic mon:ml'llb for .tdultl. .tn::
• deep inspiration 5.4 em (male>. 4.0 em (female)
. . . .
• quu:r msprranon 2.2 em
FURT HER REAIJING
Harris R~. Giovannetri M. Kim 1~"'- - Normal vcnrilatory movcmcnt ot
the right henudiaphragm ~rudieJ hy ultrasonography .tnd
pneumm.tdwraphy. Radiologv I '>IU; 146: 14 1- 144.
Houston JG. Morris AD. Howil· CA. Rcid .II.. ~k~lillan N. fcchni~al
report: lJUantitative ;h~c,o;nwnr of diaphragmatic movl'llll'nt - a
reproducible mcthod using ultr;l'iOIIIHI. Clinic<~l Radiology
1992;46:40-407.
 Diaphragmatic motion D

Figure 11 A
cursor is placed at
the position of the
dome of the right
hemidiaphragm at
end tidal volume.
and then marked at
full inspiration with
a further cursor
ABDOMEN
(VASCULAR)

Zelena A Aziz,
Keshthra Satchithananda and
Paul 5. Sidhu

Renal artery .~0

Evaluation o f acute renal obstruction
with intrarenal Doppler .H
Portal vein J6
Hepatic veins J8
Hepatic .utcry 40
Celiac and ~uperior mesenteric
arteries 42
Doppler ultra~ound measurement of
pmtpranJial inrc-;tinal blood flow 46
lnfcriur me~cntcric artery 48
B Abdomen (vascular}

Renal artery

PREPARATIO N
None.
POSITION
Supme, lateral decuh1tus and if necessary prone positions.
PRO BE
2.0-5.0 MHz curvilinear transducer.
M ETHOD
The origin of the renal arteries may he visualized using the liver/spleen
as an acoustic window in the oblique positions. Spectral Doppler wave-
forms are obtained from proximal, mid and distal sites within the main
renal artery and from interlobar or sc~memal vessels in the upper, mid
and lower poles. The Doppler angle should be kept as close to 60° as
possible.
M EASUREMENTS
Renal-aortic ratio (RAR): Determined using the highest peak sysrolic
velocity from the renal artery divided by the peak systolic velocity in
the aorta. RAR of >3.0 is a reliable predictor of renal artery stenosis of
~60%, and >3.5 indicates 60-99% stenosis.

Peak systolic L'elocity (PSV}: PSV of> 180 cm/s is a predictor of renal
artery stenosis 2::60'.V.,.
Resistance index (Rl):
Rl = (peak systolic velocity - end systolic velociry)/peak sysrolic
velocitv
The RI value of the normal right and left kidney is 0.60 and 0.59
respectively. There is variability of measurements within a kidney, and
a number of Rl values should be averaged before a single representa-
tive value is reported. In renal artery stenosis (RAS), rhe RI is measured
in the interlobar arteries.
 Renal artery

figure 12a An oblique view through the nght kidney demonstrates the
renal artery arismg from the aorta (arrow). A peak systolic velocity ol
0. 72 m/s is obtained from the proximal aspect of the renal artery

Figure 12b The resistance index IS measured as 0. 72 in an interlobar

segmental vessel m the right kidney
B Abdomen (vascular)

Mean Rl for control group aPJd in RAS'

Controls RAS >70%
Mean ± ~l> 0.64 ± 0.07 0.49 ± 0. 14
Range 0.47-0.80 0.32-0.71

A Rl >0.70 in the native kidney is indkative of abnormal rcnovaM:ular

reststam:e.
REFERf NCE
I. ~hwerk WB, Restrepo IK, Klose KJ, ~h.1de-Brininger C. Renal
artery stenosis: ~rading with ima~c-dirn:tcd Doppler US
evaluation of renal resistive index. Racfiulugy I 994; 190:785-790.
FURTH ER READING
House MK, Do wling RJ, King P, Gihson RN. Using Doppler
sonography to reveal renal artery stenosis: An evaluation of
optimal imaging parameters. American jnumal of Rocntgen(}/(Jgy
1999; I 73:7tl l-765.
"-cogan 1\1 r, Kliewer MA, Her(lhc rg B~. Delong O:vt, Tupler Rl l,
Carroll BA. R<:n.tl resistive indcxt''>: vJn.thilit}' in Doppler U~
measurem<:nt in a healthy population. Radiology
1996;199: 165-169.
Olin .JW, Picdmonrc MR, Young JR, Dl·Anna S, Gruhh l\1, Child~
M B. The utility of duplex ultra~ound ~canning of the renal
arteries fur diagnosing significant renal artery stenosis. Annals of
Internal Medicine 1995;122:833-HJS.
B Abdomen (vascular)

Evaluation of acute renal obstruction with

intrarenal Doppler
---------------------------------
PJU I'ARATJON
Nonl·.
l'OSITION
Supirw.
I,ROBE
.LS-5.0 MHz curvilinear tr.msducer.
M ETHOD
Doppler signals are obtained from arcuate arreru:~ at the corn -
comedull.uy juncrinn or imerlohar arteries .1long the border of
medullary pyramids. The Doppler wa\·eforms should he made on the
lowl·~t pulse re petition frequency without aliasing w ma,imi7.e rhe size
of thl· Oopplc:r Spl·crrum. The: re~i~mncc index (Ril i~ calculart·d from
the formula:
Rl = (peak syMolic vch:rry- end diastnlic \·clocirv)/peak ~ystolic
velocit)'

AI'I'EARANCE
Tlw normal spectral Ooppkr wavdorms in the rerl.ll .lrCWHC arteri~
are those of a low rc'i~t;liKC end-organ. with a hro.td !.}'~lillie peak and
an e levated end-dia~rolic vc:locity.
MEAS UR EMENl ~
1\ k tn Rl in normal kidneys i~ 0.60 ± 0.04.
1\.kan Rl of ohstrucll'd kidney' i~ 0.77 ± 0.07.
Fk·vation of rhe R l occur~ ,1frer juo;r 6 hours of dinrcal oh~truction . If
there i~ pyclo~inus exrr.tva~ation on the inrravenou~ uro!!-ram (IVU) or
the dur.Jtion of obstruction i~ lc" th;tn 6 hours, thl· Rl mav nor be
clcv.ned.
f U R rHER R EADI NG
l'latt II'. Rubin j.\1, Elli!. .Jll. Acute: renal obstruction: c:v.tlu.uion with
intrarenal duple' Doppler and conventional US. R,llliolugv
( <J') 3; 186:685-688.
R<~dgch PM. B.HC!> .J A, Irving II C. lnrra n:nal Doppler srudic~ in
norm.tl .~nd <lCtttdy ob~rructnl kidneys. British Juum,,[ of
R,uliology 1992;65:207-2 12.
 Evaluation of acute renal obstruction with intrarenal Doppler lEI

Figure 13 Doppler signals are obtained from arcuate arteries at the

cortlcomedullary junctiOn or interlobar artenes along the border ol medullary
pyramids. The resistance index is calculated from the spectral Doppler waveform
obtamed
IEllll Abdomen (vascular)

Portal vein

PREPARAT ION
Fastin~ for 4-6 hours.

PO~ITION
Supinl· ;~nd right anre rior ohlique.
PROUE
l.0-5.0 :\tl-lz curvilinear transducer.
M FTHOD
Ri~ht lon~irudinal intercostal approa~:h.

MfASURFM EN TS
Norm~tl portal venous velocity varies in the s;tme individual, incrcasin~
<tfter a meal and decreasing after exercise. The diameter is measured at
the broadest poim just distal to union of splenic and superior mesen-
teric vein, normally measuring II ± 2 mm. Color and spectral Doppler
imaging dl·monstrates rhe porl<l l vcn<HI!'> !'>}"Stem to he an isolated vas-
c ular unit with a rel.ni vely monoph~t ~ic tlow pattern with tluctuatiom
with cJrdi.lC or respiramry mov.;rn.;m~. Th<: V.tlsalva m •.meuver rc~uJt,
in portal vein dilatation. The normal portal \ 't:in velocity is 14-18 cm/s
(angle of inson.uion :560°).
Congestion index (Cl ) of the port,ll t•em:
porral n :in area = diameter r\ x Jiaml'tl'f H x n/4
flow velocity = 0.57 x maximum porral win velocity {angle :560°)
Cl = portal vein area/flow velocity

Till' normal va lue for the C:l is 0.070 ± 0.02':j cm/s and inaeasc!. to
0. 1..., I ± 0.075 cm/s in patient~ with cirrhosis.
FU RTH f R READIN G
Moriya!'>u f. Ni,hida 0. B.m N. Nak.tmura T. Sakai l\1, i\liyake T.
llchino H. 'Congestion Index· oi thl· portal vein. Americdll
Joumul of Roelltge11olo~)' l':j!\6; 146:7.H-739.
Weinreb J. "umari S, Phillip., G; l,ochaan... ky R. Portal vein
mea"•rt:mt'nt!'> h\ real timt: ~onogr.tphy. Amt•ric<lll }mtnr.1l of
l<oclltgcnology I '982; 139:497-49'1.
 Portal vein llil

Figure 14a The diameter of the portal vein is measured at the broadest point
just distal to the union of the splenic and superior mesenteric vein

Figure 14b A spectral Doppler waveform obtained from the portal vein
demonstrates a relatively monophasic flow pattern
B Abdomen (vascular)

Hepatic veins
-----------------------------------
PRFPARAT ION
None.
POSITION
Supine: and ri~ht anterior oblique.
PROBE
2.0-5.0 MH7. curvilinear transducer.
M ETHOD
Right lateral intercostal approach during quiet respirarion. Place srx·o.:-
tral Doppler gate halfway along lenHth of the hepati<.: vein.
APPEARANCES
There are usually three main hepati..: veins (left, middle and right) hut
m,my p.uicnrs have ,\ll .tccC!>!>ury or infc:rior right hcp,ni..: vein. fhl·-.c
join centr.llly into the IVC immediately inferior to the diaphra~m.
Pulsatiliry within let( hepatic vein is ~treater than the rniddk· vein,
which is gredter than the right vein, due ro transmitted pulsations from
heart. To minimize this effect. the right hepatic vein is normall\· used
for Doppler ~tudic!>.
M EA~U REM ENTS
Doppler spectral flow shows a tripha)ic waveform with two period~.,,
forw.ud tlow within each cardiac cvcle (corresponding to thl· rwo
ph.tses of right atrial filling) :md the one JX>riod ot normal, tran\il·nt
reversed flow due to contraction of the right side of the heart. Th1!>
triphasic pattern .liters 111 Cirrhosis. bt-coming biphasic and cventu.11ly
monophasic in advam:cd disease. Pattem alterations are :1lso observed
in heart failure and tricuspid regurgitation.
FURTHFR READING
Abu-Yousef MM. Dupin Doppler sonogr:1phy of the hcp:tru.: win in
tricuspid regurgit.nion. American ]cmm.ll of Roentgennlog)'
1991; 156: 79-tU.
Bolondi L, Li Ba!>si ~. Gaiani S, Zironi G, Benzi G, Santi V, ij,trhara
I.. l ivcr cir rhmis: changes of Doppler waveform ot hcpanc vems.
Radiology 1991: 178:5 13-5 I b.
Farrant P, ~1cire I lB. Hepatic vein pulsarilin· assessment on spectral
Doppler ultra~ouud (~horr communication). British Joumt~l of
R,zdivlog'!' t9<J..,;70:S29-S32.
 Hepatic veins U

Figure 15a
Transverse
subcostal view
demonstrates the
hepatiC veins
drammg mto the
inferior vena cava

Figure 15b A spectral Doppler gate placed over a hepatic vein demonstrates the
normal triphasic waveform with two periods of forward flow and one period of
transient reversed flow. within each card1ac cycle
D Abdomen (vascular)

Hepatic artery

PREPARATION
None.
POSITION
Supine and right anterior oolique.
PROBE
2.0-5.0 MHz curvilinear transducer.
M ETHOD
Right oblique intercostal .1pproach. Locate the <.:eliac axis anterior to
aorta and then follow arterial branch that runs to the right.
APPEARANCES
The hepatic artery originates as one of the three major branches of the
celiac axis. lying ameromeJial to the porral vein at the porta hepatis. In
50% there is some anatomic variation or aberrant origin of the artery,
either <ln accessory or more commonly a replaced artery. On the right,
the superior mesenteric artery most commonly gives rise to the aber-
rant artery, often dorsal to the portal vein.
M EASUREM ENTS
Resistance index (RI): Measured as proper hepatic artery crosses
portal vein.
Rl = (peak systolic velociry - end diastolic velocity)/peak S}'Stohc
velociry
The RI of the normal hepatic anery is 0.62 ± 0.04 and can alter sig-
nific:u'ltly after a 'stal1datd' meal, increasing to 0.1111- 0.78.
Doppler perfusion i11dex (DPI): DPI of the hepatic artery, which is
elevated in the presence of colorecral hepatic metastases, may be
ca lculareJ <lS follows~
DPI = hepatic anerial tlow/totalliver blood flow
where total liver blood flow= hepatic arterial blood tlow + portal
venous blood flow; blood flow = time-average velociry of blood
vessel x time-average cross sectional area of lumen of vessel.
The upper limit of normal range of DPI is 0.25.
 Hepat.ic anery E1

Figure 16 The hepatiC artery is located adJacent to the portal vein and a spectral
Doppler gate identifies the low-resistance waveform pattern

FURTHER RFADING
Grant E(;, S..:hillcr V l , Millcncr P, l csslcr fN, Perrella R R,
R.tg;~vendra N, Busunil R. Color Doppler im,tging of the hcp.tfi..:
vas.::ularure. Americdll foum,lf of RoemgenolofO•
1992;159:943-950.
Jornt l.K, Plan JF, Ruhin j ~ l . Ellis JH, Bude RO. Hep;nic .men·
resist.ln..:c before and <lfrcr sranJard meal. Suhjccrs with di~ea~cd
and healrhv livers. R,zd10/ogv I <J95; 196 :4!{9-492.
l.cen E, Goldherg J A, Rohcnson J, An)?Crson WJ, Sutherland GR.
Cooke TG, McArdle <...S. Early detection of oc..:ult colorc~"t<l l
mer.m.tses using duplex colour Doppler sonography. British
Journtll of Surgl:!ry 1993;80: 1249-12.) I.
- Abdomen (vascular)

Celiac and superior mesenteric arteries

PREPARAT ION
Ultrasound performed after an H-12 hour fast.
POSIT ION
Patient supine with head of bed elevated 30°.
PRO BE
2.1l-4.0 MHz curvilinear transducer.
M ETH O D
Ensure Doppler angle of :5:60°. Locate the level of the suprarenal aorta
in the transverse p lane, identifying the celiac artery (CA) and rhe supe-
rior mesenteric artery (~MA), and then examine in the longitudinal
direction. Measure the peak systolic veloc1ty (I~V) a few centimeters
from the origins.
APPEARANCE
Best seen in the longitudina l view, where the celiac axis and superior
mesenteric arteries arise from the anterior aspect of the aorta, in close
proximity m each mher. Only high-grade mesenteric artery lesions are
likely to be symptomatic; aherefore it is only importam to detect steno-
sis of >70%.
M EASUR EMENTS

Velocity (mean ± SD, cm/s)

SMA Celiac axis

Normal 125 ± 25 123 ± 27

Atherosclerotic (normal on
a rreriogra phy) 163 ±59 138 ± 38
Srenu~•~ (70-99%) PSV ;::275 PSV ~200

Unlike in ren,1l artery stenosis, the velociry r:uios of SMA and CA PSV
to aortic PSV does not offer any advantage in the detection of 70- 99%
srenoric lesions. A PSV of ~2 7 5 cm/s in the SivlA or ~200 cm/s in the CA,
or no flow within a well-visualized segment of ~plachnic artery, acc u-
rately predicts 70-99'% mesenteric stenosis or occlusion respectively.
 Celiac and superior mesenteric arteries 11!1

Figure 11a The

celiac ax1s (arrow)
is identified in the
longrtudrnal sectron
through the plane
of the aorta (arrow)

Figure 17b The peak systolic velocity is measured at 1.32 m/s in thts example
B Abdomgn (vascular)

Figure 18a
longitudinal view
through the
superior mesenteric
artery (SMA. arrow)
in the plane of the
aorta (arrow)

Figure 18b A spectral Doppler gate placed over the artery to record a peak systolic
velocity of 1.41 rn/s
 Celiac and superior mesenteric arteries

FURTHER READING
~lonet.1 GL, Yeager RA, Dalman R, Amonov i~: R. Hall I.D, Porter
JM. Duplex ultrasound aireria for diagnosis of spla.Khic artel"y
stenosis or occlusion. joumal of VasczriLlr Surgery
1991;1-4:51 1- 520.
B Abdomen (vascular)

Doppler ultrasound measurement of

postprandial intestinal blood ftow

PREPARAT IO N
Patients fast overnight and the examination is per~ormed after ~0 min-
utes oi supme rest.
J>OSIT ION
Patient supine wid1 head of hed elevated 30".
rRo nr
2.0-5.0 M l l7 curvilinear transducer.
M ETHO D
Superior mesenteric and celia~: .lrteries can be identified either lon~itu·
dinally or transversely. Angle of insonation kept at $60". and the vesS(;b
examined along their visible length. The following parameters are mea·
sured: peak systolic ,·elocity (P~V}, end diasrolic velocity (EDV) Jnd
puls.nility index (PI). A 'st.md.ud' 800 kcal (3.35 ~IJJ meal is consumed
and seri:-.1 Doppk·r measurement'> are made over the following hour.
PI = (pt-ak sy!.tolic veh:ity- end diastolic \'elocirv)/mean velocity
AI,PEARANU
Best seen 111 the longitudin;tl view, where the .:eliac a~is and superior
mesenteric .ureries ;uJse from the anterior aspect of the aorta. in dose
proximity to each other.
Mf.ASUitf MFNTS

Normal values Before meal After meal

PSV EDV PI PSV EDV PI

(cm/s) (cmts) (cm/s) (cm/S)

Superior me~enteric artery 100 16 3.6 154 4f> I. X

Celia<.: axis 120 30 l..'i IJO 40 1.5

A meal should cause .m increase in both sysrolic .md diastoli<.: ,·elocitie~

and J reduclion in lhe PI, indi<.:arive of a fall in distal me)emcri.: \',t!>CU·
br imped.mct>. The in<.:r<•ase in superior me~l:'nteri<.: arrcry EDV .:an he
 Doppler ultrasound measurement of postprandial intestinal blood flow ll:fl

150- ~00°u. ChJn~es 111 the ~diJ..: artay are less noti..:cabk .1~ rhc bulk
ot n·li.l..: hloud tlow b not ro the gut.
fll HT HFI{ REAOlNG
:-.l ulln AE Role of duplex Doppkr ulrra~ou nd in the ·'~'cs~ment ot
p.nirnr~ with postprandia l abdominal p.l in. Cut I 992;.H:4f>0-4()5.

Figure 19a Longitudinal

section through the aorta
to demonstrate the
supenor mesenteric artery
(SMA. arrow)

Figure 19b The spectratt

Doppler waveform pattern
has altered following a
meal. wrth a high forward
diastolic flow (compare
with image 18b. page 44)
1!!]1 Abdomen (vascular)

Inferior mesenteric artery

PREPARATION
Overni~ht fast.
POSIT ION
Supine.
PROBE
3.5- 5.0 MHuurvilinear transducer or 7.5 MH£ linear Jrray transduce r.
METHOD
The inferior mesenteric artery is identified uising from the .10rt.1 ante-
riorly and to the left, !>pc:ctral Doppler waveforms are obtained from
the proximal 3-4 em of the artery along its longitudinal Jxis (Doppler
angle ~60°). The inferior mesenteric arrery is sct:n in IJ2% of subjects.
APPEARANCE
The spectral Doppler waveform often hut not always dcmonsrrate~
How that tends to he triphasic with an initial high-velocity forward
component during systole, followed by reversal of tlow for a short
durarion, then low-velocity forward flow during diasrole.
MEASUREMENTS

Mean ± SD

Peak systolic velocity (PSV) 0.98 ± 0.30 m/s

End diastolic velocitv (EDV) 0.11 ± 0.05 mls

Mean velociry (V ~··) 0.25 ± O.OH m/s

Res•stance index (R I) O.H9 ± 0.06
Pul~atiliry index (PI) 4.50 ± 1.53

Rl = (peak sysrolic veloc.:itv - end diastolic veloc•ry)/peak systolic

velocity
PI= (peak systolic velocity- end diastolic velocity)/mean velocity
 Inferior mesenteric artery

Figure 20a A
1ong1tudma1 sect1on
through the lower
aorta demonstrates
the ongm of the
mferior mesenteric
artery (IMA. arrow)

Figure 20b The peak systolic velocity is measured at 1.17 m/s and the end
diastolic velocity at 0.30 mts. g1ving a resistance mdex ol 0 74
a Abdomen (vascular)

FURTHER RF ADIN<..
Denys AL, L1fornme M, Aubin B, Burke M, Breton G. Doppler
sonography of the inferior mt'sl"nteric arrery: a preliminarY srudv.
}oum<ll of Ultrasomrd in Medici11e 1995; J4:4.U-4.W.
Erden A, Yurdakul ~1. Cumhur T. Doppler waveforms of the normal
and collateralized inferior mesenteric artery. Americ.m joumcll of
Roentgmolog)• 1998; 17 1:619-627.
RETROPERITONEUM

Zelena A Aziz,
Keshthra Satchithananda,
Maria E. K. Sellars and
Paul S. Sidhu

Kidney~ (adult) U
Kidney size (pediatric) 56
Kidney c;izc (infant and ncona ra l) 60
Renal pelvic diameter ( n~'Onatal
and fetal) 6-4
Adrenal ~otlands (adult) 66
Adrenal glands (inhmt) 67
Adrenal glands (ncon.ual) 68
P.mcrcao; (adult) 70
Pancreatic d uct (adult) 72
Pancreas (pediatric) 74
Po;oas muscle 76
Retroperitoneal lymph nodes 78
Ell Retroperitoneum

Kidneys (adult)

PREPARATION
Noll\.'.

POSIT IO N
Supim:, lefr .md righr anterior nhlique :tnd if ne..:essary, prone.
PRO BE
3.5- 5.0 1\IHz curvilinear tran~ducc:r.
1\\fTHO D
lma~c the ri~ht kidne)' u~ing the lnTr .1~ an .KOlMic window. Inc: lcit
k1dney i~ typically more difficult to VIMtalit.l". Thc left anterior nbliqut·
45' or right decubims position may help, and requesting the patient to
~u,penJ respiration ensures lc::ss movement. !3oth kidneys should he
irn<tgcd in hoth longitudinal .md rranwcr\c planes.
APPEARANCE
'The reflectivity of the renJI cortex i~ l e~' rh.m the .ldjaccnt liver aud
~pkcn. The renal capsule can Ill· idl·ntiticd :h a thin high-reflective rim.
The renal p~·ramids .ue poorly defined structurl'S seen at the outer edgl·
o( the renal sinus. The renal smu~ contains multiple structure~ - thl·
pch-i~. Gl lvces, vc.;scls .md t:lt- .md is u~ually of high retlecrmr~.

~1 f. AS n fMFNTS
Three llll':b urcmcnr~ are rn.lde:
I t'll!,(th: Ohtained from the sa~i tt.ll 1 ma~c. ml·:tsunn~ the longc~t
cr.tnio.:a ullallength.
Allfl'W/WStL•rwr tlimenswn: Nka,urnl from the ~a~ittal ima~r llll':l ·
surn l perpendicular to the lon~ a xi\.
\>:/tdth: J\lcasurnl from a rran~vcr'c tmage t.1ken from the lateral mar-
gin of the kidnl')' through the renal hilum.
Ken.1l lcn~th Je.:reases with .1~e. .tlmosr entirely as a result of
p.trcn..:hym.tl reduction. !Ieight .llld age hut nor sex are determin:mt\
of renal ~izc. There is no differen..:e in kic.lney length measurement~ m
the ~upme obhque and prone position~.
 Kidneys (adult )

Figure 21 a On the sagittal view two measurements are obtained in the

longitudinal and anteropostenor planes

Figure 21 b The
w1dth is measured
from a transverse
image obtamed
througll the renal
hilum
1D1 Retroperitoneum

Kidney Position Normal values' (mean ± SO, em)

Length Anteroposterior Width

Right Ohlique 10.65 ± 1.4 3.95 ± 0.8 4.92 ± 0.6

Prone 10.74 ± 1.4 4. 17 ± 0.5 .'i.OS ± 0.8

I eft Oblique 10.13 ± 1.2 3.58 ± 0.9 5.30 ± 0.7

Prone 11.10 ± 1.2 4.14±0.8 530 ± O.H

Kidney Size (em) and age {decades)'

3rd 4th 5th 6th 71t1 8th 9th

Right 11.3 I 1.2 I 1.2 I 1.0 10.7 9.9 9.6

l dt 11.5 I 1.5 11 .4 11.3 10.9 10.2 9.8

REFERENC ES
I. Brandt TD, 1\.ic:man HI, Dragowski :\IJ. Bulawa \Y/, Claykamp G.
Ultr:hound :t~~t:'>!>lnt'nt of norm:~I renal dimension. Joum,,f of
Ultrasomzd in Medicine 1982;1:49-52.
2. Miletic 0. Fuckar Z, Sustic A. Mozetic V, ~rimae l>, z,,uhar <.;.
Sonographic measuremenr of absolute and relative ren.1l length in
,ldult,. Joum,,/ of Clinical Ultr<lsmmd 1998;26: I 85-189.
FURTH ER READING
Emamian SA, Nielsen MB, PcJcr~c:n JF, Ytrc L. Kidney dimcn~ions .H
sonography: correlation with .1ge, sex, anJ hahirus in 665 ,1Julr
volunteers. American Jutmtdl of Roentgenology 199 3; 160:8.3- 86.
 Retroperitoneum

Kidney size (pediatric)

PREPARATION
None.
POSITION
The prone po.,ition is useful in childn:n.
PRO BE
4.0-6.0 MHz curvilmear rr.msJu~:er.
M ETHO D
lmagl: the right killney u~int-: the liver as an J("OUsti(" window. The left
kidney is usually more Jiflinilt to visu.tliLc:. The: lc:ft Jnterior oblique
45n or right dl'("Ubitu!> po~ition may hc:lp. Borh kidneys mu~t he: imaged
in hoth longitudinal .md trans\'crse pbnt:~.
APPEARANCE
The reflectivity of the rcn.tl c:ortc:x i~ ll''' than the Jdjacenr liver and
spleen. The renal c.tpsule c.m he identified as a thin high-retlectivc rim.
The rc:nal pyram1ds are poorly defined structures ~c:en .H the outer l'dge
of the renal sinus. The renal ~inus conr.1in~ mulnpll· srru~:rures - the
pelv1s, calyces, Vl-.;,eJs and f:u - and is usuallv of high reflel'tivity.
MFASUREMENTS
J\·lea.,urc:menrs of 1-adney Sl7e are mken m the m:lxlmum longuudinal
phmc:. In children, the length of kidneys correbtes best to hc:ight.'
although charts against at-:c:' and weiv.ht' are available. Diffc:rc:nccs
bctwl't'n the left :1nd right kidney are minimal.
 Kidney size (pediatric)

Figure 22a On the sagittal view two measurements are obtained in the
longitudinal and anteroposterior planes

Figure 22b The

width is measured
from a transverse
1mage obtamed
through the renal
hilum
B Retroperitoneum

Body lleaght (em) Kidney lengths' (mean ± SO, em)

Right kidney Left kidney
4R-64 5.0 ± 0.58 5.0 ± 0.55
54-73 5.3 ± 0.53 5.6 ± 0.55
65-7H 5.9 ± 0.52 6.1 ± 0.46
7 1-n 6.1 ± 0.34 6.6 ± 0.53
85-109 6. 7 ± 0.5 I 7. 1 ± 0.45
100- 1 .~0 7.4 ± 0.5' 7.9 ± 0.59
110-IJI 8.0 ± 0.66 8.4 ± 0.66
124-149 8.0 ± 0.70 8.4 ± 0.74
U7-l.'i3 8.9 ± 0.62 9. 1 ± 0.84
I·B-1 68 9.4 ± 0.59 9.6 ± O.B9
I )2-17S 9.2 ± 0 ...,.() 9.9 ± 0.75
 Kidney size (pediatric) E.l

RHI: IU N( · 1-.~
I. Dmkd f', hkd :\1, l>irtri..:h \1, Peter!> H. Herrt"- 1\1. ~huhc­
\\"i-.wrm:mn H. Kidnt·\· 'itt' in ..:hildhood. ~onoJ!r.tphi..:.tl growth
..:h;uh tor ktdncy lenj.!th .mJ ,·olume. Pedintnc R,1dm/og)'
I (>U - I - 'u 4'
7o); ):.> o- ·'·
"> Roscnh.wm D~l. korngold E. Teele RL. Sonogr.tpht..: .tsSc!>~mmt
of rcnallcnj.!th in normal ..:hildrcn. t\mericun ./ottrnul of
I<<JL'Il/gt'nolog)' I YX4; 142:46 ""~-4(,9.
3. k111lll~ Ol • Onkmir A. Akka~ a A, Erba~ G. Cdik II. bik ~­
Norm.tllin:r, :.plel·n, .mtl kidney dimensions in neon.m·~. int.um••
•tnd ..:hildrt·n: cv.1lu.mon wi rh sonography. Amcrict~n /oum,ll of
Rocnl,t:£'11olog\' I ';19~; 17 1: 169.3- 1698.
 Retroperitoneum

Kidney size (infant and neonatal)

J>Rfi'AHAT ION
None.
1'0\IT ION
Supine.
JlROHI-
5.0-8.0 f..1Hl curvilinear transducer.
MfTHOD
lma~c rhc ri~ht kidney usin~ th<· liver as an acoustic window. Tht: left
kidney is u:.te.11ly mort· Jifficulr ro visualize. The left .llltl'rior oblique
45° or ri~hr Jccuhirus position m.w help. Borh kidnl'y~ mu:.r hl' imagnl
in horh lon~itudinal .mJ rr.msver.;e plane<;.
APPEARAN CE
AcccnruarcJ corricmm:Julla ry differcnriarion i!> .1 normal finding in
neonates .mJ inf.uns (.lge I J.1y to 6 month:.). The llll·Jull.uy pvramitf,
are seen as low-retlecrive rri.1ngles arranged in circul.tr fashion around
rhc central echogcnic rena l sinus: rhe renal cortex ha~ htp.he r retlec-
uvtr\'.

1\tf AI,UHfMI'NTS

Renal lengths in term newborn infants' (mean ± so. mm)

R1ght kidney left kidney
Male 41.2 ± 4.4 42.7 ± 4.8
f enull' 41.S ± 3.2 42.7 ± 3.7
 Kidney size (infant and neonatal) D

Figure 23a On the sag•ttal v1ew two measurements are obtained in the longitudinal
and anteroposterior planes

Figure 23b The

width is measured
from a transverse
image obtained
through the renal
hilum
1D1 Retroperitoneum

Birth weight (g) Renal length in preterm newborn infants'

(range, mm)
600 26.4-35.7
1000 29.4-38.7
1500 33.1-42.5
2000 J6.9-46.2
2500 40.6-49.9
3000 44.J-.H7

REFEREN CES
I. Holloway H. Jones TB. Robin~on AE. H.trpen MD, Wiseman AJ.
Sonowaphi~ dt:tcmtin.nion of rcn.tl volumt:s in normal neonates.
Pediutric R,1diulogy llJHJ; 13:212-214.
2. Schlesinger AE, Hedlund GL. l'it:rson WI', Null DM. Normal
standards for kidney length in premature infants: determination
with US. Work in progress. RLldiology 19H7; I M : 127-129.
FURTHER READING
Haller JO, Rcrdon WF~ 1-riedman AP. lncr<.".t'o(;d re11.1l corric.1l
ccho~cnicity: a normal finding in ne<.m.ttcs .wd infanrs. l<.ufrologv
19M2; 142:173-174.
1!1 Retroperitooeum

Renal pelvic diameter (neonatal and fetal)

PI{ EPA RATION

None.
POSITION
l'ronc.:.
I'I{O UE
5 .0-!U) l\1117 .::un·ilinear transdu.::er.
M ETHO D
The maximum pelvi.:: diameter is mca:.ured from transverse imaJ!e~.

APPEARANCE
The .::cnrral retle.::n vity from the renal sinm fat ts le~~ prominent th.m
in thl· adulr and the .::ortex is isorcflc.::ti\ e to rhe normal liver. l"he
mnlulbry pyr:-tmids are l.ugcr anll of lower rctlc.::tivity. resulting in
hetter .::ortil·omcdull.ur difft'rl'ntiation than in the .tdult. Norm.tlly
only a small amount of tluid is present in the renal pelvis; any Jil.ttion
of the .::.tlyc~ io; abnormal.
M EASU Rf l\I ENTS
This rem.tins a controversial area, and inJivtdu.tl institutions will h.tve
the•r own protocol; the following mc;huremcnt' are ,1 guide. The pel vi..:
diamctl'r mea:.uremcnr' during anten.H.t l im,tging thought to represent
groups .It ri,k ior ~ignific<tnt rl' n,tl ;thnorm.tlity are:
5 mm ar 15- 20 week'
H mm at 20-30 wn·k,
10 mm >30 weeks
lni;tnts wit h anten:nal renal dilatation :.hould haw ,111 ultra!>ounJ
I week after birth to naluate for \l:\Trl' ob:.tnu.:tion. In infanrs not
requiring immediate intervention or 'ur..:cry for ~evere oh~rnu:tion,
repeat ultra:.ound and a voiding cy,roun:rhrogram is su~e:.rnl a t
6 weeb. If :lt 6 week~ the renal pel vi' .., [e,:. than 6 111111 and there is no
ve:.i.::ourctenc rcflu,, than no further tnvcMi~ation i~ nt:cdnl. If the
renal pch·i:. il> II mm or greatc:r, with ~o:.tlin:ta~i~. fun her im t:~tigarion
is nl·n·, ...try. If rhl· rl·n.tl pelvis is herwe~·n f.- I 0 mm. rhcn serial ultra-
~ound examinations .are suggested unttl tht• ren.tl pelvi~ .appears normal
(<6 mm), or warr.tnrs further srudtes tor ohstrm.:tion (when >I 0 mm
with caliectasis).
 Renal pelvic diameter {neonatal and fetal) D

Figure 24 The
maxrmum pelvic
diameter is
measured from
transverse images
at the point where
the pelvis is at the
bnm of renal tissue

fU RT Ht' R !{FADING
Cl.lllrin·-Fngl.: T. Anderson N< •. All.tn Rl~. Ahhott <.D. Dr.tgnow. of
oh~trudi\'l· lwdronephrosr)> in infant~. Comp.rn-.on sonogram~
performnl o J.n·s and o wt·ck-. ~•fter hirrh. Anwrict111 }ottllt.ll of
Roc11tgem 1/og)' I 'J95; I 64;'J6.~-'J6 7.
t-.l.mdell J. Blyth BR. Peter~< A. Rt·tik AB. Estroff j.\, Ben;Kcrraf BR.
~tnu.:tur.tl gl·nirourin.uy detects detected in utero. R,1dmlogy
I'?'J I; 178; 193- l ':16.
D Retrope.-itoneum

Adrenal glands (adult)

PREPARATION
None.
PO~ITION
Supine.
I'RO B!
l.U-5.0 ~1 Hz curvilinear transducer.
MET H O D
Anrcnor transverse ima~t:~ in quiet re!>piratiun.
APPEARANCE
V.ui.thle appearance. An adrenal mass :1ppears as homogeneous area
wuh ;t distinct capsule. The trequencies of imaging normal adrenal
p.Lmds are: 7~.5% on the rip.hr .tnd 44% on rhe left.
MEASUREMENTS

Thickness 0.3-{).6 em
Length 4-6cm
\\ iJth 2-3 em

RFFERF. NCE
I. Ych HC. Sonop.r;tphy oi the adrenal glands: Normal gl.tnds and
~mall masses. Americun .foumul of Rocntgcnolog\'
1 9~0; 135: 11 67- 11 77.
 Adrenal glands (infant) D

Adrenal glands (infant)

PHEPr\RAT I0 :-.1
.\ionc.

PO~ITION
Supine
PROIH
6.0-7.5 ;\I Hz curv•lmc.H rrans..ll~<:cr.
M ET H OD
Jm,t!!e irom tlank' in o;;tgirtal, coronal .tnd tranwcrst> planl'\.

APPF :\ RA~CI
Thin hi~h-rdlectivc .:on.· reprt:M:ntm~ the corte\:. surrounded hy c1 rim oi
low retle..:uvity repre\cnting rlu· mcdu ll:t. Ar 2 months, thl· corrl'X J.tl'h
smaller and the rnctlull.t l.tl)!er in proportion. At )-6 1nonrh-. the whole
gkmd •~ ,m.tller••mJ :).:t:lll'rally of hi~h rdle..:ti" ltv. At the :t).tt' ot 12 months.
the gl.111d i, ~imil.tr til the adult gl.md .tnd ht:comt:!. low-retlc..:rive.
M EASUREM ENl ~
length j., mc.t~u rc\1 •• ~ maxunum c~:phalo~aullal dimcn'iion. irom the
df'l'' to thl· ba!.l' <•f rhe gldnd. The maximum tr.wsverse and .lntero-
JXI'tcnor diameter' are measured m .1 tr.tll!>\'cr~e plane papendindar
to the length of one ol the wing'.

Day Serial adrenal measurements in neonates' (mean ± SO, mm)

Transverse Anteroposterior length
, ~.9±2.~ 9.6±2.1 17.3 ± Ul
,
.l 14.8 ± J.J 7. .'i ± 2.2 12.13 ± 3.2
5 u.- ± 2. 1 6.9± 1.6 11.4 ± 2."'
l I 11.8 ±2. 5 ~.lJ ± 1.4 8.9 ± 2.0
21 IO.R ± 1.4 ~.n ± 0.5 8.2 ± 1.2
42 9.5 ± I.) ).~± 1.0 7 .- ±0.<)

REff RFNCf.
I. ~Kort E~ l . Thoma' A. \ kG.1rngle HI-I. I ;u:hclin GL -.eri:ll
.1dren.1l ulrrasonogr.1phy in norm.1l nenn:ltl.-... Joun~t~l II/
Ultr,lsmmd m Alt!£bcme 1990;9:2-9-28 3.
r;!lll Retroperitoneum

Adrenal glands (neonatal)

PI{FPA RATION
Nom·.
POSITIO N
Supinl'.
PIH mt-:
6.0-7.5 .\IH7 curvilinear rran~ducer.

MlT HOO
lm.tge from fl.tnk s in ~1girtal. coronal and rra n ~ver..e planes.
APPEARANCI:
Thl· .tdrcnals have :1 11 oval shape in thl· tra nsverse plane .md .tn
inverted Y-shapc in the longitu<.linal plane. A rim of low rdlectiviry ~ ur­
round!. the thin high-rdlecri vc core. The rig hrJ!Iand i~ ~l'l'll 111 1;1]01, and
thl· ldr gl.md in 83%.
MJ-:AS UREMF NTS
lenj!th is mc.1sured as m.t xim urn ccpha locaud.JI dimc:mion. Width is
m.tximum dirncnsion pcrpcndicul.tr rn the length of onc ot the wings.
DI MFNSION~
Lcn~th is mea~urcJ <h maximum ceph:tl<><.:.mlbl dinwn,ion, from thc.-
a pex to the h,1.,e of the gbnd. Thl· max1mum tran~\'crsc a nd ::torero-
posterior diameters arc meas ured in a tran~vl·rse plane pcrpcndtcul:tr
to the length of one of th t• wings. The size of the adrcn;t( gland llimin-
ishc~ r.tpidly in the nr ..r 6 weeks of posrnatal life.

Gestational age Mean adrenal length'

(weeks) (mm)

25- 30 ll

J l- 35 14
36-40 17

REFEREN CE
I. Oppenhl·int<:r D.\, ( ·.trroll BA, Yo mern S. Sonographv oi rhc
norm::tlnconatal :~drc n .tl gl.tnd. f{,1diology 1983; 146: 157- 160.
 Adrenal glands (neonatal) D

Figure 25 The
adrenal gland IS
represented by a thin
high reflective core
(arrow) surrounded
by a rim of low
reflectiVIty. Length 15
measured as
maximum
cephalocaudal
dimension and the
width IS max1mum
dimension
perpendicular to the
length of one of the
wings
B1l Retroperitoneum

Pancreas (adult)

PREPARATION
None:.
POSJ'TJON
Supine.
PRO HE
l.l)-4.0 MHz curvilinear rr.msducer.
M ETHOD
If the p.mcreas is ohSc.:un·J hy atr, vi~ualiza tion m;ty be improved lw
dnnking 500 ml of water in the ri~ht Jecu birus position. The water
holu~ outline:~ rh.: pancreatic head. l o nftitudin.tl Jnd transverse im.tl(e~
are ubraineJ u~ing the upper abdominal blood vessels as landmarkc;.
• The pancreatic head is measured .1hon: the inferio r vrn;t cava.
• Thr pancreatic neck is measured over the superior mc~l'ntcric win.
• The pancreatic body i~ mca~urt·J over thl' superior mesenteric
artery.
APPI:ARANCE
The pancreas ~houl d .tppc<H homn~l.'nous with .1 reflecti\ ity grc:.tter
thJn nr equal to adjacent li\cr. V.matums in rcllet·nviry rela te to the
dq~ree of fany infi lrr;.:~tion. After *'ll years of age, f.ttty accumuhttion m
panncatic tis~ue~ is common and rdlecti\'ity therdorc incrl-.l~l·~.
MEASUREMfNl S'

l ongitudinal Transverse
(mean ± SO, em) (mean ± SO, em)
I lead 2.0 I ± 0. ~9 2.01l ± 0.40
Body LIM± IU6 1.16 ± 0.29
Neck 1.00 ± O..lll 0.95 ± 0 ..2.6
Rcpro..Jlk.,·J with p.:rnu"'oun lrnm Jc (,r,MIIl '\, TJylur Kl. ~unnnds 1\ll.Kn-...·nhdJ ,\(.
( ''·" ..... Jc <-.:h•'l!•·•rh' of the p..tn.rc.". R,rdr"/"~>" 19-!:; 12'>: I,.-I(, I.
 Pancreas (adult) B

Figure 26 Axial plane through the pancreas at the l.evel of the confluence of the
splemc vem and superior mesenteric vein. Cursor 1 measures the anteropostenor
depth of the pancreatic head. cursor 2 measures the anteroposterior diameter of the
pancreatic body and cursor 3 measures the anteropostenor dtameter of the
pancreatic neck

Rt:FERE:'I.Cf
I. de Graaft CS, T;tylor KJ, ~unonds BD. Roscntidd .-\J. Gray-,.:alc
cchographv nf thl' pancrea,. R,u/iology 1978;119: I )7- l f. 1.
FURTHER READING
Filly RA, Lomlon 5S. The norm~tl pancn·.t~: .Kou~tK ch.tr.Ktcn~th.:s.
.mJ frl'lllll'TKY of lllla!!-111~ . .foumul o{ Clnu(,z/ 11/tr.ISOlllld
1979:7: 121-124.
Wl·i ll F, Schrauh A. hwn~cher A. Bour~uin A. Ultra.;onogr,tphy of the
nom1al p.m.:n:.1... ~uc.:css r.ttl· .mJ cntl·na for norrn.tlity.
R.uiiolog\' 1977; 12.1 :4 17-423.
 Retropaitoneum

Pancreatic duct (adult)

PREPARATION
None.
POSITION
Supine.
PROBE
2.0-5.0 I\ 1Hz curvilinear rran~ucer.
M ETHOD
The Jon~ axis of the pancre;.t~ should he determined. The duct in the
region of the head-neck and hody are obtained in the rranl>vcrse/
oblique plane~. The diameter of the duct is taken as the Jistance
between the imwr layers of the anterior ,md posterior walls.
APPEARANCE
The Ju(.'f .tppe:.rs as a low-rdlective tubular structure with reflective
walls. The lumen of the pam:re:uic duct is usually largest in tht· head of
the pancreas and gradually decreases distally.
M EASUREM ENTS

Normal pancreatic duct diameter (mm)

Mean Range
------
Hc.1d- ncck 3.0 2.8-.U
Proximal body 2. 1 2.0-2.4
Oistal body 1.6 1.0-1.7

The ~i1c: ot the p.mcreatic duct incre.1~n w1th age. with the upper limit
of norm.1l estimated at 3 mm. Administration of s~·nt·tin cau~t·s pan-
cre:Hi\.· duct dibtation in norm;tl suhjech, hut h:ts no dfect o n dilata-
tion caused by chronic pancreatitis and may be u~ed to distinguish
these two entities. The diameter of the pancreatic doer can mcrease
durin~ deep inspir.uion in .tdulrc; without pancreatic disease; up ro
1.3 mm when compared with images oht.tined at end-expiration.
 Pancreatic duct (adult)

Figure 27 Axial
plane through the
pancreas. with
cursors measuring
the anteroposterior
diameter of the
pancreatic duct in
the proximal aspect
of the body

FURTHER READIN G
Glaser J, Hogem.u1n B, "rummenerl T, Schneider M, llultsch E, van
Husen N, Gerlach U. Sonographic imag!ng of the pancreatic ducr.
New di,lgnostic possibilities u!>ing !>Ccretin srimul.uion. Digesti1•e
Diset1Ses tllltf Science~ 1987;.U: I 0 75-1 OS I.
H..tdidi A. Pancrearic duct diameter: sonographil" mt·asuremenr in
normal suhtects. Journal of Clinical Ultrasound 1983; 11 :1 7-22.
Wachsherg RH. Respiratory variation of the diameter of the
pancreatic duct on sonography. American Journal of
RIJentgenology 2000;175:1459- 1461.
Ill Retroperitoneum

Pancreas (pediatric)

PREPARATlON
None.
POSITION
Supine, decuhirus and M:mi-decubirus posmons with the left side
elevated.
PROBE
5.0-7.5 MHz curvilinear transducer.
METHOD
Maximum anteroposterior diameters of the head, body and rail of the
pancreas are measured on transverse/oblique imag~:!>.
APPEARANCE
The pancreas should be homogenous with a reflectivity equal ro or
slightly greater than rh,u of adjacent liver. The pancreatic du1.."t may be
seen as a single high-reflective line and usually measures less than
I mm.
MEASUREMENTS

Age Anteroposterior dimensions of pancreas'

(mean ± SO, em)
Head Body Tail
<1 month 1.0 ± 0.4 0.6 ±0.2 1.0 ± 0.4
I month-! y~:ar 1.5 ± 0.5 0.8 ± 0.3 1.2 ± 0.4

1-5 years 1.7 ± 0.3 1.0 ± 0.2 Ul ± 0.4

5-10 vears 1.6 ± 0.4 1.0 ± 0.3 1.8 ± 0.4

I 0-19 years 1.0 ± 0.5 1.1±0.3 2.0 ± 0.4
Reproduced With rcrm!SSI(}O from Sk"Fd M J, ~Ia run KW. Wurthinb'fUn JL. :-.lorm3l and
ahnnrmal paru.:rt·-Cl, ul ..:hilcirt·n. J<atftulugy 19~ 7: J ll.i:l5-l H.

REFERENCE
I. Siegel MJ, Martin KW, Worthington .JL. Normal and abnormal
pancreas in children. Rudiology 1987;165:15-18.
 Pancreas (pediatric) B

Figure 28 Axial plane through the pancreas at the level of the confluence of the
splenic vein and superior mesenteric vein. Cursor 1 measures the anteroposterior
depth ol the pancreatic head. cursor 2 measures the anteroposterior drameter of the
pancreatic bOdy and cursor 3 measures the anteroposterior diameter ollhe
pancreatic tail
1m Retroperitoneum

Psoas muscle

l)REPARAT JON
None.
POSITION
Supine.
PROBE
2.0-5.0 l'vll lz curvilinear tr.1nsducer.
METHOD
Lon~itud inal and transverse ima~es from rcn.1l bed to ilia.: fossa.
APPEARANCE
Tuhular luw-retlectivt' structure medial and posterior to the kidney. In
longirudinal section may demonstrate hi~h-rdlecrive line:tr echoes,
represenring inrramuscular tendon fibres. On a m:msverse section. a
rounded low-reflective oval structure lateral to the spine is !>t'Cn. In the
iliac fol>,:l pl><l:ls muscle blends with iliJcus muscle. These appe.1r as
low-rdlel.'ti\e ~otr ti..,,.ue layers medial to curvilinear high rdlccriviry
echo from dtstal shaJowin~ of the iliac wing. A high-reflective region
posterior and medial w the iliopsoas muscle represt"nts th~: fl.'moral
nerve sheath. The psoas minor muscle c.1nnot be idenritied .b a !>~:p.t­
rare suu.:rure.
FURT H ER READING
King AD. I line AL, McDonald C, Abrahams P. The ulrr.1sourul
appc.uance of the nonnJI psoas muscle. Clinic,ll R,ldmlogy
19'H:4!U 16-3 1S.
Ko~:nig~hcrg M. Hoffm.m JC, S.:hnur J. Sonogmphi~· evaluation ot rhe
r~:rroperitoncum. Seminars in Ultrasound 1982;3: 79-96.
 Psoas muscle E1

Figure 29a
longitudinal plane
through the lower
pole of the nght
kiclney
demonstrating the
linear h1gh
reflectivity of the
intramuscular
tenclon fibers in the
psoas muscle
(between arrows)

Figure 29b
Transverse sectiOn
through the psoas
muscle. again
clemonstrating the
high-reflective
tendon fibers
EJI Retroperitoneum

Retroperitoneal lymph nodes

PREPARAT ION
None.
J'>O<:ITION
Supine.
PROBE
2.0-5.0 MH.t curvilinear tran:.ducer.
MtT HOD
Longitudinal and transverse sections are used to image t he aorta ,tnJ
the inferior vena cava. Lymphadenopathy is identified around tht.'se
structures.
APPEARANC E
The appearances of norma l lymph node!- arc flattened, low-reflective
structures with an eccentric highly reflective area representing the fanv
hilum.
M EASUR EMEN T
Iris frequcnrlv nor po~~i ble ro see normal sized ~lands of< I em. Lymph
nodes greater than I cm a re considered ahnorm.llly enlargl·J. ~leasure­
mcnt ic; taken along the sho rr axis.
FU RT H ER READI NG
Dietrich Cf, Zeuzcm S. Caspary WI: Weh rmann T. Ultr.tsound lvmph
nudc imaging in the abdomen and rcrropcrironeum of health
prohands. Ultrascball in der Mediz:in I 998; 19:265-269.
Koeni~sberg M. Hoffman JC, ~hnur J. Sonogrclphic evaluation of the
retroperironeum. Semint1rs in Ultrasound 1982;3:79- 96.
.\1archa l G. Oyen R, Verschakelen .J, Gelin .J, H<lCrt AI , Sr c~~cns RC.
Sonographic appearance of normal lymph nodes. )<mm.zl of
Ultrasmmd in Medicine 19~5;4 :41 7-4 1 9.
 Retroperitoneal lymph nodes &

Figure 30 Oval low-reflectiVe lymph nodes present (arrows) in the retropentoneum

around the celiac axis
ORGAN
TRANSPLANTATION

Keshthra Satchithananda,
Zelena A. Aziz and
Paul 5. Sidhu

Kid ney rra nsplantatiun Rl

Renal artery '>teno'i' in
rransplantation R6
Liver tramplantation !:!H
Pnncreas transplantation 92
EJI Organ transplantation

Kidney transplantation

!'REPARAT ION
None.
PO SIT ION
Supine or right anrerior ohlique pmirion.
PROBE
3.0-6.0 .\I Hz cun·ilinear transducer.
M ETHOD
Renal transplants are norrn,tlly siw:ned in a retropt:rironeal posiuon in
the right iliac foss.t. Tht· ~ize may be measured in three planes. to
cakulaH· volume. Spectral Doppler waveforms from the upper, mid
anc.l lmwr .t:.pects are ohrained, .1iued hy color Doppla imav.ing.
APPEARANCE
The transplant kidney may lie in variou~ planes; there m3y he .t promi ·
nt·nr pt:lvicalyceal system. Corricomeuull.try differenti.ttion nMy he
readily vi~u.tli;rcd, and the renal sinus fat i~ of m.ukedly high retlc.:-
tivity.
M EASURE MEN f S
• Volun•c = 0 .51 x length x ~Nid th x anreroposterior diam(•ter
If <90% of the immediate pmroper:Hivt: ,·olume, consider chronic
rejet·tion or a vascul.u insult.
• The rt:SISt.liKe index (R I ) may ht: measured at the upper, mid and
lower ••spects of the transpl.mt kidney. normally trom <Jn inrer-
lohubr hr:m.:h.
Rl = (peak systolic velocity - t:nd dia!>tolic ..dm:iry)/pt:3k sysrolic
velocity
The normal me.1n value i~ 0.64- 0.73, ahnormal if >0.7)-0.90, hut
~erial measuremcnr ch.mgc!> over time arc more imponanr than single
measurements.
 Kidney transplantation E1

Figure 31a
Longitudinal plane
of a transplant
ktdney in the nght
iliac fossa

figure 31b
Transverse plane of
the transplant
ktdney. The size
may be measured
in three planes. to
calculate volume
B Organ transplantation

Figure 31c The resistance index is measured in this patient atltle lower aspect of
the transplant kidney. normally from an interlobular branch. (Courtesy of Dr. Cohn R.
Deane)

fURT HER READING

Ahsy M, Merreweli C. .\lauhews C, AI Khader A. Changes in
transplanted kidney volume measured by ultrasound. British
Journal of Radiology I ~H7;60:525-529.
Don S, Kopecky KK, filo RS. Leapman SB. Thomalla JV. Jones .JA.
Klam· El.. Duplex Doppler US of renal allografts. C.wses oi
elev:ued resistive index. Radiology 1989; 171:709-7 12.
Hricak H. Liero RP. Sonogr.tphic dererminanon of ren.1l volume.
Radiology 1983; 14 8:3 I 1-.112.
Rifkin MD, Needleman L, J>asro MF, Kurtz AB. Foy PM. McGlynn
E, Canino C, Balrarowich OH. l)ennell RG, Goldber~ Bit
Evaluation of renal transplant rejection bv duplex Doppler
examination: value of resistive index. American Journal of
Roentgenology 1987;148:759- 762.
R Organ transplantation

Renal artery stenosis in transplantation •

PRfPARATION
None.
POSITION
Supine or righr anrcrior ohliqut· position.
PROBI:.
3.0-6.0 :\IH:t .:urviline.lr rr.m~du.:er.
M ETHOt>
Ren;tl transplants are normally !>ltuatcd in,, re rropcnroneal position in
the ri~ht ilia.: foss.1. Doppler spe..:tr.ll ''"''lro;is is pt:rtormcd along the
len~th of the transplant Mtery, angl.: of insonat10n <60° using the low-
e~t filter :.ening and ~~ scale that ac.:<>mmmlares the highest peak -;ys-
rolic velocirie~ without aliasing.
Af'f'F ARANCJ-
• Cadt11•er kidney: harve~red with an int;h.:t m;lin renal arrcry and an
attached portion of the aorta, sutured ..-nd-rn-side of rht· recipienr
extern.1l iliac artery.
• I il•illg-rcl.llcd dmtur kidnc)': m.1in rt"n.tl .trterv of the donor is
sutured e•ther directly enll -ro-~iJe ro the recipil·nr exrern.1 l ilia.:
.lnl·ry or end-ro~·nd ro the redpient intl'rnal ilia.: .Jrtery.
MFA~ U REMENTS
• A pe.1k sr~rolie velocity (P~Vl of ~ 1.5 m/s i~ u"1.tll}' ..:on!>idneJ nor-
mal. A transplant ren.tl .uterv with a p<;y :<:2 .0 rn/o; is suggesti\'1:: oi
.t >50% di;lmerer reduction.
• Ratio of P~ V in rhe rranspl.tm renal arrt"fy ro rht' PSV in the c'ft'r-
nal ili.1..: .trrery. There is con!>idcrahle \'ari.Jtlon in the PSV of the
rran~plam < lrtcry, and a ratio ..:an he u.,cd; thl· upper limit should
nor l'XCt't'd 1.5.
• Changes in rhe resistann· index (I{)), accelcr.nion index (gradienr
of rhc sysrolic upsrroke ) and .tcceleranon rimt' (rime taken from the
beginning of the sy•aoli..: upstroke to the first ~ysrolic peak)
re.:orded in the inrrarenal \'l'Sscls .lrt" less tN·ful ,1\ .l di-;aim.nory
dia~nosric rest.

RI = (peak systolic velocity - end dia~tolic velo..:•ty)/pl:'ak sy'>tuli..:

velocity
 Renal artery stenosis in transplantation

Figure 32 A transplant renal artery with a peak systolic velocity of 2.76 m/s IS
SU{Igestive of a >50% diameter reduction (Courtesy of Or. Colin R. Deane)

FURTHER READINl.
Baxrcr Ireland H. ~to~~ .J(•• Harden PN. Junor B.JR. Rodger
C..~l.
R~C. Colour Doppler ulrr;houtul m renal rr:Hhpl.lm .trrcrv
..reno~i,; which Oopplcr in,Jex? Clmtc.1l Radwlog)'
I '>95;50:61 S-612.
Cochlin 01.1. \X',tke A. ~.tiJnl.ln IR. (.riffin P.JA. Ulrr,lM•und ch.tng6
in rhe rran~pl.mr kidney. Clinical R,ICfiolo,t..'1' l lJXS;.l9:.P3-376.
DoJJ C D. Tuhlin ~IF, '\h.1h A, Zajko A.B. lnlilging of ,.,t!>eul.tr
complic,triom ,l"oc•:ncd '' irh renal rr:lll'pbnr:.. Am<'ric.m.fouru,d
of Roent~t'llo/og\' I ':J':J I; J.' i7:44<J-45lJ.
D Organ transplantation

Liver transplantation

PREPARAT IO I\o
None:.
POSIT ION
Supine or right anterior oblique position.
PROBE
3.0-5.0 MHz curvilinear tran!>ducer.
M ETHOD
Ultr.1sound is the primary screenmg tc:chniq ue for detection of ,..1~cular
complications of hepatic transpl.tntation. Longitudinal and tr:msvers~
imJ~;1:S are taken from a suhco'ital or intercostal approach on inspira-
tion in the supine and right anterior ohlique positions.
APPEARANCE
Liver parenchyma should be of uniform medium strength echoes.
• Hepatic .:rtery: Visualized at the porta hepatis. Normal hepatic
Jrtery Doppler waveform shows a low-resistance flow pattern with
continuous diastolic flow. Com plication~ are hepatic artery throm-
bosis, manifest as absence of hepatic artt:ry and mtrahepatic arrer-
i.tl flow. ~ometimes flow is detected in the intrahepatic location due
ro collateral vessel form;ltion. A tardu!> parvu~ waveform is a char-
acteristic change in .uterial flow distal to a stenosis. Ahsl·ncc of
.trterial flow .u the porta hepatis with rardus p.uvus w.tveforrn di~­
tally within an intrahepatic arrt:ry is suggestive of main artery
thrombosis
• Portal l'ein: Visualized at tht" porta h~pmis. Normal porr;tl vein
Doppler wa,·eform ~how:- cunrinuous tlow p.ntem with mild veloc-
ity variations induct:J by respiration. Complications indudl· portal
vem rhromhosis .mJ stenosis. Thromhosis is seen on waysc,1lc
ultrasound <IS high-reflective luminal thmmbus or n.nn•-.vin~.
Color and spt·crral Doppler ultrasound ~hows no d~tcctahk· tlow in
the portal \'Cin.
• l-lcpt7tic l'eins and inferior I'C'Ita cut•.: (I\'\): Doppler spectral wave-
forms of the hepatic veins ilnd IV(: art: :.~mil:lr with pl1.1sic flow p,u.
tern indicanve of physiolo~ic ch.mges in blood flow with cardiilc
cyde.
 Liver transplantation

Figure 33a A
spectral Doppler
gate is placed over
the intrahepatic
hepatic artery and
an acceleration time
of 140 ms is
measured.
indicating a ·tardus
parvus· waveform

Figure 33b A spectral Doppler gate is placed over the distal hepatic vein at the
anastomoSis with the suprahepallc inferior vena cava and an increase 10 velocity
from 0.56 m/s to 2.89 mts mdicales a local stenosiS in the hepatic vein
IZJI Organ transpla ntation

MEASURe MENTS
• A tardus pan us waveform is a .:haractcri!>ri.: change in .1rterial tlo"
distal to a ~tcnosis. This waveform has a resistan<.:c inde' (R l ) <0.5
and a systolic acceleration time (time from end d i.l!>tok to nr<;t !-.}'S·
tolic peak) >0. 12 !>.
• StenoSi!> of port:ll vein shows focal color al iasin~ with a >3-4 fol.l
increase in velocity relative ro the prestenotic !>C~mcm . or .m
absolute velocity measuremem of> I 00 cm/s J t the site of the steno-
SIS.
• Thromhosis or stenosis of IVC can occur after rran)opl.lntation .md
the latter 1S usually at the site of the anasromosis. ( ;r,tyscale ultra-
sound shows high-reflective thrombus or obviou., narrowing.
Spectral Doppler ev.-.luation show~ a J-4-fold increase m \'elocitr
across the stenosis with loss oi normal caval phasicity in the hepatic
venous spectral Doppll"r w.tvcform. Loss of phasi.:iry in the hepatil·
veins also indicates upper caval ~lna,tomoric stcno~is.
FURT HER READING
Ngh1em I IV. Tran K. Winrcr Ill TC, Schmidt UP, Alth.tus ~J. Patel
NH, frl"eny PC. Imaging of complications of hvcr transplamation.
Radiogr.tphics 1996; 16:825-840.
Ryan S~ l . Sidhu PS. hlrly post-oper,uive liver transpl.mt ultrasound.
In: Sidhu PS. Bax ter (;~1. eds. Ultr<.Isozmd of abdominal
trmzspltllll«tivn. T hil"lllt'. Srurrg.ur. 2002. pp. 90-104.
Shaw AS, Ryan SM. Fk·c~t· RC. Norris S. Bowles ~t. Rda M, ~· dh u
PS. Liver rransplantarion. l m<.Iging 2002; 14:314-328.
 Liver transplantation El

Figure 33c A
spectral Doppler
gate IS placed over
the intrahepatic
portal vein. and an
absolute velocity
measurement of
103 rnts is
obtatned. indicating
the presence of
portal vein stenosis
EJI Organ transplantation

Pancreas transplantation

PREPARAT ION
l\;one.
POSITION
Supine or right anterior oblique positton.
PRO BE
3.0-5.0 MHz curvilinear transducer.
MET HO()
Commonly the entire pancreas io; trampl.tntcd with a 'cction of dumk·-
nurn anastomosed to rhe hladJer. The gland is siruarcd in rhe pdvi!.,
with thl' venous anasromosis between the donor portal vein and the
anterior aspea of the recipiem external or common ili.Jc vein. The arte-
rial anasrornosi' is from the recipient anterior wall of the common iliac
artery to a p3tch ot donor 30rtJ conr::~ining the celiac trunk .tnd 'upe-
. .
nor me~enterK artery.
APPEARANCE
Uniform parrern of refl~:ctivity simil.u to that of mu~lt-. Rekction
appears as gland enl.lrgement. focal or diffuse :lrl·as of low rdk·crivity.
and a resistance index (RI) of >0.7 (measured in the donor arterial
trunk). lmagin~ is paramounr in follow up of pam:reatic transplant as
clinical and h•ochemical evaluation is relativdy in,ensirive in deter-
mining episOl!t·s of .lcute rejection. Ultrasounll evaluation and guid-
ancl· will allo\\ percut.llll'OUS hiop~y to confirm the di.tgno!>ic; and
inMitutl' thempy. Pancrt·aric duct exocrinl· drain.t~e is via the bladlkr.
MI:.ASUREMF.NTS
• Anteroposterior c;i1e of normal gl.tnd: head J em. hody 2.5 .:m. t:til
2.5 em. P.maearic ducr should he :SJ 111111.
• Color Doppler ro loc,ue ancl show pan.-n~~ of n1.1in graft .1rtery .md
vem.
• Rl of the artery should be :SO. 7.
 Pancreas transplantation El

Figure 34 Color Doppler to locate and show patency of main graft anery and vein.
A spectral Doppler gate records the spectral waveform from which the resistance
index is calculated (Courtesy ol Dr. Colin R. Deane)

FU RT Ht:R I{EADI NG
Green ~J. S1dhu P~. Deane LK. lm:JJ.!ing of 'imulr.1ncous k!Jney
pam:re:1ric tr .1n~pl.mr-.. lmt~ging 2002; 1 4:2~~-307.
P.ud R. \X'olver~on .\II-:, :'\Lth.tnr.t B. P.m.:n:.ui~· rr.tn,pl.tnr rere.:uon:
.tssessment with Jupll'\: US. Rt~diologv I <1!>9; 173: U 1- 1 l5.
Won~J.I. Kreh, T1, Kb"'l'n DK. o.,ly 1-\, Simon F~l. Harrlt·rr Sl,
( ;rumhadl K, Dr;lt:hcnhng CB. Sonowaphic cvalu.nion oi .ll"ure
p.tncrc.ltit· rr.mspbnt rejection: 1\ 1orphology- Doppler an.!l}"~l!'>
vcr~u~ guided percutaneou" hiopsy. American /ounwlo(
Rt•entg£>11!1ft>g)" I '1'11.; l n6:X01-HO~.
Yuh Wl: Wise .JA, i\hu- Youst'l ~1~ 1 . Rez.ti k., ~a toY, Berhaum KS.
K.to SC, •tun!>il"ko~.·r l.G. Corr~ R.J. Pannl"atk transplam imaging.
R,ldiology I '1!>X; 167:6 79-nXJ.
PELVIS

Bladder 96
Bladder volume and residual
volume 96
Bladder wall 100
Urctcrovc~i~al jet" (pcdiatri~ and
infant) 102
Ma le ~cnit.ll tract I04
Tc~tcs 104
Epididymi~ IOH
Pro~tate - tmn~rcCla l ~onography 110
Seminal n.~idc~ - tramrc~tal
~ono~raphy 112
Peni!> 114
Female urogenital tract 11 H
O vary- tranwaginal sonography 11 X
O varian follicles- transvaginal
sono~raphy 120
Cervix - tranwaginal ~onogr~tphy 121
Uterus - tranwaginal o;nnography 11-1
Endometrial <;tripe - transvaginal
\Onography 116
Urethra 12X
Length of the ceni' and cervical
canal in pregnan~y 130
Ell Pelvis

BLADDER
Keshthra Satchithananda,
Zelena A. Aziz and
Paul 5. Sidhu

Bladder volume and residual volume

PREPARATION
Full hi.Jt!Jer is required
POSITION
Supine.
PROBE
3.0-).0 .Mf-lz curvilinear tra nsducer.
MEfHOO
Transverse plane for the width and depth, and then a lungirudin.1l
image provid~ the length and depth me-.t~uremenrs. \ll'aMJrcmenrs a re
estimated both hefore and after micturition. There should he no post-
micturition residual \·olumc.
API•EARANCE
When tull. the bladder is d ea rly defined as an .1lmost square stnu.:turc
of low rdlcctivity in the rrano;verse plane. Within the hiJdder the
trigone is the <lrea conr.tining the ureteric ,md urethral orifices. The
urethral orifice ma rks the bladtler neck.
M EASUI{EMENTS
hlood volume (ml) = (7t/6) x length x depth x width
(7t/6 may he 'uh~tiwted hy 0.5 I )

The accuracy o t this cakulation 1S v:Ui;thlt:, as it is b;lscJ on ;Ill d lip·

soiJ fo rmula, .1nd there is con~iderahle variation in bladder sh.tpe. At
lea~t 200 ml of tluid must be in the bladder to make a urodynamit: flow
rate study accurate. If there remams a > I00 ml resid ual volume, the
patient should artempt further bladder emptying a nd the t:xami nation
n::pcared.
 Bladder volume and residual volume El

Figure 35a Transverse plane through a full bladder with the two measurements of
w1dth and depth obtained

Figure 35b
Longitudinal plane
with the
measurement of
length obtained 1n
order to calculate
the bladder volume
R Pelvis

FURTHER RfA DING

McLean GK. Fdell ~L. L>etcrmin.uion of bladder volumes hy gray
scale ultrasonography. R<~divlvgy 1978; 128: I 8 J-1 82.
Griffiths CJ, Murray A, Ramsden PD. Accuraq and repear.thiliry of
hladder volume measuremem using ultrasonic imaging. Joumal of
l/rolngy I 986; 1.'\6:RO!l-H 12.
Posron GJ, Joseph At'. Riddle PR. The accuracy of ultrasound in the
measurement of changes in hladder volume. British )numal of
Urology I ~~G;55:J61-363.
11iD Pelvis

Bladder wall

PRFPARATION
Full bladder is rcqu1red
PO~ITION
!>upinc.
J>ROIH.
J.0- 5.0 l\IHz ~urvilinear transdu~cr.
M ETHO D
Hl:tdder w,tll is mcasurcJ on tntnsverse and longirudinal images by
pl;King the probe in rhe midline .1hove the pubis. On transverse views
the: bladder floor lateral ro the triwme and on longitudin.tl views the
posterior inferior wall arc:- the optimal site) tor me;tsurl·mcnt.
APPEARA NCE
Smooth ~:ontour with the high -rc:fk~rive mu~:os.l distinguishahle from
the low-rdlective derrusor muscle:.
MEASUREMENTS
Regardlt<~s of the patient's .tge anti j!.l'rtder:
• norm.tl empty hl:ldder S5 mm
• weii-Ji.,rendl·J hl<tddcr S3 mm
FURT HER REAL>IN<...
Jc:quier ~. Rous~cau 0. ~onographic mt>a,urcmt:m!> of the normal
hladdcr wall in ~hildren. American Joumul n{ Roentgenology
19B7: l -t9:56.~-.'i66.
l\bnicri C. Carter SSC. Romano G. Trucchi A. Valenti \1. Tubaro A.
Tht· diagno)is of bladder outlet obsrru~ tion in men by ultrasound
measurement of bladder wall thi~kness . ./mtm.,/ of UmloK)'
199R;159:761-765.
 Bladder Wall IEll

Figure 36
Longitudinal plane.
measuring the
depth of the
postenor wall of the
bladder adjacent to
the uterus
11!1 Pelvis

Ureterovesical jets (pediatric and infant)

PREPARAT ION
lngl-stion of water
PO SIT IO N
Supine.
PRO BE
5.0-7.5 MHz curvilinear transducer.
M ETHOD
Transverse im<tge through the bladder base. The site of the ureteric ori-
fice i:. UMI.tlly l.neral .md defined as the urereovesical jum:tion ar the
apex of the angle between the bladder floor and the l.ucral wall , ,,r in
the lateral vertical wall of the bladder. above rhe hiAddt·r tloor.
APPFARANCE
The urett'ric jet is seen o n graysctle wht·n thl·re is a difference of at least
0.0 I g/ml between the specific gravity of llrine coming down rhe ureter
a nd the urine present in the bladder. When a spl·crral Doppler g<He is
placed onro rhe jer, J characteristic signal is obtmnt:d ewn when the jer
is not seen on waysc.tle. Color Doppler flow imaging is more sen~itivc
in dcmmhrraring tlow than gr.tyscalt· and facilit.ttes location of the
ureteric orifice.
M fASU REM ENTS
In childrl·n with norm.tl voiding cy~rourerhrogram (VClJ(,) .md
normal renal and bbdder ulrnl\ound:
• Duration of jet: right, 2. T' ± 1.5 ~. and left 2.R8 ± 1.5 s
• Direction of jet: Usuall}' .mreromedial and upwa rd
• Spectral a nalysis: I 0-80 em/.,. (mean of] 1.6 cm/s)
Frequency of jeh and resulr.tnr signal incre.tse wtrh urine prodlll.:tion:
.tn .tlmost conrinuous signal is obtained .tfter a large tluid load.
Although identification of urererovesio.:dl jets m.1y be made on ultra-
sound, then: an· no specific fea tures reg.trJing the jets th.tt rel iahl~ dis-
t ingui.,h .1 normal from a n ahnormal url·tcrovesic.tl junction.
FURT HER READING
Jequier S, l'a lricl H, l .1fortunt' ~t. Uretero-vnic.tl jets in infants .mcl
o.:hildrl·n; dupll'X .md color Doppler studies. Rudiology
I'190; 175:349-353.
 Ureterovesical jets (pediatric and infant) ED

figure 37a Color

Doppler 1mage of
the right and left
ureteric jets
demonstrating the
anteromedial and
upward direction of
the jet

Figure 37b A spectral Doppler gate is placed over the ureteric jet. and a spectral
waveform obtained (Courtesy of Meena Shah)
 Pelvis

MALE GENITAL TRACT

Ze/ena A. Aziz,
Keshthra Satchithananda and
Paul 5. Sidhu

Testes

PREPARATION
None.
PO SIT ION
Supine. with rowel beneath the scrotum to provide support.
PRO BE
7.0- 1.l.O :'\·lH1 linear transducer.
M ETHOD
Compare reflectivity between the two sides on a 'iinglc ima~e. Obtain
transverse and lungitudin.tl images.
APPEARANCE
The testes are homo~enous and of medium-kvel reflectivity. The nu.:di-
astinum testis is a highly reflective linear struuurc in the
posterior-superior aspect of the testide draining the seminifcrou~
tubules of the testes into the rete tc~tis. Drainage from here i~ via the
epididymi~ to the semmal veside~. The rete testis is a low-reflc:ctive
area M rhe hilum of the testis with finger-like projection~ into the
parenchyma. Apart from rhc~l projc:crions, the parenchyma of the
testis )hould remain of homogenous retlectiviry. The appendix tt:'>tis (a
vestigial remnanr ot the miillerian duct) is present in the majority of
patients, most commonly at the superior testicular pole or in the
groove between the testi~ and the head of the epididymis medially.
There is m.trkt:·d variation in it~ size .wd appearance; it is u~ually nval,
although a st.1lk-likc structure;, O(Ca~ionally seen.
MEA~U R EMEI'·n·s
• Avcr;lgt' size i~ 3.8 x 3.0 x 2 ..'i em. The k·ngth ~·an he up to 5 em.
• Volumt• mt'asuremem i~ C<llcul.uc:d using tht· formula:
length x width x height x 0.5 I.
 Testes E'I

Figure 38a longitudinal plane through the testis demonstrating homogenous

medium-level reflectiVIty

Figure 38b
Transverse section
through the same
testiS. Volume can be
calculated trom the
three measurements
obtained
U Pelvis

• A total volume (borh testes) of >30 ml is indicativt: of normal fum

tion. Tcsri.:ular vo]ume >2 ml allows reliahle appre.:i;ltion of intra-
testicular color Doppler tlow. A varicocele is present if the \·ein
nu·asures > l. mm.
FURT HER RI:.:ADING
Ingram S. Hollman AS. Colour Doppler sonog raphy of rhe normal
paedi.mic testis. Clinical Radiology 1994;49:266-267.
I eung Ml, Gooding GAW, Williams RD. Hig h-resolution
sonography of scrot.ll contents in asymptom.ltio.: subjects.
Americt111 Joumal of Roe11tgenology 1984; 143:161-1 M.
Palriel HJ. Oiamond DA, Di CanLio .J, Zurakowski D. Horer JG,
Arala A. Testicular volume comparison of orchi..lomc:ter and US
rneasuremenrs in Jog~. R,ufiology 2002;222: I 14-119.
Sellars MFK, Sillhu PS. Pictorial review: Uhrasound imaging of rhe
rere testis. J-:uropeon .foumal of Ultrasound 200 I; 14: I 15- 120.
Sellars M EK, Sidhu PS. Ultra~ounJ a ppeara n ces of the rc~ticular
a ppenJ,\ges: pictorial revil'W. J-:uropemr Radmlogy
2003;13: 127- U5.
ml Pelvis

Epididymis

PREPARATIO N
None.
rosm oN
Supine. with rowel beneath rhe ~~rutum ro pronde ~upport.

PROBE
7.0-10.0 !'vi Hz linear tr.msduccr.
'VtET HOD
Transverse and longirudinal1magc~. to mdudc the hc:<td, body .tnd tail.
APilEARANCt:.
The epididymis is 6-7 ern in length. rlu- head (globus m,\Jor) is a pyr.l-
rnid-sh.tpcd ~tru~turc lying superior to the: upper pole of the tr.:sti!>. The
body course!> alonv, the po~rcrolatcral aspec.:t of rhr.: testidc. The ta1l
(~lobus minor) i!> sli~lnly thicker rhan rhe hody and can be seen as <1
curvc:d structure at the inferio r :ll.peo.:r of rhc: te~tide where it hecomcs
the: proximal po rti on of the ductus deft•rcn~. The body and 1.1il ;~re of
!>imil.1r or !>lightly lower retlecti\'ity than t he resu~; rlw ht·ad is of
slightly highc:r rdlectivity. The .1ppcndix c:pid idymis is nut as trcquently
!>CCII as the .1ppcndi:-. test is. It is p.ut o f rhe me<>onephric (wolffian
duct), and projt•t·ts frnm t he l'pilt.dym is from different sircs, most com·
mo nly rhe hcad. It usually has a sta lk-like appe.1ranc:c.
MEASU REM ENT~
T he glohus major mc:asurcs I 0- Jl mm in d~<unctc:r, the hody lc:<..' than
4 mm (a\'eragc 1- 2 mm) in d iameter.
FURTHF.R READIN G
Krone KD, Carroll BA. Scrotal uhra,ound. Rt~diologic Climes u(
North America I lJ8S:23: 12 1- l .W.
I eung M l . CoodinJ.: GAW, WilliJ rm RD. 1-lij.:h-resolurion
sonography of scrotal conrenrs 111 asymptomatic subjc:crs.
American }emma/ of Roe,tg<•nulogy 1984;143: 161-164.
 Epididymis 11m

Figure 39a A
longitudinal plane
through the head of
the epididymiS in a
patient with acute
epididymitis with
the depth of the
epididymal head
measuring 1.67 em

Figure 39b The

body of the
epididymis m the
same patient
measuring 0.57 em
ID Pelvis

Prostate - transrectal sonography

PREPARAT ION
None.
POSITION
Left lateral.
!•ROBE
A dedicated rransrectal probe is used which may vary in fn:quency
from 5.0-7.5 \!Hz. Single or multi-plane probes may he used.
MI:THO D
The examination is best performed with the patient's bladder half full
ro provide a conrr.tst to the high-reflective perive!>iwlar fat surround-
ing the prostate. Axial and longitudinal im.tges Gtn he obtained.
APPEARANCE
The prostate is usefully separated into a peripheral zone and .m innc:r
gland (encompassing the transition and ccnrral zones, .md periurethral
glandular area). The peripher.tl zone cncompa~~es 70''o of the glandu-
lar ti!>Sue, appears as medium-level uniform low refleaivity. st•parared
from the central 10ne hy the surgical capsule, which is often of high
reflectivity.
M EASURFMENTS
Measurement of .mteroposterior (H). tr.msversc (W) and ceph.tlo-
caudal (L) dimemionl>, with the volume cakulatl·J using rhe formula:
JT16 x H x W x L (7tf6 may he suhstinned by 0.51)
Tht: normal prostate measures 2.5-J.O x 2.5-3.0 x 2.0-2.5 em. with .m
esrim.tted volume of 20 mi.
FURT HER READING
Terris ~lK. Stamey TA. Determination of prostate volume by
rransrectal ultrasound. Juumal of Uroloxy I ~91; 145:984-487.
Villers A. Terris ~I K, McNeal JE, Stamey TA. Ulrr;lsound an.Jtomy of
rhe prosrate: the normal gland ..1ml anatom i~al variarions. .fvunrul
of Urology 1990;143:732-738.
 Prostate - transrectal sonography IIIII

Figure 40a Anteroposterior and transverse measurements of an enlarged prostate

Figure 40b Cephalocaudal measurements in the same patient (Courtesy of Dr lan

Stanton)
11E1 Pelvis

Seminal vesicles - transrectal sonography

PREPARATION
None.
POSITION
Left lateral.
PRO BE
A dcdi.:ated transrectal probe is used which may var)' in frequency
from 5.0-7.5 MHz. Single or multi-plane probes may be used.
M ETHOD
The: c'amin.nion •~ best performcd with the p.uienr's hl.ldder half full
to provide a contrast to the high rdlcctivc pcrivesi.:ular f.n surround-
i n~t the semina l vesides. A xi;l l and longitud inal im:tgec; C;ln he oht<1ineJ.

A PPFARANCE
T he seminal vesicles are seen as tku, paired strUl.'tures lying behind rhe
bladder. The centre of the gl:md i~ of low retlecti\'ity, with areas of high
reflectivity cor responding w t he: tolds of the excretory epithelium. If
distended, the wall .:an he seen to be compu!>ed of rwo layers. The \ ' :lS
tieferen~ bilaterally can be identified behind thL· bladder 3!. thcy run
inward and posteriorly to become the: ampulla. The junction of the
o;cmin:rl veside with the eJ.Kul:uorr du.:t usually lie~ well within the
prostate:. ThL· cjacul.uory .:omplex from each side lies in a .:ommun:rl
muscular envelope, which can he identified; the acw.1l lumen of the
normal ejacul.1tory ducts IS not normally visi h le.
M EASUREM ENTS
Mealourcnll'llt of antL·ropostcrior, rransver~e ami cepha locaudal dimL' Il-
'ion,, with the volumc cakulatt'd using the formula:
volume (ml) = (anreropo~tl·rior diml'n'iion x tr:tnsvc: r~e dirm:n,iou
x cephalocaudal dimerhion )/2

Age (years) Bilateral volume (mean ± SD, ml)

10-2<) 9.3 ± J.9
.JO-.Jl) 9.7 ± 1.3
40-4lJ I 0. 1 ± l.h
50-59 9.3 ± 2.4
60-69 7.5 ± 1.7
70-79 6. 1 +4.5
!lO-HlJ 5.1 ± 1.1
 Seminal vesicles - transrectal sonography

Figure 41a Cepnalocaudal measurements of the semtnal ves1c1es

Figure 41 b Anteroposterior and transverse measurements of the seminal vesicles

m the same pat1ent (Courtesy of Or. tan Stanton)

r URTHER RE:ADIN<..;
( ·aner SSC, Shinohara K. I ip~hulrz Ll. Tr.uhrn:ralultr.hon<>J,:raphy
in thsorders of tht• 'eminal n:srcle~ and ej.Kul.norv ducts. l 'mloKiC
Clmics o{ North Amcri(tl I 'JX'J: 16:77 >-7X'J.
REFERENCE
I. Tt·r.l!>.lki T. \X'.H.ln.the II. K.un01 K, :\.tya Y. Se mmal \'esidc
par.tml'fl'f!> .n I 0 -yca r intervals mc:a~u red hy transre..:ral
ultrasonography . .foum.d of Umfogy l lJ93; l .'iO:lJ 14- Y16.
liD Pelvis

Penis

PREPARAT ION
None.
PO SIT IO N
P.uient is supine, .md the pcms is l'Xamined on the dorsal a~pcct.
PROOf
7.5-10.0 ~ I H1Iinear transducer.
APPEARANCE
The hudy of the p<"nis ..:onsisrs ot two corpor:t cavemos:t :111d the cor-
pu~ spongiosum (cont:tining the urcthrJ), whi..:h lit'S on the ventral sur-
f.~.:e of the fu~t>tl ..:orporJ ..:.n-ernn~;l. rhe c;n·ernosal artery and the
dorsal artery ~upply the penis. l'h.um.Ko-Mimu!Jtion with color and
spectral Doppler u ltrasound allow' for the assessment of arterial flow
disorders as well as of venous leakage in erectile dvsfun..:tion.
M ETHO D
The penis is imaged longitudinally .tnd tr.tnsversely in the f1.1ccid Mate
to deten are.1s of fibrosis .md c:tkiti..::uion w indicate l)cyron ie's dis-
e:tse. A haseline a~~e~~ment uf the spectral Dopplcr w.n,l'form of the
right cavemosal artery. a~ dose ro the hase of the penis :ts possihle, i~
made, recording rhe peak sysrolic vdm:lty !PSV) in a longitudinal
plane, .tnd with a Doppler angle of <60< . Following the intr.lcavernosal
injectio n of 10 pg proMaglandin E, (PGE l ), mea~urenwnts of the PSV
and end-diastolic velocity (EDV) .uc m3de every 5 minutl'S tor 20 min-
utes .lt rhe ~amc level in rhf' right cavcrnos.,f artery.
M EASUREM ENTS
A guide to differentiation among .1rteriogenic. ,·enogcnic a nJ nonvas-
cular dystunction ,1sses~cd 15 minutes atrer cavernous snmulatton w•rh
20 pg PGE I . \'<' irhour adequate ;JrteriJI inpu£, me,tsurcmcms ot the
EDV Jrt: of limited value.
 Penis 11m

Figure 42a longitudinal image through the penis with the cursors indicating a
dilated cavernosal artery followmg pharmacostimulation

Figure 42b A spectral Doppler gate is placed over the cavernosal artery 20 minutes
after pharmacostimulation with a spectral Doppler waveform indicatmg a normal
response. The peak systolic velocity is 1.15 m/s and there is reversal of flow in
diastole
lll'JI Pelvis

Type of dysfunction PSV (cm/s) EDV (cm/s)

Arteriogenic <25 <5
Vcnogcnic >5
Normal values <5

FURT H ER REAOINC
Andresen R, Wegner HEH. Assessment of the penile vascular system
with color-codet1 duplex sonography and pharmacocavt:rnosome-
try and -graphy in impotent men. Acta Radiologicu
1997;38:303-308.
Benson CB, Aru ny JE, Vickers ~lA. Correl:uion of duplex
sonography with arteriography in patients with erectile
dysfunction. American Journal of Roentgenology
1993; 160:71-73.
Quam JP, King BF, J ames FM, l.ew i~ RW, Brak ke OM. llstrup OM,
Parulkar BG, Ha ttery RR. Duplex and color sonographic
evaluation of vasculogenic impotence. American j ournal of
Roemgenology 1989;153:1141- 1147.
lll'll Pelvis

FEMALE UROGENITAL TRACT

Kelley Z. Allison and
Wui K. Chong

Ovary - transvaginal sonography

PREPARATION
Empty bladder before e'anun.nion.
POSITION
ltrhotomy position on ad.tprcJ cxaminarion cou.:h.
PROBE
!L4 .\ ll lz cun·ed tranwagm.tl rran)ducer.
MfT HOD
Tlw longest dianleter of rht• ov.lrit~~ IS ohramed (d I ). n ll' lll:l,illllllll
.mtcroposterior di.uncrcr (dl) is obtained perpt·ndiull;tr w d I . The
tran~dm:cr is rhen rotated 90° .1ntl d3 is me;~~urt·J perpendicular to dl.

AI'PFARANCE
On1id structure bet\\l~n utcru" .md mus.:ular pdvic ,iJcwo1ll. The
int•·rnal ili.tc vc.:!>~c.:b..uc.: po~rc.:rior to the ov.uic~. The: prc~cnn~ ot
toll.de~ i~ the hallm.trk in thei r tdt·nnfication.

M EAS UR EMENT
ov.ui,m volum<' = d I x til x J3 x 0.51.3

Category Age Average volume (mean ± SD, ml)

...;;._---=-- - -
l -1 4 war~ I .Q-4. I ± .tO

Adult Premc:nop.ll"·' I 4.~ ± O.U.J (upper limtr 101

Pusrmcnopath.l I 2.2 ± 0.0 I (upper limtt 10)

FURT H t R READING
P.IVIik F.J, DePriest PD. G.tllion III I, Ueland FR. Reed y MB, Kryscio
R.I. van Naj!ell JR Jr. Ov.tri.tn volume rel.ncd ro .t)!.e.
G)•JI,u•t·o/ogic 0 11co/og\' .WO I ;80:333-334.
 Ovary - transvaginal sonography lllfJ

Figure 43 Ovoid structure between uterus and muscular pelvic sidewall. with the
mlernal•liac vessels postenor (Courtesy of Sue Rzepka)
mJI Pelvis

Ovarian follicles - transvaginal sonography

PR EPARATION
Empty hladder hefore examin:uion.
POSITION
Lithoromy position on adapted examination couch.
PROBF
8.4 Ml lz curved transvaginal transducer.
M ETHOD
Maximum diameter of follicle is obtained.
APPEARANCE
The ovary is the ovoid structurt· henwen uterus and mu~cular pdvic
sidewall. The internal iliac vessels are posterior to the ovaries. i-=ollidcs
arc ~een .ts echo-free ovoid structures within the ovarv.
M F ASUREMENT
Numher of follicles: <5 follicle~ per ovary.

Category Size
Oominanr follidl" 10-r mm
(day prior ro ovul.uion) <25 mm

Non-dominant folhdc < 14 mm

llormone treatment Same size bur more than one
dominant follicle (3-5)

FURT HfR READING

Pache TL>. Wladimiroff JW, Hop WC. rauser BC. How ro
thscriminate hetwccn normal and polycysti..: ovaries: transvaj:!Ul.ll
US ~tud}. RoJtliology 1':1'}2;183:421-423.
 Ovarian follicles- transvaginal sonography B

Figure 44 The presence of follicles (arrows) seen as low-reflective ovoid structures

within the ovary. with the diameter measured as the maximum diameter (Courtesy of
Sue Rzepka)
0 Pelvis

Cervix - transvaginal sonography

-------
PRFPARAT ION
Empty bladder hcforc examination.
PO SITION
l.irhowmy position on adapted examination ~mu:h.
PROBI~
H.4 MHz ~:urved transvaginal tran~Juct:r.

M ETH O D
Saginal tmage of cervix i'> obtained with the probe in the .tnterior
fornix. The ..:ervix is measured linearly between the external os ,lf it~
junction with the vag.inal mucosa inferior!> and the internal os at the
poi111 where it widens into the lower uterine segment. The rranslahi ~t l
(rransperineal) cen·ic.1l length demonstrates dose correlation with the
transvaginal lllCil'iurcmcnt.
APPEARANCE
The cervix is fixed in rhe midline, of midlevel echo~enic1tv.
, . The endu-
cervicotl canotl .tppeotrs as a high· retlective line, surrounded hy .1 low-
retlecrive tone (endocervical glands). In the :gravid patient, the lower
utcrinl· ~q:(mcnt .md the ct•rvix h.tvc .1 Y-shaped configuration.
MEA~U R FMFNT

Age Average length (range. em)

Prcmmopausal ' '6
.J. . ..)-~" ·

Po.;tmcnopa u~:ll l.l-l.h

 Cervix -transvaginal sonography EJ

f igure 45 The cervix is measured from the cervical tip inferiorly to tfle potnt of
widening of lower uterine segment (arrows) (Courtesy of Sue Rzepka)

FURTH FR R EAOINC
B.lltarowich OH. Female pelnc organ measurements. In Goldberg
BB, Keerrz AB (eds) Atlas n( Ultmsomul Measurements, 1990.
Chicago: Year Book Medical Publishers.
Kurttman JT, Goldsmith LJ, G.11l ~A. Spinn.lto JA. Transvaginal
ver~us tran!.pcrint"al ultr.bonograph)': .J hlinded comparison in the
a!>scssmcnt of cervical length at midgestation. American}ounz.lf uf
Obstetrics ,md Gynecology 1998; 179:H52-S57.
IDI Pelvis

Uterus - transvaginal sonography

PREPARAT ION
Empty hladder before examination.
POSITION
Lithotomy position on adapted examin.ttion couch.
PROBE
8.4 MHz curved transvaginal transducer.
M ETHOD
The transducer is oriented in a longitudinal plane ot the uterus and the
midline position is conlirmed by the endocervic<tllcndomctrial cavity.
The total uterine length is me.lsured from the top of the fundus to the
external cervical os. The mJxtmum anteroposterior (AP) di.unetcr is
measured pcrpendicuhlf to the m.tximum length. The trJnsdlKcr i~ the
rotated 90° at the k·vel of AP to oht,tin m,t,imum tr.msverse ( fRV )
diameter.
APPEARANCE
Uniform pattern of medium strength echm with a high-reflective cen-
tr<ll ~tripe (endometriJI ~tripe).
MEASUREM ENT

Age Dimensions (mean ± SD, em)

Length AP TRV
Prepuhertal
(8-U vears) 3.6-5.4 ± 1.1 0.'1-1 .6 ± 0.4 1.8- l.'J (r.ln~el

Prernenopa us.tl
Nulliparous -.I ± O.H 3.3 ± O.OS 4.6 ± o.n

Parous 8.9 ± 1.0 4.3 ± 0.6 5.~ ± o.x

Postmenopausal ..,_9 ± 1.2 3.1 ± 0.' 4.9 ± 0.8

 Uterus- transvaginal sonography II&J

Figure 46 The total utenne length (cursors 1) measured from the fundus to the
external cervical os. The maximum anteroposterior (cursors 2) d1ameter •s measured
perpendicular to the maximum length (Courtesy of Sue Rzepka)

FURTHER Rl-A DING

~ti llt:r El. Thtllll.l' RH. I ine.. r. The arrophi.: JX.l~flllt:llOJXlll':l' utt:ru...
Joum.ll ol ( 'fmtc.ll UltrJsmmd 19-- ;5:26 1-263.
Pl.m JE Brt·t• Rl. l>.n-id~on 0. Ultr.1sound of the norm.tl non-[:r.n·•d
uteru!>: .:orrdarion with gro~~ .tnd histopathology. .Jollllhtl ol
Clmtc<~l Ultr,IS(IIIIId 19':JO; I H: l .'i-1 ':J.
Siegd ~IJ. l,nltatri,· ~ynt·..:ologic -;onogra ph v. Rudiofogy
I 'I':J I; 1 7';):5<~.l-<,OO.
ml Pelvis

Endometrial stripe - transvaginal sonography

PREPARATION
Empty hladder before examination.
POSIT ION
Lithotomy position on adapted examination ~:ouch.

PRO BE
8.4 MHz curved tra nsvaginal transducer.
M ETHOD
Midline sagittal view of uterus. Measure the outer edge to outer edge
of high-reflective interfaces.
APPEARANCE
• Proliferatiz•e phase: T hin high-retlective line representmg endome-
tri,ll caviry inrerface, low-retlecrive superficia lla}'er and high-reflec-
tive deep layer.
• Secretory ph,zse: Homogenouslv high-re·flective stripe surrounded
by low-reflective zone represcntmg the hypervascular portion of
myometrium.
M EAS UREM ENT

Age group Phase of cycle Thickness (mm)

Premenopausal 'Vtenstrual 2- 3
Early proliferative 4-6
Periovularory 6-8
Secretory 8- 1)

Postmenopaus<1l
Hormom: repl.lt:ement s;S
Not on hormone ;S;5
 Endometrial stripe - transvaginal sonography EJ

Figure 47 Midline sagittal view of uterus. with a measure from the outer edge to
outer edge of high-reflective interfaces (Courtesy or Sue Rzepka)

FURTHFR RFADING
Bo~tein J, Auslender R. Goldstein S. 1\.ohan R. Stolar Z, Abramovici H.
Increased endometrial thickness in women with hypertension.
Amcri.:<111 Journal of Obstetrics <111d G)•necology 2000; 18J:583-5X7.
Brooks SE. Yca ns-Pererson :0.1, Baker SP, Reuter KL. Thi.:kcncd
enJometri.ll ~tripe .md!or cnJumctrial flu id a~ a marke r of
pathology: fa.:r or fam:y? Gynewlugic Onwlvgy 1996;63:19-24.
lfDI Pelvis

Urethra

PREPARAT ION
A full bladder is required.
rosmoN
Supine.
PROBE
3.5-5.0 MHz curvilinear rransducer.
M ETHOD
Images of the urethra can be acquired in rhe transverse and sagittal
planes.
APPEARANCE
The urethra consists of muscubr, erectile and mucous layers with a
central lumen. This gives an ovoid 'hull's eye' appearance on transvc~rse
scans. The reflectivity is similar ro that of vaginal tissues; both arc of
lower refleaivity than rhe surrounding connective tissue or the bladder
wall.
MEASUREMEN TS
The anteroposterior diameter of the female urethra, just inferior to the
hladder, mca~urc~ 1-1.5 em.
FURT H ER READING
Hennigan HW Jr. Duhosc TJ. Sonography of the fema le urethra.
American Joumaf of Ruentgennlogy l9H5; 145:!:U~-H41 .
 Urethra E

Figure 48a
Longitudinal1mage
demonstrating the
urethra (between
cursors). which has
a reflectiVIty Similar
to that of vagmal
tissues. lower
reflectiv1ty than the
surrounding
connective tissue
or the bladder wall

Figure 48b
Transverse image
demonstrating the
'bull·eyes'
appearance (arrow)
(Courtesy of Olivia
Benson-Fadayomi)
m1 Pelvis

Length of the cervix and cervical canal in

pregnancy

J>Rt-:I'ARATION
Parti.tlly distended hl.tdder for rr:tn~ahJonunal imagmg in the second
trintl'Stcr. Avoid overdistension ot hbJJcr, which arri ticially incrl·ao;e,
cervical length.
PO~ITION
Sagitt.tl image of uteru ~ and cervix
I'ROBE
• Tr.msalxlomin.ll or translahial J-5 I\1H7 cun·iline;tr tran~ducer
• Transv:t)!in.tl 5-8.0 ~ 1 HL traJhJm:er
M FT HOD
I cngth of ct•rvJcal c;tn;tl from inrcrn.tl to t•xtern.tl os. this can be mea·
sured tr.tnsahdominally, transv.tginall y or tran~l.1hia lly.
API'f ARAN( ·t-:
Cylmdric.tl structure with echogcnic central canal. T he intern;t( o!> JS
thl· jun~o:tinn of the .lmnimi..· sac .mJ the cc:rvical canal. The cxrcrn.II oo;
i~ the lower end of the cervic:tl e;mal, where the anterior and pmrerinr
lip~ of the cervix meet.

M EASUREM EN TS

Approach Length (mm)

32-4H

Translahial 2~-J5

Tr.tn~abduminal

(maternal bladder parti,tlly or fully Ji~tenJeJ) J2-5J

Empty' 32.5

Cervical length of <20 mm on tra nsv;tgin.tl ~o nogra phv is su~esti ve ot

cervica I incompetence.!.'
 Length of t he cervix and cervical canal in pregnancy ED

Figure 49 The distance from the internal os (junction of the ammot1c sac and the
cervical canal) to the external os (lower end of the cervical canal) is measured
{cursors) (Courtesy of Anthony E. Swartz)

RH ERENCES
I. 1"\(lwtt' .Jl >. AnJrt·otri RF. Ro~enher~ FR. ~onogr.1ph11.: .1ppe.1ran..:e
of rhc tUt·rine n·rvi' in pre~n.m.:-y: rhe n:rti.:-.11 .:en·ix. Amt•ri(,lJT
/uun~<llo/ Rue11tgeno/ogy l'll:U: I-tO: ... l---.to.
) l.un' JD. CoiJl'nhcrg RL. ~ki:o. PJ. ~kn:l'r H~l. ~lo:m .ul .\, 0.1~
.\. !"hom r. ~k('.;l'Jii, D. Copper Rl, .Jo hn,on 1--. Rohl'rt' .1~1. The
len~rh .,; rht· .:l'n·i, anJ rht· ri!>k oi ~ront.meou' prem.Hurc
JehH·r~ . Nl'\\ En~bnd Journal oi l\lnlinm· l <J96:.H-t: )6..,.-5"'2.
.l. ( o~um.111 FR •.\ld lon C. Vint1.1k,o, t\ ~1 . •\n.mrh CV. \X'a l n~i-. C.
<;jlhon. K. I ongrrudinJ.I ""t'"mcnr oll·ndocl'rvica llt-ngrh
lwrwn·n I ) .tnJ 24 week-i ge,r.nion in Wllllll'll ar risk for
pn·gnanq lo" or p rt•rerm hirrh. ( )[,,_tl'lnc,_ ( :ynccolog)'
I <J<JH;'>l:.l l-37.
SUPERFICIAL
STRUCTURES

Keshthra Satchithananda,
Zelena A. Aziz and
Paul S. Sidhu

Parathyroid glands 1 34
Submandibular salivary glands 136
Parotid salivary glands 138
Thyroid gland 140
Lymph nodes in the neck 144
Orbits - extraocular muscles 148
O rbits - optic nerve 150
11!1 Superficial structures

Parathyroid glands
~----------------------------------

PRFPARATlON
None.
!'OSITIO N
Supine.
PRO BE
7.0-10.0 MHz linear transducer.
METHOD
Images a re o btained in the longirudinal and transverse planes.
APPEARANCE
The four normal para th yroid glands are generally located at the poles
of the thyroid lobt-s. a lthough the inferior parathyroid glands may be
ecropic. found in the upper medi.:tstinum. Occasionally the normal
parathyroid gl,md can be idenrified !>eparate from thyroid tissue. espe-
cially in a longitudin<ll view. A linear high-reflective hand rcpresenring
an a poneurosis or a fibrous sheath may surround the gland . The nor-
mal parathyroid gland may either be seen as a slightly low-reflective or
slightly high-reflective oval area ad jacent w the normal th yroid. A
parathyroid adenoma is identified as an oval shaped low-reflective
.lrea, with increa'>ed color Doppler flow, in rhe expected locanon of a
parath yroid gland.
M EASUREM ENT S
Average normal parathyroid measures 5 x 3 x 1 mm.
FURTHER READfNG
Reeder ~B. Desser T~ . Weigel RJ, Jeffrey RB. Sonography in prinMry
hyperpa rathyroidism. Review with emph asis on scannmg
technique. ] oumaf nf Ultmsomrd in Medicine 2002;2 1:539- 552:.
Simeone .JF, Mueller PR, Ferrucci JT Jr. van Sonnenberg E. Wan~ C:A,
Hall DA, Wittenberg .J. High-resolurion real-rime sonography of
the parathyroid. Radiolog)• 198 1;141:745- 75 1.
 Parathyroid glands 11m

Figure 50a
Longitudinal plane
demonstrating an
oval low-reflective
area (between
cursors) surrounded
by the high-reflective
aponeurosis,
charactensttc of a
parathyroid adenoma

Figure SOb Same

patient. wtth the
parathyroid adenoma
demonstrated m an
axial plane. at the
lower pole of the left
lobe of the thyroid
In Superficial structures

Submandibular salivary glands

PREPARAT lON
None.
POSIT IO N
Supine.
PROBE
7.5-10.0 !\1Hz linear array probe.
M ETHOD
The gland is imaged in two planes: paramandibular and longitudinal
planes.
APPEARAN CE
Homogenous high-reflective parenchyma, well demarcated from the
surrounding tissues.
M EASUREMENTS
Three measurements are obtained: anteroposterior and lateral-medial
direction, and then depth. Volume is calculated as if gland is a spheri-
cal body, using the form ula:
volume (ml) = (n: x height x (diameter)')/4

Normal values
Anteroposterior Para mandibular Lateral- medial
length length (depth) length
35 ± 5.7 mm 14.3 ± 2.9 mm 33.7± 5.4 mm

FURTHER READING
Dost P, KaiserS. Ultrasonographic biometry in saliva ry glands.
Ultrasound in Medicine and Biology I 997;23: 129Y- 1303.
 Submandibular salivary glands

Figure 51 a The submandibular gland viewed in a paramandibular section in order

to measure the lateral-medial length

Figure 51b The submandibular gland viewed in a longitudinal plane 10 order to

document the anteroposterior and depth measurements
&ril Superficial structures

Parotid salivary glands

PREPARAT ION
None.
POSITION
Supine.
PROBE
7.5-10.0 MHz linear array transduc.:er.
M ETHOD
The gland is imaged in a transverse plane and in an axis parallel ro rhe
ramus of the mandible (parallel direction to the normal denml ocdu-
sron).
APPEARANCE
The gland is homogeneous and of high reflectivity, more so than that of
the <;ubmandihular gland .
M EASUREM ENTS

length (mean ± SD, mm)

---------------------------------
Axis parallel to ramus of mandible 46.3 ± 7.7 mm
Dimension in transverse axis 37.4 ± 5.6 mm
Parotid parenchvma
Lateral tO mandible 7.4 ± 1.7 mm
Dorsal to mandible 22.8 ± 3.6 mm

FURTHER READING
Dost P, KaiserS. Ultrasonographic.: biometry in salivary glands.
Ultrasound in Medicine and Rinlngy 1997;23: 1299- JJ<H.
 Parotid salivary gland~ ED

Figure 52a The parotid gland. homogeneous and high reflective. is imaged in a
transverse plane

Figure 52b The parotid gland is also imaged in an axis parallel to the ramus of nhe
mandible (parallel direction to the normal dental occlusion)
1E11 Superficial structures

Thyroid gland
--------------------------------------
PREPARATlON
None.
POSITION
Supine wirh the ne'k extended.
PROBE
7.5- 10.0 NIHz linear transdu..:er.
METHOD
Longitudinal and transverse images o btaine<l in the lower half of the
neck from the mid line.
APPEARANCE
Below the subcutaneous tissues is a l-2 mm thin low-rcfle,tive line
corresponding to the platysma muscle. Anterior to this is a thin high-
reflc,tive line representing the superficial cervical aponeurosis. The
thyroid gla nd is made up oi two lobes ..:onnected medially by the isth-
mus, which has a tr::mswr~c cour:.e. A minority I ~0% of norrnal
people have a third lobe (pyramidal) arising from the isthmus which
runs upwards along the same longitudinal axis as the th yroid lobe!> bur
lies in from of the thyroid cartilage. Thyroid parenchyma has a fine
homogeneous echo partern, which is of highN reflectivity than the con-
tiguous muscular srrm:tures an1.! is interruptc.:d ar the periphery lw rhe
arterial and venous ve~sels.
MEASUREMENT S

Age Length (mm) Anteroposterior diameter (mm)

Newborn 18-20 R-9
l )'ear 25 12-15
Adult 40-60 JJ-20

• The mean thickness of the isthmu!> is 4-6 rnm.

• Thyroid volume may he ..:akulatcd using the right and left antero-
posterior lobe measurements (RAP and LAP) by the following
formula;
 Thyroid gland 11m

Figure 53a Transverse plane through the thyroid at the level of the thyroid isthmus
demonstrating a depth measurement of the left lobe. The arrows represent the depth
of the isthmus

Figure 53b Longitudinal plane through a thyroid lobe

Ill Superficial structures

volume = (6.91 >< RAP) + (3.05 x LAP) - 3.48

• The difference in thyroid volume between males and females is
explained solely by a difference in body weight:
male thyroid volume 19.6 ± 4.7 ml; female 17.5 ± 3.2 mi.
DOPPLER STUDIES O F THE THYROID ARTERIES
There are rwo thyroid arteries on each side, superior and inferior.
Rarely a third artery is present in the midline, known as the arteria
•ma.
• Mean diameter of these vessels is 1- 2 mm.
• Peak S}'Stolic velocity is 20-40 cm/s.
• End diastolic velocity is 10-15 cm/s.
The thyroid veins originate from the perirhyroid venous plexus and
join to form three main groups. which drain into the ipsilateral
jugular vein. The largest vessel is a lower vein and can measure up
to 7- 8 mm.
FURTHER READING
Hegedus L, Perrild H. Poulsen LR, Andersen .JR. Holm B. Schnohr P,
Jensen G, Hansen .JM. The determinatio n of thyroid volume by
ultrasound ,md its rebtionship to body wc;ight, .1ge and ~ex in
normal subjects. j ournal of Clinical Endocrinology and
Metabolism 1983;56:260-263.
Udea D. Normal volume of the thyroid gland in children. j ournal of
Clinical Ultras(}lmd 1990;18:455-462.
Vade A, GottSChalk ME, Yetter EM, Subbaiah P. Sonographic
measurements of the neonatal thyroid gland. }oumal of
Ultrasound in Medicine l 997;16:395- 399.
IZ!I Superficial structures

Lymph nodes in the neck

----------------------
PREPARAT ION
None.
POSIT ION
Supine.
PRO BE
5.0-10.0 MHz linear transducer.
M ETHOD
Use the thyroid as a landmark and asse"' the anterior ,md posterior
aspect!' of both sides of the neck.
APPEARANCE
Ultrasound features that should be ass~sed:
• Lymph node shape: Assessed by measuring the longitudinal (!.)and
transverse (T) diameter on the same image and cakul.ning the Lrr
r<ltio. TI1is is normal when Lrr >2, that is when the shape is oval.
Another method 1s to measure the ratio of the minimal ro maxi-
mum diameter of a node in the transverse plane. A ratio of more
than 0.55 yields the highest accuracy when predicting malignancy
with ultrasound.
• Nodal hilus: This sh(lldd I~ of high retleaivity and wide. The pr<.:s-
cnce of hibr narrowing or cortical widening (either concenrric.llly
or eccentrically) should he regarded with suspicion for malignancy.
• Nuda/ size: On ultrasound. this is nor a reliable criterion for differ-
enri.Hing l>cnign from malignam nodes.
• Calcification: Calcification is found in a significanrlv lower number
of malignant nodes.
• Doppler waveforms: The resistance index can be measured, and a
cur-off of 0.70 for differentiating benign (<0.70) from malignant
but with considerable overlap in recordings.
 lymph nodes in the neck ID!:1

Figure 54a
Longitudinal plane
through an oval lymph
node demonstrating
features of benign
disease. Longitudinal
(L) and transverse (T)
diameter on the same
image, calculating the
LIT ratio which is
normal when LIT >2

Figure 54b Color Doppler image of the same lymph node demonstrating hilar
vessel architecture
Ill Superficial structures

FURTHER READING
Na DG, Lim HK, Byun HS, Kim HD, Ko YH, Baek JH. Differential
diagnosis of cervical lymphadenopathy: usefulness of color
Doppler sonography. American Journal of Roentgenology
1997; 168: 1311-1316.
Takashima S. SoneS. Nomura N. Torniyama N, Kohyashi T.
Nakamura H. Nonpalpable lymph nodes of the neck: assessment
with US and US-guided fine needle aspiration biopsy. journal of
Cli11iml Ultrtlsound 1997;25:283-292.
Vassallo P, Wernecke K, Roos N, Peters PE. Differentiation of benign
from malignanr superficial lymphadenoparhy: the role of high
n:~olution US. Radiology 1992; 183:215-220.
m1 Superficial structures

Orbits - extraocular muscles

I'I{ Et•AI{ATION
Nont>
PO SIT IO N
~upme m a redinin~ posttion wirh rhe eyelid dosed.

PROBE
I 0 :O.U lz linear rransduet•r
MfT HO O
Transverse and lonv;ituJinal pl.mes of the four recti arc ohrained. The
recti muscles ::tppear .IS lmv-rdlc.:rive stnu.:turcs.
M EASURE.\1ENTS

Muscle Diameter in normal population (mm)

--'----
Mean ± SD Med1an
Superior rectus 5.3±0.7 5.4

Lneral rectu~ 3.0 ± 0.4 3. 1

Inferior rectus l..ft ± 0.5 2.6
,\ ledial rectu~ 3.5 i 0.6 l.(,

FUI{THf R REAOIN(..
sr.
D~ lilt" Gci1Jt VII 1:1<, (;l.h.:r J!>, l"cuer w, J\tta II. Owmch:r of
normal cxrr::t<Kular rc.:ri musd~·~ with echography. Amcrict1n
juumal of Opth.llmology I 'J'JI; Il l: 70n-7 1.t
 Orbits- extraocular muscles E

figure 55 Axial
plane image
through the orbit,
demonstrating the
diameter of the
med1a1 rectus
muscle
 Superficial structures

Orbits - optic nerve

--------------------------------
PREPARATION
None.
POSITION
Supine in a reclining position, with evelid closed.
PROBE
10 .MHz linear transducer
APPEARANCE
Tubular srructure. Homogenous, low reflective:, p.tr:tlld ncrw lihrc
bundle surrounded hy a hi~hly reflecti\·e dural shc:~th.
MEASUREM ENTS
Optic nerve width 1.4 mm to 3.4 mm; median of 2.. 9 111111 .md 110 more
rh.m 0.3 mm hcrween the rwo nerves.
FURTHER REAUJNG
Ana HR. lm:~ging of the optic nerve with srandardi7cd cchography.
Ew 1988;1:358-366.
 Orbits- optic nerve m

Figure 56 Axial
plane image
lhrough the orbit.
demonstrallno the
optte nerve
(arrows)
NEONATAL BRAIN

Maria E.K. Sellars,

Wui K. Chong and
Paul S. Sidhu

Ventricular size 154

Doppler srudics of intcrcranial
blood flow 15 8
ID Neonatal brain

Ventricular size

PREPARATION
None.
POSITION
Supine.
PROBL
5.0-7.5 Mil;, l:urvilinear arrdy transducer with a "mall footprint. A
I 0 l\IH7 linear rran~Jun·r will demon,tr:Hl' the ~uperfil'i.tl o;ubdural
space.
M ETH OD
Performed through the anterior fom.mell in the neon.ue where this
remain~ patem. Posterior fontanelle allows .lcl'ess to rhe posrerior
brain :.tnu:ture~. Oblique c..uronal .md oblique saginal \'iews .ue
oht.tined, and rhe frontal horns of rhr later.1l vcntridcs are measured.
AI'Pf ARANCL
The ventridcs .ue cle.1rly idemified .ts low reflt-cti\-c arc.b wirhin rhe
midlevd reAectiviry of the brain parenchyma. The walls oi the venrri-
dl'S .lfl' well dcmomrr.HeJ in rhe prem.uure ini.mt, hut are otren
opposl·d in rhe rcrm infanr. Measurcmenr~ .trl' takt·n in rhe coronal
dire...:rion ;lt thl· lt.· vd oi the foramen of Monro. A minor Je~ree oi
a~ynHlll'try of the n :nrridcs i ~ common, rhc kit hcing 'lightl\' largcr.
Serial mca~urcmcnt~ MC imporranr to Joulllll'nt pro~rc:.sion or regrcs-
sum.
~1FASURFME!\ITS
\'clltriatl.lr widtb:' 'Ia ken from the medial wall w thl· tloor oi rhe \en -
tride ;'H rhe widest pmm, measured ar 0 mm when the \'entnde appears
.1s .1 thin high-retlew,·e line. This sho uld he JescriheJ .ts depth r,lther
than widrh.
 Ventricular size

Figure 57
Measurements are
taken m the coronal
direction at the level
of the foramen of
Monro. Ventncular
width measurement
is taken from the
medial wall to the
floor of the ventncle
at the widest point
1D Neonatal bl-ain

Gestational age (weeks) Mean depth (mm)

26-27 0.9

28-29 1.01
30-31 1.32
32-33 1.0~

34-35 0.82
36-37 0.74
38-39 1.02

40-4 1 0. 91
42 1.09

Ventriotl,lr ratio (VR)! Using a transvcr~c

:tpproach, from rlw tem-
poral window (or lateral fontalll'), the ventricular width (VW), trom
the midline to the lateral venrridc: wall .md the hemisphe ric w idth
(H\X!) from rhe midline to the inner skull m.ugin .1re used ro c.tkulare
the VR (VR =VW/HW).

Term neonates Premature neonates

Mean (range) (em) Mean (range) (em)
Lateral ventricle wtdth (VW) 1.1 (0.9- 1.31 1.0 (0.5-1.3)

H emtsphere width (HW) 3.9 (3.1-4. 7) 3.1 (2. 1-4.3)

Venrricular-henusphere ratio 28"'<> (24- JO% l 3 1% (24-34%)
(V\X!/HW)

• The upper limit of normal for venrricuhtr depth measured in the

cornn;tl plane is 1.3 em for a sm~le venrride or 2.5 em for both
mea.;u rcd together.
 Ventricular size 111D

R EI+RENCES
I . Perry R[\;, Bowm:tn ~D. 1\l urton LJ. Roy RN. <.lc Crcspigny LC
Vcnrricular size in ncwhorn i nf:tnr~. Joun~tllof Ultrdsotmd in
Mt·didnc 19H5;4:47S-477.
l. lohn~on ~11.. Mack I.A. Rum.1ck C.~1. Frost M. R.tshh;mm C. B-
moJl: cchocn•.xphalot!,r.tphy 111 the normJI Jnd hil!.h-risk inf.mr.
AmertC<111 Juum.ll of Roc•ntgenoloKY t•rY; l .H:J -.'i-.ll) I.
FU RT H FR READI N(;
Poland Rl. Slov1s Tl .• ~hank.tr,lll ~. Normal vJllll:~ for \t'ntricular
siLe .1~ Jeramint·J by real time ~onographic tcchni<.rue~. Pcdi<~tric
R.uliolof0• 19S5; 15:1l- 14.
 Neonatal brain

Doppler studies of intercranial blood flow

PREJ>AHAT IO N
None.
PO SIT IO N
• Through the <111terior fmrt<~nelle: Sagirra I .md anglcd!saginal or
coronal ;md JngleJJcoronal \ icws.
• Thruu~h the tempor,ll bo11e: Axial ima~e with transducer placed
I em anterior and superior ro tragus of rhe ear.
PROIU
I inear 7.5 MH7 transduca.
MET HO D
Re~i~t.tncc indicc!> IRIJ art• obtained from middle •.wd,ral (1\ICA),
anrt:rior ct:rebral (ACAl. intern.tl '-'Jrotid (ICA) .md posterior cerebral
c~rrencs .

AJ>PfA RANCE
Tht· ACA~ and ICA!> cour~e parallel to the ima~e plane on rrans-
fonranellar views, providing the optimum Doppler angle. l-or the same
reason, the ~ ! CAs are best visu.1lized on the transtempor;ll vtew.
M l- AS U HF M EN T S

Rl
Anrt>rior cerebral artery (prem.Hurd 0.5-1.0
Anterior, middlt: aml po~tnior l.:t'ft'hral arterit'~ (term) 0.6-0.8
Internal caro[ld arrerv (term) 0.5-0.X

• lntrJcranial Rl normally Jcaca-.c with incre.t-.inv. v.e-.tational .l)!.t'.'

• Fln.ucd or rising Rl i~ ~cn1 in hydrocephalu~ and n·rchral edema
due to hypoxic-i~hcmi..: hrain injury.
• Low HI is seen in h;lhic!> on exrracorporeal memhrane oxvv.en3tion
(ECMOJ.
 Doppler studies of intercranial blood flow m

Figure 58 A coronal image through the anterior fontanelle with a spectral Doppler
waveform obtamed from the middle cerebral artery from which the resistance index
may be calculated

RHFRENCE
I. Horgan JG, Rumack CM, Ha y T, Nlanw-johnsun ivll ,
l\.lerensrein GB, Esob C. Absolute intracranial hlood-tlow
velocities evaluated hy duplex Doppler sonography in
asymptomatic prctcrm and term neonate~. Amcri.-,w .foun~<ll of
R.ocntgcnolof{y 1989;152: 1059-1064.
FUI{IH ER I{ EA DING
Rdju TN, Ziko~ E. Rev.ional ccrehral hlood velocity in in fant!>. A real-
rime transcranial and fonranclbr pulsed Doppler study. Joumal of
Vltr,ISOlmd ill Medici11e 19!>7;6:497-507.
GASTROINTESTINAL
TRACT

Zelena A Aziz,
Keshthra Satchithananda,
Maria E. K. Sellars and
Paul S. Sidhu

Pyloric o;tcnosis 162

Appendix 164
Upper ~ao;trointcstinal tr<tCt wa ll -
cndo~copic ultra!>ound 166
Bowel wall - transabdomi nal
ultra!>ound 168
Anal cndosonography 170
mil Gastrointestinal tract

Pyloric stenosis

11R EPARAT IO N
No fn·J for at least 1 hour..
POSITION
Supin~. left anrt:rior oblique:, or n~ht Jc~uhiru~.

PI<OBF
S.0-7.5 ~1H7. ~.:urvilincar tran~du~.:cr or a 5.0-7.0 1\HI1. linear trans-
tlu~cr.

M ET HOD
l.on~itutlimtl ..1nd transverse prdimina ry views right of midline at level
of ~uln.iphoid spa~.:e. fhc infant i~ u~u.tllv hottlr fed .It the rime of til<'
t•xamination. Image with patient ri~ht side down ;md oht:1in longitudi-
n.tl .md trJns,·erse views .1s hefore.
APPEAR ANCE
Thickened rnuscl(' i~ ~n·n a ~ a low-n.:llec:rivc la~·t·r. supt·rfic:iJ.I ro the
hi~h-reflecti\'C mucosal layer. In transverse plane, the ~.:an.tl rt·scmblcs a
doughnut, medial to the ~llhl.ldder .md amerior to tht· right kidney.
There: i~ an ahsencc of pt:rist.tlsis.
M f ASU REM EN TS

_______Pylorus _: mm
D1amcrer ?: 15

Length ~17

l\1us.:lc rh i~:kncss ?:4

FURTHER R EAO IN ( ,
1-bllcr JO. Cohen IlL Hypertrophic pyloric sreno~is: diagno~i~ usin~
U~- R.,Jdiology I 'Jl:lf>: 16 1:.BS-339.
.
O ' Keefff' fN, Stanshern· ~D. Swisc huJ.. LE. H avden
. t. 1\ .lr.
Amropyloric musde rhic:knc.;s at US in infants: what is norm.1l?
R.~tliohJI;,')' 1991; 17H:S27-tUO.
 Pylo ric stenosis D1

Figure 59a Ax1al

plane through the
pylorus
demonstratmg the
'doughnut'
appearance. with the
arrows indicating
the low-reflective
muscle layer

Figure 59b Pyloric

length measured in
the longrtudmal
plane (nght
decubitus pos111onJ
11!1 Gastrointestinal tract

Appendix
------------------------------------------
11 REPARATION
full hladder. After a 10-minute sean:h for the appendix on full bladder
and if this is negati\·e, ask the patient to empty the hlaJJrr and con-
tinue the !.earch.
POSIT ION
Supmc .tnd left lateral decubitus position if retroc::l\':tl .tppt>ndix is ~u~­
pt·ctnl.
PROBf
5.0 MHl' linear array tran,ducer or a .5.0-7.0 1\·1Hz curvilinear trans-
dun~r.

MfTHO D
Place tran~ducer tram\Tr\dy below edge of right hep.tti~· lobe, in front
of the ri).\ht kidney ,md move :.lowly down to nght iliac foss.t along line
of the ascending colon. Identifying the caecum ,mJ then trace the
appendix, which is draped over the right ili.tc ~n"d' .mtenor to the
ileopo;oas muscle.
APPEARANCE
features of normal appt·m.lix are:
• A compressible hlind-endcJ tubular stnu.:ture.
• Surrounded by nurmal appearmg fat.
• \V.11l thickness <3 mm, measured from the serosa to the lumen and
di.tmcrer measun::mcnr of <6 mm. measured from ~l·rosa to serosa.
M f A~ UREMENTS
Appcndiciri~ is characterized hy a wall thickne!.' >J mm and ,1 di.1me·
tcr >6 mm. Hypervascul:~r wall with color Doppler. frl'l' fluid and pre<;-
cnce of an appendicolith, .ue secondary sib'llS of appt·nd•ciric;.
FURT H ER READING
Quillin SQ, Siegel tv1J. Appendicitis: Efficacy of color Doppler
~ono!!raphy. Radio/Cig)' I 994; I'} I :.557-5 60.
Riou' M. Sonographic dt•tcction of normal and abnormal appendix.
r\ml'rtf.Jil jourl~tllu( l<ucntgeno/ogy 1991; 158:773- 778.
 Appendix

Figure 60 A
tubular structure
representing the
appenotx •s
surrounded by low-
reflective fluid
ml Gastrointestinal tract

Upper gastrointestinal tract wall-

endoscopic ultrasound

This is a specialized procedure and is carried out in a ~imil.tr manner to

~tandard upper gastrointestinal endoscopy.

PRFPARATIOI\
The patient is sedated anJ given pharyngeal local anacsthest:t.
POSIT IO N
I eft lateral position.
PROBE
An ultrasonic endoscope consisting of a 7.5 MHz uhra~ound mt:ehan-
ical .;ector-scan transducer housed in an oil-filled chamber at rhe t ip of
,, speci.tlly .1daptcd fihreoptic endos..:npc.
M ETHOO
Aitl·r introduction ot the endoscope to the desired po~ition under
direct vision, intraluminal 1!.3~ ·~ 3\pirated.
Thn-e methods arc ,tvaibhle for exploration of the upper (;J mtL"l wall:
• Direct apposition ot the rr~tmdm:cr nn the mum~.t: u~cd for
o~ophagus.
• Conract of a sm.1ll b.tllot~n filled with w.ttcr owr the: tip of the
ultra~onic probe: u,nt lor o~:~oplugu~. ga~tnc and duodenal walb.
• Oircct instillation of dc.t<·r~ttcd water, usu.tlly .thout 500 ml: for
g.tstric .tnd duodl·nal w.tlk
APPEARANCE
The ulrr~tsound beam passmg through the gasrrointc:stin.tl w:11l will
porcnti.tlly cm:ountcr ,j, int<-rfaccs hctween tissut: la~er,, which allows
the: visualization of five ~cpar;ltc l.tyers. These l.tyers have their respec-
tive hi,tological corrcl~tte!>.

l .1 Yl"r 1 High-rdk·cnvt: line: L um in.t Umuco,.t

l.d\'er l l I)W rdlcctivit~ Dt:ep llllKO~.t

L.t~·er 3 High rdlt:erivity Suhmuco,,t

Layer 4 L!Jw rdh·tiviry .\ 1uo;cul.~ric; propria

layer 5 High rdlccttvtty Ad\·entttia/~er<l!><l
 Upper gastrointestinal tract wall - endoscopic ultrasound &

figure 61 The
gastrointestinal wall
is visualized as six
interlaces between
tissue layers. which
usually results in
the visualizatiOn of
fiVe separate layers:
layer 1.
lummaVmucosa:
layer 2. deep
mucosa: layer 3.
submucosa: layer 4,
muscularis propria:
layer 5.
adventitia/serosa
(Courtesy of Or
M1chelle M.
Marshall)

f URT HER Rf AOil\(.;

Ctlcttl ( .l.. Holonth I . /.;lni 1.. I .tho G. Tc~hmqut•
ot endo...:opi~
ulrr.N•no~r.tphy inn·.,rigarion: Esophagu~. o;rorna~h .mJ
JuoJntum . .'it'<illtlin,ll'itm /ounhll of G,/s/rucnll'rology
I':ISh;.! l :l-5.
~imllll'Y ~I H. :\l.mm R\X~ Ha~Woirt RC. Wang f..:Y. franklin 1>\X',
~il verMeil\ I· E. HiMologi~· .:orrcl.uco; oi ga-.rroi lltl·~una I ultr.t-.otrnd
im.tgc-.. ( ;,,s/ro('lll£'rolo,~)' I 9S9;96:433-44 I.
Shorvon PJ, l.t·c~ WR, host RA, Cotton PH. Uppa ~a~trointl·~rmal
cndo~opi.: ulrr.t!.onogr<tphy in gastroenterology. HritisiJ }wtnt,lf
o( Radio/og)' I tJH7:60:42l)-4.,H.
mJI Gastrointestinal t ract

Bowel wall - transabdominal ultrasound

PHEI'ARATIO N
None.
POSIT IO N
Supine.
PROBE
3.5-5.0 MHz curvili11ear trotnsducer.
M ETHOD
Bowel wall thickne~s may he meas ured before and .tftc:r ingestion of
wate r. !\leasuremenrs should he m:tde only on images obtained in rr.ms-
vcrse set:tions. In the non-Ji~rendeJ ~rare howel segments demonstrate
a target configuration. The th u.:J..ne'~ of bowel w.tll is llll'a~ured from
the edge o i the high-retlectiw core repre!>cnting the imralumin.tl f?.as .md
mucus, ro the outer border of the low-reflective represennng the bowel
w.tll. In the distended stare (following ingestion of water). the lumen is
fluid filled. Distension is considered adequa te when the lumina l cha-
llll'ter i~ grl·ate r than X em for thl• ~tom ach, ] em for the small hmvel
:md .'i em for the large ~>wcl. 1\kal>uremcnts ~hou ld lx- m:u.le from the
low-rdlective intralumina l fluid ro the mtertace rcprel>enting the !.cro!>.l.
APP FARANCE
Althoup.h it has been shown rh.tt the thickness of the ho..,·el wall depends
on the amount of distension of the bowel segment, pathologic thickening
of the bowel wall should he ~usrected when it mea,urt'S more rh:m 5 mm.
MFA~ U R EMENT

Average wall thickness (range, mm)

Non-distended Distended
Stom.Kh s ( 2~ ) 4 ( 2~ )
~ 111 a II howel J (2 J ) J (2-.l)
I .trl!l' howel ,., ( 4-~ ) 1 (l-41

FURTHER READIN G
Fll'ischer AC, Muhler.1lc:r CA, James AE Jr. Sonographic :1sscssmcnr
of the bowel wall. Amcrictl/1 f(lumul o( R uent~enulu~y
198 I; 136:887-891.
 Bowel wall - transabdominal ultrasound

Figure 62a
Normal transverse
colon (between
cursors) with no
tecat res•due present

Figure 62b
Transverse plane not
at an absolute nghl
angle (layers 1 and 5
not visualized) but
demonstrating layer
2. deep mucosa:
layer 3. submucosa;
and layer 4.
musculans propria
(Courtesy of Or.
Michelle M.
Marshall)
 Gastrointestinal tract

Analendosonography
PREPARAT ION
None.
PO SIT ION
Left lateral position. Females should be examined prone due to the
symmetry of the anterior perineal structures in this position.
PROBE
A high frequency (7-lO MHz) rotating rectal probe is used whi~:h
provides a 360° image. A hard sonolucent plastic cone covers the trans-
ducer and is filled with degassed water for acoustic coupling. TI1t· cone
is covered with a condom with ultrasound gel applied to both surfaces.
M ETHO D
Serial images are obtained on slow withdrawal of the probe down the
ana l~:ana l, images are typically taken at the upper, mid and lower anal
canal.
APPEARAN CE
The normal anal canal is composed of five distinct layers: the mucosa,
the submucosa, internal anal sphincter, rhe intersphincteric plane and
external anal sphincter.
• Mucosa: This low-reflective l.1yer is immediately adjacenr to the
probe and is continuous wtth the rectal mucosa.
• Submucosa: This high-reflective:' h1yer lies between the mucos.1 ,1nd
the internal anal sphincter, becoming progressively thicker and
den~r caudally.
• lntemal anal sphincter: The smooth muscle of the internal sphinc-
ter is seen as a homogeneous low-reflective circular band >2- 3 mm
in width, extending caudally to a level JUSt proximal to the anal
verge. The thickness should be measured at the 3 o'clock or 9
o 'd<X:k positions.
• lntersphincteric: This is a n~urow high-retleaive band between the
two sphincter planes.
• Extemal anal sphincter (1-:AS): The striated rnusclc of the external
anal sphincter has mixed reflectivity and a linear p~utcrn, giving a
streaky appearance. The EAS can be traced from the puborectalis
component of the levator ani muscle to its cutaneous termination.
Tht: EAS is consistent in appearance for both sexes posterolaterally.
However, anteriorly, in females, the muscle is deficient in the
 Anal endosonography llfD

imrncdi.He region ot the perineal body and vJgina. In males, the

sphincter rapers <lt1reriorly inro rwo arc~ that meet in rhe midline.

Figure 63 The normal anal canal is composed of five distinct layers: mucosa.
submucosa. internal anal sphincter. the intersphincteric plane. and external anal
sphincter (Courtesy of Or. Michelle M. Marshall}

FURT H ER READI N G
Law P.J, Bartram Cl. J\nal cnt.lo~onog.r<'phy: redllliqUt: <lll~l normal
anaromy. Castmintestin,,f Rudiology I 9~9; 14:349-3.B.
MUSCULOSKELETAL
SYSTEM

Keshthra Satchithananda and

David Elias

General considerations 174

Upper limb - .;houlder 176
Long head of b iceps 176
Subscapulari~ tendon 178
Supraspinatus tendon 180
Infraspinatus tendon I H2
Upper limb - elbow 184
Anterior joim space 184
Olecranon fos~a I t:l6
Lateral elbow 188
Medial elbow 190
Upper limb - wrist 1192
Dorsal tendon~ 192
Carpal tunnel 194
Lower limb - hips 196
H ip effusion 1%
Developmental dysplasia of
the hip 1 9~
Lower limb - knee 200
Lower limb - ankle 202
Anterior, medial, lateral tendons 202
Achilles tendon 204
Lower limb - foot 206
Plantar fascia 206
lnterdigital web spaces 208
mil Musculoskeletal system

GENERAL CONSIDERATIONS
PREPARATION
None.
POSmON
See individual cxJmin.nions.
PROHF
• High resolution, high quality ultrasound equipmem.
• > 10 l\1H2 linear transducer for small superficial structurelt.
• 7-15 MHz linear tr:tnsducer:-. for tendons of extremities.
• 3.5-7 MHz linear/curvilinear transducers ro image large or deep
muscles.
Linear probes ideal to provide uniform field of view with s uperior
near-field resolution.
METH OD
See individual examinations.
APPEARANCE
• Muscle bundles: Are low-reflective with high-reflet:tiw intramuscu-
lar fibroadipose septa, perimuscular epimvsium and intermuscular
f<tscia.
• Tendons: Cm1:.1st of par;tllel f:~scides of collagen tihrt'S, whkh
appear as parallel high-re tlcctive lint'~ due ro mu ltiple reflective
interfaces. M ost tendons are lined hy a synovial sheath, wh1ch con-
tains a thin film of tluid. This appears as a low-reflective rim nor-
mally <1 mm thick. Those without a sheath (e.g. tendo Achilles)
have a surrounding high-reflective line due to the dense connective
tissue of the epitendineum.
• I igaments: Have more interwoven and irregular collagen fibres
th<lll tendons :tnd thus appe:tr as 2-3 mm thick homogmeous high-
reflective bands.
• Bursa: A nnrmal bursa appears as a l uw-rdk~w1:ive lin~· n:pn.-~cnting
fluid -;urrounded by a high-reflective line.
• Peripheral 11en•es: Exhibit parallel linear intem.JI echon on lon{!i-
tudin:tl im<~gcs. On transverse im:1Res nerves are round or ov,d
stmctures with tiny pun..:rare internal echoes. Ne rves do not move
with flexion or extension of rhc regional muscles.
 General considerations

MEASUREMENTS
Set: indiviJu.llc~.llnin;ltiono;

ARTIFACTS
Anisorropi~ ~trth.:ture~
d.:mon,rrate different .:har.1~·ren'u~' dc:pcnding
upon the dirl·.:uon from whi.:h thl·y .1re naluatnl. "knc.lon~ .ue
m.ui..~:Jiv .mi,ntwr•.:; nerve~. musdt·s and li~ament~ 1e~~ ~o. 1 hu\. tor
tl·ndon' in p.un~ui.Jr. the an~ le of msonarion mu~t rem.1in perpc:ndi.:u-
lar ro the inu~nl 'tru.:ture to demonstr.ne its nom1al h1gh-rdll·.:nve
ultr~lsmmJ .lppl·aran.:e. Loss of perpendi.:u larit~ rt~uhs m :trtif:~.:ru.1l
low retle.:ti,·ity. l'or ~upcrtl..:ia l tendons w1rh a .:urved ovcrl~ in~ slkin
surf.Kc:, th.: ll'l' ol a sramloff pad, or imagin~ of o,tru.:turl·~ in .1 wat.:r
hath (c:.g. for tlngl'r tl·ndons) .:an he helpful to .11low m.1intc:n.m.:e of
pruhc .:ont.Kt w1th thl· ~kin .md at rhc same rime keep a pcrpcndi.:ul.1r
in~oiUtion .111)-tll•. Alternatively, modern units. wh~~:h allow hcarn 'it~:cr­
ing or .:ompound im.lgin)!., may he helpful in reJu.:ing the: anisolropy
.utcf.Kt.
B Musculoskeletlll system

UPPER LIMB- SHOULDER

Long head of biceps
------------------------
POSITION
Patient is imaged while sitting on a revolving chair or srool. Humeru1>
internally rotated I 0-20° wit h elhow flexed and hand, with palm up,
resting on patient's lap.
PRO l3E
7.0-10.0 l\.H 17 linear transducer.
M ETHOD
Transducer placnl tran~verselv and longitudinall y across bicipital
groove.
APPEARANC E
• Tm11s1•erse Sl'ctimz: The biceps tendon is a high-rdlccrive oval
structure within bicipital groove. lmporram view ro detect intra-
arricular fhnd.
• Lmzl(itudmal sectum: Should idenr1fy fibrillary echo P•lttern of ten-
don. Measurements are made in the transverse plane of t he width
of long head of hin·r~ wirhin the bicipital groow.
M EASUR EM EN T S

Right (mean ± SO) Left (mean ± SO)

Male 3.2 ± O.S mm 3.3 + 0.4 mm

Fem.tle 2.7 ± 0.3 mm 3.0 ± O..l nun

f U RT H ER R I:.ADING
l\tiddleton WI>, Teefey SA, Yamaguchi K. S<.mography of the
shoulder. Scmmars m Musculoskeletal Radiology
I ~9H;2 1 I :2 1 1 222.
Van Holsheeck !\IV, lnrroc.1so JH. Appendix: tahle oi normal ,·alul'"!>.
In: \"an Holsheeck !\.1V, l ntroca~o JH. ed~. Musdnskeletal
Vltrasormd, 2nd cdn. Moshy-Year Book, Sr. Louis, 200 I,
pp. 625-62H.
 Long head of biceps IIIII

Figure 64
Transverse image
through the biceps
tendon in the
bicipital groove
(cursors)
ml Musculoskeletal system

Subscapularis tendon
---------------------------
POSIT ION
Patient is imaged while sitting on J revolving .:h;lir or 'mol. Humeru~
externally rotated ro stretch the suhscapul.tris tendon.
PROBL
7.0-1 0.0 l\.1 HL line;lr tran~ducer.

M ETH OD
Transducer placed tran~vc:r~dv and longitudinally aero~' the suhscapu-
laris rend<m. which li .:~ medial rn the bicipital groove imcrtin~ inro the
les~r n1bcmsity.

APPEARANCI
Sub!>C:.lpubris tendon h:1' .1 .:om ex mar,.:in ~upcrti.:i.1lly :~nd follow~ the
convex humcr.ll.:mrcx on it~ deep ;l,(X'Ct. Transver!>ely thl· multipt:nare
anatomy of the rendon nuy lx· appreciated. Small suhddroid efiusiom
may he apparent supertici.1l w !>uhscapulan~.
FURT HER RfAOING
Middleton WD. Teeiey ~A. Y:~magu.:hi 1\.. ~onoj!.raph~ ot the
shoulder. Sem111<1rs 111 Musw/oskelt>tcJI R.,ulmlo}ly
I 998;21 1 :l ll - 222.
 Subscapularis tendon llfD

Figure 65 Subscapularis tendon has a convex margm superflcrally and follows the
convex humeral cortex on its !:leep aspect (between arrows}
IElll Musa.doskeletal system

Supraspinatus tendon
----------------------------
POSITION
Pauenr is imaged while sirring on a revolving chair or srool. Humeru~
extended and intemall}' rotated; 'hand in o pposite back pocket'.
PROBE
7.0- 10.0 MHz linear transducer.
M ETHOD
Transducer placed transversely and lo ngitudinally across shoulder
joint.
APPEARANCE
• Trmzsverse section: High-reflectivity fibrillary pattern of tendon
fibres with a !.moothl )' convex superficial contour deep to deltoid
and subdeltoid fJt stripe. The tendon lies .,uperficial to the low-
reflective cartilage of the humeral head.
• Longitudinal sution: Tendon is thick as it emerges (rom under the
acromion and thins distally as it inserts into the greater ruheros1ty.
This results in a triangular shape.
FURTHER READING
Middleton WO, Tectcy SA. Yamaguchi K. Sonography of the
shoulder. Semi1wrs in Musculoskelt!t<~l Radiology
I ~'18;2 11 :2 1 1-222.
 Supraspinatus tendon 11m

Figure 66a Transverse view of the supraspmatus tendon (arrow) as it passes over
the humerus (H). Note the CCfacoid process (C)

Figure 66b Longitudinal (mediolateral) v1ew of the supraspinatus tendon (arrow)

as it passes beneath the acrom1on (A) and over the humerus (H)
mg Musculoskeletal system

Infraspinatus tendon

POSITION
Patient is ima~cd whllc ~itting on .1 revolving .:hair or stool. lp~ilateral
hand is pl>t<.:eJ (>n the contralater.ll ~houlder ro stretch out infra~pina­
tu~. Probe plan·tl on the posterior shoulder, inferior and par.tlld to the
M:a pular spine, swn:p in~ laterally to identify the muscle hdly and then
tendon.
PROBE
7.0-10.0 Ml-lz lint·ar transducer.
M ETHO O
Tr.ln~duc;er placed tran:-.n:rsdy and lon~itud111allv acros' infr;l\pmarus.
APPEARANCE
Infraspinatus tendon appears as dongated soft tissue trio.mgle that
attaches to gre.artr tul->erosity of the hurncru~. The infraspinatus tendon
needs to be differentiated from tcre~ minor tendon. Tht' hmcr i~ infe-
rior to the infraspm.a ws tendon and .lppt:ar!> tr .tpezoidal with internal
echoes that run in ohlique lines as opposed to horizont.allint·, of infr.a-
spinatu~ tendon.
FURTHER READING
Middleton WD, Teder SA, Y:un.tguchi K. Sonography of thL·
shoulder. Srmi1111rs in Musculuskelrtt~l R&ldiulugy
1998;211 :2 11 - 222.
 Infraspinatus t endon EJ

Figure 67
longitudinal v1ew
through the
infraspinatus tendon
(arrows)
II!II Musculoskeletal system

UPPER LIMB - ELBOW

Anterior joint space

POSITION
Pm ic:nt lying or seated with fo rearm supinated and d how extended.
PRO BE
7.o- l 0.0 :\1Hz linear transducer.
M ETHOD
Transducer placed longitudinall} a lon~ antl."rior radio-.:ap•tclbr joint.
Identify .tnrerior synovial rect:~s.
APPEARANCE
T ht· .mtcrior capsule of elhow joint is ·• hi!!h- rdlective line rh<~ t follo wo;
the vc:ntral contours of the pro ... imal radi.1l hc:;ld and dista l IHJrnt·ral
c.1pitcllum. Between the c lpsule a nd rhc hone lies a I mm thic k low-
rcllc.:tl vc layer re presenti ng a rtic ula r clrtib~e which should nor he
lllJSt.Jkcn for ahnorrnal joint fl uid.
FURT HER READING
Ha~h un mn HE. Kramer DJ , Wiitala L Appli.:a rions of
mt".:ul n~kt:let.ll
sonography. Joum.lf of ('/im cJ I Ultrusomuf
1999:17:293-3 18.
 Amerior joint space lll'D

Frgure 68 Transverse view through the anterror joint space of the elbow (RAD.
radius: CAP. capitellum). The arrow points to the anterior synovial recess. where the
joint may be evaluated for the presence of an effusion
l!ll Musculoskeletal system

Olecranon fossa

I'OSITIOI\
Patil·nt"s dbow i~ flexed at 90°.
I'ROBI
7.0-10.0 MHz linear transducer.
M ETHOD
rran,ducer placed longitudinally and transverselv .tcross rhe olecranon
(o''"·
APPEARANCI
Wirh.n the olecranon fossa is the posterior fat pad. T he: tibrous joint
c.1psule is a high-retlective line ~uperticial to rhe fat pad and the
trochlea.
FURTHER R EAD ING
I f.1shimom BE. Kramer DJ, \X'iit<ll.l L. Applications of
musculoskeletal sonography. /cmm,JI of Clinical Vltrdsound
1999;l 7:29J-3 18.
 Olecranon fossa III3

Figure 69 Long1tudmal view through the olecranon fossa. The arrow points to the
postenor fat pad (OLEC. olecranon: OLEC FOSSA. olecranon fossa: TRICEP. triceps
tendon)
D!!l Musculoskeletal system

Lateral elbow

POSffiON
Patient's elbows are extended with rhe palms of both h:mds together.
PROBE
7.0-10.0 MH7. linear transducer.
METHOD
Transducer placed in longitudinal oblique di rection on the lateral side
of elbow.
APPEARANCE
The common forearm extensor tendon arises from the lateral epi-
condyle of the humerus. The radial collateral ligament lies deep to the
tendon and attaches to the ann ular ligament at the radial head. The lat-
eral ulnar collateral ligament form s a sling around the posterior radial
neck to insert into the proximal ulna. These Jig.amenrs may lx· followed
from their origin at the lateral epicondyle.
FURTHER READING
Hashimoto BE, Kramer OJ, Wiitala L. Applications of
musculoskeletal sonography. j ournal of Clinical Ultrasou11d
1999;27:193- 3 18.
 lateral elbow 11m

figure 70 The
common forearm
extensor tendon (1)
arises from the
lateral epicondyle of
the humerus (EPI)
and lies superior to
the radial head (RH)
D MusC\Jioskeletal system

Medial elbow

POSITION
Forearm placed in supination.
PRO BE
7.0-10.0 MHz linear transducer.
M ET HOD
Transducer placed in longirudinal oblique position a t the medial eloow
)0111(.

AI'PEARA NCE
The common tlexor tendon arises at the medial epicondyle of the
humerus. The :.mrerimr band of the ulnar collateral ligament arises from
the medial epicondyle of the humerus and inserrs on the medial coro-
noid proce~:o. of the ulna. The postt'rior and o bliqut> hands a re less func -
tion,l ll y important.
FURTHER READJNC
Hashimoto BE. Kramer OJ, Wiit.\la L. Application!. of
musculoskeletal ~onography. jnurnal of Clinical Ultrasound
1999;27:293- 3 18.
 Medial elbow

Figure 71 The
common flexor
tendon (1) arises
from the medial
ep1condyte ot the
humerus (MED EPI)
B2l MuSOJioskeletal system

UPPER LIMB - WRIST

Dorsal tendons

POSIT ION
Palm face down on ex.tmination table.
PROBE
7.0- 10.0 MHz linear transducer.
M ET HOU
Transducer placed transversely across wrist at the level of the dorsal
radial tuherde, .tnd then moved ro follow individual tendons in longi-
tudinal and tran~versc \t:Ction.
APPEARANCE
The dorsal tendons course through six separate synovial compart-
ments. The dorsal radial tubercle acts ac; an anatomical landmark
separating extensor pollicis longus, which lies on irs ulnar side. from
exten!.or carpi radialis brevis and longu!>, which lie on its radial side.

Radial side Abductor pollicis longus tendon (volar aspect of

anatomical snuffbox) and e xtensor pollicus brevis
tendon (base of anatomical snuffb<>x)

Extensor carpi radiali'> longus and extensor carpi

radialis brevis tendons

Ulnar side Extensor pollicus longu~ tendon (dorsal aspect of

anatomical snuffbox)

Extensor digitoru m and e xtensor indicis tendons

Extensor digiti minimi tendon

Extensor carp i ulnaris tendon lying in a groove on

t he medial ulna
FURT HER READING
Hashimoto BE, Kramer OJ, Wiir.tl.t l.. Applic,uions of
muc;culoskeletal sonography. }uurnal of Umical Ultrasound
1999;27:293-318.
 Dorsal tendons DJ

(a)

(b)
Figure 72 Transverse images through the dorsal wrist (a) at the level of the dorsal
n.
radial tubercle and (b) approximately 1 em beyond the dorsal radial tubercle and
to its radial side. A prom tnent subcutaneous vein is noted superlicialto extensor
digitorum tendons. 1A. abductor pollieis longus tendon: 1B. extensor pollicus brevis
tendon: 2A. extensor carpi radialis longus tendon: 28. extensor carpi radialis brevis
tendon: 3. extensor pollicus longus tendon; 4. extensor digitorum and extensor
indicis tendons
ml Musculoskeletal system

Carpal tunnel
-----------------------------------
POSITION
Ventral side to ev.aluate carpal tunnel.
PROBE
7.11- 10.0 Mllz linear transducer
APPEARANCE
The floor of the carpal tunnel is formed by the carpal bones and its roof
by the flexor retinaculum which .maches to the scaphoid tubercle and
the trape1it1m l.uerally and the pio;iform and hook of hamate medially.
The median nerve lies just deep to the retinaculum at the radial aspect
of the carpal tunnel. Also within the tunnel lie the tlcxor lhgirorum
superficialis and profundus tendons and Within Its r;ldial aspect, tlexor
pollic•s longus and tlexor carpi radialis. Superficial to the ulnar \ille of
the carpal tunnel lies Guyon's c;mal cont.tining the ulna nen·e and
arter~·. Flexor carpi ulnaris lies medi.1lly and ino;erts inro the pi~iiorm.
ldenrification of the median nene is aided hy noting that in the
distal forearm it lies deep to tlexor digirorum superficialis. and more
distally it courses around the radial aspect ot these tendons to reach the
superficial c.upal tunnel. Additionally it shows lcs!> movement on
finRer flexion/extension than the flexor tendons.
In carpal runnel s~·ndrome, W<l~ting of the nerve .ll> it pdsses into the
carpal runnel, palmar howing of the flexor retinaculum and swelling of
the nerve proximally may he idemified. The cross-sel.'tional area of the
nerve should he measured .u the distal carpal crease (i.e. the level of the
pil>iform and \C:!phoid wherde). The wrist should he in .1 nc:utral
position for a reproducible mea~urcmem.
~f f A~UH £MENT

Normal cross-sectional area (mean ± SD. mml)

Male Female
8.3 (± I.9) 9.3 (±2.3)
 Carpal tunnel

Figure 73 Transverse image obtained at the distal radial crease to demonstrate the
PISiform (PISI). and circumferential area measurement of the median nerve (arrow)

FURT HER READING

Bu~o:hherger
W. .Judmaier W, Birbamer G, Lener M, Schmid<lucr L
Carpal tunnel syndrome: di.1gnosis with hi~h -resolunon \Oill>graphy.
Americun fount.~I of RoentgenoloKy 1992; 159: 793-79X.
H.l~himoto Bf , Kramer OJ, Wiitala L Application .. of
musculoskeletal sonograph~. joumcJI of CliniccJI Ultr.,smmd
1999;27:293-J 18.
Lee Oli, van Holsbeeck ~ IT, f anl'\'~ki PK, Ganos DL, Ditmar!> 1>~1.
Darian VB. Diagnosis of carpal tunnel syndrome: ultral.ound
versus electromyography. R.ltllugra{>IJic Clinics of N01 th Amrnctl
1999;3 7:859-l:l?l.
B Musculoskelet;:,l system

LOWER LIMB - HIPS

Hip effusion

POSIT ION
Supine with hi p extended and '>lightly abducted.
PROBE
3.0-7.0 MHz linear or curvilinear transducer (dependent on patient
age).
M ETHO D
TransdU<.:er placed along the length ot the femoral neck.
APPEARANCE
The high-reflective anterior capsule is identilied ,mterior to the femora l
neck. Separation of the capsule trum rhe tcmoral neck is normally
2-4 mm • •1nd a difference of 2 mm or more bctwL-cn symptom.nic and
.-~~ym promaric ~ides is considered sig.11ificant for a joim cffu~ion.

FURTHER READING
N imiryongskul P, McBrrdc AM, Jr., Ander, on LD, Crott)' JM.
Ulrra~onography in the management of painful hips in children.
Am t:rictln } rJIITIItll of Orthopedics 1996;25 :4 1 1-414.
 Hip effusion lliJ

Figure 74
Longitudinal section
through the anterior
recess over the
femoral head (FH)
demonstrating
normal appearances
with no evidence of
a hip effusion. The
arrow indicates the
position most likely
for fluid to
accumulate
mJ Musculoskeletal system

Developmental dysplasia of the hip

POSffiON
Right and left lateral decubitus position for e-xamination of each hip.
PROBE
Linear transducer; 7.5 NIHz (newborn), 5-7.5 MHz (3 months).
M ETHOD
Infant sho uld he as relaxed .ts possible (recent feed, parental prel.ence
a nd examination in a darkened room are helpful). Each positio n is
a-;sessed in t he coronal and axial planes hr placing the transduct:r lon-
gitudinally and tr.msve rsely at the lateral hip. A static examination
may be perform~:J with the hip in t he extended and 90 tlexed posi·
tions. For dynamic examination the hip is flexed at 90° nnd gentl y
adducted and abducted, and gentle posteriorly directed stress is applied
ro the flexed, adtlucted hip.
APPFARANCE
On coronal rm,tgc~ tht: iliac wing rs seen as a horizontal high reflective
line paralleling the t ransducer. The bony acetabulum form s a high-
reflective curve mcdi.\11} wirh a defect representing the normal triradi-
ate cartilage. Before ossification the femoral head is low-reflective with
scanered specular echoes due ro vascular channels. Superolateral ru the
femoral head the jo int capsule is seen a1. a high-reflective line an<tching
to the ilium. J ust deep ro thts a small high-rdlective focus represents
condensed fibrocartilage at the l.thral tip. T he remaining labr um is
low-retlecti ve cartila~e similar in rctlccri\'ity to the femoral head.On
transverse images in hip flexion, the low-rcflccti~e femoral ht:ad lies
within a 'V' shape formed by the femora lm et~1physi~ antcriorlv .1nd the
ischial part of the ::Ketabulum posteriorly.
MFASUREMENTS
• Gru{ alpha angle: The .tngle herwcen the iliac line and a lin~
a long
the osseous acetabular roof on a coronal image of the hip. Normal
is >60°.
• Percentage of the fe moral head diameter covered hy the bony
acembulum. Notm;\l is >58uf.,.
 Developmental dysplasia of the hip 11m

Figure 75a
Coronal sect1on
through the hip
demonstrating the
femoral head (long
arrow) within the
normal acetabulum
(short arrow)

Figure 75b
Coronal section
through the h1p
demonstrating the
measurement of the
alpha angle

FURT HER READING

(;r.tf R. hmd.unenral~ oi sonop.raphic diagnosi~ oi tnbnr h1p
dy,pl.hi.1. {u11m,,{ of Pedi,lfric Orthopedics I IJ!i4;4 : ~ l )-740.
;\Iorin C. H.trd;l· HT. !\I.Kfwt'n GO. fhe infant hip: rt';tl-ume l l \
.h'l'"lll<'nt oi .Kl't,thui.Ir dt'n·lopmeut. R.1diologY I 'JX 'i;
L-'l-,-.
1.)-7:n L--1 •
fD Musculoskeletal system

LOWER LIMB - KNEE

POSIT ION
Supine for anterior structures; knee extended for assessment ot collat-
eral ligaments. Quadriceps and patellar tendons are ex:1min~J 10 tlex-
ion and extension. Measurement of fluid in the suprapatellar pouch
should be performed with the knee flexed at 30". Prone with the knee
extended for assessment of the popliteal fossil.
PRO BE
5.0-10.0 MHz linear transducer.
METHOD
The presence of joint flu id should be sought in the suprapatellar bursa
and the medial and lateral jomt recesses. The quadriceps .md patellar
tendons, medial and lateral coll.ncral ligamenrs, the popliteal vessels
and any cysts about the knee are evaluated in axial and longitudinal
planes. Doppler and colour flow are usl·d to assess the popliteal vessels.
APPEARANCE
• The suprapatellar pouch is a low-rctlecrivc band ahovc the patella
and deep to the quadriceps tendon. It lies hcrween the suprapatel·
lar and pre-femoral fat pads. At 30° of knee flexion it should he less
than 4 mm thick.
• The med1al coll:tteral ligament h,,s superfi..:ial and deep compo-
nents. The superficial ligament .maches to the medial epicondyle of
the femur and the medial tibial metaphysis and should mea!ture no
more than S mm thick proximally and no more than 3 mm thick
distally.
• The lateral ligamentous structures indude the iliorihial hand ante-
riorly, which inserts onto the anterolateral tihia, the fihular collat-
eral ligament which runs obliqcly from the lateral epicondyle of the
femur w insert on to the fibular head in \:Onjuction with the distal
tendon of biceps femoris, and rhc popliteus tendon which attaches
to the popliteal notch of the lateral femur.
 Lower Limb- knee

ME:.ASUREMENTS
lenglh (mean ± SD, mm)
Males Females
[)i,ral quadnl.'l.'p~ tl·ndon 5.1 ± 0.6 4.9 ± 0.6
Xlid patell,u tendon 3.1 ± 0.4 2.9 ± 0.5

Figure 76a Longitudinal view through the quadriceps tendon {QT). which lies
antenor to the distal femur (F). The thickness of the suprapatellar pouch is measured
(between cursors). Note that this joint recess lies between the suprapatellar fat (SPF)
and the prefemoralfat (PFF)

Figure 76b Longitudinal view of the patellar tendon (PT) extending from the patella
{P) to its insertion at the tibial tuberosity (T)

FURTHER READING
H,t,himoto BE, Kraml·r DJ, \'('iital.l L. Appli.::nion~ of mus.:uloskekt:~l
'<HJO~r:~phy. /oumdl of Clinic,ll L'ltrt1SOlllld 1999;27:293-3 18.
Van llolsbcc.:k MV, lmro.:aso Jll. Appendill.: tahk oi norm.1l values. In:
v.tn llo lsheeck .\tV, lmro.:.1so JH. eds. A1usdoskc/ct,d UltrLZsound,
2nd edn. Xlosby- )'e•u !.look. ~r. Louis. 200 I, pp. 625-628.
EiDI Musculoskeletal system

LOWER LIMB - ANKLE

Anterior, medial, lateral tendons

POSITIO N
Supine.
PROBE
7.0- 10.0 MHz linear transducer.
M El H<.>O
With the patient supine, the tran!.duccr i~ pl.tced longirudin.1lly across
the tihimalar joint w assess for fluid in the anterior reet:'>!.. With the
transducer plan·d tran~ver!>ely behind the lateral malleolus the per-
oneal tendons are identified (peroneus hrevis lies anternmcdiall y ro
longus). On a tnlllsvnse image at the rned1al an kle tibialis postt•rior is
identified just behind the malleolus and flexor digirorum longus lies
just posterior to rillS. Flexor hallucis longus lies deep and rna)· he more
read1ly identified hy a posterior .1ppro:~~.:h . Anterior to the tihiotalar
joint the three tendon:. identified (medial to lateral} are tibialis anterior,
extensor hallucis longu:. and extensor Jigitorum longus. E.1ch tendon is
then followed in transverse and longitmlina l !.ection through it~ length.
APPEAR AN CE
• Tihialis posterior is the largest of tht· medial tendons, mea~uring
4-6 mm in diameter. It mav be followed to irs insertion inro the
navicular where the fibres normally fan our.
• Peroneus brev1s mserts into the hase of the 5th metatarsal.
Peroneus longu:. crosses the sole to insert .u the ba~c of the l st
metatarsal and the medial cuneiform.
• fhe anterior recess mav norm01lly cnnt.1in up to J mm depth of
fluid. Fluid may norrn.tlly he idl'lltifieJ in the tibia lis po~tt:rior ten-
don sheath .u or helow malleoi,H lcvd. ilnd within the peroneal ten-
dons below malleolar level a nd m c1y he a~ymmerric. Th~: .tnrerior
rendons do not normally show •mrrounding tluid. fk xm digitorum
longus .10d fll"\or ha ll uds longu\ may normally show !>urrounding
fluid on M Rl scan, hut this is nor rl·portnl on ulrra:.ound.
 Anterior, medial, lateral tendons EJ

Figure 77a Transverse plane through the lateral malleolus of the ankle (LM)
demonstrating the peroneus longus (Pl) and peroneus brev•s (PB) tendons

Figure 77b Transverse plane through the medial ankle demonstrating the tibialis
postenor (T). flexor !lig11orum longus (D) and flexor hallucis longus (H) tendons

FURT HER RE <\DING

H.1-.himoro BF., "-r.uner DJ, \X'iitab L. Appli.:;l!lon-. oi nm-..:uloskelet.ll
"'IH>graphy. /oum,d o( Clinic,zl L'ltr.Jsuuml 19'.:1'1:17:29J-31 !l.
N.11..Jrian 1.1"\, Nandk umar :\IR. :\lartin CE. S.:hweitlt:r l\IF. Synovia l
thud in thl· hindfoot and .111kle: detection of .unount anll
di~trihuti on with liS. Rt~diology 1995: 197: 27.'i-27H.
E:l Musculoskeletal system

Achilles tendon

POSITIO N
Prone with feet hanging over rhe edge of the exammation couch.
PRO BE
7.0-10.0 rvt H1 linear transducer
M ETHOD
Transducer pla~:cd over the A..:hilles tendon longitudinally and trans-
vcr~cly to as'~:"" the full length of the tendon from musculotendinous
junction to ..:abmcal insertion. Dorsiflexion of the ankle is helpful to
fully evaluate rears.
APPEARANCE
The Achilles tl·ndon has a rounded or C-~hapc in transverse section.
The calcane::tl insertion of rhe tendon may a ppear low-reflective due to
anisotropy or the pr<.-sence of cartilage at the cnrhesis. The· pl.mtaris
tendon should he !.cparately identified as it runs from the posterolateral
knee to insert on the posteromedial calcaneus. The retroc::tlc::tneal
hursa lies between the Achilles tendon and the calcaneus.
M EASUREMENTS
• Up to 3 mm depth of tluid m:ty normally he identified in the retro-
calcane:tl bursa.
• Achilles tendon is taken at the level of the medial malleolus in the
transver'ic direction to ohram the anteroposterior measurement:
normal: (age range 12-7R )'car~): .Ll mm (range 4-6 mm)
FURTHER READING
Fornage BO. Achilles tendon: US cxammation. Radiology
1986;159:759- 764.
Hashimoto BE. Kramer OJ, \Viital~l 1.. Applic::ttions of
musculoskeletal sonography. joumal of Clinical Ultrusound
1999;l7:29J- J I H.
Nazarian LN, Nandkumar MR. J'vl,min CE. Schweitzer ME. Synovial
Huid in the hindfl>ot and ankle: detection oi amount and
distribution with US. RadiuluJ..,')' 1995; 197:275-278.
 Achilles tendon lfm

Figure 78 Longiludmal plane through the Achilles tendon (AT) at the insertion into
the posterior aspect ol the calcaneal bone (C)
lEa Musculoskeletal system

LOWER LIMB - FOOT

Plantar fascia

POSITION
Prone with feet h<tnging over the examin::nion couch.
PROBE
7.0- 10.0 t-..lHt. linear .~rray rran~ducer.

M ETHOD
The rr:~ nsdu.:cr •~ placed longirudinally and transver~-1~ :u:rm.!> the
plantar fa~1a. The ori!;in i' at the .:.tk.meal tuberosity, .1nd the tas.:ia
i~ tra.:l·d to the midan.:h hut lx·coml"' supcrticial and th in in rhe fore-
fm•t. ~leasuremcnts of thl· thicknc~~ of the proximal planr.u fascia .ue
t.tl..cn in the lon~i tudinal plane clo~c to rhe cak.meal .machment.
APPE ARANC E
Thr.: plantar f.t~i.1 i~ well ddincJ .mJ of rnoder.uely hii'!h reflecriviry
with ;I uniform tihri llar~ p.mern. hut ma~ lw low-reflective at rhe cal-
caneal rubc:rosity dut: to anisotropy.

Mean ± SO, (mm) Range (mm)

Control :U ± 0.1H 1.4-4.3

Pl.lllt.u t,t!>ciitis 5.':1 ± 0.9"" 4. 1-':1. 1

FUR fHE R RFAI>I NG

(;ihhon ~'. I ong G. Ultr.Jsmmd of pi.Jm.1r ,1poneuro~•~ (t.Jsci.ll.
Ske/eltt! R,ulio/(lgy I'N9;28:2 1-26.
l la!>himorn BE. Kramer DJ. Wiital.t 1.. A pplicttinn~ oi
mu!>Culo~kclcral 'onography. jt~urn<il of Clinical UltrdSOIIIId
1999;27:29J-3 11\.
 Plantar fascia a

Figure 79 Longitudinal plane through the plantar surface of the loot over the
calcaneal bone (Ct. w1th the plantar fascia demonstrated between the cursors
fD Musculoskeletal system

lnterdigital web spaces

----------------------------------
POSITION
Supine
PROBE
7.0-1 0.0 Mllz linea r array tra n~Jm:cr.
M ETHOD
The tran~ducer is placed transversely acroso; the dorsum of the foot to
examine the space~ between the metatar~al heads. At the same rime fin -
~er pre~~urc is applied ro rhe plantar surface nf web spact• under exam-
ination. Alternatin•ly_ ior..:ed tlexinn of the tc>t's, or sq uee1in~ of the
metatarsal heads to~ether by pres~ure trom the examiner\ hand, mar
d ispl,tee a neuroma towards the prohe for improved visualiz,ltion. The
pro.:css is repeated with the probt• on the plantar surf;Kc and finger
pressun: on the dorsum of the fo1•t.
APPEARANCE
The no rmal inrcrl.pa.:e appears a~ high reflc.:tive fat houndcd hy the
high-rdlcctivc metat.w •.tl cortex on rach side. A Monon\ neu roma
appear' a~ a non cu mpre~ible low-rdle.:tin- ma~~. whif, t •1 hur:.a i~ .1
compre~~ihle low rctlecti\·e mass.

FURT IIER READIN(.,

Redd RA, Peters \'j, Emerv SF, Brandt l iM. Rifkin :\10 . Morton
neuroma: sonographic evaluation. Rudiolog\' 1989; 17 1:4 15-4 1""'.
 lnterdigital web spaces m

Figure 80 The f~rst (1 ). second (2) and third (3) metatarsals are visualized on this
transverse image at the dorsum of the distal foot. with the interdigital webspaces
indicated (arrows) within which a Morton's neuroma may occur
PERIPHERAL
VASCULAR SYSTEM
(ARTERIAL)

Zelena A Aziz and

Paul 5. Sidhu

Upper limbs - peripheral arteries 2 12

Abdominal aorta and common
iliac artcrie~ 2 14
Lower limb) - pcrlphcrill arteries 2 18
I ower limb~ - peripheral arteries
for ~tcno~is 220
Extracranial arteric' 212
f '\tracranial arteries - me.Isurcmcnt
of internal carot id artery ~tcno~is 2 26
Tran!>cranial DopJ,.Jer ultra~uund 230
fD Per-ipher-al vascular system (arterial)

Upper limbs - peripheral arteries

------------------
PREPAR ATION
P.ttiem should rest in a supint: pu~1tion for 15 minutes in .1 room where
remperarure is 2 1~c ro .woiJ v:tsm:on.. rrictiun.
POSITION
Supine.
J>ROBF
5-7.5 l\l Hz linear t ransducer.
MfTHOO
Examin:uion of rhc upper extremity usudlly starts at the level of the
sulxtwi.tn a rte ry fulluwed hy the axi llary artery, hrach1al anery and
the radial and ulnar arteries. The radial and ulnar :trte rit·~ arc imaged
with the a rm in supination, and )lightly abducted. The w~~eb should
be examined in the longitudinal axis.
APPEARANCE
T he arteries appear as non-compressiblt·, pulsating ruhular !.trucrures.
Ouc to the ir h1gh peripheral resistance the spectral Ooppla waveform
arising from peripheral ,trteries show a typical triphasi~· flow pattern,
con~isrinp: of a )tcep systolic up~lopc, a systo lic peak, .1 reverse flow
.:nmponem, forw.trd flow 111 late d1astole and presystolic zero.
l\·1EASUREM ENTS

Artery Diameter Flow velocity

(mean ± SO, mm) (mean ± SO, cm/S)

Subclavian 100 ± 49
Brachial .1 .5±0.9 75 ± 1H

R.1di.tl (wriM) l.H ± (Ui 57± 16

Uln.Ir (wnst) l.H ±0.6 66 ±17

f URTHI:.R REA D ING

Trager~. Pignataro M, Anderson J, Kleinerr .JM . Color flow Oupplt·r:
imaging the upper extremity. Jmmt.Jf of H,md Surgery (A m)
19'13; 18:62 1-625.
 Upper limbs- peripheral arteries &J

Figure 81 a The
subclavian artery is
visuahzeo in a
longitudinal plane
by placing the linear
probe in the
supraclavicular
fossa and angling
caudally

Figure 81 b The spectral Doppler waveform demonstrates the typical triphasic

waveform panern
fZI Peripheral vascular system (arterial)

Abdominal aorta and common iliac arteries

PREPARAT ION
None.
POSITION
Examine in the supine position. l eft anterior oblique a~ needt'J.
PROBE
1.5-5 MHz curvilinear transducer.
APPEARANCE
Pulsating tubular low· reflective structure lying sl.ighrly to the left of the
midline, anterior w the vertebral column. The distal aorta is most often
involved in aneurysmal dilatations. An enlargement of the distal aorta
and common iliac artery should he considered when:
• The luminal diameter exceeds 23 mm in the distal aorta and 14 mm
in the common ilia~· arrery in men, and 19 mm and 12 nun respec-
tively in women.
• There is demonstration of focal enlargemem.
M fTHO O
Arms along the body to relax the abdominal wall. Luminal size of the
1bdominal aorta can be measured at two levels;
• Proximal Lliameter: At the level of the confluence of the splenic and
portal veins and the left renal vein.
• Distal diameter: Measure just above ao rtic bifurcation.
• l.uminal diameter of the common iliac artery: Measure just distal
to the aortic bifurcation. Anteroposterior di:tmeter is measured in
both transverse and longitudinal sections from inner edge of the
anterior wall to the inner edge of the posterior wall.
 Abdominal aorta and common iliac arteries 1ED:1

f igure 82a
Measurement at the
confluence of the
splemc and portal
veins at the level of
the left renal vein:
the proximal
diameter

f igure 82b
Measurement just
above the aortic
bifurcation: the
distal diameter
flm Peripheral vascular system (arterial)

M EASUREMENTS
Age Vessel diameter Range
(years) (mean ± SD, (mm)
(mm)

Proximal aorta 15-49 Male 16.9±2.4 12-22

Female 15.0 ± 2.4 11-22

50-89 Male: 19.9±3.4 14-2X

f emale 18.3 ± 2.7 14-25

Oisral aona 15-49 ~I .tic 15.1 ± 1.7 12-19

fl'nl<llc 12.7 ± 1.3 10- 16

50-89 ~t alc 16.H±2.9 11 -23

Fcm;lk 14 .6 ± 1.9 I 1- 18

Common iliac.: ancry 15-49 M.1le 9.7 + 1.2 7.5- 1 1.5

fcmak 8.S ± 1.0 6- 10

50-!lY ~ l .1le I 0.1 ± 2.0 6.5-16.5

f emale 9.2 ± 1.3 --U

FURT HER READING
Pedersen O .M . Aslaksen A. Vik-Mo II. Ulrrasound mca:.un:mcnt of
rhc: luminal diamerer of rhe abdomin.tl aon a and iliac arrcric:s in
paricnr~ wirhour vascular disease. fcmmtJI of Vaso1lar Surgery
199 3; I 7:5CoJI'>-60 I.
B1il Peripheral vascular system (arterial)

Lower limbs - peripheral arteries

--------------------
PREPARAT IO N
Patient should rest in 3 supine posttion for I ) minutes in a room where
temperature is 2 1"C w :n ·oid vJsoconstricrion.
POSITION
Supine. For the poplite:Jl region and lower leg the patient should be
moved ro a later dc.:uhitu~ position or the prone position.
PROBE
5-7.5 i\.IHz lincilr rr.l!lsdu.:cr.
.METHO D
:\lajor a rteries should be ima~ed in the l on~irudina l plane. Color
Doppler tmaging is performed from the midaspect of the :lrtery under
inwstigarion and tht· l>oppkr angle kept at <fl0°.
APPEARANCE
T he .uterics appear as non-compressible, pulsating tubular structure~.
If cakificd, .:olor .1nd spectr;tiiJoppler interrogation is difficult. Due to
tht· high pcriphcml rc ..istatJ<.:t· the ~pectral Doppler waveform arising
from pcriphcr.tl artt•ric'i show a typical triph,tsic flow pattern. consist-
in~ of a steep sysroli.: up-.. lopc, a 'i}'stolic peak, a reverse flow compo-
nent, forw.trd tlow in l.ne Ji.1~role .mJ presyswli.: zero.
M EASURF!VI FNTS

Arterial segment Peak systolic velocity (mean ± SO, cmts)

Distal common ilia.: 90 ± 21
Oist.tl common ft•moral 7 1 ±15
Profunda femoris 64±15
Proximal 'iupcrficial femoral ~.l ± 10
1\1 iJ ~u pcrtid;l I fcmor .1 I ~4 ± u
Oi:.tal Mtperfici:tl femoral 56± 12
Distal popliteal 'il ± 4
Tibioperoneal trunk 57± 14
Proximal antenor tihial 40 ± 7
Proximal po.,tcrior tihial 42 ± 14
Proximal pt'roncal 46 ± 14
 Lower limbs- p eripheral arteries -

Figure 83a
Longatudmal plane
through the
proximal super1icial
femoral artery,
above the
superficial femoral
vein (arrow)

f igure 83b Normal spectral Doppler waveform pattern through the

super1acial femoral artery demonstrating a normal triphasic waveform pattern
FURT H ER R l:ADING
H.1N1bmi TS. l'rimozich J, /.acrkr R F. Str.tndnc~~ DE J r: Color
Doppler .:hanKtcri~ti..:s in normal lower l'Xtrcmity arterie~.
{lfrr,tswmd in Mcdicim•.md lliolog1' 1992; Hl: 167- 171.
ED Peripheral vascular system (arteri;:~l)

Lower limbs - peripheral arteries for stenosis

PREJ>ARAT IO N
Patient should rest in a suptnc pmition for 15 min urcs in .l room whl·re
temperature is 21 °C to avoid v.tsoconstncrion.
POSIT ION
Supine. For examination ot the poplite<tl region a nd lower lq~ the
patient should be moved to a lateral decubitus posttion or the prone
position.
PROBf
5-7.5 ~1Hz linear transducer.
M ETHOD
Ma1or arteries shou ld be imagnl in t he longirudin.ll pl.tnl·. Color
Doppler imaging is performed from rhe midaspect of the arterr under
investigation and the Do ppler angle kept at <60°. Tht· no rmal prc~ys­
tuli..: velocity (PSV.) is measured in a normal segment of a rtery proxt-
mal to the stenosis, and the <>tenoric presystolic velocity (PSVJ i~
meJ.sured at the reg•on of highe~t ..:olo r t urbulence to indicate thl· ,trl·a
of maximum n ·locity, J.nd thc.:rciore g rc.:atcst stenosis.
APPEARANCE
The artl·ric::~ appear,,~ non-comprc:.sihk·, pulsating tuhular structures.
It ..:akilied, Doppler inrerro~ation is difficult. Plaque appears as intra-
luminal a reas of va rying retleni vity.
M f ASUREM ENTS

% Stenosis PSV (cm/s)

>50 120 1.4
>70 160 2.0
>90 IHO 2.9

f.U RTHER READI NG

Sa.:ks D. Robin~on l\l l, ~1J.rincllt DL, Perlmutter GS. j<Jumal ()(
Ultrus(Jimd i11 Medicine 1Y92; II :95 103.
 lower limbs - peripheral arteries for stenosis ED

Figure 84 The spectral Doppler gale has been moved from the proximal superticial
femoral artery to a point JUSt distal to a focal stenosis. The peak systolic velocity
measured before the stenosis IS 64 cm/s and distal to the stenosis 355 cmls.
indicating a stenosis of more than 90% (Courtesy of Dr Col1n R. Deane)
1!!11 Periphercd vascular system (arterial)

Extracranial arteries

J>RF.PARAT ION
None.
PO~ITJON
Supine. Neck extended and head turned slightlv away from the side
being examined.
PROBE
5.0-H.O MHz linear transducer.

M ETHOD
Examine the common carorid artery (CC A). internal carond artery
(ICA), external carotid arten· (ECA) and vertebral arteries in mHls-
verse and lon~itudinal planes. The ICA runs lateral or posterolateral to
the ECA in its lir'it parr and the extracmni.tl portion does not give off
any branches.
APPEARANCE
W!,weforms: The spectral Doppler waveform of the ICA is low res•:.-
t~tnce with a high diastolic component in comparison to the ECA,
which is of high resistance with .1 low diastolic component. The
wa\·dorm of the CCA is usu.11l~· of low re•il,tance. hut may appear
.ts a hyhrid ot rhme of the ICA .mJ ECA. The w.tveform of rhe ,·er-
rehral .utery is of low re"'tance <oimilar to that of the ICA hur with
lower .unplirude.
t>/,,que morplmlog)•: Plaque disease nor causin~ significant arteri.tl n.tr-
rowinv, hut wi rh fearures such .ts haemorrhage and ulceration m.ty
h<.· .tssoci,tted with cerebrnvasc.:ui;Jr symptoms. Plaque morphology
h.ts hn~n d .tssined inw catt-gonl''i:
• Typt•s t-4. with Type I ht:ing lnw-rctk·ctive and Type 4 beinv, uni-
formly high-reflective. Type 2 .md 3 are inrermediate forms. l.ow-
rdll'c.:rive areas seen on ultrasound of an atherosclerotic plaqul' implv
a ~rl·arer risk of symptomatic ccrehrov,tscular disease, althoujth cm1-
rroversy cxtsts as to the componenrs th.lt make up these low-rctkc-
rive areas. It has hl'en suggl'Mcd rh.lt fihrous plaqut'~ are
high-rctlective and st.thle where.ts more low-retlecti\·e plaques con-
t.tin increased lipid and dmlt:~tcrollcvcls, which render these plaques
unstable. Other studies have o;uggcsrcJ rh.n rhe low-reflective areas
of a pla(llle correlate with .trc~t~ of intrapl.tque haemorrhage and .ue
assoc:iared with an inc:re•lsc:J ri~k of cl'rehrovascular evenrs.
 Extracranial arteries lED

• HetcrOKCIIOIIS or hnmnge11olls. where heterogenous plaq ues :ue

those exhibiting ma jor differences 111 rdlectivity. These plaques are
the predomina nt type of pl.1que in symptomatic patiems with a
greater th,\11 70% stenosis.
• l11timu-mediu thick11ess (IMTJ: The inner high-reflective line
represents the luminal-intima mrerface and rhe outer high-
reflective line represents the media-adventiria interface, w ith the
distam:e between the two lines heing a measure of the th ickness of
the intima .md media combined. Measurements should ideall y he
taken at several sites and averaged as the mean o f the ma ximum
I MT in the CCA and ICA. The median wall t hickness in ~1 dults
ranges from hcrween O.S mm a nd 1.0 mm with rhe measurement
inc reasing w•th age. v~1lucs o f 1.0 mm o r greater are usually mken
to he c1hnormal.

ICA
ECA

CCA VA

F 85

Figure 85 The spectral Doppler waveforms obtained in each of the four sites of
measurement in the extracranial carotid arterial system. CCA. common carotid
artery: ICA. mtcmal carotid artery: ECA. external carotid artery: VA, vertebral artery
fD Peripherc!l vascular system (arterial)

Figure 86a Longitudinal plane through the carotid bifurcation demonstrating the
external carotid artery (ECA) and the internal carotid artery (ICA). The arrow points
to an ulcerated plaque situated on the posterior wall of the carotid bulb

Figure 86b
Transverse plane
through the carotid
bulb demoostratino
a heterogeneous •
plaque (arrow)
 Extracranial arteries lfm

Figure 87 Measurement of the intimal medial thickness is from the inner high-
reflective line to tile outer high-reflective line (arrows) on the far wall of the common
carotid artery close to the carotiel Oulll

FURT HER READINC

Sidhu PS, Alliin Pl.. Till' t'Xtended rolt: of carotid ,trrery ultrasound.
Clinical R.uliology llJ'J7;52:64J-653.
Sidhu PS, Oe~ai SR. A simple and reproducible method of ,tssessing
intimal-medial thickness of rhe common carorid artery. Hritisb
.foum<Jl of R,ufiology 1997;70 :RS- X9.
Stet fen CM, Cray· \XI.:alc AC, Hyrn.: KE, Lu,by RJ . Carotid atheroma
ult rasound appcaran..:c in .. ymptom:uic and a~ymptomaric v.-~~ds.
Australtun and New Zettlmzd .JourntJI of Surgery
1989;59:529-534.
fD P~iphew-al vasc.ular system (arterial)

Extracranial arteries- measurement of

internal carotid artery stenosis
----------------------
PREPARATIO N
None.
POSITION
Supine. Neck extended :md head turned slightly away from the side
heing examined.
PROBE
5.0-8.0 MH7 lmear transducer.
M fTHOD
Examine the comnl()n carotid artery (CCA), inrernal carotid artt:ry
(ICA), external carotid ,1rtery (ECA) and vertebral a rteries in trans-
verse and longitudina I planes. The ICA run~ lateral or posterolateral to
the ECA in its first pnrt and rhe extraaanial porri<m d()C~ nor give off
.mr hranchcs.
APPEARANCES
Grayscale imaging by direct measurement of luminal redut.-rion; mea-
suremenr of lumim1l diameter <lnd area reduction should he made nn
the .:ro,_,.,.ccrion of rhe vessel. Spectr.-1 Doppler analysis: many para-
meter~ have been suggested to quantify a 70% diameter reduction, and
different centres will have rheir own established diagnmti.: crircria.
The esrahlishmcnl o f spectral Doppler critt·ria for gratling clinically
significant c<Jrotid !>renosis of 70% or more is rhc objective in assess-
mt:nt of intern;~ I cilrotid artery (I<'A) ~tenosi<>, as symptom:nic parienrs
benefit from carotid end<t rrerecromy.
MEASUREM ENTS
Velocity measurement~ are most e.. ,.d~· oht<tined on longitudinal
images ,1way from rhe bifurcatiou. Flow velocity must be ,mgle cor-
rected and a standard examination an~lt:, alo near as possible ro 60°
should be used. The rwo velocity pammcrcrs ..:ommonly used are the
peak systolic velocity (PSV) and the ratio o f the PSV at the maximal
ICA stenosis ro the PSV in rhc normal ipsilateral common carotid
artery (CCAl. The end diastolic velocity (EOV) may he used as a dis-
criminator at higher of stenosis. 'String-flow· occurs when the stenosis
is severe enough (>~5%) ro cause a drop in velocity.
 Extracranial arteries- measurement of int ernal carotid artery stenosis lfm

Figure 88a An
area of high-color
turbulence (arrow)
is detected in the
proximal internal
carot1d artery
indicating an area of
arterial narrowing
mJ Peripheral vascular system (arteria~

Diameter reduction (%) PSV (cm/s) EDV (cm/s) PSVICJPSV11:.0

0-29 <100 <40 <3.2
30-49 110-UO <40 <3.2
50-59 >130 <40 <3.2
60-69 >130 40-110 3.2-4.0
70-79 >230 11 0-140 >4.0
80-95 >230 >140 >4.0

FURTHER READING
Grant EG, Benson CB. Moneta GL ct a/. Carotid artery stenosis:
gray-scale and Doppler US diagnosis. Society of Radiulogi~ts in
Ultrasound Consensus Conference. Radiology 2003;229:350-346.
Monera GL. Edward~ Jl'-·1, Papanicolaou C, Hatsukami T, Taylor LM,
Strandess DE. Porter JM. Screening for asymptomatic internal
c.uorid artery stenosis: duplex criteria for discriminating 60% to
99% stenosis. journal of V.lsc11lar Surgery 1992;21 :989-994.
Monet:~ Gl, Edwards JM, Chitwood RW, Taylor LM. Cummings CA,
Porter J~l. Correlation of North American Symprom,uic Carotid
Endartt-rccromy Trial (NASCET) angiographic definition oi 70%
to 99% inrcrn<ll carotid stenosis with duplex scanning. .foumal of
Vascular Surgery 1993; 17: 152- 159.
Sidhu PS, Allan PL. Ultrasound assessment of internal carotid artery
stenosis. Clillict~l R,1div logy 1997;52:654-658.
 E><trac:ranial arteries - measurement of internal carotid artery st enosis ED

Figure 88b A spectral Doppler gate is placed over the area of color turbulence and
a peak systolic veloCity of 4.31 m/s and an end diastolic velocity of 1.73 m/s is
obtained. suggesting a stenosis of 8~95%
ml Peripheral vascular system (arterial)

Transcranial Doppler ultrasound

PREPARAT ION
None.
POSITION
Patient supine and facing forward for the transtemporal and tramor-
hiral views and sirring with the head flexed forward for the trans-
foramina! view.
PROBE
2.0-2.5 ~I H1 curvilin1.-ar tran~ducer with a small footpr int.
M ETHOD
Transtcmport~l appro,u·b: The suprasellar cistern or midhrain is identi-
fied and u~ed ro locate the ctrde of Willis. The ipsilateral amerior,
middle and posterior cerebral arteries can he identified; the po::.te-
rior conununicating .trteries are difficult to locate. Tlie contralat-
eral arteries m~1y ht: o;een. The terminal internal carotid artery may
he seen in the coronal plane.
Tr,ms{oramilt,/1 appro,tch: Identify the vertebral artenes and follow
anteriorly and superiorly to identify the basilar artery.
Tr,msorlJital t~ppmach: Transducer face placed on the closed eyelid.
directed through the orbit ro idenrifv the ipsilateral inren1.1l carotid
and ophthalmk arteries.
API•EARANCES
u~ing color l>oppla will enable the arteries to he located and .lid in thl.
placement of rill' spectral Doppler gare ro measure Jrteri.ll velocity.
Power output should lx· reduced for the transorbital vit·ws. Thl· ~pec.:­
tral Oopplcr wavdonm. will rclll'l:t th~: low r~:si~tance of the intraaa-
ni.ll .~rtcril'"· with a hroaJ 'ysrolic peak anll high forwarJ di.l!otolic
!low; a low rc!.iM~HKC inJc:\ {Rll will he documcnrc:J.
 Transcranial Doppler ultrasound ED

Figure 89a The

transcranial
ultrasound probe is
placed over the right
temporal bone. and
following an
infus1on of
microbubble
ultrasound contrast.
the intracranial
arteries are clearly
dep1cted. MCA R;
right middle
cerebral artery; Pl
PCA R: first portion
of the right posterior
cerebral artery: Pl
PCA L: first part of
the left posterior
cereoral artery: A1
ACA R: first part of the right anterior cerebral arlery: A1 first part of the left anterior
cerebral arlery

Figure 89b A spectral Doppler gate is placed over the right m1ddle cerebral artery
(R MCA) to obtain a normal low-resistance spectral Doppler waveform pattern
Ifni Peripheral vascular system (arterial)

MEA SU R E M ENT~

Flow velocities and Rl (mean :t 95%CI)'

Age (years)
2G-39 4G-59
Anterior cerebral artery

PSV 9 1 (87-95) 88 (83-93) 79(75-H41

EOV 41 (39-43) 42 (40-45) .H (3 1-.H)
Rl 0.53 (0.52-0.55) 0.53 (0.5 1-0.54 ) 0. '9 (0.57-0.62)
Middle cerebral artery

PSV 113 ( 109- 1 16) I 06 ( I 0 1- 1 I I ) 92(ll8-96)

EDV 5 1 (4 9-53) 4 7 (45-50) 35 (33-37)

Rl 0.55 (O..B-0.56) 0.54 (0.54-0.561 0.62 (0.60- 0 .64)
Posterior cerebrLII <ITtery

rsv s 1 (7~-84 > 71 (68-74) 00 (63-69)

EDV ~6 (35-.38) 33 (3 1- .Hl 26 (24-2ll)

Rl 0.54 (O ..B-0.56) 0.53 (0.52-0.55) 0.60 (0.5!l 0.62)

Vertebral arter)'
PSV 66 (63~9) 59(55-63) 52 (4H-55)
EDV 3 1 (29-32) 27 (26-29) 22(20-24)
Rl 0.54 (O.B-0.561 0.53 10.5 1-0.541 0.59 (0.57-0.6 I)
B,lsilar urtery

PSV 74 (70-78) 63 (56-69) 54 (49-59)

FOV 34 (Jl-36) 29 (26-.Ul 23 (20-llll
RI 0.5 I (0.46-0.Sf.) 0.53 (0. ~ 1-0.55) 0.60 (0.56-0.64 1

PSV, peak w~roh' vrh..:lly (cm/sl: H>V. rml dld>lllli.: \"dO<:Jty tcnlls), Rl, n :mtJIKC mdex.
 Transcranial Doppler ultrasound lfm

REFERENCE
I. Marrin PJ, Evans DH, Naylor AR. Transcranial color-coded
sonography of the basal cerebral circulation. Reference data from
115 volunrcer~. Stroke 1994;2S:390-3'J6.
FURT H ER REAOJNG
Lupl·tin AR, Davi!'> DA, Bc..:kman I, Da!>h N. Tr.llls..:rani<ll Doppler.
Parr 1. Principle~. tc..:hniqul·, ilnd normal .lppcar.m..:t·~.
Rt~diographics 1995; 1S: 179- 19 1.
Ringelstein EB, Kahbcheuer B. Niggemever F., Oris S!'vl. Transcranial
Doppler sonography: anatomical landmarks and nomtal velocity
measurements. Ultrasound in Medicine and Biology
1990;16: 745-76 I.
PERIPHERAL
VASCULAR SYSTEM
(VENOUS)

Paul S. Sidhu

Inferior vena cava 236

Neck veins 238
Leg veins 240
E£!1 Peripheral vasrul11r system (venous)

Inferior vena cava

PREPARATIO N
None.
PO SITION
Supine.
PROBE
3.5- 5.0 M Hz curvilinear transducer.
M ETHOD
The patient is examined in three phases: ( I ) quiet respiration, (1)
d unng breath holding (Valsalva maneuver) and (3) on leg raising.
Examine in the transverse plane in the epigastrium, measure the short
and long axi, Jiamcter I em below the level of the left renal vein.
APPEARANCE
A tubular structure lying to the right of the midline, with variable
diameter with respinuory cycle.
M EASUREMENTS

Phase IVC diameter (mm)

Mean Range
Quiet respiration 17.2 5. 1- 28.9
Breath holding 11:!.8 7.7-Jl.J
Leg raising 17.6 9.7-3 1.0

FURT HER READING

~ykes AM, McLoughlin Rl-~ ~u CBB, Cooperberg PL, Mathieson JR.
Gray RR, Brandt R. Sonographic assessment of infrarenal inferior
vena caval dimensions. }Oimlill of Ultrasound in Medicine
1995; 14:665 668.
 Inferior vena cava EEl

Figure 9Da
Transverse plane
through the
eptgastnum
measuring the
diameter ot the
inferior vena cava
dunng Quiet
respiration

Figure 90b
Measurement at the
same level during
breath holding
B!!l Peripheral vascular system (venous}

Neck veins

PREPARATIO N
N<~tle.

POSITION
Supine.
PROBE
S.0-8.0 ~1 Hz linear transducer.
,\1ETHO D
Both longitudinal .md transverse planes to examine the vessels.
Spectral Doppler measurements are made in the longitudinal plane,
with angle correction applied.
APPEARANCE
The vessel lumen is echo-free, tht· veins are compressible and the
venous conUuence is Y-sh.tped. Blood flow is ~ymmerrica l and hiphasic
in 57%, conrinuou~ and monophasic in 29% and monophasic in 13%.
Velocity is ~~;,, t ha n I 00 cm/s.
MFASUREMENT S

Measurement location End systolic velocity

(mean ± SD, cm/s)'
Right inrern31 jugular 28 ± 15

Right innomin3te 33 ± 16
Right subcbvian If>± 10

I eft internal jugular 22 ± 16

Left innomin.lte 22 ±II

Left suhclavi.m II ± 7

R EFER FNCI:.
I. Pucheu A. Evans .J, rhom.ls 0, ~cheuhk <:, Pu~:heu M. Doppler
ultra~onography of norm.1l neck veins. Joum,ll of Clinical
Ultrt~swmcl l 9':J4;ll:36 7-37 3.
 Neck veins

Figure 91a
Long•tudinal plane
demonstrallng the
Internal jugular vein
(arrow)

Figure 91b
Transverse plane
through the internal
1ugular vein (arrow)
ad1acentto the
common carotid
artery

figure 91 c
Spectral Doppler
waveform obtained
from the internal
1ugular vein
demonstrating a
normal spectral
waveform pattern
£::1 Peripheral vasculilr system (venO\Js)

Leg veins

PRfPARATION
None.
POSlT lON
Supim:.
PROBE
4.0-6.0 ~ 1 Hz linear array transc..lucer.
METHOD
Measuremem~ performt.>d at the cmnmon femoral vein. high ~u~rfi~.:i.tl
vein, mid superficial femoral vein. low \uperticial femoral vein .mJ the
popliteal vein. Anteroposterior mca~urcmenrs taken in tlw tran~ver'l·
plane. A vein-to-artery ratio can he cakulatec..l from an .lrtcriJI mea-
surcmcnr at the same level as rhc vein measuremenr. Vein~ with .m
acute thrombosis are larger .tnd veins with a chronic rhrnmhn<a~ .tre
smaller than normal veins. There i~ considerable overlap in the mea-
surements.
APPEARANCE
The veins of the legs arc identified J ' echo-poor srrm:ture~ that are
reJdily compressible, with ::t conrimnn•~ fon..-ard spcctr::tl Doppler
trace with snmc rcspir::ttory modulation.
MEASUREMENTS
Vein-to-artery ratio calcul::tted hy dividing the anrcropo~terior v-cm
diJmeter by the anteroposterior Jrtcr)' diJmcter ar the o;amc poinr.

Vessel Vein diameter Vein/artery ratio

(mean ± liD, m m) (mean ± 'il>l
--------------------~------~--~--~
Common ternoral ..-ein I 0.57 ± 2.88 I.J4 ± 0.37

High ~u~rficial vein 7. 10 ± 1.96 1.24 ± 0.36

Mid superficial vein 6.41 ± 1.72. 1.11 ± O.Jl
Low superficial vein 6.S2 ± I .74 1. 19 ± !U2
Popliteal vein 6.HO 1 2. I I 1.22 ± 0.36
 Legveins B

Figure 92a Color

Doppler flow is
seen in the
superficial femoral
vein (arrow) in the
transverse plane at
the level of the
bifurcation of the
superficial femoral
artery and deep
femoral artery

rigure 92b
Compression
completely
obliterates the color
Doppler flow and
lumen or the
superf1c1al femoral
vein: there is no
mtraluminal
thrombus
ED Per-ipheral vaSOJiar system (venous)

Figure 92c Spectral Doppler waveform pattern obtained from the proxtmal aspect
of the superticial femoral vein showing a normal configuration

FURTHER REAOlNG
Hertzberg BS, Kliewer MA. DeLong DM, La louche KJ, Pa ulson EK,
Frederick MG, Carroll BA. Sonographic a5~:.sment of lower limb
vein diameters: implications for t he diagno-;is and characterization
of deep venous thrombosis. American Journal of Roentgenolng)'
1997; 168: 1253-1257.
 OBSTETRICS

Wui K. Chong,
A nthony E. Swartz and
Janice Newsome

Comparison of 'erum 13-hCC E~timared fetal weight

level~ and ultrasound based on biparietal
landmark' to !lC\latinnal di.tmctcr and abdominal
age on tran,\a!linal circumference 276
sono~.r;tphy (fim trimester) 24-J h !tal femur lett~th 286
Cc.~tatinnal sac (tir't Fetal humerus len11th 190
trimester) 246 ~ystolic/diastnlic ratio i11
Fetal heartbeat (first 1he umhilical ;~ rtcry 294
trimester) 2.'i0 Cerebra l ventricl e~ - lateral
Crown-rump kn!lth 2'i2 ventricle tran~ver\e :ttrial
Nuchal fold thicknt.'Ss 254 measurement 29R
Nuchal tran,luccncy Ci~tcrn.1 ma~na 300
thickness 256 I horao.:ic circumference .102
Biparietal diameter 25~ Renal pclvi~ diameter 304
Head drcumfercncc 262 M ean r.enallength~ for
Abdominal circumference 266 ~c~tOltiona l ag<.-s .l ()(,
Multiple fetal pammerer~ in Outer orbital diameter lOR
the assessment of t'ctal 'tomach diameter 112
g~tational age 270 Fetal small bowel :-ll4
Ratio of head to abdomen Fetal colon ~16
cin:umfercncc 274 l'rcdicted feral wei~ht
percentiles throughout
pn:gnancy .'WI
Amniotio.: fluid .no
S!ll Obstetrics

Comparison of serum ~-hCG levels and

ultrasound landmarks to gestational age on
transvaginal sonography (first trimester)

PREPARATION
Fmpty hladdcr for trans\·a!!inal imaging
POSITION
Mid~agirral image through embrvo
PROBE
Transva!,!in.tl: 5.0- 8.0 ~ lll z rran~Juccr

METHO D
Longest dimcn~inn nf cmhryo from top of sk ull ro hortom of tor~o.
The extrem iric~ .1re nor indudnl.
APPEARA NCF
Embryo: Hgurc-of-cight shaped solid structure within gestatinn,tl s.t..:.
Gestt~twnal s.1c: Flu iJ colle~-.-rion with high-reflective nm embt-ddc:d
within the endometrium.
Yolk sue: Spherical cystic strm:tun: with \veil-defined h•gh-reflrcti\·e
m.tr~in lyin!! within gestational sac.

M EA~U R EM E NTS

13-hCG' (miU/ml} Ultrasound landmarks Gestational age (days)

1000 ( ,c:~tational :..tc 32

7200 Yolk sac 36-40

10 000 hTJhryo with heart motion 40
· hn.t lnt\·rn~tunn.d Rdc.'rt,.'lh:t.' 1-.n.:p.u.llmll.

Other predictors ol Lllmomldl outcome:

• \kan s,u,: d.:tm~o.·ter (:-.1SD) - crown- rump len~th (CRL) <5 nun
(\·aliJ up to 9 weeks ~est.t tional age)
• Yolk sac >5.6 mm (5-10 weeks gestational age).
 Serum f>.hCG levels, ultrasound landmarks and gestational age

H 'R f HER RE ADIN<;

Brcc RL. hlwar~J, t\1, Bohm-Vd~·;r :'vi, &:vierS. Roherts J, 1\kndel<,on
Eft Transvaginal sonogr.tphy in the ev:tlu.Hion of norm.ll earlv
prt1,:nam:y: Corrdation with HCG level. AmericLln ./num,,/o(
Roe11tgeno/og)' 19!{9;153:75-79.
Keith ~C. London~:". \X'cit7man GA. O ' llncn "lj . ~tiller \ t \1. x·ri.1l
tran~,·aginal ulrr.1~ound s.:.ms and het·.t-human chorionic
gonadotrophin level!. in cMly singleton .mJ multiple prcgn.mcit·s.
fertility ,mJ Staility I <j'H;59: I 007- 10 I 0.
l!l'll Obstetrics

Gestational sac (first trimester)

J>REI>ARAT IO N
Fmpty bladder.
I'()~ITION
~upinc. Sagittal and transverse images of the endometrial stripe.
I)ROBE
.'iJl-H.O MHz transvaginal transduce r is uo,cd ior early first-trime<>ter

M ETHO D
. ( , [) sum of three right onhOAonal measurcrm·nto,
mean sac d ramett.'r " 1!> I =
3
APPEARANCE
Gc:sr,ltional sac is normally vi!>ualizcd hy 4.5 weeks with tranwaginal
...onography (TVS) as a sn1.1ll lluid collc..:tion with high-reflective rim
l'mheddcd within the endometrium.
MEASUREMENTS
P· hC<; threshold level Jbovc which ge~r.uiona l sac should be seen on
TV\:
• !olll{!:lcton I 000 mllJ/ml (first lnrernanorl.ll Rl·icrt.'rKC Prcpamrion)
• twin 1556 m!U/rnl
• JVftGIFT 3372 mlll/ml
Yolk sac norm;llly vi-;ihk (TVS)' if MSD >H mm
fmhryo normally vi!oi hlc (TVS)' if l\1SD > 16 rnm
Nonvisualizanon ,,hove these threshold levels is suggesri~e ot non·
vi,lhle pregnancy.'
 Gestational sac (first trimester) IIIB!I

Figure 93 The
gestational sac is
iOentifted as a flwd
collection (cursors)
with an embryo
present (Courtesy
of Jane L. Clarke)
ml O b stetrics

Mean sac diameter (mm) Estimates of gestational age'

Mean (weeks) 95"/oCI (days)

2 5.0 34.9 134.3-35.5)

3 5.1 35.8 (35.2-36.3)

4 5.2 ~"-" (31>.1-37.2)

5 5.4 37.5 (37.0-JIU))

6 5.5 3H.4 (37.9-38.9)

7 5.6 39.3 (3R.9-J9.7)

8 5.7 40.2 (39.8-40.6)

9 5.9 41. 1 (40.7-41.4)

10 6 .0 4 1.9 (4 1.6-42.3)

II 6. 1 42.8 (42.5-43.2)

12 6.2 43.7 (43.4-44 .0)

13 6.4 44.6 (44.3-44.9)

14 6.5 45.5 !45.2-4.UH

n.n 46.3 (46.0-46.6)

"
I(> 6.7 47.1 (46. 9-47.5)
I ~
6.9 48.1 (47.8-48.4)

18 7.0 49.0 (48.6-49.4)

20 7.3 50.8 (50.3-51.2)

21 7.5 52.5 (52.0- 53.0)

25 7.9 55.2 (54.6-55. 7)

30 :-!.5 '\9.6 (58.8-60.4)
 Gestational sac (first trimester) Ea

RH UH-.NCE
I. l>ay;l ~. \X'ood' ~. \X1;ud ~. l appalamen R, Ca co(.: E.uly
prl·gn.m~y <1\'icssment with transvaginal ulrr;:~sound s~.m nin~.
( ·,lli<l.li.m Mcdit"&~l Assoo.llicm Jnum&~l 1991; 15:44 1--446.
ml Obstetrics

Fetal heartbeat (first trimester)

------

PREPARAT IO N
f mpry l>l.tddcr for tr.trlW•tgin.tl im.t~ing.
PO~I TIOl\
Cormuf or sagerraf •mage through embryo. Locate pulsating he.ut
within the cmhrvo.
PROBE
Tr;tnsvaginal: 5.0-~.0 t-.ll lz transducer.
M ETHOD
M -Mode or spectr•JI Doppler gate placed over pulsating heart. ~pccrral
Doppler <;hould he used o;paring.ly .md avoided where pc"'ihlc hcc..1u'e
it uo;c~ grc.ttcr energ~·.
APPEARANCE
Fetal heanhear shoult.f he visible if the crown-rump length (CRI.) •~
5 111111 or greater on tranw.tginal 'onography.'
M EASUREM ENT S
FetJI brJdycJrdiJ.

CAl (mm) Heart rate (beats/min)2

<RO
5-9 < 100
10- 15 <110

R EFER ENCES
l. L1ing FC. Ulrr.tsoLmd evaluation during rhe first tmnestcr ot
prep.n.mcy. In: Callen PW. l'ltr,lsonogr,lpiJy in Obstctnt·s und
Gyu.uyu/ogy. 4th edn. \\'13 S.tunders. Phi !adelphia•.WOO.
2. I lowe RS. ls..t.tcson KJ. Albert JL, Courif;.uis CI3. Emhryonic heart
rate in human pre~n.tncy. {oum,tf of Vltrasozmd in Me,licine
I ':19 1: 10:36 7-J71.
 Fetal heanbeat (first trimester) B1

Figure 94 A spectral Doppler gate is placed over the embryo, which has a
crown-rump length of more than 5 mm. to demonstrate the normal fetal heartbeat
(Courtesy of Jane L. Clarke)
m Obstetrics

Crown-rump length

PRFJlARAT IO N
Empty bhldder for transvaginal imaging. Full bladder fo r tr.ms-
a hdomina l imaging in first trimcstt:r.
POSITION
Mtdsagtnal image through embryo. Midcoronal plane less accuratt:
Ot:c.tuse flexion/extension cannot be determined and should only Ill:
u~nl .IS I.1M resort.

!'ROB(
Tr.111sahdominal: 3.0-5.0 MHz curvilinear rranM.Iucer
Tr.msvaginal: .'i.0-8.0 MHz tr.msducer
MET HOD
Ac..:uratl' only in fi rst trimester. l.ongt·st Jimen!>ion of embryo from top
of skull to honom of rorso. The extremities J re not induded. Embryo
should nm be Hexed.
API'EARANCE
Bilobed solid density within gestation;:ll sJ..:. Spine should be visible in
long a:-..is in mids.1girral view in late first trimester.
M FASURFM F.NTS
Predicted menstrual age (1\.tA, weeks) from <:RL mca~uremcnro; (mm)
from 5.7 ro 1.! week~' (95°oCI j., ± WY,, oi rlw prnlictcd age)

CRl (mm) MA (wks) CRl (mm) MA (wks) CAL (mm) MA (wks)

2 5.7 12 7.4 H 10.0
J 5.9 14 7.7 33 10.2
4 6.1 16 8.0 35 10.4
5 6.2 18 ~u ]-. 10.6
6 6.4 20 H.6 40 11).9

7 6.6 JJ 8.9 43 J 1.2

8 o.7 24 9. 1 46 11.4
9 6 .9 26 9.4 49 II. 7
10 7. 1 28 9.6 53 11.0
 Crown-rump length

Figure 95
Crown-rump length
(between cursors) is
obtamed by
positioning the
cursors from lhe
apex of the skull to
the base of the torso.
not including the
limbs

REfF REN( ' ...

I. II.1Jh:k fP, Shah Yl'. !>..Ilion D.J. ~l.uh B. L imbn JV. h:t.ll
trown-rump lt-n~rh: Re-ev.1lu.uion of rel,uion to menstru.tl .11-(t
(5- 18 wec:b1 wirh high-resolution real-time US. R,u{iology
1992; 182:50 I- 50S.
fZI Obstetrics

Nuchal fold thickness

Pl{fPARATION
Full hladdcr for transabdominal irn.1ging.
110SITION
Axial plane through feta l skull <lngled postt:riorly to include cerebel
lum.
I'ROHE
3.0-5.0 f\.IH1 transducer is used for .1!1 ~econd- and third-trimester
ohstetric imaging.
METHOD
Performt·d hetween 14 and 21 wed.:<; gestation. \l.1ximum Ji.,t.lllCt:
from tne outer skull table to tht: outer .,kin edge. Tne cerehdlum
should he symmetrical witn tne cavum septum pellucidum visualiLed
anteriorly.
AI•PEARANCE
Tni..:kt:ning of soft tissue of the neck posterior to the occiput.
Ml- ASUREM ENTS
Normal: ~5 mm between 14- 18 weeks increases with gestational .1ge.
Nu..:h;tl fold thickness 2:6 mm hetween 14-1 !l weeks is suggestive of
Down's syndrome
FUR f HFR READING
lkna..:crrat HR. B<1r~s VA, L1hod.! I.A. A sonographic sign for the
dt:tl·..:rion in the second trimt:ster oi tht: ft:tus with Down's
syndromt:. American Jnum,lf 1J{ Obstetrh·s <111d Gynecology
l9H5 ; 15 1: I 078-1079.
 Nuchal fold thickness lfm

Figure 96 Nuchal fold th1c1<ness is measured from the outer table of the skull to the
skin surface at the level of the cerebellum 1n the axial plane (between cursors)
- Obstetrics

Nuchal translucency thickness

-----------------
PREPARAT IO N
Full bladder for transabdominal imagin~
PO SillON
Midsagitraltmage through .:mhryo.
I'I{OBE
• Tr1111Sabdomi11a/: 3.0-5.0 M H z transducer
• Trmzsv11Ri11al: 5-St-.l hz transdu..:cr.
METHOD
Performed at I 1-14 weeks. Thi~kness of the cystic area posterior to the
oc~ipur alone is measurc.:cl. Thl· skin surface and occiput are excluJeJ.
Calipers on machine !.houJd be capnhlc of measuring down to 0.1 mm.
APPEARA NCE
Cysti~ area in the sofr tissue posterior to the occiput.

M EASU R EMENTS
Normal nuchal translucenq· (1'-o'T) incrc.IM:s with gestational age:
• 95th cemile NT th•ckness at cruwn-rump length of 38 mm -
2.2 mm
• 95th Cl'lltilc NT thkkness at crown rump h:ngrh of S4 mm -
2.8 mm
Increased NT thickne~~ is suggcstiVl' of chromosomal disorder!>
(especially tri~omy 21, cystK hygroma .111d ~kdetal dnpl.!si.t!>). Curoft
fi~ures oi 1.5 nun, .; mm and 9 )rh ct:mill· h,\\:e heen used.

FlJ RTH FR R I::.AD ING

Nicolaides Kl l, Bnzm MI. <;nidjcrs R.Jl\ 1: Fetal nuchal rransluc.:n~·y:
ultr.lSound ~crcenin!!- tor ft:tal rri,omy 111 the first trimester of
pregnancy. Rrttish joum,zl of Ohstctrics ,md Gy11aecoloJ,r)'
19<J4; I 0 I:..,82-7S(i.
P.1jkrr E. v.m Lith J~ IM, ~ lol HWJ, Rlt:kcr,OP. Bibrdo C.r..t. ~creenm~
for Down's syndronw by fc.:talnuch:ll tr;mslucency mt:asu remenr
in a gener;\1 obstetric popul.uion 11/t,,zsoulld in Obstt•trics mul
Gyncculogy 1998; 1.!: 163- 169.
P~1ndya PP, Brizor ~ 1, SniJjc~ RJ i\1, Nicolaides KH fir~t TnmeMer
fet;ll nuchal translucency thicknt:~~ and ri~k for rnsomies.
Obstt•trh's 111UI CynccoloK)' 1994;84:420-423.
 Nuchal translucency thickness 1Em

Figure 97 Thickness of the

cyst1c area poslenor lo the occ1put
alone IS measured carefully
CI\Ciudnlg the skm surface and
occiput
flDI Obstetrics

Biparietal diameter

PREI'ARATIO I\
Full hl.tdder for tran!.ah<lominal im.tging in first ;tnd <.ct:onJ tnmesrer.
POSITION
Tran~D.ial imnge of f~·ral '>kull .lt level of rh.tl.tmi .tnJ ~:avum septum
pdh~~:tdum. Transducer must Ol' perpendicular to thl· paricr.tl hones.

PROBE
3.0-5.0 MI-l.- rr.m~Jucer i~ used for .111 !.econd- and thtrd-rrimesrer
oh.,retnc imaging.
;\IET HOD
:\1easured from outer edge of aannun nean:st w the transducer ro tht'
inner edge of cranium farthest from transJm:er.
AJ>l' l:ARANCF
Thalami appear a~ ~ymmetric low-reflective stnKturt-,. on cithl·r ~•de ot
linear midline high-n:tb:rivt< line (third ventride). Calvaria must
.tppl·;u smooth and symmetric bilaterally.
 Biparietal diameter

figure 98 Measurement is taken from the outer edge of the cramum nearest the
transducer to inner edge of the cranium furthest from the transducer at the level of
the paired thalami (between cursors + and+). The occ1prtofrontal d•ameter 1s
measured at the same level (between cursors x and x)
ml Obstetrics

M EASUREM ENTS
Biparietal Gestational age Biparietal Gestational age
diameter (weeks, mean• diameter (weeks, mean•
(mm) and range•) (mm) and range' )
20 11.0 ( 12.0 42 J!U ( 16.6-1'J.Hl
21 12.0 ( 12.0) 43 I ~.4 ( 16.8-20.1)

22 12.7( 12.2-13.2) 44 18.8 ( 16.9-20.7)

23 u.o (12.4-13.6) 4S 19. 1 (17.0-21.2)

24 I U ( 12.6-I 'U<) 46 19.4 ( 17.4-2 1.4)

25 u.s ( 12.9- 14.1 ) 47 19.7 ( 17.8-21.6)

26 13.7 ( 13.1-14.3) 48 20.0 ( 18.2-2 Ul)

27 14.0 ( 13.4-14.£>) 49 20.3 ( 18.6-22.0)

28 14.3 ( 13.6-15.0) 50 20.6 ( I 9.0-22.2)

29 14.5 (13.9- 15.21 51 20.9 11 9.J- 1.I.5l

JO 14.S ( 14. 1- 15.51 S2 2 1.2 ( I 9.5-22. 9)

JI 15. 1 ( 1 4.3- 1 5.~1 53 21.5 ( 19.8-23 .2)
J2 15 ..3 ( 14.5- 16. 1) 54 21.9 (20.1-.:!3.7)
33 I ).6 ( 14.7- 16.5) 55 22.2 (20.4-24.0)

34 I '·9 (15.0-16.8) 56 22.5 (20.7-2.4.3)

.l'i 16.2 (15.2- 17.2) 57 22.8 (21.1 - 2.4.5)

31'> 16.4 ( 15.4- 17.4) 58 2.3.2 t2U-24.9l

J~ 16.7 ( I S.6- l ..,.l{) 59 B.5 121.9-25.1 I
.>l:l 17.0 ( 15.9-il:l.ll 60 2.3.H (ll.J-25.5)
)'J 17.3 ( 16. 1-I!UJ 61 24.2 (22.6-25Jq
40 1"".6 ( 16.4- l lUl) 62 24.6 (lJ. l - lh. l )

41 17.9 (16.5-(9.,\) 63 24.9 (2..3.4-26.4)

 Biparietal diameter IBD

Biparietal Gestational age Biparietal Gestational age

diameter (weeks, mean• diameter (weeks. mean•·
(mm) and range•) (mm) and range•)
64 ? - ••'> \-·'
_) '6 •8)
p · !)-- IP
(- .H.o (.1 1.2-l4.0)
6'i 2.'\.6 (24.1-l'"'.ll H.~ .H.O(31.5- 34 .5)
66 26.0 (24.5- 1'.5) X4 33.4 (3 1.9- 35.1 )
67 2o.4 t25.o-r.sJ RS 34.0 (32.3-35.7)
nH 26. 7 (2'i . .l- 2X. l ) X6 l·U (32.X-36.2l
(19 27.1 t2.U-2H.4) IC )5.0 1.1 1.4-.16.6)

70 27.5 (16.3- 28.7) XX .l.\.4 (U.9- J7. 1)

71 27.9(26.7-19. 1) H':l l6. 1 (34.6-37.6)

72 liU IP.l- 29.4) 90 lf>.f, !.U.I-3X. I l

-l 28 ....,. (2""'.6-29.8) ':I I "\-")(' '-" ·-,
) ·- .).)... . ~-.>!\.)

74 29. 1 (28. 1- .lO. I) 92 .l?.H (36. 7- .lX. 9)

75 29.5 (28.5- 30.5) 9J l X.X (.l73- W..ll

76 30.0 (lY.0-3 1.0) 94 W.O (.P. 'i-40. 1l

--
I 30.3 129.2-3 1.4 ) 95 39.7 (.lX.5--4U.9l

:'S lO.X (29.f>-.H.O ) 9(, 4 0.n (.N. I-1 1.5)

79 .>1.1 (19.9-32..5) 97 4 1.0 (.\9. 9--42. 1)

xo .l 1.6 (30.2-3.3.0) <JS 4 U i (40.5-43.11

81 .H. I ( )0.7-.B.5J
\X ,·,ghr,·J le.•-.r n1l'.to ''Ill·'"" fir ~<Ju.mun: Ill'() unml - ;4, ,-o I + '.Ill ,-c .A
11.1).14 I(,:\ t wh,·r,· Ill' I} " rh~ h•p~ncr~l JJ.lnll'h'r ,,n,t <.A •< rh,• nw.m "-''''·"'""·'' .1~;tc •.
')f)ttH \ ,10,1tiH0.

f URTHt::K READING
Kurt7 AB. Wa p nl'r HI. Ku rrz RJ. lk r,h.lw DD, Ru bin CS. Cole·
lkugler <.:. ( .olll hcr~ Kit An.1ly' i' oi hip.1rieral di.lml't<•r .1~ .111
.1.:.:uratc indi.:.Ho r of ~cst,uion.ll .1gc. Joumul ol Clmtc.ll
Ultr.,smm.l I <JSO;H:.) 19- 326.
ml Obstetrics

Head circumference

PREPARAT ION
J-=ull hladder ior tran!><!hdominal im.1ging in first and sewnd trimester.
POSITIO N
Transaxial image of feral !>kull ar level of thalami and cavum scprum
pdlucidum. paralld w the skull h,1~.
t•ROBE
.t0-5.0 MHz transducer io, uo;ed ior all <>econd- and third-tnme:.rer
ohstctric imaging.
METHO D
<)uter perimeter of cranium. Alrcrn.trively 1r can he calculated hy the
following iormula:
1.57 x l!ourer-ro-outer BPI> I + louter-ro-ourer OfDil
where BPD is the biparietal diameter and Or:D is the occipiroironral
diameter.
APPEARANCE
Th.1bmi appear as symmetric low-reflective strU<:ture~ on either ,.iJc of
linear midliuc high-reflective line (third vcnrridc). Calvaria mu-.t
.1ppcar .;mouth and "ynunerric hi laterally. The cavum seprum pcllucidi
mu~t he visihle .mreriorl y and thl· tentorial hi..ttul> po,.tt:riorly.
 Head circumference EJ

Figure 99 In the axial plane at the level of the thalami and the cavum septum
peltucidum. parallel to the skull base. an outer perimeter of the cranium is
constructed
ml Obstetrics

M EA~ UREMENTS

Head Gestational age Head Gestational age

circumference (weeks, mean circumference (weeks, mean
(mm) and 95%CI) (mm) and 95%CI)
80 13.4 (12. 1- 14.7) 190 21.2 (19.8-22.8)

85 13.7 (12.4-1 5.0) 195 21.6 (20.0-23.2)

90 14.0 (12.7-15.3) 200 22.1 {20.5-23.7)

95 14.3 ( 13.0-15.6) 205 22.5 (20.9-24.1 )

100 14.6 (13.3- 15.9) 210 23.0 {2 1.4-24.6)

105 15.0 (13.7- 16.3) 215 23.4 (21.8-25.0)

110 15.3 (14.0- 16.6) 220 23.9 (22.3-25.5 )

I I5 IS.£> (14.1- ln.9) 2.,-

_) 24.4 (22.1 - 26.7)
120 1.).9 ( 14.6- 17.2) 230 24.9 (2.2.6-27.2)

125 1113 (15.0- 17.6) 2'-

.>.) 25.4 (23. 1-27.7)
130 I n.6 l 1S.3-17. 9) 240 15.9 (.B.6-28.2J
us 17.0 (15.7- 18.3) 145 26.4 (14.1-28.7)
140 17.3 {16.0-18.6) 250 26.'} (24.6-2~.2)

145 1-.7 ( 16.4-1 9.0) 255 27.5 125.1-29.8)

150 11:!.1 ( 16.5- 19.7) 260 28.0 (25.7-JO.J)
155 I S.4 {I f>.H-.20.0) 26) 28.1 (25.R-.10.4 1
160 I S.8 ( 17.2-20.4) 270 2~.2 (2£>.9-31.5)

165 19.2 ( 17.6-20.8) -.,--' 29.8 (27.5- 32.1)

170 19.6 ( I 8.0-21.2) 2RO 30.3 (27.6-.H.Ol

175 20.0 ( 18.4- 21.6) -')8-
.) 3 1.0 (28.3- 33.7)
ISO 20.4 ( I8.R-22.0) 290 Jl.f> (2R.9-34.J l
185 20.1> ( 19.2-22.4) 295 32.2 (29.5-34.8)
 Head circumference ED

Head Gestational age Head Gestational age

circumference (weeks, mean circumference (weeks. mean
(mm) and 95%CJ) (mm) and 95%CI)

300 .E .S (30.1-35.5) 335 l7. 7 (34.3-4 1. 1)

.~0' U.5 (Jll. 7- 36.2) HO .~s.s c.H. t-4 1.91

J IO 34.2 (3 I .5- 36. 9) 345 J9.2 (.H.H-42.6)

3 15 l4. 9 1.n .2-r.t>l 350 40.0 (36.6-43.4)

.no , J X-
_,, ,- _.,- (.>-. 38 ·-J) 355 40.H (.)7.4-44.2}

.ll5 ~6.3 (32. <J- 39.7) 360 4 1.6 (3H.2-45.0)

.HO U .O (.B.b-40.01

H 1RT HER READI N C

H.lJiock FP. Deter R L, I turisr RH, Park ~f..... Fetal heaJ
ctrcumference: rebrion ro mcnsrr u;ll a!!c. Americ,;n Journ.:zl of
RoentgL'IIology I YX2: 138:649-653.
B!:l Obstetrics

Abdominal circumference

PRFPARATJON
Full hbdder for tran!>ahJominal1maging in lirst and ~e~:ond trimeo;rn.
POC\ITION
Transwrse ima~t' of feral .1hdomcn at level of the stom.1..:h and intra-
hepati~: umhili..:.1l vein.

PROBE
3.0-5.0 ~1Hz transabdonunal tran.,Ju..:er i.; u~ed for .111 second- anll
third-trimester obstetric imaging.
METHOD
Length of outer perimeter of fet.l l ahdomcn.
APPF A RANCE
In the correct pl.1ne, thl' ,1hdomcn ~hould .1ppcar round {rather th.m
ellipric.tl}, the rihs .uc ~yrnmetric .llld the ..:onlluence of the ri~ht :md
left portal veins and the f~:ral srom.tch should he vi~ible. The inrra-
hcpilti..: umbilical vein .1ppe.us in ~hort :t).l!>.
 Abdominal circumfet"ence DJ

• • • /

• / 0
• / Sto marn
/
•
•
• /
•
•
•
• •
•
'' '
''
'' -
....., ''
•
'' '
'
j •
•
~J ve1n
•
•
•
.. •
• •
"e0'111uenc.. • • •

' •
'
.
~

Figure 100 Abdominal circumference is obtained by placing electronic cursors

around the perimeter of the fetal abdomen at the level of the stomach. 1ntrahepahc
umbilical vein antl confluence of the right antl left portal veins
f!!l Obste trics

M EASU REM f NTS

Abdominal Gestational age Abdominal Gestational age
circumference (weeks, mean circumference (weeks, mean
(mm) and 95%CI) (mm) and 95%CI)
IOO 15.6 ( 13.7-17.5) 2 10 25.4 (23.2-27.6)

105 16. 1 (14.2-1H.O) 2 1) 25.9 (23.7-2R.I )

I I0 16.5 (14.6- l !l.4) 220 26.3 (24.1-28.5)

11 5 16.9 (I 5.0- 18.8) 21"

_.) 26.8 (24.6- 29.0)

120 17.3 (15.4- 19.2) 230 173 (25. 1-29.5)

125 17.8 ( 15.9- 19. 7) 135 27.7 (25.5-29.9)

uo 18.2 (16.2-20.2) 240 28.2 (26.0-30.4)

us 18.6 (16.6-20.6) 245 28.7 (26.5-30.9)

140 19. I (17. 1-2 1.1 ) 250 29.2 (27.0-3 I .4 l

145 19.5 (17.5- 21.5) 255 29.7 (27.5-3 1.9)

150 20.0 (I 8.0-22.0) 260 30. 1 (27. 1-33.1)

IH 20 .4 ( 18.4-22.4) 265 30.6 (27.6-33.61

160 .!O.S ( 18.X-22.8) 270 3 1.1 m u -34. 11
16) 21.3 ( 193-l.U) 27.'i 3 1.6 128.6-34.t>)
170 2 1.7 ( I '1.7-23.7) 280 32.1 (2'i. l-35.1 )
1-.s 22.2 (20.2-24.2) -
1 !)"
.) 32.6 (29.6-35.6)

180 22.6 (20.6-24.6) 290 3.1. 1 (.lO. I- 36. I)

185 l.l. I (2 1. I- 25. I) 295 33.6 (30.6-36.6)

190 23.6 (2 I.f.-25.6) 10 0 34. 1 (] 1.1 - ."l 7. 1)
195 24.0 (ll .X-26.2 ) 305 34.6 (Jl. J-J7. 1)

200 24.5 (21.3- 26.7) .l i O 35. 1 (32. 1-38. 1)

205 24.9 (22.7-27. 1) ."l IS 35.6 (32 . 6-.~ H.f> l
 Abdominal circumference lfm

Abdominal Gestational age Abdominal Gestational age

circumference (weeks. mean circumference (weeks, mean
(mm) and 95%CI) (mm) and 95%CI)
320 36. 1 (.H.n-JI\.6) '4-)
,) .UL7 (36.2-4 1.2)

Jl5 Jn.li (.14.1-.1~.1 l ··o

l) YJ.l (.16.7-4 1. 7)
.n o 37. 1 (.l4.n-3':1.6l .l55 .39.7 (37.2-42.2)

3.15 r.6 (J'i. l -4o. l 1 .360 40..! (37. 7-42. 7)

HO ~R.I (.H.n-40.o) )65 40.H (.lfU-4.1.3)

Furtba re.J1Iing
hom H;~d l ock FP, Derc:r RL, Harrr~r RB, Park SK. Ft:tal .thdomin.tl
.:in:umferen.:e as ,1 prc-di.:tor oi m~·nstru.1l age. Amcric,m /llltiiMI
of Roentgcnnlo~· l':IH2; 1.W :367-J70.
El!l Obstetrics

Multiple fetal parameters in the assessment of

gestational age

JlREPARATIOI\o
Full bladder for rr.m<>.li>domin.tl imagin~ in first :md second rrim~srer.

JlROBI:
3.0-5.0 ~ 1 Hz rransabdommal rr::msdm:t•r is u~ed for all second- and
rhird-rnmcsrer ohstetric ima~ing
MFT HO D
Take the mean measurem~nrs for the lour par.1meters - biparietal
diameter, head -.ircumference, abdomi rul circumference, femur length.
Find the mean gestanonal ages of each, add them together .md divide
by four.
 Multiple fetal parameters in the assessment of gestational age

MEASUREM ENTS

Mean Mean Mean head Mean abdominal Mean Femur

gestational biparietal circumference circumference length
age (weeks) diameter (mm) (mm) (mm) (mm)

11.0 ,- 68 4(1

12.5 19 7) 5J 9

n .o ll X">
t - 60 II

13.5
.,,
- -l 89 67 12

14.0 l5 97 -3 14

14.5 .,- 104 xo 16

15.0 29 110 Xo ,-
15.S 31 I I ., •:n 19

16.0 32 124 '-)') 20

I 6.5 34 13 1 1()(1 n.
17.0 36 (3g I 12 24

I --' JS 144 I I9 J -
-·'
I X.O )9 15 I 125 r
18.5 41 ISS 13 1 2X
19.0

19.5
43
4)
164

1""'0
··-
.l

144
30
>I
20.0 46 177 150 .B
20.5 48 l tl3 15f> lot

lJ.O 50 18'1 162 H

-') 1__,• 51 I'~' 16X
,_
_,.
.,
,_,
22.0 20 1 .-4 'S
lt

-'2 ·-'- 55 10- .-') 40

&a Obste t rics

Mean Mean Mean head Mean abdominal Mean Femur

gestational biparietal circumference circumference Length
age (weeks) diameter (mm) (mm) (mm) (mm)
23.0 56 lU I H5 41
23.5 SH 219 19 1 42
24.0 59 224 197 44
24.5 ol 230 l Ol 45
25.0 62 235 2.U8 46
-'5 . -
.) M 24 1 213 47
26.0 65 246 2 19 49
26.5 67 151 224 )0
27.0 f,R 2Sf> no 51
27.5 69 261 235 52
28.0 71 266 240 54
-'8 -
.) 72 271 24o H
29.0 7] 2~5 2'1 1 56
29.5 7.5 280 256 57

30.0 "76 2!{4 261 )8

30.5 77 288 266 .)9

31.0 78 .!93 27 1 60
3 1.5 ""'9 297 276 61
32.0 81 JU I 18 1 62
32.5 82 .104 286 61
33.0 83 .308 291 64
33.5 !l4 312 21)' 65
34.0 8.5 3 15 JOO 66
 Multiple fetal parameters in the assessment of gestational age

Mean Mean Mean head Mean abdominal Mean Femur

gestational biparietal circumference circumference lenglh
age (weeks) diameler (mm) (mm) (mm) (mm)
34.5 Xfl w~ '0-
.> .) {-,...,

35.0 IC .)
'}) __ .J09 6S
.b ..' XX 325 ; 14 6'1

36.0 X'f _,_

')8 ) IX '7()

36.5 !::<I 330

,..,, ~ ,

-'- ·'
r .o YO '''
.l _l .) ]2...., 7l

37.5 ':J l l.)S 332

...,, .)

38.0 42 '"S
,.) . l 336 74
JH.5 'J2 l4() HO 74
,W.O •H '4)
) - 344 -s
]9.5 ':14 l44 348 -6

40.0 94 l46 l53 T

FURTHER REAL>ING
From I i.ldlock FP. Deter Rl.. llarrist Rn. I' a rk ~~-. . F'i!imated kt.ll
.1ge: .:omputl'r·.l~!>i~reJ .m.1 l y~is o f multiple tetJI ~rm\'lh
par,1 meter~. R.t~dioloKY I ':11:!4; 152:49- - 501.
EEZI Obstetrics

Ratio of head to abdomen circumference

PRFPARATIO N
Full bladder for tr ,ms.1hdominal imaging in first and second trimester.
POSIT IO N
Tran~axial image of fetal skull at level oi thalami and ca\'Um septum
pellucidum. Transverse image of feral abdomen at lt:vd of the ~tom.Kh
and intrahepatic umbilical vein.
PROHf.
3.0-5.0 \1 Ht. transabdominal tmnsducc:r is used for ;til second- and
third-trimester ohsretn<.: tmaging.
MfT HOD
Outer perimeter of cranium. l xngth of outer perimeter of tetal
abdomen. Eln.m:d he.1d to abdomen cin:umference ratio is a sign of
imrauterine growth n.• t;lnJatton (Sm;tll for gl-station.ll .1ge).
AI'PEARANCf
Thalami appeilr as symmetric low-retlccrivc 'rructures on either side of
linear midline high-rdlccri,·e line (third ventricle). Ctlvaria must
appc.tr smuOlh .111d symmetric hil.uemlly. The cavum 'cprum pdlucidi
must he visibk anteriorly and the tentorial hiatus po!>teriorly. In the
correct plano.:. the ahJorncn should appear round (rather than c:llip-
tic.lll. the rib~ .ue symmetric and the contluencc: oi the right and left
porml vei n~ and the fetal stomach should lx· visihlc. The intrahepatic
umhtlical vein .1ppe.us in !>hort .n.is
 Rettie of head to abdomen circumference lfm

M t:A~U REMENTS

Gestational age Head circumference/ abdominal circumference

(weeks) (mean and range from 5th to 95th percentile)
13-14 1.2.1 ( 1.14-U I )

15-16 1.12 ( I.OS-1.\IJ)

17- I X I. I X ( 1.07- 1.29)

I 1.)-20 I. I X ( 1.09- I..W

2 1-22 I. I .'i ( l.llf>- 1.15 l

:U-24 l. l l ( l.ll'i-1.2 11

2)-26 I. 13 11.114- 1.22 I

1--1!\ I. U ( I.U.'i 1..?.1 I

I. 10 (0. IJIJ-I.l l )

.l l-.l2 1.07 (0.%- 1. 17)

l.ll4 (0. ':16 1.1 I

.l5-.l6 1.02 (O."J.) 1.1 I l

.U-Jil ll.'JX (O.I.Jl-1.051

ll. <J- ( ll.I:P-l.l)f> I

41-42 0.% (O.'J.~- 1.00 )

f URTHER READING
from li.H.ilock FP. Deter Rl.. 1-!Jrn!ll RB. 1\trk ~"- Frt.JI .1hdominal
l:in.:umference a~ a predactor of llll'llStru.tl .t~e. AmertCIIII /oum,ll
of Roc,tgL'IIr~lo.t..'Y 19X2; JJ<J:.ln --l "70.
fD Obstetrics

Estimated fetal weight based on biparietal

diameter and abdominal circumference

PREPARAT ION
Full hhtdder for tr.m.;.thJomin:tl imaging in first and ~l'~oml trimc~rcr.

PRO BE
3.0-5.0 ~Hh tntn,.thdommJI tran<>ducer is used for <til ~n:und - and
third-trimester olhtt•rri~ im<tgingf
M ETHOD
log (BW) = - 1.74':}2 + 0.166 BPD + 0.046 A<.')- O.OOlM (AL x BPD)
who:rc AC is the .tbdomin.tl ~ir~umfcrcnce. BPD is the.' hip:~ril·t.tl
di.um:tl'r and BW i~ the htrth weight (in gr.ams).
mJI Obstetrics

Abdominal circumference (mm)

8PD(mml 155 160 165 110 115 180 185 190 195 200 205 210 215
"(l'i -ll --- "N N04 Hill Nil. Kbl Yl! ~41 ~- 1 11~1! lOll
"111 "61 r· Hill Rl7 NO NNII 'Ill- 1116 ~1.1 'I'll> 101- llll>ll
~, 1 -., ..,'}'J Nl4 HI() N7b YIN 912 91>1 WI 1022 lll14 IUN 7
,_l ..,tj- g!! M- N"4 IIIli 'llll "' 'IN" 1111- 1114'1 IIlli I II 14
-; "'11> Hlll H4\ H7 1 NYH 'Ill Yl4 'l~j lUll Ill' un, I Ul9 1141
"fo HI~ 844 !Pil ~'If. 921 91 1 "NU 11~1'1 HI4U HJ7! 1104 11r 11"2
77 N4l Nf>l> N'14 '~ll '14'1 y-- IIlii • lOP IUM IHMI 1111 111,7 12112
"N ~R R94 'I!U 'H7 ""< IU114 ICII4 llll>i Jll'lf, 112" 111>2 11'1" Ill!
"Y k91 919 1141\ ""4 Hllll 11111 lllf>.! I!N4 1126 llW 11"1 lll~ I!M

---------------------------
Nil
)(1
'11'1
1141>
9%
,.-1
.. -\ IIMI! lUll IClf>l 111'11 11!.3 llif> llk'l 1!.!4 I!W 11"1>
IIMII IUIO IOMl IO'JO 1121 IIi\ 111!7 1!11 1!'1> 12112 Ill"
Hl 1174 lOili llllel 111<" IUH~ 11!11 Il l! IINI 121N llil I!NK 13!1 Ill>\
Nl 11102 lUlU 111<" lllX'I II lii 1111 IIN1 Ill" IHI I.!SI. 1121 11\'1 11'1"
N4 lUI! 101>11 111'111 lllll 11<1 IIN1 1111> 1249 I!N4 lUll IHf> IW4 1411
HI ll)f.2 lf)9J lUI 11<1 IJMI Ill!> 114'1 llNI IIIN 11H IWl 14111 14~>"
HI> 111~1 II!.! 1111 IIN4 llll\ 124'1 12N1 111N IJH JIYII 142M 14t.- 1111"
N7 1111 1151 IIMt. 111M 121fl 12N4 IIIN IHI II'IH 142" 141>1 1101 1141
NN 111· IIIIN 11!11 1!12 llH< lilY 1114 11\111 142- 141\1 Jm4 1>41 IIH4
k~ 1191 I!!.! 1214 llH- llll 1111. IIYI 141M J4f>l J;(ll )141 JINl 11.!1
\Ill 1226 12\~ 1!"11 liN IHK 1\Yl 14l'J 1·4'1> li04 1'41 IIHl 11.!4 1.,.,..
Ill Ill\! 12'14 II!" I 1#.1 119f, 1412 14hM 1101\ J\44 I'M 11>14 IMI\ I-IlN
'11 12"9 131! 111>1 I41KI 1411 14-1 IIUK b41. liNt> 11>211 11>1\- n101 1"12
~~ 1117 n-u 1-1114 1419 1471 Ill.! IIIII IIKR lf>!K IMN 1-111 1'71\ l "'<f•
'14 1176 1410 14-14 14~11 i\11. I H4 IIY! 11.11 1671 1-1! 1-11 17YN 1M2
Ill 1416 14111 14~1> Jill IH\1 ll'f- 1"11 11>"1 1-lf> l-IN ININI IN44 INM"
% 14~~ I.J'I! I\!~ l~ft~ l~lt! 1*""'1 lt.KU 1-2.0 1-h! (XH.. IX.f- IH"'.! I'H-
y- lltKI IHI 1.1"! lf,IIY 114" I ~NII 1-!11 1-(,- IHIW IHI! IN'II 19411 I'INf•
QH 1144 l.IHII lhl" 11>14 IMII 1"11 ~--1 INii IHI- I YI~I 1'141 JY\1\J 1017
"" IIH'I 11>25 11>6.1 1-11 1 1"411 I"KI IXl! IKM 19U7 1"11 1'1'11> !114! !IIX'f
1110 lt-31 If>-! 1-ltl 1-4'1 l"N'I l~lel IN-1 IYI4 I"IM !IMI2 !114M !11114 214!
 Fetal weight based on biparietal diameter and abominal circumference

Abdominal Circumference (mm)

SPD(rnml 22G 225 230 235 240 245 25G 255 200 265 270 275 280
II N< 4 1! 4ll 4111 4"11 4'~1 HI <II> H~ 'H4 f>lll f>IK """
I! 41lt 4 .:!'\ 4-41 4~ 1 4M I 'ill! ~!' '~X ,-! )q- t.l4 h'l Mffl
H 41' 4 ll 452 4"! 4'11 114 II" il\l> '~I f>l l f>IX ""'' ""'
14 4!1 444 41>\ 4KI <114 l!t, H" 1~1 I'IX liH f>i! !>XU "Ill
II 4\f> ~H 4"1 4'1i q · i\'1 II>.! IX" h i .! 1\ lH f,i,f> M'' "!'
It, 4r 4M 4Kf> <0" 1!'1 ill 1"1 MWI h.!l> MJ 681 "Ill "411
·HS 4-~ 49R 'J~ '4.! '*'' .:j)i11 hH h4U Ml- #.IJf. -z, -,n
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4q4 >!4 Ht. ~~~ <HI Mil> "II ,,- I>M4 "II "41 ""I !!<If>
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, ... \ 'ii.Jfo 6.!U t.44 f,~u n~t. 72-J ....\\ "'t\ l HH N-lf, X.))ll ') I 'i
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hi" M i 6M 1>~.! "IQ "4" ""1> HIU. HI" H"ll 'in: 'i\X ""I
h\1 6\" 6~3 "UN "In "f>) -~ 4 S1 ~ Mlh WS~ 9!1 ~i~ Y'lh
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""' t-'111 "I" "44 •• , ~HI ~q X..l ~~~ <Jl'i <JM IIHII II>N
f>),! -,1~ "14 "f,! " "<I ~!II XII S~l 9 1,_ <hO 'l~f, lfl.!l IIU.I
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"I" "41 "" 1 "'I<J X!S "'" S"l 'I!~ ~;,; <NJ 1030 HII>S lltl"
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X'lh Y!- '1~~ i1YI IU.!~ ltl'\1.,1 1UYh IIH 11-1 l2.11 l!'l L!'·H I~W

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mJI Obstetrics

Abdominal Circumference (mm)

.,,BPIJ(mm) 220 225 230 235 240 245 250 255 260
1066 IICNI JIH 11-1 1211~ IH- !!It- ll2R I J7U 1414 I H~ l ~lt'i I H~
265 270 275 280

-1 109J II!R II~~ I.!CKI 12.11! 12-- Ill- IHI! 14UI IH~ 1491 lql! I~Rt>

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-4 114Y IIH4 122 1 us<~ 12.,.- 1Hs u-.. 1421 14~' 1<11 111- I"'" 16><
11-R 1214 12\1 121!'1 1111! Ill>" 1411 14q H'l'l c;H I\~! 10>411 lt.'ltl
-, 110- 1244 llHI ll2U llt.tl Hfll 14~4 HIC !HI J'-9 ll•r lt>-t> 1-2-
I!JM 1!-1 Ill\ liS! JIYI 1414 14~ II!! J>t.- lf-14 11>1.1 1- 1! 1- M
'X 116" l ltlt. llH liM I 1421> I41•M 1511 I--- If-Ill lt\50 11>'1'1 1-4'1 I HOI
"'Y 1.101 l.lW 11-x 141M 14611 I HI.I 154"' 11'1! lt.l~ lt.H- 171"' J7H- IMU
Hfl l.lH l r ! 141! !HI 14'1~ 111M IIMI lt\2'1 lt.71> 1"'!1 , .,.,, IR!t. IM-'1
HI 116"' 14111> 14•11. 141!1! Jill 11"'1 11>20 IMl• 1714 1"'1>1 11!14 11!66 1'11'1
X! 141ll 1441 14Ml 11!-1 lit\- 11>11 lf,;- )-(14 I-n 11!11\ 11!14 J'l(" l'lf>ll
1!1 14)1> 14-- l'il~ 1~ 1 lt>tll 11.10 16% 1-44 I-'ll 11!4\ 11!91 194M 1110!
1!4 14-j l.lll Jl.i'i 11'1'1 11>4\ lhR9 1-H 1-1!4 11!\1 IHH4 1'111> 1'1911 21)41
1!1 J\10 Ji l l l'iY4 lhl- lhH! 1-!R 1--1> 11!!1 11!-1 1"21> 1"-" 2033 2U8"
Hn 1'4N Jll<'l lhll 11>-- 1- 22 ,-,y 11!1- IKM I'll- I'~I.Y 2012 211-- .!IJ4
x- l'iRn In!') 11>-1 1-1- 1-M 1 ~11 IH5Y 1'111'1 IYI>Il .!1111 !IH>., 11!! ll-'1
I!M 1621> 166'1 1-H 1-W I Kill, ll!i4 I 'Ill\ I'll,\ !IKII lOll! !II l 2 11>9 .!!!1>
1!'1 !lin- 17 11 17 \1. IMtl! 11!4'1 11!'17 J'l47 1"91! 21110 lHJ.I 11.1" 2! 16 :!:!-4
'Ill 1.,0'1 1-H 17'19 1~4~ l~'JI I'J4 ! 1'1'1! 2U44 .!U"7 .!Il l .22117 !2M 2.11!
'II J-;;1 1~q- 11<41 JR..Jil J9\M Jf·)~K 2U.l~ !UY I .'!144 .!Jt,~'l 2.!<'i !.lJl l.l-2
'll 1-Y!> 11<41 11!~1! IYlh 1'11!4 !till .lll~l. .l lW 21'11 224M 11111 !l!>l 24ll
ll \ HW I UUC PH.-.1 JV"'.! ~Ill.! .!CUH ~ 1 ; 1\ ! ) )(t\ !:!4..! !!'~H ..! Ht, ~414 24 -~
'14 lXX- lq~ I'll<! !lll(l !ORO .!112 .21~4 .l!l~ 22<~1 .lllll .24(1- !46- .Hr
t.J' 19H )4Jll! !OlH !tum !l \() .!I~.! !.!.H .!.!M'i ,!14' .!-IH! ..!4f-U !~:!tl .!~M!

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.,- .!1111 !OR! 2111 211!1 llll !lllf. 2340 !3'16 Nil Hill lnl .2611 !tWI
'J}ot 10H.~ ! I t\ !IH\ !.!l4 llH6 ll40 .!3~' !4Ci l .!<U~ 2<tt7 .!~.!- ,!f,)(S 27~1

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JHU .!19 1 2241 !l'-'.! .!l44 ll'l- !452 .!5U- .!\M ..!ll!l .!~X.! .!-4\ .?~Ut. .!M-0
 Fetal weight b ased on bipariet al diameter and abominal circumference ED

Abdominal Circumference (mm)

9PD (mm) 285 290 295 300 305 310 315 320 325 330 335 340 345
\1 f,t)h -2 ~ H.!H Mf.. ~ 'let t -.H ~~~ ltl!'l ill- \ 11!1 11-l
1! -HI -4! M44 MM.! '1.! 1 "~ I ICMI4 i 04R 111'14 11 41 11 '11
-!~ -,7 -'KI ~1\ llbl NW '11~ .,.,<1 Ill!.! lllh- 1114 Jll,l 1! 14
--~ 1) -, MHI> S41 H-M '1 tt.. 'ICi,., 'I'IH ICJ.II 111M- 1114 IISI 1.!1\
-;, -R9 ll! 1 ll\ll H'lh q \... Y~~ 101- ICII>I 1111- 11'4 i!CJ.l 1!11>
-- , HUI 8.JtJ x-f> '~ l l "'Cj\ ~\ I CII1> ltl~n II!- 11-\ 1!!1> ~~ -x

- H~ H.!! !<i- ~...,, ·nt -..- a lU I ! ltt'f• I lUI l l ... - I )"if• ll..t- I tUO

Mill Ml9 ~-4 91 1 9111 'I'ICI tUt.! IU-h 11!1 l iM\ t!1M l.!,'i ll,!\
ISH ti'i6 S"'~.! 'JlU Yf,\J lf)(l'f IU"! Uffll 114.! II ~· 1.2-ftl 12Y! 1\41\
ld'< x-4 'Ill ~4'1 'INN ICJ!'I Ill- ! Ill - 111>1 1.!1! J.!o.! l l l l 111>'1
x;- M'l.! '1!9 'I~H IClllM 1114'1 111'11 11\X llMI I.!W 1!~1 Ill~ 11'11
s· ~ 'Ill '<-IX vx• ICI!N 1n• u Ill~ liN l~n· 12<1> lliiM 11~>1 1~1 ·
X" I '1111 'I~~ 1<1()- IH4X ICJ'll 11 I> I lXI 11.!'1 1!-., IJ31 13Xi 1+11
'II! '14'1 'Ill- ICI!- 1<11>'1 II I! Ill- I .!IJ.I I~\! ll<H I HI 14111 HI•-
'H.! 'Jt.9 IHUN H...aH: I ll~· tll4 lf ...'J J.!.!f'- 1!-Ci l l!h llMtl 1.4 \Ci 1-I \J.!
'1\1 'IX'I IO!M JCJ(,'I Il l ~ Jl\f, l!ll! 1! 4') 12"'l I HI 1-IU-1 141lf. ildM
•1- 1 IIIII> HWI ICI'II 1114 ~~-~ l!!i 1! - 1 11!1 11-< 14111 14XI> l \4\
'I'll ltlll ltl~ l 111 \ II\ ~ 1!111 124M IN- 1\4~ 14111 14" lq.! 11-1
ltlJI 11112 Hl'J1 Ill; 11 -., 1!!1 1r1 II!.! il- l 14.!1> HM: 111'1 11'<4
11114 111--1 Ill\ IIIX l!lll IH'I 1!'•- 114- 11"" 14i! IIIIX ~~~~ l~!f>

JU'~ Ht'M J I it\ 11}(1 l .!.!t, I!- l ll!.! I;-,! J4.!' 14-t.,i I';.; 1'~4 l b H
IU-M l ilY' llhl I.!U' 1.!'1 J.!~s J\4- J\~X 14'1 1\ttf> Jif>~ l{..!.! I~)(;

111J I ll·t! JUH I!!~ 1.!-,., 1\.!l n-t 14.!( 14- X t'H 1~'1 1 lh'l 1-11
11!4 liM I!CIY ll\4 llcll 114'1 PW 141! IIIli> II".! lf>!fl l ...~n 1-4!
, .... ){ tl'lf" J.!t~ 1 2-~ 11.!- n-,., 1-4.!•~ ... tn.s
a ~, '~ J'o.H• It-·•"' .-~~~ , - -;
11-! 1!11 1!1'1 iltll 11<1 14<l! 1414 1\CI- ilh! 1.. 19 II>-~ 1-411 1 ~<11

II'>"' 1!-11~ 12l<l 11\2 1\XII 14111 l4l<! 1111 !I'll IM'J 1-ll'l . - - 11 l XII

I!!! I!M, 111 I I HH 1-tcl- I-IlN 1\icl Hh-1 If,! I 11-•'J I~W !Hell I~M•
1 ~4X 1.!~! 1 H)( HXfo 1 -H~ 1-IMh l'd'J 1'\'I..J lhH 1-W ~--o U04 II<'-'"
t.tl 1!-·1 Ill'> llN. 1414 14M hll 1'~'1 lt..!-1 lhX! 1- 41 lXII.! IHM 141!

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ll.!X 1\ -~ 14.!.! l·rt I\.!.!,,-, Jt,\U II\~~,-.,, I~Ui IMbK l 'H.! J~"<.j

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ll!\;, l·.n.! )4)(1 1'~1 l'~t lt-.\- lt\\Jl a-q IXIH HC:! lql( .!tllfll .!tH,<.~

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144-1 14"1 1\41 11'14 )1,-1- n1! 1-1., l XI- IK-K 1'141 1•1<11> !11-1 !14!
''"
14- -1 l~!\ ,,-... lfl!h lh-~ , .. ,, ~ -~.! Jh:'.! 1"'1l 1"-t. .!lH.! lt•~"~ 21 ..c.•
l\tli tH\ IMif- It>\). I - l l l - 1\'1 IS.!-. 1"')\- 1~1'1 .!til! .!U-,.. .?1-1- !.!I-
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E3l Obst~trics

Abdominal Circumference (mm)

BPOtmm) 285 29CJ 2'95 3011 305 310 315 320 325 330 335 340 345
71 !hOI II>H Ptlf> 1-1>1 lXI- IM-~ 1~14 l 'l'lt> 21ll'i 212~ 2191 22t>2 H.\4
,, 11>'11. lb~M 174 1 I ~'#!> IMH 1'111 ~ ~- 1 .1.044 209M liM llU .1.102 21-~

lf>-1 1723 1--r IU! 1~'10 1~4~ 201"' 20-2 211- lW.I 22'.1. 2141 !4 11'>
~~~ 1->9 IHI\ IH!>9 IY!~ 19~- 104M 211 1 21~1> 1244 !II\ !IH4 !4>H
1-4.1. 1-9~ IR~O 190- 1%~ !Ill~ .!OM- .!l'il 221- llf>~ 2H4 2421> l.~UI

~--~ 1~33 IMM~ 1~41 .1.004 2(~1 lll- :!.192 225~ 23.1.6 .1.39, l4f>'i .1.144
1){16 1H""1 1V!- l 'l)t\ !U44 ~1U\ .! lhK !,!"\l .:!100 2lh'l 14·10 .!'I l ,!\~).:

tXH 191U 1'/fo.f., lUl\ !UN\ .!14h !!H) !..!-i .!Hl .!41.! .!4~ .?.ii- .!&J.l

Il l 1~7l 1031 20H9 2 1 4~ 2211 .1.271 2140 140- 24~1> 2147 2f>!fl !t>•H !"7,,
X.! !llll> 107l .!Ill 2 1 ~1 !!H 21 1 ~ 2lX5 141>2 2522 2l'l4 !M- !'41 !Hl l
HI 10l9 2111\ 2174 ll.P l.ltKl !'11.4 2411 24!1'1 H69 2641 27 1\ P'il !x-o
M4 .!102 .!160 2.2.!0 .!.!H2 .!\4\ !4 1U .!4.,.., 15-% 26)7 2ft1<'* .!-M .!H41 !'i.!O
Jot\ 2141-l 22U~ ll6b .!.l.!M .!l'l.! .!4" 2 \ .!' 2~':14 l~tt\ 2-lc) 2~1 4 .!S"lll .!'1-o
Kl> ll'll 2!1 1 l.lll ll-~ .!419 l~ll .!l-1 U"'l r1> l-N'I lKM .1.~! IU!.!
l!- .!.!IH !.!9K LlN 24!1 !4WM 2~;4 21>2\ .!6'1.l 2-6; 21!40 29 11> .1.•N4 30'4
M)l 21M.\ .!141-- 240S !4-! !'t- .!MJJ 1,-l l-44 !8 1- !X~! !~M< ~u-'- li!J<
H~ 2133 .!3~ 1.4>- li.!l !~H- !1>,_ !"!~ 1-% lNf>~ .!9' lOll IIIII liM!
'ill 2\&l 2444 HU' 21-2 !1> I~ PU" z-- 1R49 .!'12.1 l';I'IH lfl-1> ll II 11r
'I I 2411 1.49; H 1'1 !1>14 11>'1 I l~MI !X IU 1.9<11 11>77 .IllS I Ill I I! II 11~ 1

'I~ 1~1<-l 254"' !fill Zh-- .! ..,~~ .!M I 4 .!XX1\ !'I~~ Wt! lHW UM7 \!nH 1 \~n
<JI 2 qt, 2>\1'1 1 f>f>4 27.11 !"'i'' lHI><J l~4H ~114 ll)~<J \11\1> 114 ~ \\2h 14UY
'~"' l. i'Xt .!65 i 1. 7 I 'I ,!7U .!M i4 .!'I!~ .!~'1- 107(} \ l4b .lll4 llU 1 l 1M4 14 hH
'H .?.f\44 270~ l.-...4 !H4! !YIJ .!YM.! ltl<4 l l 1'1 }!It~ l!~l ll(-.1 l-444 l~!Joi

'lo roo rt.; .!.Hl I lM'I'I l%'1 1(140 1111 I Ul& 12M II-II 1421 HUI HM\1
~- !"I- lgll lHX'i !<J'M IUlK IM9 ll-1 IH~ lJlS 1404 14K4 Ht>- 16H
'I~ 1~1~ 2RRI !'i4M lli l" llblx 111\11 U\4 JJM 33k" \.16(, H4" 'll.ltt 1"1~

~~ 2~-4 2'141 ltMI'I lo-x 114'1 I!!! ll'if> n-z 14iU Hl<~ lf> ll lf>Q4 ~-.,

IIMI .1.'111 IUO.!. 1<1"0 lt4ll 1!1 1 \!HI IH9 l416 1~14 .11'14 l"h- I-N 3~4 S
 Feta l weight b ased on biparietal diameter and abominal drcumference IE!J

Abdominal Clrcumlerence (mm)

BPO{mm) 351) 355 360 3$5 370 375 380 385 3911 395 400
I!!> lr'l 111" 1\'1" 1~\K IIH 1~'<1 lt>bl J-H 110! JK'Il
1!4h J\(11 ll\H 141~ 14KI 114h lhll 1Mf> 1-hl IX" 1"!11
ll 121>- llH tiKI H-11 1'114 11-11 161'1 1-11 1-R, I~"~ I"~"

l!X'I ll.JI 1411\ HM II!~ 11'1\ lt>t>4 ~-~- !HI! 11!"1 1.,-1
Ill! llt,- 142h HX~ IH2 11>1'1 I..X\1 1- 1>! II!IY I"IH !IKll
IHl 1l•1o I·HU I'L! 1\--. I#\·H 1-l"i ~-~4:1 IXhCi l l/4( .!U.?"~

Ill" 1411 H - 4 hlb l bll.! 11'-(1 1-41 11!1\ IK\11 1'< 1 .!ul- 7

11"'1 141- 1·1'11! llhl 1~>2 7 lh'lh l-1>1! 1~4! l'l!t> !1MII .!OKI>
l4tl2 14hl 1\!l 1\~h I1>H 1-2! 1-'14 IK-11 1'14K .!Uifl 211\
14.!<> I4Xh I\4H lt> l ! lh79 1-49 IX22 IK'IH 1'1"- .!111'1 !141
14\1 1111 1\ 1 11>11! 1-06 17 -6 IIWi l"ll> 1(Ml> !IIHI! 11·4
7

1-t -~ ~~,,., ~~~ lhn-' r-n tso.J '"'-~ '"'4 !U~' .!tiN .!lnc;
I \UU Ht..? Ill! "i I h~ I 1-t-0 I H l! 190h I tfX4 !tth4 ! 14M !.! Jf,
lilt. 1\HH 1(,\! 1-lti 1-tiK 11!1>11 I 'IH 21111 2094 21""'1 .!!,-
1\\.! 1,_14 ~~-"' 1-4#1 lto\lf. I ~SQ I'Jh4 2tl4.l !I!+~ .!!IH !..!••M
I)-~ IMI , ..,~ 1-4 P<·H l~l~ 1'1'1-l !U... \ !I'" !!4 1 ,!HU

lt.UI '""" 1-14 IHtll IH-4 1'14R 1014 21114 111!- .!1-1 !lf,l
lfoU 1#1.'1- , ...,_l IXU 1~)4 1""-6 .!ll~"i .!llt. !!I~ !lt~ !\'it-.

'"'"'' 1-.!, 1...'~.! IWhl IYlJ 20<W .!0~ .!In- ,!2'it .!ll~ .!4.!"1
lt>){Y ~-~4 JH.!I UNI I'J~-4 20-lu :!I IX .!!Ut) .!.!X..J ,!;-! .!4nl
1-IH 1- Wl IM'I 1"'~.!2 I'"""' .:!0-1 .!lltl .!.!l.! .!l l - .!41)1.. !4~>;

1-4- JN1l JH)(,! JQ(l .!H.!- 21tH .!U\l .!.!tm !HI !44tJ .!'l.!
~-- IJI\4l t'ill IYX4 ,!U'i'l .!ltf+ .!.!I~!!~~ .!~fol,., !4-( !'\Moi
lXII- 1X-4 1'1-14 !lilt. .!ll<JI 21"'1 2.!~0 1lll .!4!fl .!<Ill !~>tl4

IXHt 1Yi~ l'~ "h !U·t'l .!11~ .:!!Hl 22M4 .!lM•: .!·HI-. .!l4t. !t-4U
II'Chl.t I~ lK .!UU"' .!UN.! .! ),lt< :!.!.l- .! l 1'I ,!41) \ .!-IV I .! lX! .!.ft--
IYUI ~~-u lfl41 !11'\ !I'll.!!-.! .!354 .!4lY ..?.t:!M .!td'l ..?.- 14
I'J\.4 .!tHH lU ... ~ .! l 'iU .!!.1~ !lU- ,!l'l(t l47~ !1-.M lt-+~ "' ! ...<!
J \Jfih .!O t~ .! atW 1 UN !.!1'2 ! 'H.! .!4.!6 .! 'I! .!htl! .!f'l\14 .!-~>~o

Ml !Ut)U !W' I !144 !! IY .!.?.'-~K !3-'1 l-4-b~ !~'0 .!MO .!-_n !M.!Y
!!l\4 .!Ill~ !1-'l l!H 1114 1-11~ !51l!l l\X~ !~~M !-~.! !Xt.'l
!HI,~ .!HH !!I" !.!'II ~l-1 !4\l ,!(lR 2111,; !-1 - !Mil .!'AN
!lU-I .!1-, .!!(I !\..!S .!4UM !41.,11 !i-- .!ht-~ .!.. , ... .!H(I ~'14\J

!14U .!!1\ !!Xt\ !lt1h .!.S..tn ~:\10 .!hl, ,!-(h .!"""i- .!~'(".! 2'-~"1
.!1-., .!.!'\11 .?'.!#. .!~tW !4H5 .!'b'~ !~'t, .!--l\ .!Mlt< .!'>ll 101.!
hh ~.! l l .!.!S"' ! lto-a !-l ... l .! 1\.!4 .!~otOY !fo'lf, .! - AA ~S-'1 .!'~-{ ~n-(

!2H .! t~t. !4tH !4R! .!i~ .!to4Q .!-l"' ~S.!- .!'il.!1 \1J1Jo. \11-
.!.!~0 .! t" '\ .!-14.! .b.!.! .!t-n' .!fo"'i) 1-H .!~q .!'lf-4 lOft I ll hI
.!1.2'1 .!~~ .!~S.! ,!\fo.t .!Mf. .!-t.! .!>\.!1 ,!\oil! UKJ- tJH4 l.,!Ui
-~~
_:____ __...:..._::::._
1 h ,J.i. .!444 .:! (_! ; .!hU4 ,,..~s 1---l .!~., l .!f.J:;' lcHU ll -14 l! \u
E.\31 Obste trics

Abdominal Circumrerence (mm)

81'0 (mm) 350 355 3111) 365 370 375 3811 385 390 MS 400
-I .NO~ 24~5 ! ~64 !Mn !7 141 !~ J'7 1.'107 1'1'1" llw> ""' 129~
-· !4'n Hr !.,.,, ! .. x~ 1~11 !~"'' 1.'.151 ltH4 ll4n I!W 1141
-~ 24'11 l~MI !MY Pll lM I" 2'10$ 2996 IOl!'l II~" UK; IlK"
-4 15l4 lt\ 11. !t>'IJ !""t. 2116.! 2~'0 .1041 1115 1!12 Ill! 14 11
-, !5-- !t\5t. !"I" 1Hll 1'111" !~'If, WRH liM! \!"'1 llKU WKI
-~- lbll ! "fMl !"K! !Xh;. !'In ltl4.! 1134 lll'l lJ.!- 14.!~ \HI
,!f,f,f, !"41> !H!H 191! .1000 lti'IO 1118 31- In; 14"- HH I
"H l -11 .!~'1! !K-4 1'1~'1 1114~ .II P 12!0 111" 14!< I'!" II> II
"'I l"i" .!SJN !'Il l UMI7 IfNI IIKn 11"9 II"" \4"\ IPh lt.MI
KO 2R04 !RHI> !%9 lOin 1144 1211 H29 J41b IllS 11>27 1-11
XI !K5.! .!'1.14 10IH 1111< 11'14 UN~ !IHO w~ 11~· 1n~'l I"KI
H! !901 !'IX 1 lflf,H II H 1144 1111> 1411 111.'.1 11-1.'1 r 12 IX IX
XI !'110 \011 lt!X l.!l)f. l}.'lh HXK l4Xl HXI 11-K2 1"H ' IX"I
X4 1001 l0R4 11"'1 121" 114K 1+11 1'36 .1634 !".11 IKI'I 1'<4\
XI 1052 llll 1.!2 I 1110 14111 14'14 H'IO II>MH 1-'111 1K'I4 41MMI
K6 3104 l!KK 1.!"4 111>1 1414 114H lf>44 l - 41 IH41 \'14'1 401(.
X" II\" 1141 112M \.1 P l\09 1MI3 P(KI 3"Y'I l'IUI 41MII 411 I
XX l2lll 1.!91 .llH.I 14"2 1\f,l II>''~ 3"'6 IXH IY<H 4111>1 41-11
H'l l26S ~.11 1 141M lllX lhll l~lf> IRII I'JII 4U I I 4 1111 411K
'10 3.111 1411- W\1~ HKI ~~-H P"l l~~l 3\17 1 4ll"~ 4 1-11 41tl"
¥1 ll~ 14M l'il2 IMI 1"11> IRll 3~111 411\tl ~IH 42\¥ 414-
'11 34\5 31~~ 1~11 1"111 I"Y< IH'I I I'IH~ 441'111 41~1 41'1'1 44UK
¥1 14'14 IIIII 11>~0 l"nl I~H 1'1~ 1 40111 41H 4}.14 411>1 44!>'1
<1~ 3.\,H 11>41 3".1~ IK!! l'iln 44111 4111 411\ 41Jf> 44H 411!
'I< 1614 l-UI 1"\11 IKK4 1\I"H 40"1 41"4 42"' 4l"'l 44M~ 41'11
'If, ~~-~ 1"1>1 1M54 1'14~ 4ll41 413~ 411" 411'1 4441 4HU 41>1'1
.,. rJ~ 3~2~ ~~~- ~"'" 4Jn' 41111 4.10! -14u4 4m~ 4"'' 4~24
Ilk .lKOl IX'III I\IKI 41174 41711 42f.7 4lf>" 44h9 4<71 4t.KII 4~"il

11'1 \!!()(, 19.11> 4047 4140 4!.16 43.1l 44\l 4111> 4Mil 4"4- 4KI7
Wd 3«~31 4H.!2 411 t 4.!U7 ..Jltll 44UO ·HU t 4h0l 4 ...HS ·UO Iii 4Q24
 Fetal weight based on biparietal diameter and abominal circumference ID

FURTHER REAOING
hom Sht:parJ ~1.1. RidJrJ!> VA. Berkowiu Rl.. \X'.usof Sl. Hohhin ..
JC. :\n t:\ .llu.uion of rwo t:qu.uions for prnl•.:ring feral \n·i!!-ht hy
ulrr:tsounJ. Amcrica11 .foum<~l of Ohslt'trics .md Gynecology
1982;147:47-54.
 Obstetrics

Fetal femur length

PREPARATION
full hladdcr for transabdominal imaging in first and sn.ond trimester.
POSITION
l.ong axis image of fetal lemur.
PROBE
3.0- 5.0 MHz transabdominal transd u~cr 1s used for all :-.c~ond - and
third-trime~ter ohstetric ima~ing.

M ETHOD
Length of os~ified di.tphy~i~ of femur. \ uNlr pl.tced .tt jmKtion of
hone and c.trtilage. Epiphy"i' .. hould not he nwa,ured.
APPEARA NCf
The ~orr~r po!tition of the transducer .tlong the femoral Jon~ axis is
confirmed by idenrifying the femoral c.:ondyl.tr epiphysis plus either the
femora l head epiphysis or ~rcater trochanwr w1thin the se.:non plane.
tv1EASU REMENTS

Femur length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
10 12.6 ( 10.4- 14.9)
II 12.9 {10.7- 1S.l )
12 I.U ( J l.J-15.6)
13.6 ( J 1.4-!5.9}
14 13.9 (11.7- 16.1 )
15 14.1 (12.0-16.4)
16 14.6 ( 12.4-16.9)
14.'J {12.7-17.1)

ll'! 15.1 (IJ.0-17.41

19 I .\.6 ( 13.4-1""'.91
 Fetal femur length ED1

Figure 101 Femur

length is obta1ned
by imaging the
femur in long ax1s
then placmg
cursors on each
side of the ossified
diaphysis of the
femur. The
epiphysis should
not be included

Femur length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
--------------- ~---

20 1
15.9 1U. -l x.l>
21 16 ..l ( 14.1-l~.h )

11 I f>.6 ( I 4.4- I X.9)

.!3 If> .~ I 14.-- 19. 1)

I -. \ ( I '. 1-1 9.6)

1-.6 I I ~.4-19.9)
16 I ~.0 I I ~-q-20. 1 )

I ~3 116.1 -20.6)

2X IS.' ( l6.o-l0.9l
19.0 I 16.9-.! l.l l
19.4 11-.1-2 l.nl

.H 19.9 ( ,-.6-2.2.0)
'1 20.1 ( 1""'.9-22 ..~1
·'-
10.n ( l lL~-22. 7)
34 :!0.9 11x.-- 23. 11
ml Obstetrics

Femur length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
---------------------------
J5 2 I. I ( 19.0-23.4)
J6 2 1.6 ( 19.4-23.9)
37 22.0 ( 19.9-24. I)
38 22.4 (20. 1-24.6)
39 22.7 (20.6- 24.9)
40 23.1 (20.9-15.3)
41 23.6 12 U-25.7)
42 23.9 (2 1.7-26.1)
4J 24.3 (22. 1-26.6)
44 24.7 (22.6-26.9)
45 25.0 (22.9-27. 1)
46 25.4 t2J. J-r.61
4"7 25.9 123.6-l!W>
4H ln. I (24.0-2~.4)

49 .!6.6 (24.4-2H.9)

50 17.0 (24.9-29. 1)
5I 27.4 (25. 1-2'J.6)
52 27.9 (25.6-JO.O)
53 28.1 (26.o-J0.4)
54 28.6 (26.4-30.9)
,, 29.1126.9-] 131
56 29.6 1r.2-J 1.11
57 29.9 (27.7-H. Il
51i 30.3 (llt 1-U.61
 Fetal femur length

Femur length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
---------------------------
\9 l0.7 (21l.6-32.9)
60 31.1 (21'.9-33.3)

61 ) l.o (2<.J.4-33.9)
61 u.o 12<.1.9-34.1)
6.l ~1.4 (30.1 - 34.6)

64 32.9 (30.7-35.1,
6) .U.4 (.) l. I-.H.6)

M n.7 (.'~ 1.6-.l5.9>

67 l4.1 n2.o-.l6AJ
6X 14.6 (3.!.4-36.9)
u.o (32.6-3'7".1)
.U.6 (3.3.3-37.7)
J5.9 (33.7-3!>.1)
36.4 (34. 1-JX.6)

~ll.<.J { l4.6-.W.0)
l-..l (35. J-J9.o)
' - 6 -.)
,) 7 • .., (..>.). '9• 9 l

JX.I I .>6.0-40.4 l

Jx.6 <36.4-40.91
7X l<.J. I (36.9-41.3 )
.V-.>.6 (.l73-41 .7)

H ' RT H FR R EA DING
.Jt:.um· 1>. H.ml«.>~ch F. Odhd:l· D. Dumont JE. Estun.mon ot
gl·~t.uional .1gc from mt:a~urt'ments oi fetal long hont:'. /olll"ll.llof
llftr<~suund in Mc.ftcmc I<JX4:.l:-s--'J.
1D Obstetrics

Fetal humerus length

~---------------------------

PREPARATIO N
full hl.tdder for tran ..alxlominal imaging in tirst and ~n:ond trimester.
PO SIT ION
Long a xi., image of teral humerus.
PRO BE
].0-5.0 ~1 H z trans.thdominal tramducn is used for all ~wnd- and
rhird-rrime~ter ohstctric im.tging.
l\·\FTHO D
Length of ossified diaphysis of humerm. C u r~or placed .11 junction of
hom: and carrilage. Epiphysis should not he mea~ured.
APPEAR ANCE
The correct position of the transducer .lion!!, the humeral long axis IS
confirmed hy idcnrifying hmh the proxim;ll .llld di'ital epiphy~t·s Within
the section pia ne.

Humerus length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
10 12.6 (9.9-1 U)

II 11.'1 ( 10.1 - 15.6)

12 13.1 ( 10.4-15.9)

n 13.61 10.9-J(>.I)

14 13.Y ( 11.1 -16.6)

15 14. 1 ! I J.4- Jn.9 )

16 14.6 ( I 1.9-1 7.3)

17 14.£) ( 12. 1-17.6)

IS 15. 1 ( 12.6- 1S.O)

19 15.6 ( 12.9- I H.J)

 Fetal humerus length 11m

Figure 102 length

of the ossified
diaphysis of the
humerus. with
cursors placed at the
junction of bone in
car111age. The
epiphysis should not
be included
(Cour1esy of Jane l.
Clarke)

Humerus length (mm) Gestational age (weeks)

Mean and range (5th- 95th percentile)
-----------------------
].() 15.~ I U. l- l lPl

ll In.~ I I ~ .f>- 1'). I l

))
ln.? 11 ~.9- 1 9.41
_,'
) ,-.1114.]-1 ')_<})

1-.4 I I·P- 20.1 )

25 1-.9 ( 15.1 - 20.fl)

26 I H. I ( 15 .f>--21.11)

27 I H.6 ( I ).9-21.4)

I I.J.O ( I fd-ll.~l

I <J.4 I I n. 7-!l. l l

30 19.9 ( , -.1 - 2.2.61

.H 20. ~ ( 1-.6-ll.UJ
'l_
) 10.7 ( I >1.0- 2 ,_hI

.U 21. 1 ( 11{.4- .!J.Y)

fD Obstetrics

Humerus length (mm) Gestational age (weeks)

Mean and range (5th-95th percentile)
34 2 1.6(18.9-24.3)
35 ll.O ( 19.3-24. 9)
36 22.6 ( 19.7-25.1 )

.l7 12.9 (20. 1-25. 7)

JR 23.4 (20.6-ln. l l
39 23.9 (2 1.1- 26.6)

40 243 (l l.n-27.11

41 24.':1(22.o-r.6l
42 15.3 (22.6-21{_0)
43 2 ).7 (2.3.0-llU'i)
44 26. 1 (23.6-29 .())

4' 2n.7 (24.0-2':1.6)

46 z-.1 (24.6-J<J.Ol
4- r. 7 t25.0-30.0J
48 2H.I (25.6-.l i.OJ

49 2R. 9 C26.0-.H .6 )

50 29.3 (26.6-32.0)
51 2':/.IJ 127. 1-32.6)

51 3o.J tr.6-JJ .t l
D 30.9 (21{.1-.H .t>J
)4 .11.4 (2!!.7-34.1)

ss .n.o !29. 1- 34.7)

56 .l2.6 (29.9- J5 ..l)

•
 Fetal humerus length DJ

Humerus length jmm) Gestational age (weeks)

Mean and range (5th- 95th percentile)
S7 .U. l UO.J-35.':1)
5S .H.n (30.'J-36.4)

)9 34.1 (3 1.4-36.9)

no H.<,> (32.o-r.6J
6I ~5 .3 (32.6-38.1 )

62 U.<J(H.I - 38.7)

6J 31'>.6 (.H.':I-J9.3)

<>4 r.t 134.4-J<J.<J)

65 P ...., (.)5.0-40.f>l

66 .lS3 (35.t1-4 1.l l

&9 40. 1 t rA-42. 9)

FURT HER REAOING

.k:.Jm,· 1'. RoJc ..ch F. Ddlwkl· D. Dumonr JE. Esnm.tnon llt
gc.. t.uion,ll .1ge from nw.hun·m<·nr' of f<•t.ll long hone~. /11unr.d of
{ ' ftr.wmnd in Medicml' I YX4:.'\: -5--9.
mJI Obst~trics

Systolic/diastolic ratio in the umbilical artery

PREJ•ARATION
Full hl.1dder for rr.msahdominal inMging in fir~t and ":..:ond trimester.
POSITION
Spe.:tr.ll Doppler ..:ursor pla..:cd on umbilical artery OUblOe the fctu~.
PROBE
J.O-S.O ~ 1 Hz transabdominal tr.msducer is t"ed for all ..ccond- and
third-trimester oh~tetri..: illl<lging.
MFT HO O
~peo.:tr;tl Doppler ultra~mmd re..:ordmg of umhili..:al.un·ry peak ~ysrol i..:
vcltx:ity divided hy enll Ji.•~roli..: velocity (SID r;Hio).
APPEARANCE
Norm.JI umbilical ..:ortl.:omain~ two arteries and one vein. The vein i~
l.uger than the artcric,. A ~inglc umbilical artery is assn..:iatcd with
tct.tl .momalies.
MEASUREMENTS
l'k·vatcd SID ratio~ arc a ~ign of pl<~cemal drsfuncrion and arc :"ltoci-
<ltl'J with imraurerine growth restriction and pregnancy-induced
hypertension.
 Systolic/diastolic ratio in the umbilical artery lliD

Figure 103a The

arrow pomts to the
umbilical vessels

figure 103b The

cOlor Doppler 1mage
demonstrates flow
in the 1:\vo umbilical
artenes
ml Obstetrics

Gestalional age SID ratio percentiles

(weeks) 10% 50% 90%

lo 3.01 4.15 6.07

20 3.16 4.04 5.14

24 2.7 3.5 4.75

28 2.41 3.02 J.9...,

30 2.-H 3.04 3.8

31 2.27 2.7.1 3.57

34 2.0X l ..Sl 3.41

36 1.% 2.H 3.15

38 l.l\'::1 2.24 3.1

40 l.!U 2.22 1.6ll

41 I.(H 2.21 ') .-
_,..)..)

42 1.9 1 2.51 3.21

FURT HER READING

fogarty P, Beanie B, Harper A. Dornan J. Continuous wave Doppler
flow velocity waveforms irom the umbilical .utery in normal
pregnancy. /oum,d of Perill,ll<ll Medicine I '::I'-JO;l8:5I-5'.
 Systoliddiastolic ratio in the umbilical artery EiJ

Figure 103c A spectral Doppler gate placed on an umbilical artery returns a normal
spectral Doppler waveform. from which the systolic diastolic ratio is calculated
(Courtesy of Jane l. Clarke)
mJ Obstetrics

Cerebral ventricles - lateral ventricle

transverse atrial measurement

PREPARAT ION
rull hl.llldcr for rran~abdominal imaging in firsr and second trimester.
PO SffiON
Axi.tl im<tgc ohmined at the level of the thalamic nuclci.
PROBE
.3.0-S.O \1Hz transabdominal transdu.:er is used for all second- ,mcl
third-trimester obstetric imaging.
M ETHOD
Transverse atrial measuremenr taken at confluence of body, occipit.tl
and temporal horns o f the lateral ventricles. Calipers positioned at
level of glomus of the choroid plexus, imidt: tht: retk-ctiviry generarec.J
hy the ventricular walls
APPFARANC E
The choroid plexi is are high-retlecrive strucru res filling rhe atria of rhc
l.ucm I ventricles.
M EAS UREME NT S
• The normal value is 7.6 mm hetween 14 :mJ 38 weeks. Choroic.J
plexi should complete fill rhe atria.
• Atri,tl measurement of > 10 mm i~ abnormal and suggestive of
hydro.:cphalu~. Choroid plexu~ that falls away (drooping) from
.nrial w,tll is al~o abnorm:tl .:vcn if atri.II measurement i~
< 10 mm.
 Cerebral ventricles- lateral ventricle transverse atrial measurement

Figure 104 Transverse atnal measurement taken at confluence of body. occipital

and temporal horns of the lateral ventricles. Calipers positioned at level of glomus of
the choroid plexus. inside the reflectivity generated by the ventricular walls

FURTHER HEAL>IN<...
Cardoz~t ]D. Gold~tein HH. rillv l{t\. Exdu~ion of fetal
ventriculomegaly with a single measurement: the width of the
lateral ventricular :ttrium. Radiology J 981>; 169: 7 11 - 7 J 4.
15-25 gestational weeks
Pretorius DH. Drose .JA, Man..:o-Johnson .\IL. Fetal lateral
ventricular ratio determined during the second trimester. journal
of Ultrasowzd in Medicine 19R6;5: 12 1-124.
26 gesta tional weeks to term
Almog B, <..amzu R, A.:hiron R, Fainaru 0, .Z:tlel 'r. feral breral
venrncular widrh: what should be irs upper limit? A prospective
cnhorr ~rudy and rcanaly~i~ of the current anJ pre\'ious dJta.
Journal of Ultruswmd in Medicine 2003;22:39-4.~.
John~on MI., Dunne :\·IG. 1\1,\ck LA. R.-~shha um Cl. Evalu.nion of
fetal intracr.mi.tl ;matomy hy static and real-rime ultrasound.
fwmuzl of Ultrasmmd m M(•dicme I 9S0;8:3 11-3 1~-
B Obstetrics

Cisterna magna

PREPARAT ION
full bladder for transabdominal imaging second trimester.
POSITION
Cerebellar view: transverse axial image with posterior caudal angula-
tion passing through the posterior fossa at level of cerebell um.
PRO BE
3.0-5.0 MHz transducer is ust:d for all second- and third-trimester
obstetric imaging.
M ET HO D
Maximum width of the cerebrospinal fluid space between cerebellum
and occiput.
APPEARANCI:.
fluid-filled space between cerebellum and occiput.
MEASUREMENTS
• Anteroposterior depth (mml at 15- 36 weeks:

Mean 5
Range 2-H

Maximum 10
• Ahscncc of the cisterna magna is suggestive of Chiari malforma-
tion.
• Mega-cisterna magna (> I 0 nun) is associated with chrornsomal
abnomalities, but can bl· norm;tl.
FURTHER READIN G
Mahony BS, Callen PW. ri ll y RA, Hoddick WK. The fetal cisterna
magna. Radiology 19!34;153:773-776.
 Cisterna magna

Figure 105 The

cisterna magna
measurement is the
maximum width ot
the CSF space
between cerebellum
and occiput
(cursors x- x ). The
transverse
cerebellar
measurement(+- +}
and nuchal fold
measurement (0 - 0 )
are also displayed
 Obstetrics

Thoracic circumference

!>REPARAT ION
Full hladJer for rransabdominal imaging in first and second tnmester.
POSITION
Axial image of thorax at the level of the four-chamber heart.
PROBE
3.11-5.0 MHz transducer il. u~c-J for all ~econd- and rhird-rrimestt·r
oh~rerric imaging.

M ETHOD
The thoracic circumferenl.'e. excluding the skin anJ sulx:uraneou!>
tissues at the level of the four-chamber view of the heart.
APPEARANCE
fransaxial view through the thorax ~howing four cardi::ll.' l.'hamhers.
M EASUREM ENTS
• r--.;orm.ll thoracic to ;lhdominal circumference \ fC/AC) r.Hio •~
O.H9-l.O.
• TCIAC ratio of< 0.8 is ;lssoci.m:d with pulmonar\' hypophlsia.
FURTHER READIN<...
John~on A, C.1lhln NA, Bhur.mi VK, Colmor~c-n Gil, Weiner S.
Bolognese RJ. Ultrasonic ratio of fetal thoracic to abdominal
circumference: an assm:iarion wath fera l pulmon:try hypoplasia.
American .Journ..ll of Obstetri,·s ..md GynccololtY
1987; 157:764-769.
 Thoracic circumference 11m

Figure 106 An axial image at the level of the four chambers of the heart through the
thorax. with a thoracic circumference calculated excluding the skin and subcutaneous
tissues
ED Obstetrics

Renal pelvis diameter

PREPARAT ION
Full hladder for transabdominal imaging in first and second trimester.
POSITIO N
Transverse image of feral abdmm:n ,n midrenallevel.
PROBE
3.0-5.0 1\IHz transducer is u!>Cd for all ~conJ- and third-trirnc~n:r
obstetric imaging.
M ETHOD
Anteroposterior diameter measurcmenr of renal pelvis.
APPEARANCE
Fluid filled structure in rhe cenrn: of the renal sinus. Mild distension of
the renal pelvis is nornul.
MEASUREMENTS
• Up to 20 weeks gest.ltion: <4 mm. ~4 mm may indic~ue fetal
hydronephrosis .md requires follow-up !>Can in third trimester.
• After 2() weeks ~csl<ltion: 5-9 mm is intlcrcrminate.
• /11 third trimestn: 7-9 mm i ~ indeterminate and require~ neonatal
iollow-up.
• Obstruction is more likdy it calrceal or ureteral dii.H:Hion is al~o
present.
• > I 0 mm is abnormal
FURTHER READING
Grignon A, filion R. Filiatraulr D. Robitaille P, Homsy Y, Rourin H,
Leblond R. Urin.1ry traer dilatation in utero: da~~i fic.nion .md
clinic.tl .tppli~:ation . Radiology l lJl-36; 160:645--64 7.
~landdl.J, Blyth RR, Peter~ C ;\, Rt·tik AB, hrroff JA. lkn.Kerrat BR.
Structural genitourinary dl'fcct~ detected in utero. R,u/iology
199 1;1 78: 193.
 Renal pelvis diameter 1Em

Figure 107 Transverse image of the fetal abdomen at the midrenal level. with an
anteroposterior diameter measurement of the renal pelvis. LK. left k1dney: LS. lumbar
spine: RK. nght kidney
m Obstetrics

Mean renal lengths for gestational ages

-----

PREPARATION
full bladder for transabdominal imaging in first and sc.:cond trinu:~tcr.
l'OSmON
S;lginal or coronal image~ of hoth kidneys.
PROBE
3.0-5.0 MH7 transducer is u~ed for all second- and third-trinu:sn:r
olmerric imaging.
M ETHOD
t-.taximum long axis measurements. Enlarged kidneys are associated
with obstruction, mulricystic kidne)· and polyc)'snc kidney.
APl'EARANCE
Elliptical structures with high-rdlc.:crive margins caused by periren.ll
fat. Mild pelviectasis is normal.
MEASUREMENTS'

Gestational age length (mm)

(weeks) Mean and 95%CI
18 22 ( 16- 2H)
19 H ( 15-.ll l
20 26 ( I H- 34 )
21 27 (21-32)
22 27(20-34)
B .10 (22-37)
24 31 (l 9-44)
25 33 (25-42)
26 34 (24-44)
,-
- 1 35 (27-44)
2X 34 (26-42)
29 36 (2_l-48)
30 .lX(29-46)
 Mean renal lengths for gest ational ages

Gestational age length (mm)

(weeks) Mean and 95%CI
.) J \7 (.!~-46)

') 41 (3 1-5 I J
·'-
.H 40(3 1-47)
.H 41 n l-'iOJ
].'i 42 (32-52)
36 42 (.B-501
,..,
4.!( _B-51 1
·'
.-;x 44 (.E-56)
39 42 (35-4H)
40 4~(31-5~ )

41 45 (3<f-' I J

Figure 108
Sagittal image
through the kidney
(cursors+-+) with
the maximum long
axis measured
(Courtesy of Dr.
Maria E.K Sellars)

RHE.KENCF
I. Cohc:n HI . Conpc:r J. Ei'>l'nhc:r~ P. :\l.mdel r S. Gross HR.
(;oltlmiln \I.\, Jkutd F. R.nvlin•;on KF. Norm.1lkngd1 oi fl·r.tl
k i.lnt'~ s: \ono~r.1phil· study 111 3'~- oh•tetric p.niems. Amt•n,·,u,
jmtm,rl ol Romtge11olo~)' 1991: 157:545-54H.
E1 Obstetrics

Outer orbital diameter

PREPARAT ION
full bladder for transabdominal imaging in first Jnd second trirncstl"r.
PO SITIO N
Coronal plane through skull •.tpproxlmJtelv 2 em posterior to the
~labellar-alveolar line or tr.lllsvcrsc plane along orbiromeatal line
(2-.l em helm..· biparietal di:-~mercr. IWD).
PRO BE
J.U-5.0 :VlHz tran~ducer is u~d for all -;ccond- JnJ rhird-rrimestt"r
ob'itetric imaging.
M ETHOD
from late ral border of the orbit ro oppo,itc lateral horder. Cm be used
in place of IWD when this cannot be measured.
APPEARANCE
Tht> orbits should he symmetric. with both .1ppe.1ring clJual and l.uge~t
po~<>ible diameter visualized.

M FASU REM ENT~

Binocular distance measurement'

Predicted outer orbital diameter BPD Mean gestational age
(mm) (mm) (weeks)
u 19 I 1.6
14 20 I l.ll
15 21 12.1
16 n 12.6
17 23 I 2.6
17 24 13.1
IH 25 13.6
19 26 13.b
20 27 I 4. I

21 lH 14.6
21 29 14.6
 Outer orbital diameter ED

Figure 109 The

transverse plane at
the level of the
orbitomeatalline
witn measurements
from the lateral
border of the orbit
to the opposite
lateral border
(+- +)(Courtesy of
Jane L. Clarke)

Binocular distance measurement'

Predicted outer orbital diameter BPD Mean gestational age
(mm) (mm) (weeks)
21 30 I ).0
23 .3 1 IS.5
24 32 15.5
) -
-.'I 33 I o.O
1- 34 16.5
-·
'
2h ',,- 16."'
.,-
_I J6 1"'.0
2' 37 J7 5
18 3~ J7. ':1
30 40 lll.4
JJ 42 18.9
J2 4J l lJ.4
,.,
.>- 44 I '1.4
.B ~5 1'1.':1
J4 46 20.4
mJ1 Obstetrics

Binocular distance measurement'

Predicted outer orbital diameter BPD Mean gestational age
(mm) (mm) (weeks)
34 4- 20.4
35 4R .20.9
311 49 21.3
36 50 21.3
17 51 lUI
38 52 22.3
38 53 223
39 54 n.s
40 55 -) 3. '
.)

40 56 2.U
41 57 23.8
41 5R -)4 __,,
42 29 24.3
4l 60 24.7
4l 61 r.,
.)._

44 62 1.' -1
44 63 25.7
45 64 16.1
45 65 16.1
4(, 66 26. 7
46 67 17.1
4' 6S 27.6
4"' 69 lS.I
48 70 28.6
48 "'1 29.1
49 ..,.3 29.6
50 -4 30.0
 Outer orbital diameter ED

Binocular distance measurement'

Predicted outer orbital diameter BPD Mean gestational age
(mm) (mm) (weeks)
50
..., - 30.6
·'
51 '""(; .l i.O
~~

Sl li.S
-l ~g ') 0
·' - '-·
-1 ~9 31.5
·' -
53 l:!O .B.O
54 82 .B.5
'-t -
5-t 8.)
') ··'
54 !l4 l4.4
55 85 .u.o
55 86 .H.4
% I{~ H.9
)6 R9 .l6.4
,~

90 if> .lJ
s~ 91 J 7.3
)I{ 92. .F.8
58 91 .l~.3

5!> 94 HU
59 9o J<U
59 •r ~9.8

RfFERFNCF
I. ~lavden "L. Tortora ;\I, lkrkowirz Rl, lk.H:ken ~I. Hohhul'> J(..
Orhit:ll dt.lllll't~rs: a rww par:tmerer tor pren:tral diagnos1~ .md
d.tting. rlmeric,m ]om nul o{ Ohstetrics und (;ynaolog)'
llJR2.; H 4 :2XlJ- ,2<r.
llDI Obstetrics

Fetal stomach diameter

PREPARATION
Full bladder for rransabdominal1maging in firo;r .llld 'ccond rrirncsrer.
r osmoN
Long axis, transverse and ~agirta l images rhrough rhe fera l scom.t.:h.
PRO BE
J.o-5.0 ~1H z transabdominal rramducer i!> u~cd for .111 second· .md
rhirJ-rrimesu:r ohsrerric imaging.
M ETHOD
1\ lax imum long axis, rransn·r~~: .md .tnr~:roposrt>rior dia m~:rns.
Fnlarged sromach is associated with duodenal .nr~:~ia.
APPEARANCE
Normal fetal sromach appears as a low-retlecnve ~tructure on the left
side of rhe ahdomen. lr should he seen by 13 weeks gesr:uion.
M EASUREM ENTS

Gestational Stomach measurements with range or 5th to 95th

age (weeks) percentile' (mean ± 2SD, mm)
Anteroposterior Transverse longitudinal
U - 15 4 (3-5) 6 (4- !ll 9(6- 12)

16- 18 6 (4-8) g (6-1 0) 13 (9- 17)

19-11 H (6-llll 9 (7- 11 ) 16(11-21 )

21-24 9 (6- 12) 18 ( 15-1 1) 19 ( U-15)

25-!7 10 (5-1 5) 19(14-24) 23 ( 13-J.l)

2l:l-30 12 (9- 15) 16 t 12- 20) 28 { 19-3...)

.l l-33 14 (11- 17) 16 ( 12-10) 18 ( 19-37)

.l4-J6 14 ( 10- l!l) 16 t 12-201 2R (19-.17)

37-J9 16 ( 11-20) 20 ( 16-24) .ll (B-4 1)

 Fetal stomach diameter 1BD

Figure 110
Longitudinal image
through the fetal
stomach(+-+)
measuring the
diameter (Courtesy
of Jane L. Clarke)

REFERENCl
I. Goldstt·in I. Rt•t•n· EA. Y.1rkoni S. \X'.m :\1, (;rcc:n .Jl, llohhin-. JC.
Growth ot the fetal smm.Kh 111 normal prc:f.n.m~ics. Obstetrics
,md Gyll<'colog)' 19H7 ;70:n.J 1-644.
ID!I Obstetrics

Fetal small bowel

PREPARATION
Full bladder for tran~tlxlominal in1.1ging in first and o;econd tmnester.
POSITIO I\
Short axis image of fluid-tilled small howel.
I'ROHE
3.0-5.0 J\IHz tran~ducer is used for all second- ,md third-trimester
obstetric imaging.
M ETH OD
Max1mum di.tmerer ot transverse o;mall bowel. Dilated small howel is
associated with volvulus. meconium ileus and jejunal, ileal or colonic
atresia.
APPFARANCE
Fluid conraining lunwn of small howel is normally seen after 10 weeks.
MEASURFM ENTS

Gestational age Transverse diameter of fetal small bowel (mm)'

{weeks)
Predicted mean value 90th percentile
10-15 1.4 2
25- 30 1.8 3
30-35 .2.9 0

35-40 .).7 X

FURTHFR READING
P.uulckar sc..;. Sonogr.aphy of norm.tl tcral bowel. joum,tl of
Ultr,1su1md i11 Mt•dici11e 1991; I 0:21 1-220.
 Fetal small bow el IE'I1

Figure 11 1 The
maximum diameter
of transverse small
bowel is measured.
Fluid-containing
lumen of small
bowel is normally
seen after 20 weeks

R EFI-JU·I\:CI~
I. Cold~tein I. Lo..:kwood C Hohhin' .JC. Ulrra~ound assessment of
feral inrnrinal dt:v~:lopment in tht· n.tluation of ~esr.nional :~ge.
Ubstl'lrics ,md C)•m·cology 19R7;70:6Hl-6S6.
1D Obstetrics

Fetal colon

PREPARAT ION
Full bladder for tr.tn ~abdomina l imaging in fir~t Jnd second trimester.
POSIT ION
Snl>\irt.tl view through rrausvcr!.l' ~o:olon .
PRO HE
3.0-5.0 t>.IHz tran~ducer is u!>cd for all se~.:ond- and third-trimester
ob~tetr ie im.tging.

M ETHOD
ror maximum diameter of rran~verse colon, the colon i~ mc:<l!>Urcd
from outer-to-outer mnrgin. D1lated colon is nssuciated with
Hirs~.:h~prung's dio;ea,e, volvulu~ and coloni..: .Hrl><>ia.

APPFARANCE
The lumen of norm•tl colon is rcli.thlv visu.tlized after 25 weeks.
M EAS U R EM ENT~

Gestational age Transverse diameter of fetal colon (mm)'

(weeks)
Predicted mean value 90th percentile
26 5 9

]0 R II

.H II 15

40 20
'"
RHERENCE
1. GoiJ~tcin I, l ockwooJ C, Hobbins JC: Ultrtlsmmd as~tt."!.Mllent ot
feral intestinal development in the evaluation of gc:sr:~tion.ll age.
Obstetrics and Cwlccology 19!l7;70:681-6H6.
FURT HER READING
P.trult:k.tr SG. Sonogr.tphy of normal fetal howcl. joumt~l of
Ultrt~smmd ill Medicine I 'J9 1; 10 :2 11 - 220.
 Fetal colon 1111

Figure 112 The

maximum diameter
of transverse colon
is measured from
outer-to-outer
margin. The lumen
of normal colon is
reliably visualized
after 25 weeks
1mB Obstetrics

Predicted fetal weight percentiles throughout

pregnancy ____________

PREPARATION
full bladder for transabdominal imaging in first and St.'cond rrime!>ter.
PROBE
3.0-5.0 MHz transabdominal rransdm:er is used tor ,111 second- anll
third-trimester obstetric imJging.
M ETHOD
log (B\V) = -1.7492 + 0.166 BPD + 0.046 AC)- 0.00264 (AC x
BPD)
where AC is the abdominal circumference, BPD is tht' biparietal di.lm-
eter and BW is the binh weight (in grams). (Predicted from aboned
fetuses ll- 2 I weeks and hirths 21-44 weeks.)
MEASUREMENTS

Menstrual weeks Predicted fetal weight (g), percentiles'

10 25 50 75 95
8 6.1
9 7.3
10 !l. J
II 11 .9
12 I I. I 2 1. I 34.1
13 22.5 35.3 55.4
14 H.5 51.4 76.X
15 ~6-
51.0 .I IOH
16 79.X 11 7 151
17 1.25 166 2 12
I ll 2SO 172 120 298 860
19 320 2 1- 283 394 920
20 370 .,--
_.).) '') 5
·'-· 460 990
21 420 .no 410 570 1080
 Predicted fetal weight percentiles throughout pregnancy D

Menstrual weeks Predicted fetal weight (g), percentiles1

10 25 50 75 95
Jl 490 4 10 4!W 630 11 80
., ',
__ 'i70 460 5)0 61JO 1310
24 (l()() 530 640 780 14...,0
r
_.) 770 630 ..,40 890 lh60
26 X90 -.~0 S60 1020 IN40
.,.., 1030 840 91)0 11 60 2100
28 I I X(l 9XO 1150 1350 2290
29 1~10 I I 00 UIO 15.l() 2500
~0 1480 1260 1460 ,-,o 2nW
31 16-0 1410 1630 1880 28)-:(l
32 IS70 1)..,0 IXIO 2090 \OYO
33 2 190 1720 20 10 22XO l290
34 23 111 1'110 2220 rio )4-o
-·
'
'-
.l) 2510 2130 24.10 rJo .ih I 0
J6 2Mi0 24-0 2o'io 2950 .l750
r 2750 2580 2X..,O 3 160 .)!;-()

JS 2lWO 2""'70 .\030 3320 J9HO

3'-.1 2X~O 2lJ IO )170 3470 4060
40 2X40 ~010 llXO 3590 4 100
41 P<JO 3070 .UhO J61:W 4110
42 ~ 1I 0 H 111 \740
4 .~ 3 110 ~410 3780
44 3050 .tWO ,_..,0
.) '

REFERl:NCI
I. Brenner WE. tddman DA. H\:nd ru:b ('II. A \trmda rd of fet.tl
growth for the Llnitt.>J ~tatl"~ o f Anwnc.:.t. Amt•t ic..m journt~l of
0/Jstt•tri,·s ,uul Gwruolo~v
. .
. 1976;1 l6: SSS-564.
mJ Obstetrics

Amniotic fluid

l'REPARAT IO l'\
None.
POSITIO N
Uterus is divided inro four quadr.mt~ using t he maternal sagittal mid-
line vertically, and an arbitrary tr.msvase line h<~lfway between uterine
fundus and upper edge of uterine fundus horizomally.
PRO BF
3.0-5.0 MHz transducer ts usetl for all second- .md thtrd-trime~ter
ohstetric ima~inp;.
METHOD
Transducer is paralld to m.u~·mal sagittal plane, and perpendicular to
m.nernal coronal plane. Amniotic fluid index (Arl) 1s the sum of the
nMximum venicJI depths of the .unnioric fluid pockt:ts in the four
qu.tdranrs. It can he used to determine the volume of amniotic fluid
.1 iter 16 wee b.

Al,l,EARANCE
The deepest pocket ot amniotic tluid in each quaJrant i~ vi!>ualized.
The pocket should he free of umbilical cord or feral t:xtn:mirics.
 Amniotic fluid IE'SI

Figure 113 In the

sag1ttal plane
measurements are
made perpendicular
to the maternal
coronal plane.
Measurements are
taken in four
quadrants (Courtesy
of Jane L. Clarke)
 Obstetrics

M EAS UR EM EN T S

Gestational AFI percentile values in normal pregnancy {em)'

age (weeks)
5th 501h 95th
16 7.9 [ 2. [ [ 8.5
17 8.3 12.7 19.4
18 8.7 13.3 20.2
19 9.0 U.7 20.7
20 9.3 14. I 21.2
21 9.5 14.3 21.4
22 9.7 14.5 21.6
23 9.8 14.6 21.8
24 9.8 14.7 21. '-)
l6 7.7 13.8 24.9
37 7.5 13.5 24.4
38 7.3 U.2 23.9
39 7.2 12.7 22.6
40 7. 1 12.3 21.4
41 7.0 11.6 19.4
42 6.9 I 1.0 17.5

An AFI below the 5th percentile is suggesti ve of oligoh}dramnio~, ,tnd

above the 95th percentile is ~uggestive of polyhydramnio~. Hm\"C\'Cr.
the validity of this table for diagnosis of oligohydramnios and polyhr-
dramnios has not been clearly established. The ultrasound diagnosis of
incrca!\ed nonnal or decreased fluid should be complemenreJ hy the
sonographer's subjecrive analysts.
FURTH FI~ R I: AJ>I N( ,
t\ loon: TR. Clmical .tssessmenr ot ammotlc fluid. Climc,ll Obstctncs
,md Gynecology 1997;40:303-J I J.
REfERENCE
I. Moore TR. C.tyle JE. The .tmnioric fluid mdex in normal human
prc~nancy. Amcricun j ou111al of Obst(•/rics und Gynecology
1990; 162:1168- 11 73.
 INDEX
.1bJomin.tl .eon.• .! 14-16 amrmm, fluid mdn: {/\H l l20. 122
.1lxlomin.tl .:ir.:umterence (AC). ier.1l ~111.11 cruluM>IIOj!.raph~ 1-0-1
l6f>-9,27o.rJ-3 <llli\l>!ropi.: artii.Kt' 1-5
birth wei~o:ht<''!lmatinn .!7f>-lU. :mkl<· 202- ~
31X- 19 anren.tt.llrm.tgrng see obst<'tn,·
head cor.:umf.-renct" r.ltlu .!""'4-\ illl,IJ.:IIlf!
rhorac~~.: .:trcumiereiKt: ratio 302 .llll<'flor ro111t 'P·KC ot elbow I X4- '
.1hdmnin.tl im.t~lll).: :1 nterror t i hr.1l .t rtery !I!!
common htk dm:t 14-19 sc<' .1lso luw<·r limb. :tnt'r;,.,, ,r,·nor..i~
diaphr.1,.:m.IIK monon 26-7 aorta
)!allhl.tJJer n-Il .thdonun.tl214- I 6
~.JIIhl.tddc:r w.11l 12-13 p.1n.:re.1, rr.m~plams ':12
hep.l!t.: du.:r 20-1 r~:n.1l rr.tn,pl.lllt' Rn
lin:r 1-5 ren.ti-.H>rric r.nio 30
pcJi.ltri,· .tppenJi.:tti~ 164
common hrlo: dl,.:t ll!-19 .t ppo:nJi, I 64-5
g.lllbl.tJJcr X-II .tppcnd i" <'prdr,h-mis ICll!
ft\·cr 4- 'i .tppcndi' t<''t'' I 04
spleen.! l-5 .Jr.:u.l!t' .trt<'nc' ui kidney .l-1, H
spleen H-'i arterre\, ,·ern-ro-.uterv ra!to 240
v,l\.:ul.tr SI'L' ,l{So \ ,\ 'l·uiJr Sy~tt:lll
acute:" rt"n.tl uh~rru.:llon .H- 5 ani(,~<:b, mu-.:ulo,kelc:r.tl tlll:lJ.:IIIJ;t
.:di.tc .trro:n· 42-.l. 4n-7 PS
hcp.Hi.: .m<·n· 40-1 .rl\illary .1r1ery 111
hep.l!lc n·m~ 11::- 9
interinr mcwntt:n.: artcr' ·U!- 50 h<bii.H .lrtcn· .! lO. l.l1
port.ll \t"IO l6- 7 ht<:Cf'' ll:nJon t - f>--
rmrpr.m.!i.tl hlooJ tluw 4n-7 bile du.:h
renal arto:r) ~0-l adult I +-I-, 20- 1
'IIPl'rtt>r llll'Willt:ric art<'r\ 42. pt'diatrt<' I N-1 ~
44. 4(.-7 bipam·tal Jtamcrer 1IWD1 25~-61.
see .1/so ol"tctru.: lmJgtnJ! .!..,n• .!-1-3
.tnducrm polli.:i, lonJ.:u~ I 92, I'H hirth wt•rt;hr c•rim:nion 2-6- 1> \,
J..:~:t.lhulum. tkwlopmenr.ll dy,pl.l\1.1 HX-1~
oi hip 19!!. 199 and mhir.1l di.uneter~ lOll- I I
tkhillcs rcnJon 204-5 bi.HlJer
.lllcnom.l, p.lr.uhyrotJ t 34, I 35 pa1Krc.t> tr.Jn>pi.Jnb '~2
.1drcrl.ll gl.tntf, rc"du.tl <·ulumc <16- X
:tdult f>n urctcr<>«·,r~.ll i<·r' Ill.!->
pedtatri.: 6-- 9 ,·olunw '16- X
.unnimk tluiJ 321l- 2 W,IIJ 100- J
ED Index

howd ..:hromusomal di><~rders

l·ndo...:opic ultr:l,mmcl 166 cisterna m.1gn.1 100
feral .\ 12• .ll4-15, .l l 0--17 nuchal fold thickne's 254
wall of 161l-9 nuchal rran,lucc:n..:y thickn~~ 256
hrachial artl·ry 212 cin·hosi~
hra..:hiocephalic (innommatc:) vc:m hepari..: veins l!!
Hll portal ,·ein • ..:on~e,tton mdex 16
hrain ci~rerna magn.1, frt.1l 300- 1
ic:t.ll colon 161!, 169
,·erehral venrricle; 291!-9 fetal 314 • .H 6-17
.:i>terna magna 3Uo-l common l>ile d uel
imra,·r.mial blood flm~ l.'ill-9. .1duh 14-1..,
l.lo-3 peJi.ttric ll!- 19
atc.·tHlat._ll common c:lrntid .mc:n• (CCA) 222.
intr.ICr.mial l>lood tlow I ~ll-~ 223
venrn,·u Ia r ~11e 1 .~4-7 common ihac arrc::ry 214-16.218
hur,.u· pancre.1~ rr.m,plam' 92
.lp~.lr.lll\.'1:' 174 common iii(!.: \'t'lll, p.mcn:as
imerdip.ual 201l tr.Jnsplant~ 92
rc:trc><.Jkanc:al 204 congestion inO<'X (Cil. portal vein 36
Moprapardlar 200 crown-rump length, fer:tl 250, 251,
252-3
cak.mc:u' 204, 205, 206, 207 cystic dtKt I X
carotid am·nes 222-~. 230 cystic h}'grom.l 2 'I'>
carpal rnnnd 194-S
carpal wnnel S\'ndrome 1':14 developmental Jyspla~ia of the hip
..:.nerno,.tl.lrtery 114, 115 198- 9
..:di.1..: .trtery (CAl 42-J, 46-7 Jiaphragmatio.: mmion 26-7
p.m.:re.1~ transplant' ':1 2 Doppler perfu,um ondc:x (1)1>1) 40
cc:rd>ral artc:ru~s 23 I, 232 Doppler sonogr.1phy
neon.ual I 'ill, 159 ;Kute rl"n.ll nlhtrtlL'non )4-5
.:erehr.tl venrrides appenJi, 164
lct.ll 29!!- 9 .:dia.: anc:ry 42-3, 46-7
lll'Oil:ltC:\ 154-7 f'Xtr:tcrani.ll Jrterie• 222, 223.
wntricuiJr ratio (VR) 156 22f>- 9
,·erd>ro\',l'..:ular di,ea,c:. pl.lqlll'1> .:?.22 fetal hearrheat 1.\0- 1
L'l'f\'i.:JI .:.tn.ll 130-1 hepatic .mery 40-1. KX. !<'J. ':10
cernx 122-l hep.Itic '-t'in, JH- ':1. HH. H9. 90
111 prep.n.mq 130-1 inferior me~nrc:ric Jrterr 4&-50
ChoJri malforn1.1rion 300 inferior \l'IM .:a\',1 Ill:!. 90
..:hiiJrc:n S<'t' pediarri..: ultrasound intracrJni.ll hloc.U tlow 151l-9,
..:hok·q·,tc..:romy. bile duct doamc:h:r 230-.l
.lftrr 14 leg ,·eins 240-2
.:hok·.:y~tms. g.tllbladder w.11l liver tmn•pbnt' ll&-91
thi<:knc'' 11 lower hmh arraic~ 218- 19,220-1

lymph nnJl'~ 111 ne.:k 144. 145
ned, vein' 2lX-9
p.mcn;.l' rr.m~pl.tm~ 'Jl-3
p.1rarhnou.l .ll.ll'nOmJ 134
penile '"a~ul.1r 5~ ~rem I 14-1 fl
puna I Vl'in .~6-7, XI>. '.1(). 'II, '12
po,tpr.mth.ll lnte,tmal blood tin\\
46-7
ren.1l .lrtcry ~0- 1 . ,::6--
ren.tl tr.Hhpl.um X!. lH. X6- -
'upcnor mesenteric :men· 4 2. 44.
46-7
thyroid .merit.., 142
utn!->ihc::~l .meri~ 294-7
upper limh .urcri..,; 2 12- l .l
uretemn-.~~:.tllt'l~ I U2-.l
dor,al tt'ntlon'. wnst 19.!-3
Down's ~yndromc
nudldl fold tl11ckncs' 1 ~4
nuch:tl tr.m,lu.:cncy thicknc~~ !56
duodenal arre-1.1 .ll2
duoJen.tl w.tll, I 61'>
effus1ons. 101111 su syno,·•al llwJ
<'l.tculatnn· Ju.:r I 12
dhow
.mrenor lt>lnt 'P:lt'e I !M-5
later.tl I SX-9
medi.tl 190-1
olecr.1111>11 in"·' 1S6--
elderly pcoplc
..:ommun hilc dtKI 14. 16
k1dncy >l£c 54
p.tn.:n:.h -.0
.:nd dia,rohc \'dm:iry 1EDV)
b.1sibr .mery 231
..:.n·erno,.•l .urer~· 114. I 16
.:eha.: artcr' 46--
,·crchral .Hit"nt·~ 2 .l2
interior mc,t:ll!cri.: <lrtcry 4X. 4'1
Internal .:.~roriJ .Jrtery 226. 111!.
21'1
supt-rinr mncmt:nt .trtt:r) 46--
rhyroltl ;Htcnc' 142
umhilao.:.1l .lftt·nt·, 294
Index &
vcrtd>r.tl .trtery 232
end wsruiK \elo.:iry, nt:.:k \'<'Ill' 2 :;x
endomctri.tl ,tript· 126-7
.:ntlo-o.:opat· ulrr.1smmd
anal ..:.mal 1-0-1
uppt•r (;! u.~.:r w.tll 16o-7
cpitlitl) mi' Iilll-9
erecnle dy,funt'tion I l 4- I 6
extensor .:.1rp1 r.td1.tli' hrcn' I 92,
[93
cxtcmur .:.1rp1 r.1diali~ lnn~n' I <~2,
I 'I .l
extciiMlf o.:.trpi uln,ui~ I'12
exten..,,r Ji~ati minimi l '11
exren~or di~irorum I 91, I <J_l
exten~or ...hgaturum lun~u' 102
c'l:tt'll"lr halltKi' longu~ 202
e:-..ten!>or im.hcis I <Jl, I <J l
t''\ten~ur pnlli.:i> brevi; 192, 19~
C:\!t'll~or polli..:a. longu; 192. I ':IJ
t'xtern.ll .111.11 ,phin...'ter ( r :\~) 1"'0- 1
exrt-rr1.1l c.uon.l .trrery cECA) 112.
2.!.l,1.!4
e'\rern.tl 1h:t•· .~rrery, renal rr.uhpl.lntS
Xfo
.:xu ,~.:orpt~r<";II mcm bnuw
m:y~t"Jl.ltinn 1ECMOl 15X
exrr.~..:r.tnl.ll .mc:ri~ 222- 9
iemJI<: 1-:t'nit.ll rra.:r Sl'l' p.emr.tl rr.1.:r.
lem.1k
tt·mnr.ll .u"tt't)" 1 l X. 1 I'1. 11 l
f<"mnr.ll \"t:lnl-l\1, 14 1, 241
femur
feral. len)!th !-0.2'"' 1-J. !lli>-':J
hip ama~in~ 19-. 198. !99
knee im.1~in!( 200, 10 I
f.:t,lllm.l~lllt-: S<'l' ol>~rernc un.1wn~
fil>ul.u .:oll.ttrr.ll hl(amc:nt 200
flexor tl1~11nnam longu~ 102, 20 l
tle:\.ur diguonun profundu:. I 94
flexor Ja~1ronun 'uperlio.th' I 'l.j
flexor h.lllt..:" longus 202. 20 >
flexor rt·nn.t.:ulum 1':14
food. rv~tprandial bluvd flow 46--
1D Index
foot
Achrlle\ tendon insemon 204,105
interthgn.tl wch sp.h:n 20l!-9
plantar fascia 20t>-7
g::~llhl.tddcr
adult ft-7
pedi.uric ll- 11
wall tl11ckness 12-13
g:tstric w.tll\ 166
g.tstroimestinal tract
,mal cndnsonography r-o-1
:tppendi" 164- 5
b<lwel w:tll 161!- '1
ict.tl ~·olon .l I 4, .l I 6-1 7
tctJI '"'·'II huwel312. l14-15
feml ~tnmach diameter .l12- IJ
postprandial intesnn.1l hlood flnw
46-7
pyloric 'rennsis 162-.3
upper (;I tract wall 161'>-7
~en it.JI tr.Jct
femak
amniotrc flUid volume 320-2
Ct:r\1'1( 122-3, 130-1
endometrial stripe I !n-~
0\·.ui.m follicle, I ..!0-1
ova ry ll!l- 19
uto:nr:. 124-5. 126-7. 320-2
male
epidtdynus IU!!-9
peni, 114-16
prnstate I i 0-12
seminal ve<>ide~ I 12-l .l
testes I 04-6
~C>t.ltlnnal :.ac 244. 246-9
Gral alpha .m~:le 19l!
head circumference, fetal 262-5,
270.27 1-3
Jhdon\cn circurnleterlce r:~rio
274- 5
he:mntw. ft:ta 1 250-1
hep:1tic .mer~· 40-1
li ver tr.Jn:.planrs 8l!. !l~. 90
tardu> pan·us wa,·efurm 1!1!, 89, 90
hcp.Jtic dimcn:.ions
.1dult 2-J
pcdiatru.: 4- S
hepatic du~·t • .1dult 20-1
hepatic tr.m~plantation l!!j-9 I
hepatic vems .l!l-9
liver tra nspbnts l!ll, I!Y. 90
hip
de,·elopnll'nt,tl dyspb:.i.1 191!-9
effusion 196-7
Hir,d1:.prung':. disease 3 1f.
fl-hum.m .:horionic gonadotrophin
(HU;l 244-5, 246
humeru:.
c:~pnd lum l ll4. IllS
fer:~l. len~rh 290-3
l..trer .11 t'picondyle of 1!:11!. 11!9
medial epicondyle of 19(1. 19 I
hydrocephalu\ 15!1. 29R
hydronephms1s
feral .l04
neonar.1l 04
hypcrremwn. pr~nancv-mduceti 2'J4
h~l)(l'I(U:-i:.chcmic bram injury 15ij
ilc.1l arr.:s1.t ~14
iliJc aneries Xf>, 92. 214-16, 2 IR
iliac veim 92
ili.1..:u~ mu~·le 76
ilimihiJI h-.md 200
imporen..:c:. , .•N;ulogc.'llic I 14- I6
infanrs
adrenal ~lands 67-'1
brain 154-'J
common h1le duct I ll
dc:vdopmcnral dv~p1.1sia oi hip
I'JH- 9
~allbl.uldt•r 10-1 I
kidneys 60-2. 64-'
pan.:rt'~'" 74
pylnrit· ..rcno'i' I n1-.l
splenrc length 21
th}'rord ~land 140
urctcroH~ical rets I 02-3
 Index

inlt.>nor Olt''('lltt:nc .Hrery 4ll- ~O ;ldulr 2-l

mierior ,·en.t '·'"·' (IVC) 136-.., c.:irrhu'i' lX
.md hepan.- n:ut> 38. 39 ncp:ttll' .trten· 411-1, Xli, X<J, <Jf)
lil'o.:r rr.tn~pl.tnr' XX. 89. <J(l hep.nt.- du.:1 20- 1
mtraspin.uu~ t.:ndnn 182- 3 ht'p.n~t· \'1:10' .>X-'J, XX, X<J, 'JO
mnomin.ue (l>r.Khit...:eph,tli, J \'l'tn inkrit•r \'l'IIJ c.n.1 HH, X<J, <JO
231l pctli.nnc 4-5
inrerdigir.tl weh \p.tees 20!:!- 9 portal n:in .ln-7, RR. 90, 91
imernal cJrutid .trr.:ry (I CAl 221. tr.ln,pl.mt.trinn M!!-91
22.l .. .!24 .. .! )() lonj!. h~:td nl ht.:t'ps I -6-7
Oeflll,H~' I 'X lo\\t'f Inn!>
..reno'i' l.!t>- '1 Ac:htJic, tl'mlnn 204-5
inrerna l ltti(UI.tr wm .!.1ll ~nkle 202-.l
tntesti n.tl rr.tct S<'('l(.t~rrointt'~!in.tl :meri<·, 2 I X- I <J
u ..h.'( \ICIIO'I\ .!.!11-1
intintJI·ml'di.Jl dud..nl'" (1\ITI. fnt>t .!Oh-9
·t ,,. n·
~..trnru..u-fl·~· __ .,., ---' hir 1%-<~
tnrra.:ralll.tl .m.Hnm\', ier.tl l<JS- \(II kn<·e 2011-1
nuracrani"l hlo<lt.lllow .!JU-.1 Vl.'lfl\ 1411-l
n,..,.l.llt:' I.'X-<1 lymph noJ<''
.:en·io.:al 144-6
JeiwtJI .nr~i.t .\ 14 retrupcrironc;ll -t!- ':1
joint dtu~ton' St't' 'ynonal tlwd
jul(ular ''"''"' 2 \!l, 2J9 rn.tle ~emr.1l tr.~~.:r sec 1/,fllit.ll tr.~~.:r.
tll.llt•
ktdncy' m.1lkolu, 202, 20.l
:u:urc uh ..rru.:rion .l4- 5 meal~. P<"tpr:mdiJI hi()(.U !low 46-7
.tdulr 51-4 meJtt ,,K dtanu:rer (.\l 'iDl .!44. l4t.,
feral 64- ), .>04-5, ~Of.-­ .!4R
ncnn.l!al Ml-2, h4-> mean ,eJo~ot\. t\' 1. intcnur
~

pcdi.ltrt<: 5f>.-f>' m<·wntcr~<: artery 4X

n:n.tl artt·ry ~tl-2, Xt>-7 mecnnnnn >leu~ 114
rr.m~pl.mr.mnn 82-4, 1:!6-7 tnt'tiM n nnw 1"14. 19 5
knee 200- 1 mc:tJi,t~£11111111 11:~!1~ 104
met.lt.Jr,,ll~ .!ON, 209
l.~rge bnwd \lnrrnn \neuroma 108. 20':1
feral q 4. ll f--1- musde hun.lk-s, .1ppear.JtKt: 1-4
wall I Ml, I n<J mus.:ulo,kt:lcr.tl ~ystem 1-4-s
lt'l( see lowt•r limh .trtol.ll'[\ ~ --
lig.Jilll'nt' hur...\l' 1- 4 . .!UO. 104. lOX
a ppe....Inc,· I -4 ligament> 17-J, I !!ll. I 90, 200
dhow I XX. I'JO lower lnnb
knt't' .!00 ;\..:hi lie' 1t·ndnn 204-5
ltmhs st'C lm\'l·r lnnh; upper limh .mkk 202-.l
ltl'cr tnot 2Uo-'1
mil Index

tmlst·u/oskeletul system <

"W1t. cervix/ccr\'lcal C3nal length 130-1
loll'er limf1 cont. few I ahduminJ I .:ircumiercnce
hip 19<-.-9 266-9.r0.27 1-J
kne:-e:- .!00- 1 birth wctghr est im.monl-.6-85,
mu~le hundles 174 .> t!!-19
nerves 174, I 94, I 9' he::td CJrntmference rano274-'i
tendons rhor.~eic .:ircumlerence r.Jtio
artit.J.:ts 175 l02
gencr;tl appcaratKc 174 feral htparier.ll di:unert·r 25!!-fi I,
see .1/so specific tmdm1s 270,27 1-3
upJX:r limll hmh weight csrimanon 2-6-85,
clhow I !!4-91 .\1!!-1 9
~houldcr 176- 83 and orhn.1l diameters .lOll-II
wri~t I 92-S ictal ~·;~h•Jri•• 258
fera l .:erd>r.JI venrrick·~ 29!!-'1
neck vein' l.l!!-9 feta l churmd ple-.i 29!!
neonates iera I cisterna m:Jgna 300- I
.Jdrenal ~-:lands 67. h!!-9 icr;~l wlon .l l4, 316-17
brc~in feral crown- rump length 250. 15 1.
inrra.:r.mial hloud flow 15ll-9 252-3
,·enmcular size 154-7 icrJI femur length ro. rt-3,
commnn hile duct I!! 2!ll'.-9
gallhl.uldt•r 10-11 fetal he~1d circumterence !61-5,
kidne~·s ti{)-2, fi4-S 270. 27 1-3.274-5
pa!lCrl':IS 74 feral hcanl>car 250- 1
prem.uun· feral humerus length 2Wl-l
inrro~.:r.tni.JI hlooJ llnw 158 tct.ll orhit.ll Ji.lmeter~ 10M-II
\cntricular size 154. 156 ieta I ren.1l lt>ngrh ]06-7
renaI nh,rmcrinn 64 feral renal pelvis di.unere:-r 64-5.
splemc length 22 304- 5
thn01J ~l.md 140 feral ~tm11l howe! 314-15
nerve~ feral ~mmach diamera 3 12-13
appearanu:- 1"'4 kt.1l th.JI.uni 258. 159
carpal t unnd 194. 195 fctil l rhor.tcic circumfcrcn.:e 302- J
optic nerw 150- I f<·talumhili.:.ll arrene~ 294--
neuromas, foot 20!!, 20'1 feral \\'t'tghr percentil~ .~I !!- 19
nuch.1l fold thickne~s 254- 5 gesr.mon.1l .1ge
nuch;ll tr.mslucency (1\lT) rhid.: nc~~ J huomim1l circumferc:-nce 26ll- ':1,
256-7 170,271-3,275
ammotic fluid index .~22
nh~rerric tm.l~ting biparif't.ll di.1merer 26(!- 1, 2-o.
amniotic fluid 320-2 r 1-.l
amn iotic fluid index 320, 322 btrth weight prediction J 18-19
birth we1ghr esnmJtiun 276-84, colon J i:um:rt:r 3 I h
118- 19 crown-rump length 252-3
 Index lim

femur len~rh 270, 271 - .l, 286-':1 P<HKream•' 72

and ge,t.Hinmll , ,1.: ~•ze 14n, parathyroid gland~ I 14-'i
248 parotid salivary glJnds I 38-9
head cir.:umic:ren.:e 264-5, 270, pardlar rt·ndon 200. 201
271-3,275 peak sysrolic velocity IP~V)
~-h<...C levels compared 244-5 h.tsilar a rrcry 232
humerus length 290-3 C:lvcrno-..11 .lrtcr~· 114, I I 'i, 11h
multiple feral pa rameters 270- J celi,K artery 41. 4J. 46
orb1ral diameters 30!!-11 cerebral ancries 232
renal len~rh 306-7 inferior mc-cnreric arrcrr 41!, 49
'mall 1->nwd d1amcrcr ] 14 internal carotid nrrery 22n, 22!1,
'tomach diamncr 312-13 229
ultrasound landmarks comparni lowt."r limo arreric~ .!Ill, 220, 221
244-5 rena l a rtery .~0• .ll, !!6, ~~-
umh•lical artery l9f> renal tr<lnsplants li6. 8~
~estarional sac 244, .!46-':1 o;upenor mescnrcri( artery 42, 44,
~- hCC level' 144-5, 2 4f> 46
mean ~ac d1amerer 244, 246, 148 thyroid a rreries 142
nuchal fold thickness 254-5 umbilical arrerie~ 294
nuchal rranslucenq rhicknc~' vcrrehr.1 l artery 232
2.\6-7 pediamc ultrasound
placenr.1l dysfun.:rion .!':14 .1dren.1l glands 67- 9
yolk s,1c 244, 246 brJin ( n~"Onaral) 154-9
IIL"IIpha~U' 166 common h1lc dm:r I R-19
okl~r people sre elderly people developmental dysplasia oi hip
olecranon iossa I !l6-7 198-9
oli~ohydramnio~ J22 gallhl.ldtlc• 8-1 1
ophthJlmic ,urcry 2JO hip effu~wn 196- 7
optic nerve I 'i0-1 kidneys 56-62, 64-)
orbir~ hver4-5
exrr.10cular mu~d<"' 148-':1 0\'<lf)' 118
feral, dt.uuerers 30!1-11 pancre.t~ 74-5
opri.: ncrw 150-1 pylori.: 'tcno~i' I f>2-.l
organ rransplanrarion rena I obo;rrucnon 64
kidner 1!2-4, 1!6-7 renal pelv1s d1amerer 64- 5
liver !H!-<.J I spleen 13-5
pancre.ts <.J2-3 rhvroid gland I 40
ova r~ I I R- I 9 urcterovesiol jer~ I 02- l
follides 1.!0-1 uterus 124
peh·1s
pan.:reas bi.1Jd.:r
.1Juh 70- 1, 72-3 rcMJual volunw ':16- !l
p.lll<:r<:;ctri.: du.:r 72-.l urercrove,icnl wrs I02- .l
peJiarnc ""4-5 volume ':16-X
rran~pl.u11:11ion 92-3 w.1ll 100-1
- Index

(Jc/l'is t:<mt. prt·~nancy-induccd hvpcrrcn~inn 294

fcmale uru~cnital rra..:t
..:ervix 122-3. 130--1
em.lomc:mal stnpe 121'>--7
ovari.111 follidt'S 120-1
ovary I I X-21
urethra llH-9
uterus 124-7
male genital traer
epidadymas I Ul)-':1
pt:ni~ 114-16
prostate 110-12
semmal ve,ides 11 2- U
testes I 04-6
pedi.uru:, urererovesa..:al1cr~ I 02-3
penis 114-16
peripheral nc:rvt:s
<!ppcar:IIKC 1..,4
c.upa l runnel 194, t 95
peripher.1l v.t~ubr system see
vascular ~y~tem
peronea I a rrcr}· 2 IH
see also lower limh, arrcric,,
StellOSIS
peroneal !l::ndons 202, 203
Peyronic's di'<".lSc I 14
pisiform I '14, I ~5
pi;Jcenral dyo;luncrion 294
planrar fa,caa, foor 206-7
plaques. exrr.Kr.wial arrenes 222-4
polyhydr.unnios 322
poplirc;~l .ur.:rr l t 8
see also lnwcr limh, .~rtcrit·,,
srenoo;is
popliteal vein 240
pophreu~ tendon 200
pnrr.tl n.-in ll'>-7
liver rran~pl.tms 88, 90, 91
pancreas transpbms 92
posterior rihi.1l .trrery 2 1!l
see alsv lower limb, arrcn<'j,,
srcno~is
pu~rprandi.tlamesun;~l l>lovd fluw
46-7
pregnancy sc•c• ohstetric imaging
prem.lture neon.ues
inrmcr.tnial hlood flow 158
\entri..:ulttr si7.<' I H. I )6
profund:t femoris 1 1X
pn"tatc ~tland I I 0-12
p«ua' mu-cle 71'>--7
pulmonary hrpopl.1~1a .~02
pul,.mlit)' index (PI ) 41\
cchac artt:f)' 46
infl•nor me~enrcra: .trtt:ry 48
~upenor mesenteric arrerr 46
pylori.: S(CnO~IS 162-3
qu.tc.lnceps rendon 200, 20 I
radi.tl .merv 2 12
radi.tl he.td
•mrcnnr ioinr )pace 184, 185
l:ut·ral elbow IllS, I !!9
r(•cri muscles, exrr:wcul.tr 148-9
renal-.wrnc rario ( RA R) lO
renal Jrcu.tre :trren~ 34, 35
renal .trrt:n· 30--2
renal rr.wspl.mrs 1)6-7
rcn.1l artery sren<>)i., ( RASl 30, 31,
32,!!6-.,
rl·nal dimcnsaon~
.tdulr 52-4
feral 64-), .~04-S, lOt-.-7
neonatal 60-2, 64-5
pedi.unc 56-65
renal ohsrrucrion
.u:ure l4-5
neon.uc~ 1'>4
renal rmnspl:tnr.lti<>n 81-4
rcn.tl arret'} steno«is in 116- ~
rc~idu.1l \'Oiume, hbddcr 96-H
rc~i~r.mcc index (RI) .lO
at·ur<' rena I ol>~rrw.:rion 34
ha~alar arret'}· 2.H
.:erdmll .ureries 232
llt"UIIiltes I 5S, 159
hcp.ui..: .1rrcry 4U
rardus parvus w,tveform 90
 Index ED

infenor nw"<.'nrt·nc artery 4!!, 49 ~ulxl;nun .men· 212. 21J

nonn.1l ren.1l Ill ,ubdavi.m vein 2.lR
p.mcreas tr.ubpl.mt• 92. 9.l ,uhmandihular ';111\·ary ~l.md~
renal .~rren· 'tt·no~•~ JO. l l . J2. Xn 136-7
renal tr.msplant> !!2, !!4. !in 'uhc:t pul.m' tt·ndon l..,R-9
vertel>ral .lrtc:rv 2.ll ~uperlkial 'tructures
rete tnth I 04 cen i.:.t l lymph nodes 144-f>
rt•tropentoneum orh1t'
.1drenal )!l.llld, bn-9 cxtr.w.:nl.u muscle, 14X-9
' ,).,
k I'd llC:~~ Ll f>4-"
_-o_, ,), 8'
-- 'T optic nCr\'t' 150-1
lymph nodt•, "1<-<J p:lt.Jtlwmal~tland• 134-S
pancrt'.h -0-.~ p.trorid ,all\·:t~ ~,:l.1nd' UH- 9
pancreatic duct 72-3 suom:lndihul.u S:llivarr glands
pedi.ltnc 1>6-7
<~dren<~l ~l.u~<l, n7- 9 thyroid gl.tnJ 140-2
kldl11.'\\ 56-62. 64-5 superfict.JI ''<'IllS 240, 141, 242.
pancn•." -4-5 >llpt'nor lll<"•<·nt.-ri.: Jrter~· I ~XI.\1 42..
renal pel"' d1.1meter 64- 5 44,46--,92
P'o"~ mn-ck -f>-- ~uprapart>ll.1r pnuch 200, 20 I
supnt>pin:llu' tendon ll!0- 1
~.1liva r~· gl.mJ, 'ynu••~l fltud
p.uotid l .lS-9 anklt: 211.!
'uhm.mJ•hul.1r I ]n-7 elhow 11:!4, 1!!5
~rotalultm~ound hindtnor 2114
epididymi~ I UX-9 hip 1%- -
testes I04-f> ~ystnlidchastoh.: (~fO) rano.
-.·,·rerin .1dmmt~tranon, p;lncre:HK umhili,·.•l aneries 2"14--
duct 7 2 see ,1/so enJ di.Nolic H'lt~·•ry: r<·ak
'eminal '~•ck' I Jl- 1l ,~,rot..: ,·elncity
,houldcr
inir.t>pin.nu' tt:ndon l li2-.l tardu' p.1n u' \\'a,·etorrn XX. H'J, 90
long hc.ul of h11:eps 176-7 tendon'
'u~.1pui.Jr" tl'ndnn 1-H-9 ,u·ritH:r~ 1-5
'upraspmatu~ tendon 180-1 gencr.ll :lpp~arance I 74
teres minor tendon lli2 see ulso spenfic tendons
sma ll howe! tcre' mmor rt·ndnn I !!2
cndoscnpK ultr."nund 166 resr<."s I04-6
fetal3 12. l14- 15 t>piJsd~ nu' IOX-9
wall th•ckn.-.., 16!! rhura.:•.: .:in:umicrcncc. ict:ll .l02-.l
~plecn 23- 'i rhn nnho'"
>tomach ht·patK .lrt<.·n H!l
end<hcop" ultr .hound I bf>-- inicnor \t'll.l .:,1\'J 90
fetal, dJ.llll<'tl'r l 12-l .l le~
H:ins .!411- 2
wall thlcknt'" 16M portal \'CIII !ill
'•mng-flnw' 2.26 rhyrwJ .lfl<'fl<'' 142
IDI Index

thyroid gl.tnd 140-2 infraspinatus tendon I !!2- ~

·1nd par:nhymid 134. LU lonv. head of bicep> I ~ 6-7
rhvmid vein~ 142 suh~apularis tendon 1-!l-9
rihia. kn"" im.t~in~ 200. 20 I >upr.l>plllatus ten~lon I HO-I
rioialis anterior .!02 \vri!tl
rihiali~ po~tenor tendon 202, 20.~ carpal tunnel 194-5
rihintai.H joint 202 dor!<.ll tendons 192-.l
transcr:mial Oopplcr ultra,ound uretcmwsacal,ets 102-J
15ll- 9,.230-3 urerhr.1. fcn1.1lc 12!l-9
mmsorhiral Ooppler ultrasound .!JO urmary tr.Kr
transplanr.mon hladdcr
kidne)' H2-4. H6-7 rl·.,idua l volume 96-!!
liver !!H-9 1 urctcn"'csical jets I 02-J
pan4.1<'<1~ 92- .l Yolume 96- H
tr.msrect<~l sono!!.raphy wall 100-1
prostate I 10-12 ieml 104
semm:~l ve"d"' I l l -U k idncy> S!'L' kidneys
transvaginal son(Jl(raphy Cf V!)) urethra, female 12!!-9
cen+-. 122-.l, 130 uteru' 124-5
ohsretric~ amniotic fluid \'olume .ll0- 2
crown-rump length 252 emlomctnal stripe 126-7
feral hearthe-.Jt 250
~e~tation.ll ~1c 244, 246-7 Y,trico.:ele I 01\
nuch.1l rr.m~l uccn.:y rhid.n~'l>S Y<l~Ufar S)'Stem
2Sn .thJuminal ,wrta 214- 16
and M"rurn 13-hCG levels 244-'i, acure ren.1 l obstruction .14-5
246 Cdi,IC .lrtt'r\' 42-.l, 46-7
ov.1ry I I !!-19 common iliac arrer~· 214- 1fl
inIIic lc<o 120-1 exrr.~e r.maal arrene~ 222-9
utcru~ 124-.'i hcpan.: .mery 40-1 , HH. H9, 90
endometrial ~tripe 126- 7 hepatic 'eins Jl!- 9, l!ll, H9. 9(1
trisomy 2 1 s\·ndmme see Down\ mterior mt>Senreric artery 4!!-50
'rndrome mferior \'Cil:l cava 2.>1\--
and hepatic veins .lH. 39. 88. 89,
uln.1r .1rrcry 212 9()
uln,u coll.ueral ligamenrs I XX, 190 liver transplant~ l!S, !19, 90
umbalical .uteries 294-7 anrern.tl .:.trotid ancr)' stenosis
upper limb 21~9
arrerie~ 2 12-1.3 llltra.:r.mial blood flow 23()-]
dhow neona t('S I .'ill- 9
anrerior joinr space l l!4- 'i liver transplants !!!!-91
l.uer.1l I XH-9 lower limh .meric~ 2 1H-21
medial 190-1 lower limh veins 240-2
ole.:ranon fo~~J 186-7 neck \'etns 23!>- 9
shoulder pan.:rea> transplant~ '12-J
 lndex E J

penile 1 14-l o \'CIIl' Sl'l! V:l~ul.tr 'Y'tl'!ll

porta l win 36- 7, l\!!, 90, 91, 92. wnrriclcs, cerehral
po~tprandial blood tlow 46-7 fet.tl l'Jl>-9
renal arrcrr 30-2. S6-7 ncon.ltc' 154-7
renal rr.Hl>pl.mrs !!2, S4, !!6- 7 \'C'Iltricular ratio (VRl 156
~upenor ml"'t'nteri.: < Htery 42, 44, ,·crtebntl .u·rer,· (VA!222,l23, 230,
46-7 132
rhynud arrcril"' 142 volvulu~ .H4. \ 16
thyroid vein~ 142.
rranscranial Doppler 15l:!- 9, wri~t
210-\ c.~rpal runnd 194-'i
umbili.:,tl .ureries 2.94-7 dorsal tendons 192- 3
upper limb <trtcric~ 2. 12-13
\'Cill· tn· artcry r.ltin 240 yolk ,.,,._. 244. 246