Radiol Oncol 2006; 40(4): 211-5.
case report
Doppler ultrasound in the diagnosis and follow-up of the muscle rupture and an arteriovenous fistula of the thigh
in 12 year boy
Zlatko Pavčec1, Ivan Žokalj1, Hussein Saghir1, Andrej Pal1, Goran Roić2
1Department of Radiology and Ultrasound, Čakovec County Hospital, Čakovec 2Department of Pediatric Radiology, Children's Hospital, Zagreb, Croatia
Background. With this case report the authors wish to present the accuracy of non-invasive vascular imag-ing methods, especially Doppler ultrasound, in the evaluation of the muscular trauma and periskeletal soft tissue vascular anomalies.
Case report. Twelve year-old boy has been admitted with the right femoral quadriceps muscle traumatic rupture. Postoperative B-mod sonography (US) visualised recidivuous haematoma and Power Doppler de-picted hypervascularized area, suspected vascular malformation (angioma). Doppler findings obtained on the right thigh vasculature gave us reasons to think about posttraumatic arteriovenous fistula. Doppler has been repeated in the specialized paediatric institution with the same results. Digital subtraction angiography, 8 months after trauma, did not confirm suspicions reported in US findings. Spiral computed tomographic angiography (CTA) performed 11 months after trauma clearly depicted a lesion which had been repeatedly described in US findings. Fourteen months after trauma the vascular surgeon performed the deep femoral artery muscular branches ligation, but in the official report only arteriovenous fistula was mentioned. After the surgery the patient was clinically better. The aetiology of the right femoral arteriovenous fistula and hypervascularized structure remains unclear.
Conclusions. Every inadequately behaving, recidivous posttraumatic haematoma should be evaluated with Doppler ultrasound. CTA can be performed if it is needed to clarify US findings.
Key words: hematoma – ultrasonography; arteriovenous fistula; muscle, skeletal - injuries
Introduction
Received 24 November 2006 Accepted 2 December 2006
Correspondence to: Ivan Žokalj, MD, Department of Radiology and Ultrasound, Čakovec County Hospital, Ivana Gorana Kovačića 1e, 40 000 Čakovec, Croatia; Phone: + 385 40 375 297; Fax: + 385 40 313 325; E-mail: ivan.zokalj@ck.t-com.hr
Soft tissue injury and its complications can be accurately evaluated with ultra-sonography (US) because this method has possibilities of multiplanar approach, the dynamic examination of muscle during the contraction and rest and assessment of the potential concomitant vascular injury with Doppler  modalities.1-4  US  doesn't  carry
212
Pavčec Z et al. / Doppler ultrasound in muscle rupture and an arteriovenous fistula
danger of ionizing radiation and it is widely available; these facts make US the imaging method of choice for the diagnostic evaluation of muscular injuries and first method for vascular injury diagnosing.
A muscle rupture of the lower limbs with consequent haematomas is often relat-ed with a sports injury. Haematoma is the most important sign of a muscle rupture, it is usually depicted as a hypo- or anechoic circumscribed lesion1-3 an arteriovenous (AV) fistula is an abnormal communication between the arterial and venous systems. AV fistulas of the extremities are the conse-quence of trauma or medical procedures in most of the cases. Post-traumatic AV fistula is usually the consequence of penetrating trauma, very rarely after blunt trauma.5-7
Non-invasive imaging diagnostic meth-ods, such as US, computed tomography (CT) and magnetic resonance imaging (MRI) have big potentials for the safe and even quick assessment of vascular anomalies and traumatic vascular lesions.8 Doppler ultrasound methods can give the majority of necessary information about traumatic vascular lesions and vascular anomalies, especially if US is combined with another vascular imaging method, such as computed tomographic angiogra-phy (CTA) and magnetic resonance angiog-raphy (MRA).3,4,9-12
Case report
Twelve year-old boy was admitted with signs of the right femoral quadriceps mus-cle traumatic rupture caused by sudden extension during the football match, six months after trauma actually happened. B-mod US, performed before the surgi-cal intervention showed the right femoral quadriceps muscle rupture with haemato-ma. First postoperative US included B-mod and Doppler modalities (colour and power
Radiol Oncol 2006; 40(4): 211-5.
'K
f           Iff
Figure 1. First Doppler ultrasound registered high flow and high systolic peak values in the popliteal, superfit-ial and deep femoral vein (horizontal orientation).
Doppler). B-mod US depicted recidivous haematoma. With Doppler methods high flow and high systolic peak values were revealed in the popliteal, superficial and deep femoral vein, the AV communication was suspected (Figure 1)
Hypervascularized area with sonograph-ic characteristics of vascular malformation (haemangioma) was depicted near the haematoma, ventrolateraly in the proximal third of the thigh (Figure 2). Recidivous
Figure 2. Hypervascularized area with sonographic characteristics of vascular malformation (hemangi-oma) positioned closely to the hematoma ventrola-teraly in the proksimal third of the thigh (horizontal orientation).
haematoma was evacuated by punction after the US control. Clinically, the patient had bigger diameter of all parts of the right leg and oedema ventrolateraly in the right femoral region, but without a thrill and bruit over the site of the muscle injury.
Pavčec Z et al. / Doppler ultrasound in muscle rupture and an arteriovenous fistula
213
The patient has been sent into the paedi-atric hospital to clarify the suspicion of the post-traumatic AV communication (fistula) and the right thigh vascular malformation. Control US and axial CT scan showed again recidivous haematoma and right femoral hypervascularized structure. The digital subtraction angiography (DSA) indicated by the paediatric surgeon and performed 8 months after trauma, also depicted neither AV fistula nor vascular malformation.
The repeated Doppler US, performed 10 and 11 months after trauma, showed a higher flow with high peak systolic values only in the deep femoral vein and the reduc-tion of the right femoral hypervascularized structure size. The spiral CT scan, per-formed 11 months after trauma, depicted a hypervascularized lesion supplied from the deep femoral artery muscular branches posi-tioned ventrolateraly in the right thigh proxi-mal third. The hypervascularized lesion was equally good opacified with contrast material in the arterial and venous phase, with one avascular zone ventromedially (Figures 3, 4). The patient still had swollen right leg but there was no palpable mass in the area of vascular malformation described in the CT report with thrill and bruit over them.
Figure 3a. Volume-rendering VR reformation – right femoral region-coronal plane (vertical orientation).
Figure 3b. Multiple intensity projection reformation MIP- right femoral region –axial plane (horizontal orientation).
Hypervascularized lesion located ventrolaterally in right thigh proximal third, equally good opacified with contrast material in the arterial and venous phase, with one avascular zone ventromedially. A lesion receives arterial supply from the deep femoral artery muscular branches.
The vascular surgeon performed the deep femoral artery muscular branches ligation, 14 months after trauma. In the surgery report only AV fistula was men-tioned. After the surgery clinical manifes-tations and AV fistula ultrasonographic signs disappeared. This was an indirect confirmation of posttraumatic AV com-munication, which had not been supported with the digital subtraction angiography. The control US, performed two years after the surgical intervention showed neither haematoma nor AV communications, and the patient was clinically better without right leg oedema.
Discussion
Ultrasonography is a standard diagnostic method for the evaluation of soft-tissue structures trauma. Doppler ultrasound vas-
Radiol Oncol 2006; 40(4): 211-5.
214
Pavčec Z et al. / Doppler ultrasound in muscle rupture and an arteriovenous fistula
cular imaging is routinely included in the assessment of suspected vascular trauma. Duplex ultrasonography has sensitivity 95%, the specifity 99% and 98% accuracy in the assessment of peripheral vascular injuries, even 100% sensitivity and specifity compared with the conventional arteriogra-phy and operative exploration by Fry and colleagues 1994.4 Doppler vascular imaging can help to detect the origin and pattern of vascular supply and the degree of blood flow in periskeletal soft tissue masses.3,4 The combination of B-mod and Doppler sonography has 90% sensitivity and 91% specifitiy and 91% accuracy in the evaluation of musculoskeletal masses.9 Soft tissue vascular masses can be distinguished with these characteristics: morphostructural features, the presence of colour or power signals, the site of vascular branches, their cal-ibre and course, the number of afferent vas-cular poles, resistance index, vessel density and peak flow velocities.10 ,11 Haemangioma and AV malformation have higher vessel density than other vascular malformations. There is no statistically significant differ-ence between haemangioma and vascular malformation in vessel density and mean peak velocity. Solid-tissue mass is the fac-tor for differentiation between haemangi-oma and vascular malformation.11,12
AV fistula clinical manifestations in the extremities usually are swelling of the in-jured limb, a thrill and bruit over the site of injury, but if the thrombus has occluded the AV communication the appearance of these signs will be delayed. The severity of AV fistula clinical manifestation can vary from local changes, as it was in this case, till the venous hypertension and congestive heart failure.5,6
In the case reported in this article the patient had unrecognised AV fistula. The pen-etrating injury of the right thigh was denied by the patient. There were no characteristic clinical signs like bruit and thrill over the
Radiol Oncol 2006; 40(4): 211-5.
region where the AV fistula was situated, although the right leg was swollen. The ae-tiology of the AV fistula and hypervascular-ized structure near the femoral quadriceps muscle rupture remained unclear. Working hypothesis about vascular malformation injured by trauma was not confirmed with DSA and operative findings. To the authors' knowledge the differential diagnosis of posttraumatic bleeding of a congenital AV-malformation has not yet been reported.
In this case of inadequately behaving posttraumatic haematoma, the correct diagnosis of an abnormal AV communi-cation, an AV fistula, was made on the non-invasive vascular imaging methods findings (Doppler and CT angiography) ground. DSA didn't depict a right thigh AV fistula the existence of which was indi-rectly confirmed with the disappearance of clinical signs after the deep femoral artery muscular branche ligation, an AV fistula feeding artery. The point is that every inad-equately behaving, recidivous posttrauma-tic haematoma should raise the suspicion of vascular injury, and must be evaluated with the vascular imaging methods. The facts presented in this case report support opinion that non-invasive vascular imaging methods like Doppler ultrasound and CT angiography can give enough information for diagnostic and therapeutic decisions and a follow-up after the treatment.
Pavčec Z et al. / Doppler ultrasound in muscle rupture and an arteriovenous fistula
215
References
1.   Krolo I, Babić N, Marotti M, Klarić-Čustović R, Matejčić A, Hat J. Ultrasound in the evaluation of sports muscular injury. Acta Clin Croat 2000; 39: 15-9.
2.   Peetrons P. Ultrasound of muscles. Eur Radiol 2002; 12: 35-43.
3.   Bynoe RP, Miles WS, Bell RM, Greenwold DR, Sessions G, Haynes JL, et al. Noninvasive diagno-sis of vascular trauma by duplex ultrasonography. J Vasc Surg 1991; 14 : 346-52.
4.   Fry WR, Smith RS, Sayers DV, Henderson VJ, Morabito DJ, Tsoi EK, et al. The success of duplex ultrasonography scanning in diagnosis of extrem-ity vascular proximity trauma. Arch Surg 1994; 129: 669-70.
5.   Khougeer G, Bayoumi Okda AH. Difficult femoral aretriovenous fistula in a child. Ann Saudi Med 2000; 20: 150-1.
6.   Tayama K, Akashi H, Hiromatsu S, Okazaki T, Yokokura Y, Aoyagi S. Acquired arteriovenous fistula of the right forearm caused by repeated blunt trauma:a report of rare case. Ann Thorac Cardiovasc Surg 2005; 11: 59-62.
7.   Bail HJ, Melcher I, Raschke MJ, Schroeder RJ, Schaser KD. Unknown AV-fistula as reason for post-traumatic hematoma of the thigh. Vasa 2003; 32: 108-10.
8.   Bohndorf K, Kilcoyne RF. Traumatic injuries: im-aging of peripheral musculoskeletal injuries. Eur Radiol 2002; 12: 1605-16.
9.   Belli P, Costantini M, Mirk P, Maresca G, Priolo F, Marano P. Role of color Doppler sonography in the assesment of musculoskeletal soft tissue masses. J Ultrasound Med 2001; 20: 587-95.
10. Taylor GA, Perlman EJ, Scherer LR, Gearhart JP, Leventhal BG, Wiley J. Vascularity of tumor sin children:evaluation with color Doppler imaging. AJR Am J Roentgenol 1991; 157: 1267-71.
11. Paltiel HJ, Burrows PE, Kozakewich HPW, Zurakowski D, Mulliken JB. Soft-Tissue Vascular Anomalies: Utility of US for Diagnosis. Radiology 2000; 214: 747-54.
12. Latifi HR, Siegel MJ. Color Doppler flow imaging of pediatric soft tissues masses. J Ultrasound Med 1994; 13: 165-9.
Radiol Oncol 2006; 40(4): 211-5.
274
Slovenian abstracts
Radiol Oncol 2006; 40(4): 211-5.
Uporaba Dopplerskega ultrazvoka pri ugotavljanju in sledenju mišične rupture in arteriovenozne fistule na stegnu 12-letnega dečka
Pavčec Z, Žokalj I, Saghir H, Pal A, Roić G
Izhodišča. V članku avtorji na kliničnem primeru prikazujejo natančnost neinvazivnih slikovnih metod, zlasti Dopplerskega ultrazvoka pri ocenjevanju mišične poškodbe in ob-skeletnih žilnih nepravilnostih v mehkih tkivih.
Prikaz primera. Obravnavali so 12-letnega dečka s poškodbo desne štiriglave stegenjske mišice, kjer je nasta mišična ruptura. Po operaciji so z običajnim 2-dimenzionalnim ultrazvokom videli ponavljajoči hematom. Z ultrazvočno preiskavo so pravtako ugotovili hiper-vaskularizirano področje in posumili na žilno nepravilnost (angiom). Ko so prekrvavljenost bolnikovega stegna pregledali z Dopplerskim ultrazvokom, so menili, da ima lahko bolnik arterijovenozno fistulo, ki je nastala po poškodbi. Podobnega mnenja so bili preiskovalci v pediatrični bolnici, kjer so dečka ponovno pregledali z Dopplerskim ultrazvokom. Vendar digitalna subtrakcijska angiografija, ki so jo naredili 8 mesecev po poškodbi, ni potrdila izvidov ultrazvočnih preiskav. Zato so 11 mesecev po poškodbi naredili računalniško tomografsko angiografijo, ki je jasno pokazala spremembe, ki so bile že večkrat opisane ob predhodnih ultrazvočnih preiskavah. 14 mesecev po poškodbi je bolnika operiral žilni kirurg in klinično stanje se je znatno popravilo. Kljub preiskavam in kirurškemu posegu vzrok nastanka fistule pri dečku ni popolnoma pojasnjen.
Zaključki. Ob neobičajnih ponavljajočih hematomih, ki nastanejo po poškodbi, je indicirana Dopplerska ultrazvočna priskava. Z računalniško tomografsko angiografijo laho natančneje opredelimo ultrazvočno vidne spremembe.
Radiol Oncol 2006; 40(4): 273-8.