webinar for the SVU e-learning committee. Before we get started, before I introduce our speaker this evening, I just wanted to mention that at the end of this, there will be an email that will be sent out with an evaluation form. It will be distributed to all registered attendees within seven days. Please complete that evaluation form and return it in order to receive your CMEs. And now for tonight's presentation, the non-vascular findings in upper extremity venous duplex. Our speaker this evening, Ms. Manal Abdelhadi, was a radiologist in Egypt before immigrating to the United States in 2012, where she graduated from the ultrasound program at the Massachusetts College of Pharmacy Health Sciences in 2017. Although registered in multiple modalities, abdominal, OBGYN, breast, vascular, and musculoskeletal, she is particularly passionate for the MSK ultrasound, devoting one full day each week to it and working at the Mass General Brigham at Salem Hospital in Massachusetts. Welcome Manal. And with that, I'm going to turn it over to you. Hi. Thank you and thanks for all the attendees who have given some of their time to attend the webinar and thanks for the organization committee and the Vascular Society. We'll start today with the disclosure. I have nothing to disclose. And then we'll move into the learning objectives. So today's webinar, we will differentiate between the diffuse and localized abnormalities that we see during scanning for upper extremity DVT studies, differentiate between solid and cystic masses, recognizing the common causes of these masses, and differentiating between reactive and invasive lymphadenopathy, and recognizing some of the panic findings where further management is required. The overview of my presentation will talk a little bit about the anatomy, then the causes of solid and cystic masses, and then some mention of muscle tears and soft tissue tumors. Why this is important. Because of the pandemic, a lot of our patients are referred through virtual visits. And sometimes your examination of the patient is the patient's first encounter with a health care provider. So we should always do our best to answer the clinical question of this patient. Usually they are coming because of swelling or pain. And the doctors will order a DVT study. So if we find something else that's causing the problem that's not a DVT, we should say something because this answers the clinical question of the patient. And because this is the best patient care and the best practice. During our examination, we usually use linear transducers. In the vascular studies, usually it's between 9 and 11 megahertz. And the higher frequency, 11 to 15, is what we use in MSK. Sometimes it is used to scan the superficial veins, like when you're doing venous mapping, for example. We'll start by a short introduction of anatomy. So MSK anatomy is a little bit different because we see all the superficial structures. So in this image, this is in the upper arm, it's a transverse image. We have this echogenic layer, that's the dermal layer. And this is the subcutaneous fat layer. And then we have the muscle layer. And this is in SAGE. Again, we have the dermal layer, which is superficial. Deep to it, it's the subcutaneous fat layer. And then the muscle layer. And the muscle in long scans have this long striations. This is what we call a panoramic view, and sometimes it's called logic view. It's like an extended view of the region. So it shows us a longer version of the limb that we are scanning, for example. So again, this is the dermal layer, the subcutaneous fat, and then the muscle. So we'll start first by diffuse changes. And usually the patient would have a swelling, induration. There might be some redness, and the patient is referred for a DVT study. On ultrasound, edema would be limited to the subcutaneous fat layer. And it will have, the fat itself will appear as echogenic, and then there is anechoic fluid in between the fat lobules. And this is the subcutaneous fat layer. So we have these echogenic lobules, and then the anechoic fluid in between. And it's a good thing when you can compare both sides. This is another thing that we usually do in MSK studies, is that we compare the pathological side, the left forearm, with the normal side. So when you look at these two, this is the normal subcutaneous fat, and this is the subcutaneous fat that has edema in it. Even the muscle layers have some edema in them. You see how these muscles are echogenic and comparable to the normal hypoechoic appearance of the muscle. This is the same patient. Again, it's the left arm to forearm. So the arm is this way, the forearm is this, and this panoramic view shows the full extent of the edema in all the subcutaneous fat. Again, the fat lobules are echogenic, anechoic areas of fluid in between. Moving on to localized masses. So we can see either solid or cystic masses. And the solid masses, the most common thing that you will see is lymph nodes. Then we have lipomas and other soft tissue tumors. Cystic masses are either sebaceous cysts, ganglion cysts, which is most common, and then we have abscess and hematoma. So lymph nodes are the most common structures or masses that you will see while you're scanning for your DBT study, either in the neck or the axilla. And it's important to know the difference between benign and malignant lymph nodes. So benign lymph nodes are grouped with reactive lymph nodes, while malignant lymph nodes are grouped together. So the reactive lymph nodes could be due to bacterial infection, like cellulitis, could be to viral infection. Malignant lymph nodes are either primary or secondary. Metastatic is the most common. And there are other causes like lymphoma, leukemia, and skin cancer. Just a quick mention of the structure of the lymph nodes. So the lymph node is formed of a peripheral cortex and the central part where the hilum is. And on ultrasound, the central part where the hilum and the blood vessels go inside the lymph node through the hilum. This hilum usually has fat in it and has collagen. So on ultrasound, the hilum, which has fat and collagen, is echogenic. This is the normal hilum. It has echogenic appearance or hyperechoic appearance. And then the peripheral part or the cortex is hypoechoic. And in musculoskeletal ultrasound, the baseline is the subcutaneous fat. So the subcutaneous fat is where the isoechoic or hypoechoic to it and the hyperechoic is to the subcutaneous fat. So what is the ultrasound of lymph nodes? So lymph nodes on the normal or reactive lymph nodes are oval. In the neck, they're usually less than eight millimeter in short axis. They have low vascularity. Vascularity increases when they are reactive lymph nodes. And sometimes there is peripheral hypoechoic cortex that is thickened, but it is symmetrically thickened. With age, the cortex becomes thin and the lymph nodes become more hypoechoic. They are more of the hilum and the fat and the cortex become thin. Malignant lymph nodes, on the other hand, are rounded. Their center is hypoechoic because the fatty center is infiltrated by malignant tissue. The blood flow is usually heterogeneous and the cortical thickening is asymmetrical. Example of normal or reactive lymph nodes. So the lymph nodes are oval. This is the lymph node and this is in transverse section and it has a fatty hilum inside, echogenic fatty hilum, and the blood supply goes through the hilum. Another normal lymph nodes, oval in shape. The fatty hilum is echogenic. The reactive lymph node has increased vascularity. It's still oval in shape and it has a vascularity that goes into the hilum and then branches. The echogenic hilum is not seen here because of the gain. Reactive lymph nodes in the axilla sometimes, the axillary lymph nodes have a different appearance. So this lymph node has a fatty hilum, but the cortical thickness is asymmetrical. You see how the cortex is thin over here, thick over here. The vessels go into the hilum and they branch, but because of this irregular cortical thickness, this lymph node was biopsied and it was proved to be a reactive lymph node. This is a patient that was 92 years old. She had enlarged axillary lymph nodes on a CT and it was referred for ultrasound. And we saw this next to the axillary vessel. And at first glance, it was thought like, oh, is this like a vascular breast tail? Is this a mass? And then when we zoomed out, because this is so much zoomed in, when we zoomed out, we saw it was just a reactive lymph node, thin cortex, echogenic hilum. So it's good sometimes to zoom out and not to be very tunnel vision and focus on just the blood vessel. If you see an abnormality next to it, zoom out and look, have like a global look at what you're looking. And another reactive lymph node, it's oval in shape, has echogenic hilum here and here. The blood vessels go through the hilum and they branch. This lymph node looks completely different from the reactive lymph node that we just saw. This lymph node is globular in shape, rounded, has bizarre shape here. The vessels are not through the hilum. We can't see the hilum, like the hilum is all infiltrated. There is no echogenic hilum in the middle and the vessels are like cortical. And then even the soft tissues, this echogenic area beside the lymph nodes looks abnormal. And this is a metastatic lymph node in the neck. Another malignant lymph node, markedly hypoechoic. There is no fatty hilum. The blood vessels here look bizarre and there is like increased echogenicity of the surroundings of tissues. They are almost rounded. And this is another malignant lymph node. Again, we have globular or rounded lymph nodes with bizarre vasculature, no fatty hilum. And this lymph node even like compresses the internal jugular vein, malignant lymph nodes. This is an oval lymph node. So it's not globular, it is oval. It has very thin hilum. And then it has asymmetrical cortical thickness and bizarre distribution of blood vessels. And this lymph node was a metastatic lymph node. Axillary lymph node. We have globular appearance, again, bizarre vasculature. And on PET, there is increased activity. This was cancer breast with metastatic lymph nodes in the axilla. And in this patient, you can see this lymph node. So this lymph node is oval, has echogenic hilum. This lymph node is not worrisome. But the problem, this is like a worrisome sign when we have normal and abnormal lymph nodes next to each other. And these lymph nodes, it's a known case of cancer breast with metastatic lymph nodes in the axilla. This patient had a swelling in the epitrochial region next to the elbow. And this lymph node has no fatty hilum, irregular outline, bizarre vasculature. And though it's not common to see metastatic lymph nodes near the elbow, this was a metastatic lymph node. So just to recap what we talked about, we have reactive lymph node and malignant lymph node. The reactive is oval, fatty hilum, has blood vessels branching from the hilum, malignant lymph node is globular, bizarre cortical vasculature, no fatty hilum. Moving on to another common finding you might see is the lipoma. So the lipoma is commonly, and the lipoma is a benign tumor of the fat cell. The common sites are trunk, shoulder, and back. We have two types of lipoma according to location. We have superficial lipoma, which is located in the subcutaneous fat, and then we have the deep lipoma. Anything deep to the subcutaneous fat is a deep lipoma, whether it's in the fascial planes or inside the muscle. It happens that it occurs at any age, mainly in adults, and on ultrasound it's either isoechoic to the subcutaneous fat or hyperechoic, and this depends on the histological component of the lipoma. If the lipoma has more fibrous, it's a fibro-lipoma, then it's more echogenic. If it has like blood vessels more, it will be angiolipoma, and this will be reflected on the ultrasound appearance. So here we have in the right upper arm, we have a lobular mass in between the cursors where we measure, and it is similar to the subcutaneous fat, and if it wasn't for this capsule and lobulation, we might miss it. So this is an isoechoic lipoma. Lipoma isoechoic to the subcutaneous fat. It's located in the subcutaneous fat. These are the muscles, and then this is the humerus in transverse, and the humerus in sag, and the bone is usually an echogenic line, smooth echogenic line with posterior shadowing, and this is a panoramic view, and the point of the panoramic view is to show like the full extent of the lesion. If it's like too big, then the footprint of your probe, and sometimes it makes things more prominent. You can see like the subcutaneous fat here, and then there is a disruption here with indentation of the fascial plane and the muscle, and then the rest of the subcutaneous fat. So this was another isoechoic lipoma, and it was in the arm. This is the humerus, and it's at the lateral aspect of the arm, so we have the brachioradialis and the triceps, and the muscles again have this fibrillar appearance, and the muscles are usually hypoechoic, and this is the forearm. We have left forearm at the long axis, long axis at the radial aspect, and we have this hyperechoic mass seen inside this muscle. So this is the brachioradialis. I know because like it's lateral, and it's where we found this lipoma. We have the cephalic vein next to it, and then it's what we call, this is what we call a deep lipoma. If it was here in the subcutaneous fat, it would be a superficial lipoma, but because it's deep to the subcutaneous fat, it's a deep lipoma, and it's hyperechoic. It's inside the muscle. So this is the normal appearance of the muscle, continuous fibers, and this is the subcutaneous fat. The dermal layer would be over here, and this is like the fascial plane where the veins, the superficial veins, lie. And this patient, this is not a common site of the lipoma. To see it in the neck, this was in the neck. In this patient, there is some vascularity. We have this oval mass in the subcutaneous fat of the neck, and we compare it to the other side. It helps us to see that this subcutaneous fat, the thickness and the appearance, is completely different from this, and it just convinces like the radiologist and even the doctor of the patient that this abnormality is real because it is different from the other side. So the comparison with the other side is another thing that we usually do in MSK. Another case of lipoma, but this is hyperechoic lipoma. This hyperechoic area with almost no vascularity, our scale is at 5, and then this hyperechoic area in the subcutaneous fat, this is another appearance of lipomas. So lipomas can be hyperechoic, it can be hypoechoic, it can be in the subcutaneous fat, it can be inside the muscles itself. Moving on to sebaceous cysts or epidermoid inclusion cysts. They are usually very superficial in the subcutaneous fat near the skin. They are hyperechoic. They are a cyst, so usually they will have posterior enhancement, but it's not very prominent posterior enhancement similar to that you see in regular cysts. It is avascular and the epidermoid cyst or the sebaceous cyst is diagnosed when you see a tract to the skin. I will not demonstrate the tract in these images because when you're scanning it's very difficult to find the tract unless you're trained to do it. So but what you will see is this structure and there is some posterior enhancement here but it's not very prominent. These are usually small in size like maximum 2 centimeter or something, so their posterior enhancement is not very prominent. They are hyperechoic, avascular, these are artifacts, and when we do these studies, if I find these and I'm sure that this is a cyst, these are artifacts, I just put pulse Doppler on them and show that there is noise or there is nothing there. Another case of sebaceous cysts, very minimal posterior enhancement here and here. It's hyperechoic, sometimes it's heterogeneous, and it is avascular. And the patients usually say, oh I've had that for a long time and no it's not painful, it doesn't grow. Sometimes when you look at the skin you will find like a black punctum, black dot on top of it. All of these are characteristic of the sebaceous cyst. Moving on to another common finding, especially if you're scanning next to the wrist, it's the ganglion cyst or the synovial cyst. And the ganglion cyst is like a true cyst appearance. It's anechoic, well-defined, there is posterior enhancement, it is avascular and compressible. And this is like the dorsal aspect of the wrist. We have this anechoic structure, there is some posterior enhancement around it, it's next to the radial artery. And that's a common site for the ganglion cyst. It is superficial to the scapholionate joint, another common finding. And when we see a cyst in MSK, we usually look for a relation of a joint or a tendon. Another dorsal ganglion cyst, this is the capitate bolt, it has this plateau appearance. And the cyst, there is posterior enhancement, it's anechoic and of course it's avascular, but I don't have the color images here. One more ganglion cyst, this is the radial artery and veins. And we have this anechoic structure, it's septated, there is some posterior enhancement here, it is avascular. So this is another ganglion cyst. And when we scan these cysts in MSK, we always describe the relation to the radial artery and veins, because if they want to intervene and they want to remove it, they should know what vascular structures lie next to it. This is another panoramic view of the rest. So we have the rest at this region, the bones of the rest, and the hand is this way and the forearm is this way. And the muscles have this striated appearance. And then we have this large cyst, this is a synovial cyst or a ganglion cyst. It has echogenic dots inside and that's the synovial fluid. And this cyst actually extended through this neck into the hand as well. Moving on to the next thing, we'll talk a little bit about hematoma. So in order to diagnose any cystic structure as a hematoma, you have to have either a history of trauma or that the patient doesn't remember a trauma but has a history of anticoagulant or blood thinner intake. If there is no history of trauma, usually we cannot say that this is a hematoma. We look at the overlying skin. Sometimes there are bruising of the overlying skin. And on ultrasound, the age of the hematoma depends, the appearance of the hematoma depends on the age of the hematoma. So it can be hypoechoic when it's acute or complex and this is when mostly you'll see the hematoma. You will see it in its complex state. And then hypoechoic when chronic because usually these patients like have a trauma and then wait for a day or two and then there's a swelling. The swelling doesn't go away so they contact the doctor and their doctor would like through like either telephone or like a virtual visit will recommend a DVT study. So you mostly always will see the patient in the acute state when this hematoma has a complex appearance. So this is a forearm okay and this patient had the trauma and is on anticoagulants as well. And the skin, the overlying skin was bruised and then he has this collection of fluid. It's hypoechoic with these echogenic strands representing some of the agulopathy that goes inside. So this is a complex cystic structure. This is the radius. We are in transverse in the forearm and when we put color Doppler on it, the structure itself is avascular. And this represents a hematoma at the forearm. The same hematoma, this is in sagittal. Again this is a complex structure okay and it is avascular and these are like the muscle beneath it and this is the area of the skin and it's located in the subcutaneous fat. We use always the panoramic view when it's like a big hematoma and as you can see this hematoma measures almost 10 centimeters. So the panoramic view gives you like an extended larger view of the region you're scanning and you can when your panoramic view is done smoothly with no interruption, you can actually measure and it has accurate measurements. This is another hematoma and it looks completely different from the one I showed you. This is a more complex and it's more difficult to pick up because it looks very strange but again we have this is the panoramic view and you can see this is the normal subcutaneous fat and then the subcutaneous fat is echogenic and there is that complex structure in it. It's thickened. All of this is a hematoma that has this is L-defined appearance and then this is a localized area with an hypoechoic inside and this is another appearance of the hematoma. Next we'll talk a little bit about an abscess. With an abscess usually there is swelling, redness, hotness, there is pain, might be a history of drug abuse, there is elevated white blood cells, and on ultrasound we have a cystic area that has thick vascular wall. It's usually complex or hypoechoic and it's surrounded by edema. So anechoic complex, mainly anechoic but it's a complex structure, has L-defined wall. When we put color on it there is a vascular thick wall and then surrounded by edema on top. As we said the edema is the fat lobules are echogenic and then there is anechoic fluid in between. Okay. Moving on to another thing that you might see while you're scanning is tenosynovitis, which is inflammation of the tendon and the tendon sheath. There sometimes is swelling, redness, and pain. And this is a transverse section of the extensor digitorum at the wrist. So this is the rest at the dorsal aspect. These are the tendons that we see rounded, surrounded by fluid, anechoic, and when we put color Doppler there is increased vasculature in the synovial membranes denoting tenosynovitis. And I show the tenosynovitis because I want you to know the difference between this tenosynovitis, for example, and the abscess that we saw in the previous image and the ganglion cyst. They are all fluid but everyone has a different sonographic appearance. Sometimes patients are referred for DVT study when they have like a muscle rupture and again it's because of the virtual visits and patients would call and say hey I have a pain and swelling in my arm I can't move my arm and then they are referred for a DVT study. So usually the patient will have a history of trauma, will have inability to perform some movements, there is swelling. On ultrasound the muscle fibers are interrupted so the continuous muscle fibers that we saw throughout the presentation are interrupted. Sometimes fibers, you can see fibers retracted to each side and there is a heterogeneous hematoma. So this is a patient that was actually, these are images of one of our vascular techs and this patient was referred for a DVT study and what the tech told me is that when the patient extended his arm the muscle fell from his arm. This is the exact word that she used and this is the biceps muscle. There is like the muscle looks heterogeneous. This is not the appearance of the normal muscles that we saw. There's fluid around it, this anechoic area, there's fluid around it. For example, this is another muscle that this muscle should look like this, like continuous lines, continuous fibers, but here we have these are what we call the retracted edges. So this is a retracted edge of the muscle, this is the another retracted edge of the muscle. There is anechoic area of hematoma in between and this is a complete rupture of the biceps tendon. For soft tissue tumors, usually there is a swelling. So you might encounter this while scanning or while you're scanning for a DVT, the patient might say, oh I have a swelling here or I have a lump here that I feel as well. Okay, so the differential diagnosis of these swellings, they can be a fibroma, histocytoma, sarcoma, any soft, they can be any soft tissue swelling. Nerve swelling, for example, nerve tumor, and usually there are solid masses with internal vasculature. So this is a neck mass and we have heterogeneous mass here. It's located in the subcutaneous fat indenting the fascial plate and on color there is intense vascularity inside. Unfortunately, I don't have the pathological diagnosis of this patient, but this is just one of the differential diagnosis of soft tissue tumors. This is another mass. This mass is seen in the proximal forearm next to the brachial veins and arteries, the brachial artery and two veins. It's not the forearm, it's more of the anterior aspect of the elbow. We have this solid mass, has some vasculature inside. This is what we call the fascia split sign with the fascia split and the mass is in between. This is part of the biceps tendon and this mass is next to the neurovascular bundle. So the differential diagnosis included nerve tumor. So some take-home tips. Normal and reactive lymph nodes have fatty hilum and malignant lymph nodes are usually globular and have abnormal vasculature. Abscesses have vascular wall. Wrist ganglions are the most common. Cystic swellings near the wrist. Lipomas are the most common solid tumors in general. And I always encourage you, if you see something, say something. You might be the first one who scans this patient and I know that not all of you, like it's different if you work in a vascular lab, different from if you work in an outpatient clinic, in a hospital setting. Some imaging is reported by a radiologist. Others are reported by vascular doctors and cardiologists who might not be like comfortable reporting something other than the vascular study. But it's up to us to pick like the panic findings, the things that are important that might cause a change in the management of patients like abscesses or malignant lymph nodes or might just simply answer the question why the patient came to do this study, like why he is here. And sometimes it's just the swelling of that lipoma or the swelling of that edema or the swelling due to a hematoma. So always, if you see something, say something. Thank you. Thank you so much. That was a wonderful explanation of so many entities that I think most of us have seen at one point or another during our scanning years. We do have some questions that are coming in. When do you, when do we have to scan a nerve? So like a, you mean a vascular tech or MSK tech? Like the person who asked is a vascular, so. Okay, so we don't, the only time we scan nerves and ultrasound is when there is a mass. And like this mass, if it had, if we can connect the mass to a nerve, like the mass is near a neurovascular bundle or the mass is in the distribution of a superficial nerve or the mass has a tail on both sides that can connect to a nerve. So without actually having a mass, we don't usually scan nerves because they're better seen by MRI. Okay. Does a ganglion or synovial cyst connect to a joint space between the bones? Yes. So this, because the ganglion or the synovial cyst, it comes from a joint or a tendon. So it's either related to the synovial membrane surrounding a tendon or it is related to a joint space. And the important of this is that a lot of the times these ganglion cysts, what they do is that they aspirate them. And when they aspirate them, they come back because the neck that connects them to the joint, it's still there. So if you don't want this one to recur, you have to find the neck and you have, the surgeon has to tie that neck to prevent it from coming back. And when we do MSK ultrasound, we demonstrate this neck. Sometimes we can't, but most of the time we can show the neck and define the joint that this neck come from, even like in the small joints of the hand. Okay, I'm getting lots of compliments here, by the way. And the next question is, in the lymph node series, was the lymph node compressing the carotid? Was there that much pressure from the lymph node? No, it was compressing the internal jugular vein. It's very difficult for a lymph node to compress the carotid because of the arterial wall, but it can easily compress the vein because the vein has no wall, like no muscular wall. It has a wall, but no muscle in the wall to combat, that's why veins are compressible. So that lymph node was hard enough to compress the internal jugular vein. The person that asked that question actually put in another comment that it did appear to be compressed in that image. Okay, I'll look at the image again and I will like put images that are not questionable. I'm getting more compliments about your great images. Thank you very much for that. Hold on, I have another question. I just have to scroll around here a little. Can a ganglion or synovial cyst appear in the jaw? Have you ever seen that? So in the jaw, we have cysts, but they are not synovial cysts because there is no synovium in the jaw. We have different kind of cysts that appear in the jaw, but they are not synovial. There are other bony cysts because the synovial or the ganglion cysts have to have a synovial membrane to originate from. So it has to be like a synovial joint in order to have a synovial cyst or a ganglion cyst. And even like the TNG is not a synovial joint. Okay, so more compliments, informative, and much appreciated. But I think that actually might be it for questions, unless somebody else has something to put. Excellent presentation, getting lots of compliments here. Paula, I saw one more question. Can you review, if it's possible, distinguish between lipoma versus liposarcoma? Sorry, lipoma versus liposarcoma. So we cannot, through imaging, differentiate lipoma from liposarcoma. But we have a set of criteria that if the lipoma grows suddenly or become painful, and if a lipoma on imaging is more than seven centimeter in long axis, we usually do MRI for it and we take it out. Because the low grade of liposarcoma cannot be differentiated from lipoma. When it is high grade and it's infiltrated, it's like a sarcoma. It looks completely different. But the low grade liposarcoma, we cannot differentiate it from lipoma on ultrasound. That's why we have the size and the clinical criteria to guide us. And this is what we tell the patients. We tell them if this grows quickly in a short period of time, and what we mean about growth is to increase 50%. Like if it is three centimeter and then it's doubled, it's six centimeter in a period of three months, for example. That's a short period for something to double the size. Or if it became painful, or if initially we are scanning and we see a lot of large lipomas, it's more than seven centimeter, we always recommend removal. Because that might be a low grade of liposarcoma that at this time when we scan, it looks benign. Do you ever palpate before imaging and do you ever use a standoff pad? We do palpate because when we do MSK ultrasound, if the patient cannot feel it, we cannot target it. It's a targeted ultrasound. So we usually palpate and look for consistency, mobility. I don't use standoff because of like I have the hockey stick and I have like the 15 and they are very superficial and I don't need a standoff pad with it. I just sometimes if something is so small, we put a little bit more gel, which is a sort of standoff, but it's gel only. Okay. Do Baker's cysts have necks attached to the knee joint? Yes. So Baker's cyst, when it is in the popliteal fossa, it's attached to the knee joint and we can see the connection. But sometimes Baker's cyst rupture into the leg. So if they rupture into the leg, sometimes you have like a small Baker's cyst in the knee and then most of the Baker's cyst is in the leg and you can see the connection between these two swellings and you cannot demonstrate the connection with the knee at that time. But Baker's cyst is always secondary to osteoarthritis of the knee. Always, always. Unless you see it in children because we have synovial cysts in children and this is another category. It's not due to osteoarthritis, but it is related to the knee as well. Okay. So do we miss any other questions? Does anybody have anything further while we have her with us? I'm not seeing anything else come in. So Manal, thank you so much. This was really a wonderful presentation and I know we've all learned a lot. I do want to remind everybody that all registered attendees will be receiving an email within the next seven days and that will contain an evaluation form. You do have to complete that form and return it to the SVU office in order for them to issue you your CMEs. One second. I'm sorry, Paula, to interrupt. In actuality, you just have to complete the evaluation and once you complete it, your CME will be awarded to you at the conclusion of the evaluation. But you have to go through the entire evaluation and then your CME will come up for you. Perfect. Thank you for clarifying that. No problem. Thank you. All right. So if we don't have any more questions, I want to thank Manal one more time and thank all of you for attending tonight's presentation. We are completed. Good night. Good night. Thank you. Thank you.

webinar

non-vascular findings

upper extremity venous duplex scans

abnormalities

ultrasound examinations

linear transducers

MSK anatomy

interpret findings