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Subcutaneous Fat Necrosis

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821. Lower Extremity Reconstruction, Foot

-M5, BT-C - Bone loss of WB areas By free flaps Previous Next: Relevant Anatomy The foot generally is divided into 4 regions, which are the ankle, sole, dorsum, and toes. Skin and fat The skin of the foot, except for the sole, is similar to skin in other regions of the body. The epidermis is thin in the newborn but becomes thicker as a reaction to weight pressure. Hair and sebaceous glands are present only in the dorsum. Eccrine glands are diffused in the sole. The subcutaneous fat is poorly (...) present in the dorsum but is very thick and granular in the sole, where it is divided by the retinacula. The retinacula are connective fibers between the dermis and the plantar fascia that build a sort of "shock absorber" for the standing position or during movements. The foot sole consists of 4 layers, which are skin, subcutaneous fat, plantar fascia, and muscles. The plantar fascia is a strong connective tissue stretched between the inner tubercle of the calcaneum and 5 metatarsal heads. Numerous

2014 eMedicine Surgery

822. Cellulitis (Overview)

, the tissue is hemorrhagic and necrotic. Hematoxylin and eosin (H&E) stain, high power. This image shows deeper subcutaneous tissue involved in a case of cellulitis, with acute inflammatory cells and fat necrosis. Hematoxylin and eosin (H&E) stain, high power. This image shows cellulitis caused by herpes simplex virus, with the multinucleated organism in the center of the picture. of 14 Tables Table 1. Empiric Antibiotic Therapy for Cellulitis by Etiology and Anatomic Location Location Likely Organisms (...) Herchline, MD; Chief Editor: Michael Stuart Bronze, MD Share Email Print Feedback Close Sections Sections Cellulitis Overview Practice Essentials The term cellulitis is commonly used to indicate a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection (see the image below). Cellulitis usually follows a breach in the skin, although a portal of entry may not be obvious; the breach may involve microscopic skin changes or invasive qualities of certain bacteria

2014 eMedicine Emergency Medicine

823. Burns, Chemical (Overview)

as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis. The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline (...) it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral. Next: Pathophysiology Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known

2014 eMedicine Emergency Medicine

824. Burns, Thermal (Overview)

go completely through the eschar. The subcutaneous fat will appear to bubble up into the escharotomy wound. Bleeding is minimal and is easily controlled by pressure. Upon completion of the escharotomy, a dressing with antibiotics is placed on the wound, and the extremity is elevated to help maintain homeostasis. If the chest is involved and the eschar compromises ventilatory motion, perform an escharotomy involving the anterior chest. Incisions are made along the costal margin, along the anterior (...) be debrided (see the image below); the intact skin serves as a hermetic barrier, although the blister fluid can serve as an excellent medium for bacterial growth. Another argument for debridement is that removal of the blister roof allows topical agents to reach burn tissue. Blisters that are intact but are located in areas that have a high likelihood of rupture may be sharply debrided. The World Health Organization (WHO) recommends debridement of all bullae and excision of all adherent necrotic tissue

2014 eMedicine Emergency Medicine

825. Breast Cancer, Ultrasonography

examination include Zonderland et al and Rahbar et al. [ , ] Typical US Patterns of Specific Types of Breast Carcinomas The appearance of specific types of breast carcinoma have been studied. Although appearances vary greatly, some patterns are typical. Mucin-containing carcinomas are often circumscribed but may have irregular margins. These lesions may be either hypoechoic or isoechoic relative to subcutaneous fat. In a study of these carcinomas by Conant et al involving 8 patients, US showed hypoechoic (...) . . . Caterson SA, Tobias AM, Slavin SA, Lee BT. Ultrasound-assisted liposuction as a treatment of fat necrosis after deep inferior epigastric perforator flap breast reconstruction: a case report. Ann Plast Surg . 2008 Jun. 60(6):614-7. . Kim KH, Son EJ, Kim EK, Ko KH, Kang H, Oh KK. The safety and efficiency of the ultrasound-guided large needle core biopsy of axilla lymph nodes. Yonsei Med J . 2008 Apr 30. 49(2):249-54. . Kopans DB. Clip placement during sonographically guided breast biopsy. AJR Am J

2014 eMedicine Radiology

826. Breast Cancer, Mammography

. For screening mammography, each breast is imaged separately. See the images below. Image from a mammogram shows a benign mass: a fibroadenoma with well-defined edges and a halo sign. Benign microcalcifications: secretory change. Traumatic fat necrosis. Mammogram shows traumatic fat necrosis following removal of a lesion. The stellate lesion has a halo center. Research has shown that regular mammograms may decrease the risk of late-stage breast cancer in women 80 years of age and older. [ , ] Some studies (...) . The presence of very low density fat in a lesion often indicates benign findings such as oil cysts, lipomas, galactoceles, and hamartomas. Calcifications can also be the first sign of cancer or a harmless process in the breast. Benign calcifications are usually larger than calcifications associated with malignancy. They are usually coarser, often round with smooth margins, and more easily seen. Benign calcifications tend to have specific shapes: eggshell calcifications in cyst walls, tramlike in arterial

2014 eMedicine Radiology

827. Cirrhosis

has a limited sensitivity (68%) in cirrhosis but is highly specific The authors described an enlarged, pericholecystic, fat-filled space that often contains collaterals (note the patent paraumbilical vein [arrow]), with no visualization of the medial segment of the left lobe of the liver at the level of the gallbladder fossa. On ultrasonographic examination, the liver contour may appear nodular, as in the first image below, although Ladenheim and colleagues have questioned the specificity (...) , ranging from regenerative nodules, dysplastic nodules, and focal fat to benign neoplasms, such as hemangioma, many of which have no uniquely discriminating features on US. Because these occur with significant frequency, they pose a diagnostic challenge. A significant minority of patients may have benign focal masses, such as hemangioma or focal fat, requiring further imaging evaluation, or focal lesions that may not be corroborated on other imaging studies or on subsequent US. The relatively high

2014 eMedicine Radiology

828. Chordoma

for preoperative planning and is observed as follows: Proximal extension - Bone and sacral canal Distal-lateral extension - Gluteus maximus, hamstrings, and sciatic nerve and notch Anterior extension - Retroperitoneal lymph nodes and rectum Posterior extension - Subcutaneous fat Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development (...) it. 6b. Invasive pituitary adenoma. The signal of the mass in the sphenoid is not homogeneous. No posterior extension is observed; extension is mostly into the sphenoid sinus. The pituitary gland is not visible. On magnetic resonance imaging (MRI) scans, chordomas show a signal heterogeneity, possibly due to a variety of components, including fluid and gelatinous mucoid substance (associated with recent and old hemorrhage) and necrotic areas within the tumor (see the following images). In some

2014 eMedicine Radiology

829. Liposarcoma, Soft Tissue

not enable a specific diagnosis of a liposarcoma. Moreover, any lesion consisting of edema, an extracellular matrix with a high level of mucopolysaccharide, hyaline cartilage content, and necrosis may appear cystic on MRI scans. [ , ] Findings on plain radiographs are nonspecific, and the modality usually offers little except perhaps aid in confirming the presence of a soft-tissue mass. Frequently, fat is not detectable radiologically. Ultrasonography is helpful in confirming the presence of a mass when (...) , on the degree of cellularity and vascularity, and on whether or not necrosis exists. [ ] Most myxoid tumors have linear or lacy, amorphous foci of fat. [ ] Some myxoid tumors may appear cystic on nonenhanced MRI scans, but they are usually enhancing after the administration of contrast agents. [ , ] Pleomorphic tumors show a markedly heterogeneous internal structure and moderate contrast enhancement. The malignancy grade is believed to increase in parallel with tumor heterogeneity and contrast enhancement

2014 eMedicine Radiology

830. Liver, Metastases

who had undergone a left hepatectomy for a hepatocellular carcinoma. The patient has developed a small metastatic deposit within the liver remnant (arrow in the upper 2 frames). The lower 2 frames were taken after alcohol ablation. Recurrent/metastatic hepatocellular carcinoma following chemoembolization. Note the intense iodized oil uptake, tumor necrosis, and air within the necrotic tumor. Also note the iodized oil uptake in the smaller, satellite tumors. CT scan of a 52-year old man (...) has the signal intensity of normal liver and not the spleen. Lipoma Fatty liver tumors are rare. Lipomas are well-defined tumors that are hyperintense on T1-weighted images. The signal intensity is usually similar to that of subcutaneous and retroperitoneal fat. On fat-suppressed images, the tumor appears hypointense; it may be differentiated from other hyperintense lesions on T1-weighted images. These lesions may be caused by copper deposition, hemorrhage, or peliosis, for example. Hepatic

2014 eMedicine Radiology

831. Knee, Extensor Mechanism Injuries (MRI)

of chronic patellar tendonitis (jumper's knee) and helps distinguish this condition from an acute process. Note the lack of subcutaneous edema in this patient. It is important to recognize that intermediate signal on T1-weighted images is observed in the posterior margin of the proximal patellar tendon and near the tibial tuberosity in normal tendons, as described by Yu. [ ] Edema in the paratenon, infrapatellar fat pad, and subcutaneous adipose tissue is associated with acute patellar tendonitis, which (...) thickening of the infrapatellar tendon as well as linear areas of abnormal intermediate signal intensity within the substance of the tendon. Findings are consistent with an acute partial tear of the patellar tendon. Chronic patellar tendonitis complicated by chronic tears associated with inflammation and necrosis can appear similar on MRI; however, in this patient, subcutaneous edema anterior to the tendon also is seen, suggesting a relatively acute injury. Quadriceps tendon tear A tear of the quadriceps

2014 eMedicine Radiology

832. Non-Hodgkin Lymphoma, Thoracic

, lung, liver): Stage IV A - constitutional symptoms are absent; Stage IV B - constitutional symptoms are present Limitations of techniques The appearances of a mediastinal mass on chest radiographs are nonspecific, with a wide differential diagnosis, and the differentiation of benign and malignant lesions may not be possible. Subtle bone erosions can be missed on conventional radiographs. Underlying masses with pleural and pericardial effusions may not be detected. Fat attenuation in benign lesions (...) calcification and obliteration of fat planes, mediastinal lymphadenopathy, and bone erosions. Most patients with anterior mediastinal masses are referred for a CT scan. PET/CT scanning may be more commonly used depending on availability. Previous Next: Computed Tomography Computed tomography is the preferred imaging method for diagnosing mediastinal, lung parenchymal, and pleural disease (see the images below). Protocols for staging lymphoma include CT scanning of the neck, thorax, abdomen, and pelvis. All

2014 eMedicine Radiology

833. Musculoskeletal Tumors, Staging And Treatment Planning

, superficial and skeletal muscle hemangiomas, benign neural tumors, periarticular cysts, hematomas, and pigmented villonodular synovitis. The most common soft-tissue lesions diagnosed with MRI are lipomas. They appear well circumscribed, homogeneous, and isointense relative to subcutaneous fat on images obtained with all pulse sequences. Thin, low-intensity septa also are sometimes seen in lipomas. Some general guidelines regarding the relationship between MRI signals and histologic tissue types can (...) -weighted, spin-echo sequences because they provide reproducible images. Typically, pathology appears as areas of low signal intensity on T1-weighted images and as areas of high signal intensity on T2-weighted images. Fast spin-echo sequences with fat suppression also are popular imaging sequences, and they are used in many centers because of the time-saving advantages (see the image below). [ ] Osteosarcoma of the right humerus. Fast spin-echo, T2-weighted, coronal magnetic resonance image shows

2014 eMedicine Radiology

834. Kidney Transplantation, Surgical Complications

examinations, which may be necessary during the postoperative period. [ ] Concurrent with sonographic studies, radionuclide studies are frequently performed. The nuclear studies provide valuable information concerning functional status during the immediate postoperative period and during episodes of rejection. Correlation between renal sonographic and nuclear medicine findings helps to differentiate between purely functional disease, such as acute tubular necrosis or rejection, and abnormal fluid (...) of the transplanted kidney. In cases in which native vessels are thrombosed, unusual alternate venous outflow patterns may result. In cases of IVC thrombosis, the transplanted kidney renal vein may drain into the mesenteric veins. This should not be mistaken for a pathological AVF or other primary venous anomaly. Surgical complications after pancreas transplantation include difficulties in the management of organ rejection, as well as the potential for pancreatitis with or without ischemic necrosis. Previous Next

2014 eMedicine Radiology

835. Osteomyelitis, Acute Pyogenic

in 2-3 days Sequestrum: Increased pressure, vascular obstruction, and infective thrombus compromise the periosteal and endosteal blood supply, causing bone necrosis and sequestrum formation in approximately 7 days Involucrum: This is new bone formation from the stripped surface of periosteum Resolution or progression to complications: With antibiotics and surgical treatment early in the course of disease, osteomyelitis resolves without any complications Preferred examination Imaging plays (...) osteomyelitis. Findings on MRI accurately demonstrate the extent and structure of the area involved in the pathologic process. The reported sensitivity is 88-100%; the specificity is 75-100%. Fat-suppression sequences allow for better detection of bone marrow edema; however, infection and inflammation cannot be differentiated. MRI may be the imaging modality of choice for infections involving the spine, pelvis, or limbs because of its ability to provide fine details of the osseous changes and soft tissue

2014 eMedicine Radiology

836. Toxicity, Warfarin and Superwarfarins (Diagnosis)

and in patients with preexisting protein C deficiency and is found, less commonly, in men and in patients with protein S deficiency. Patients initially become hypercoagulable because warfarin depresses levels of the anticoagulant proteins C and S more quickly than it does coagulant proteins II, VII, IX, and X. Extensive thrombosis of the venules and capillaries occurs within the subcutaneous fat. Women note an intense, painful burning in areas such as the thigh, buttocks, waist, and/or breast several days (...) ) who underwent dialysis, warfarin was found to be associated with a 44% higher risk of bleeding and did not reduce the risk of stroke. [ ] Skin necrosis Skin necrosis, usually observed between the third and eighth days of therapy, is a relatively uncommon, adverse reaction to warfarin. When skin necrosis occurs, it can be extremely severe and disfiguring and may require treatment through debridement or amputation of the affected tissue, limb, breast, or penis. It occurs more frequently in women

2014 eMedicine Emergency Medicine

837. Fournier Gangrene (Diagnosis)

. Skin and superficial fascia Because Fournier gangrene is predominately an infectious process of the superficial and deep fascial planes, understanding the anatomic relationship of the skin and subcutaneous structures of the perineum and abdominal wall is important. The skin cephalad to the inguinal ligament is backed by Camper fascia, which is a layer of fat-containing tissue of varying thickness and the superficial vessels to the skin that run through it. Scarpa fascia forms another distinct layer (...) . Ultimately, an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described. Infection of superficial perineal fascia (Colles fascia) may spread to the penis and scrotum via Buck and Dartos fascia, or to the anterior abdominal wall via Scarpa fascia, or vice versa. Colles fascia is attached to the perineal body and urogenital diaphragm

2014 eMedicine Emergency Medicine

838. Hidradenitis Suppurativa (Follow-up)

recurrence. The block of tissue excised should be adequately wide and sufficiently deep. To ensure that the deep coils of the apocrine gland are removed, the subcutaneous tissue down to the deep fascia, or at least 5 mm of subcutaneous fat, should be excised. The extent of the sinus tracts is intraoperatively marked by injecting 3-5 mL of a methyl-violet solution. Complete surgical excision is achieved when all color-coded areas are fully removed. In cases where blue-stained areas occurred (...) was developed. Wide excisions reach into the healthy deep subcutaneous fat, but the STEEP procedure with its successive tangential transsections leaves the epithelialized bottoms of the sinus tracts and a large extent of the subcutaneous fat intact, leading to more superficial and smaller defects. STEEP is done with the patient under general anesthesia. For the performance of the multiple transversal sections, electrosurgery has some important advantages over the carbon dioxide laser, since transversal

2014 eMedicine Emergency Medicine

839. Hernias (Follow-up)

rotation, adduction, or extension at the hip Sciatic hernia - Tender mass in the gluteal area that is increasing in size; sciatic neuropathy and symptoms of intestinal or ureteral obstruction can also occur Perineal hernias - Perineal mass with discomfort on sitting and occasionally obstructive symptoms with incarceration Umbilical hernia - Central, midabdominal bulge Epigastric hernia - Small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude; may be adjacent (...) approaches to other hernia types may vary, as follows: Umbilical hernia - After exposure of the umbilical sac, a plane is created to encircle the sac at the level of the fascial ring, and the defect is closed transversely with interrupted sutures; if the defect is very large (>2 cm), mesh may be required Epigastric hernia - A small vertical incision directly over the defect is carried to the linea alba, and incarcerated preperitoneal fat is either excised or returned to the properitoneum; the defect

2014 eMedicine Emergency Medicine

840. Inflammatory Bowel Disease (Follow-up)

and severity of disease; they may be administered intravenously (ie, methylprednisolone, hydrocortisone), orally (ie, prednisone, prednisolone, budesonide, dexamethasone), or topically (ie, enema, suppository, or foam preparations).Corticosteroids are limited by their adverse effects, particularly with prolonged use. The potential complications of corticosteroid use include fluid and electrolyte abnormalities, osteoporosis, avascular bone necrosis, peptic ulcers, cataracts, glaucoma, neurologic (...) and endocrine dysfunctions, infectious complications, and occasional psychiatric disorders (including psychosis). The consensus regarding treatment with these agents is that they should be tapered once remission has been induced. (see Surgical Intervention, below, for information on Tapering corticosteroids in the postoperative setting). Corticosteroids do not have a role in maintaining remission. Patients who are concerned about immunosuppressive therapies, including immunomodulators or anti–tumor necrosis

2014 eMedicine Emergency Medicine

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