Water Bath Evaluation Technique for
Emergency Ultrasound of Painful Superficial
MICHAEL BLAIVAS, MD, MATTHEW LYON, MD, LARRY BRANNAM, MD,
SANDEEP DUGGAL, MD, AND PAUL SIERZENSKI, MD
Researchers have described the use of bedside emergency ultrasound
as an effective way to evaluate for and accurately drain potential ab-
scesses. Similarly, descriptions exist of long bone fracture evaluation in
the wrist and hands. Tendon injury can also be detected with ultrasound
and exploration can be obviated or at least focused. Sonographic exam-
ination of painful extremity pathology such as abscesses or lacerations
involving the hand or foot can be challenging. Patients may be uncoop-
erative if they experience significant pain when the transducer is placed
on the area of interest. While ample amounts of ultrasound gel can
decrease the need for firm transducer contact with the skin it is still
difficult to obtain a good evaluation without causing any discomfort. The
solution may lie in an old technique that has been recently brought back
to life for use in hand evaluation in which the patients extremity is
placed in a water bath. The water bath replaces the need for ultrasound
gel or contact between the ultrasound transducer and the patients skin,
thus eliminating discomfort. We describe 7 cases in which, despite
aggressive attempts at pain control, adequate evaluation of extremity
pathology was not possible without the use of the water bath technique.
Patients reported no discomfort and superior quality images were ob-
tained due to the water bath properties. Emergency sonologists should
keep this technique in mind when contact between skin and the ultra-
sound transducer is likely to cause a patient significant discomfort. (Am
J Emerg Med 2004;22:589-593. 2004 Elsevier Inc. All rights reserved.)
Several recent studies in emergency medicine and some
from outside the field have shown the utility of ultrasound
for visualization of superficial structures for line placement,
abscesses, foreign bodies and effusions.1-5 Work on abscess
visualization has shown an increase in accuracy for abscess
detection when only cellulitis was suspected.2 Similarly, a
needle can be guided directly to the abscess obviating the
need for fishing which is sometimes required with blind to the palm of his dominant right hand. The patient was
sticks that do not use ultrasound or other imaging tech-
niques for needle guidance.6
When visualization of a potential abscess or other super-
ficial structure is sought, ultrasound gel is applied to the skin
surface and a linear, high-resolution ultrasound probe is
From the Department of Emergency Medicine, Medical College of
Georgia, Augusta GA and the Department of Emergency Medicine,
Christiana Care Health System, Newark DE.
Manuscript received September 11, 2003; accepted September
11, 2003.
Address reprint requests to Michael Blaivas, MD, RDMS, Depart-
ment of Emergency Medicine, Medical College of Georgia, 1120
15th Street, AF-2039, Augusta, GA 30912-4007. Email:
blaivas@pyro.net
Key Words: Emergency ultrasound, water bath, superficial ultra-
sound, tendon laceration, soft tissue ultrasound, abscess.
2004 Elsevier Inc. All rights reserved.
0735-6757/04/2207-0017$30.00/0
doi:10.1016/j.ajem.2004.09.009
Structures
used to image the top several centimeters of tissue. This
may work well on a large flat or pliable surface such as a
thigh but can be much more difficult on a finger or in the
web space between two adjacent fingers. In these areas,
conforming to irregular body surfaces is difficult and ex-
cessive movements of the transducer may cause significant
discomfort to the patient. An emergency physician (EP)
may be able to use such a large amount of gel that contact
with the skin surface is hardly required. However, irregular
surfaces are still a problem as the gel can easily move away
from the targeted area. The ideal solution could be to
immerse the hand entirely in a medium that transmits ultra-
sound waves. This would mean an extravagant use of ul-
trasound gel or another means must be sought. Furthermore,
typical ultrasound gel is not sterile, an important factor if
wound contamination is of concern.
Although not typically thought of, water is an excellent
medium for ultrasound transmission as evidenced by blad-
der use as a window to pelvic organs in a transabdominal
pelvic ultrasound. We describe 7 cases in which the use of
a water bath technique was helpful in providing painless and
high quality images of superficial structures in areas diffi-
cult to image with standard gel application techniques.
CASE 1
RG is a 23-year-old man without significant past medical
history who presented to the emergency department (ED) 3
days after suffering a laceration from a broken piece of glass
unable to flex his right index finger after the injury. Vital
signs were within normal limits and the patient was afebrile.
On physical examination, an approximately 2 cm linear
healing laceration was evident distal to the thenar eminence
of the right hand (Fig 1). The site was moderately tender,
but there was no erythema or swelling. The patient was
incapable of flexing the index finger of the right hand.
Extensor function was intact, as well as 2-point discrimina-
tion distal to the laceration. An attempt was made to image
the area to visualize the flexor tendons using HDI ATL 4000
(Phillips, Bothell, WA). However, adequate visualization
was not possible due to the superficial location of the
tendons. The patients hand was then placed in a clean
bedpan filled with sterile water (Fig 2). The linear probe was
then placed in the water in close proximity to his palm. The
ultrasound revealed a complete flexor tendon disruption
(Fig 3). On attempt of flexion of the index finger, the
proximal tendon was noted to shorten, while the distal
segment of the tendon remained stationary. The wound was
589
590 AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 22, Number 7 November 2004
FIGURE 1. A laceration is shown in the patients palm.
explored by a consulted plastic surgeon and the diagnosis of
complete flexor tendon laceration was confirmed and later
repaired.
CASE 2
PG is an 18-year-old man without significant past medi-
cal history who presented 10 days postrepair of a laceration
to the web space between his right 4th and 5th digits. The
patient had his sutures removed 3 days before this ED visit,
at which time the wound was noted to be healing well. Two
days before the ED visit he noted swelling and pain at the
scar site without erythema. On physical examination vital
signs were within normal limits and the patient was afebrile.
The site was exquisitely tender, but there was no erythema
over the area of swelling (Fig 4). An attempt was made to
image the area to look for abscess using the ILook 25
(SonoSite Bothell,WA.). However, despite good oral anal-
gesia the patient could not tolerate contact with the ultra-
sound transducer. The patients hand was then immersed in
a clean bedpan filled with saline and the ultrasound probe,
which was suspended in the saline, was held over his hand
without touching it. The ultrasound revealed a small abscess
measuring 5 mm by 7 mm that was incised and drained after
local anesthetic (Fig 5).
FIGURE 2. The injured hand is seen submerged in a water bath.
FIGURE 3. The ultrasound image shows a hematoma (H) where
the tendon was lacerated and the proximal end of the flexor tendon
(arrow heads) bunched up(arrows) where it was cut.
CASE 3
CJ is a 54-year-old woman with a history of diabetes and
hypertension who presented to the ED with a complaint of
right great toe pain and mild swelling. She was afebrile and
the rest of the vital signs were unremarkable. Her right first
toe appeared mildly swollen in comparison to the contral-
eral side and there was mild erythema on the tip of the toe.
Complaining of severe pain, the patient refused further
inspection of her toe. Despite oral narcotic analgesia and
considerable discussion, she refused a digital block and
further evaluation of the tip of the toe for signs of an
abscess. An ILook 25 was brought in to evaluate the distal
toe for fluid collections, however the patient again refused
to have anything touch her the tip of her toe. Her foot was
then placed into a water bath and the tip of the toe was
imaged through the water with a linear transducer on the
ILook 25. A small complex fluid connection was located.
With this visual evidence of an abscess the patient was
convinced that a digital block, and incision and drainage
were necessary. Approximately 2 cc of puss was drained
FIGURE 4. A healing laceration is seen between the 5th and 4th
digits, arrow.
BLAIVAS ET AL WATER BATH ULTRASOUND
FIGURE 5. An abscess is showed marked A, with fluid (dark
area) clearly noted above the skin.
and the patient placed on antibiotics. Follow up showed a
slow but complete resolution of the process. No evidence of
osteomoylitis was ever found.
CASE 4
TK is a 24-year-old man with no significant past medical
history who presented to our ED with a complaint of a
puncture wound to his left thenar eminence. Earlier that
morning, the patient had been holding a piece of wood when
it slid out of his hand and he felt a splinter. He removed the
splinter, but continued to have pain and now swelling. The
patient had no fever and remaining vital signs were normal.
Examination of his left palm revealed a small puncture
wound in the middle of the thenar eminence. The area was
extremely tender to palpation, but no foreign body could be
felt. Plain films showed no evidence of a foreign body. The
patients hand was placed in a water bath and an ultrasound
examination was performed. The patient did not complain
of any discomfort. Ultrasound revealed a thick anechoic line
at an angle in the soft tissue. The foreign body itself could
not be seen, however small forceps were guided to the
anechoic areas 0.5 cm deep to the skin a piece of wood was
retrieved. The patients wound was thoroughly irrigated and
tetanus updated. He recovered without side effects.
CASE 5
IL is a 54-year-old woman with diabetes and hyperten-
sion who presented to the ED with a complaint of right foot
pain, swelling and redness that began five days prior and
had steadily increased. The patient was no longer able to
wear shoes and limped when walking. She was afebrile and
her vital signs were within normal limits. On physical
examination the patients right foot showed erythema and
swelling over the first metacarpal-phalangeal joint, dorsally.
The erythema involved most the distal dorsal foot which
was exquisitely tender. The patient balked at further palpa-
tion of the affected area. To evaluate if an abscess was
present, the patients foot was immersed in water, using a
clean bedpan. The ILook 25 showed diffuse skin changes
from cellulitis and a 1.5 cm x 1.0 cm x 0.7 cm complex fluid
collection. The patient refused local anesthesia, but allowed
591
a single 18-gauge needle to be placed into the fluid collec-
tion after sterile preparation of the area. Purulent fluid was
drained and the patient was placed on antibiotics after a
dose of intramuscular ancef. The patient returned for fol-
low-up in 2 days, at which time no fluid accumulation was
noted and the area of erythema was reduced significantly.
CASE 6
JP is a 6-year-old boy who presented to the ED with a
complaint of right thumb pain and swelling that woke him
from sleep at 2 a.m. The patient was afebrile and other vital
signs were within normal limits. The patient admitted to
thumb sucking, but denied any specific injury. Immuniza-
tions were current. On examination there was an obvious
paronychia, but no evidence of blistering or pustules. He
refused to flex his thumb due to pain. No subungal infection
was noted. The pad of the thumb was erythematous, swollen
firm, and tender. Capillary refill was within normal limits
and sensation was intact. The child and his parents refused
a digital block for pain relief. Diagnosis of a felon was
considered and a water bath evaluation using a clean basin,
and warm water for patient comfort was performed using a
linear transducer and the Sonosite 180 PLUS (SonoSite
Bothell, WA). The thumb was evaluated in both sagittal and
transverse images. A fluid collection representing the paro-
nychia was evident, however the pad of the thumb revealed
only edematous tissue consistent with cellulites and drain-
age of a supposed felon was avoided. The child continued to
refuse a digital block and anesthia was obtained using a
thumb tourniquet and the perenichia was released within the
water bath. The patient was discharged on oral antibiotics
with hand surgeon follow-up in 2 days, revealing full res-
olution of the infection.
CASE 7
GG is a 25-year-old man with no significant past medical
history who was transferred to our ED with a suspicion of a
septic joint. Nine days before arrival the patient had a
wooden splinter penetrate the skin over the dorsum of his
left third metacarpal-phalangeal joint. The patient pulled out
the splinter and did well for 6 days. Approximately 3 days
prior, the patient noted redness and swelling over the joint
and increasing pain on movement. He was seen at an outside
ED where the diagnosis of septic arthritis in the joint was
entertained and he was transferred to us.
On arrival the patients vital signs were within normal
limits and he was afebrile. His left third metacarpal-phalan-
geal joint was exquisitely tender and swollen. There was
generalized and poorly demarcated erythema over the joint.
The patient had considerable pain to touch and refused to
move the finger. His hand was placed in a water bath and a
linear array on an Philips HDI 4000 was suspended in the
water just above the hand. Long and short axis images were
obtained showing a thickened extensor tendon with fluid
around the tendon, but not in the joint (Fig 6). Areas of
increased blood flow were seen on power Doppler in com-
parison to the other hand. The consulting hand surgeon
elected to forgo the planned joint exploration in the oper-
ating room and admitted the patient for intravenous antibi-
otics. The patient improved on the antibiotic regimen and
was discharged home on oral medicines.
592 AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 22, Number 7 November 2004
FIGURE 6. A long axis cut through the extensor tendon (T) is
seen sitting on top of the 2nd metacarpal (M) and proximal phalanx
(P). Fluid (F) is seen under the tendon. Note power Doppler signal,
arrow heads.
DISCUSSION
Evaluation of superficial pathology such as soft tissue
infections, foreign bodies and long bone fractures is becom-
ing more common in emergency sonography.7 Benefits can
include a more accurate diagnosis of cellulitis or abscess,
improved ability for needle directed drainage of fluid col-
lections and improved localization of a foreign body.2,8
Since ultrasound examinations are typically not consid-
ered painful, it may not be intuitive that evaluation of an
injured or infected extremity may be difficult due to patient
discomfort. However, ultrasonographic evaluation of a dis-
tal extremity often requires some manipulation, especially if
the areas of interest are not immediately on the dorsal or
ventral surfaces. Rotation or abduction of fingers or toes can
be extremely painful if an infection, tendon laceration, or a
fracture is present. In addition, direct contact and subse-
quent pressure from the transducer may lead to increased
pain in certain types of pathology such as infections.
As described in the cases presented, a water bath using
saline or water, can be used to obviate the need for direct
contact between the transducer and the affected body part
allowing for several advantages. Better resolution of near
surface structures can be obtained, as the ability of most
transducers to focus in their extreme near field is
limited. The lack of direct contact between the transducer
and the patient greatly increases patient comfort and
cooperation in the exam. In the past, stand-off materi-
als such as saline bags or solid gel blocks were used to
gain appropriate distance from a near field target and
allow better resolution. A water bath obviates the need
for this as distance from the surface of the skin can be
readily changed. Because pressure from the probe could
still be transferred to the patient with these stand-off
devices, they may still cause discomfort to the patient,
whereas this is not the case with a probe suspended in a
water bath. In addition, the transducer can be rotated and
slanted to obtain different angles of intersection with the
curves of a digit without losing contact between the skin,
transducer, and sonographic medium, which often occurs
with ultrasound gel. This technique has been described
previously by Sierzenski et al, for evaluation of finger
tendon injury.9 The researchers compared standard, di-
rect contact ultrasound versus water bath for visualiza-
tion of a healthy flexor tendon in a models hand. The
water bath technique was rated superior in ease of use,
image quality and ability to evaluate the entirety of the
flexor tendon when compared with the traditional direct
contract technique.
Water bath use increases patient comfort by allowing the
emergency physician to avoid using gel in an open wound
and thus eliminating the need for direct contact between the
probe and the skin. In addition, if for some reason total
sterility is desired, the basin as well as the saline or water
can all be sterile and the transducer can be placed in a sterile
sheath.
Tendon anatomy can be difficult to visualize using
ultrasound. However, several studies have shown effi-
cacy in using ultrasound to diagnose tendon lacera-
tions.10,11 Tendon lacerations can be searched for under
high resolution ultrasound and surgical exploration
avoided in some cases. However, it may be difficult to
follow the path of the tendon, since the linear probe has
difficulty conforming to body curvatures like those of the
finger. Maintaining good skin contact is thus difficult and
often requires firm consistent pressure, which may cause
pain, or risk further injury to the tendon. Even with
appropriate technique, the typical scan will often have
portions of the image missing due to poor contact of the
probe with gel and the skin surface. Tendon evaluation is
also complicated by a unique artifact called anisotropy,
which results in apparent washout of the tendon when the
ultrasound beam is not striking the tendon fibers perpen-
dicularly. This is a particularly important concept to bear
in mind when evaluating a tendon for injury, such as a
laceration or disruption. To compensate for curvatures of
the digits and other portion of distal extremities the
ultrasound transducer is angled when possible. However,
the linear transducer by its nature is does not allow
conformation to small body curvatures. However, with
the use of a water bath, any angle can be easily achieved
by increasing the distance from the transducer to the
affected part. Furthermore, due to the high transmissibil-
ity of the water medium, very little signal is lost by this
increased depth. Therefore, high-resolution images are
still possible.
Finally, ultrasound evaluation for foreign body has been
shown to be very efficacious for diagnosing radio-opaque
and radiolucent foreign bodies. In addition it has proven to
be superior to standard radiography in localizing the foreign
body.12,13 In this context, the water bath and direct contact
techniques have been compared for the detection and eval-
uation of foreign bodies in turkey breast tissue. The re-
searchers found that a water bath afforded the same image
detail and quality as the direct contact technique, but re-
sulted in an improvement in image resolution.14
In summary the water bath technique provides a helpful
option for evaluation of a painful distal extremity or an area
that simply does not allow for easy access using the direct
contact technique. Image quality is maintained and often
BLAIVAS ET AL WATER BATH ULTRASOUND
improved and patient comfort and cooperation with exam-
ination is increased. As emergency physicians broaden the
boundaries of emergency ultrasound away from the tradi-
tional and limited scope of practice seen in the early 1990s
the water bath will be an excellent alternative technique in
their armamentarium.
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