Common Pediatric Rads Flashcards
Imaging workup for bilious vomiting
- Three view abdominal series
- Upper GI fluoroscopic series
Transverse view of pyloric stenosis
On axial you see the classic donut sign
Midgut volvulus “small intestinal beak” sign
Results of a normal upper GI fluroscopy study
Anatomy of malrotation (as seen on barium enema)
Double bubble sign on fetal ultrasound
Presence of a gastric bubble is important, but there should not be two discrete bubbles
Results of upper GI fluoroscopy in a child with malrotation-volvulus
Corkscrew jejunum is also often seen
What is the key to diagnosing malrotation?
Identification of the location of the ligament of Treitz
Usually, it is on the left side of the abdomen underneath the stomach.
In malrotation, it is attached to the right abdominal wall and crosses over the cecum. (Ladd’s bands)
The appendix in a Ladd procedure
To avoid future diagnostic confusion, the appendix is usually removed as the intestinal anatomy is so altered.
What is going on in this infant’s radiograph?
There is hyperinflation and increased perivascular markings. It can be fairly subtle, the perivascular markings are the biggets tell. Sometimes complete RUL collapse is observed.
On the lateral radiograph associated with this case you can better appreciate the hyperinflation via the flattening of the diaphragm.
In the right clinical context, this is suggestive of bronchiolitis, particularly RSV.
How frequently should a baby have CXRs when intubated to assess tube placement?
As infrequently as possible
Bronchus intermedius
Where the lesion is here
After the take-off of the RUL bronchi, before the separation of the RLL and RLM bronchi.
What is going on in this hand/wrist x-ray?
Taurus fracture or Buckle fracture
Common in kids and adolescents where the periosteum is stronger than the bone. More than half of these fractures involve the metaphysis only.
Any cortical “bump” should be considered a Taurus fracture if the kid has symptoms at the site.
Tx for nondisplaced fractures: splint of < 48 hours old, cast for 2-4 weeks if > 48 hours old. Repeat radiography is not indicated if symptoms improve.
Salter-Harris system
Graded in terms of increasing risk for growth disturbance (so 5 is the highest risk!)
Nomenclature of bone components
What is going on in this radiograph?
Greenstick fracture of the radius and ulna
Usually seen in pediatric patients (strong periosteum)
What is going on in this radiograph?
Greenstick fracture of the radius with associated plastic deformation (but not fracture!) of the ulna.
What is going on in this radiograph?
This is a Toddler’s fracture
The mechanism/traumatic event is often not witnessed. Radiographs may reveal a non-displaced spiral fracture of the tibia without fibular involvement.
However, initial radiographs may be negative and only after there has been time for periosteal reaction (~1 week, maybe more) will you be able to see the fracture.
What is the most likely site of elbow fracture in pediatric patients?
Supracondylar
Unfortunately, they also tend to be hard to see on films. We often have to rely on elevation of the fat pads on plain films.
Where should you see a fat pad in a healthy elbow joint?
SCFE lesion
Osgood-Schlatter disease aka Osteochondrosis
- Condition of painful inflammation of the tibial tubercle, caused by traction apophysitis of the tibial tubercle
- Occurs in active children and adolescents between ages 9 and 17
- Diagnosis may be made clinically
- Treatment consists of decreased activity, ice after exercise, and NSAIDs
- In severe cases, immobilization of the knee and use of crutches may be required
- Symptoms may recur until ossification is complete (~17 years)
- Long-term prognosis is excellent
Patellofemoral pain syndrome
- Broad term used to describe pain in the front of the knee and around the patella
- Also called “runner’s knee” or “jumper’s knee”
- Characterized by anterior knee pain and stiffness with motion, popping or cracking sound when climbing stairs or standing after a long period of sitting, and tenderness of the inferior patella
Slipped capital femoral epiphysis (SCFE)
- Occurs in adolescents during the growth spurt. Most common in overweight adolescents. No history of trauma.
- Leads to a limp and groin or thigh pain, however hip pain may be referred to the knee.
- On exam, there is limited hip flexion, internal rotation, and abduction
- Frog leg X-ray reveal widening of the femoral epiphysis and osteopoenia.
- These inviduals are at risk for avascular necrosis of the femoral epiphysis and require orthopedic evaluation
- Treat w/ surgery
Iliotibial band friction
- Frequent cause of lateral knee pain in runners and bicyclists
Legg-Calve-Perthes disease
- Age ~6 years old
- Insidious onset of antalgic gate, unable to bear weight on foot
- Avascular necrosis of femoral head in acetabulum
- Diagnose w/ x-ray
- Treat w/ cast
Osteosarcoma
- Distal femur is typical presentation
- Associated w/ pRB mutation, may have had retinoblastoma
- “Sunburst” pattern on x-ray, confirm with MRI, then biopsy
- Focal, atraumatic bone pain
- Treatment is resection
Stages of avascular necrosis of the femoral head
Note the subtle periosteal elevation in stage 1 in comparison to the degenerative change and loss of bone mass in stage 4
Transient synovitis
- Post-infectious or idiopathic, self-limited joint pain in kids
- Will appear with a joint effusion detectable on ultrasound, which is helpful in diagnosis
- Common cause of limp in kids
- Treat with NSAIDs and rest. No follow-up needed if symptoms resolve.
What is going on in this radiograph?
This is a metaphyseal corner fracture, or a “bucket handle” fracture
This occurs when a small piece of bone is avulsed due to shearing on the growth plate. The mechanism of these fractures is thought to be an acceleration/deceleration force during shaking or grabbing.
This is pathognomonic for child abuse
What is going on in this child’s radiograph?
There is callus formation around multiple posterior ribs
This is highly suggestive of child abuse with injury to posterior ribs that occurred one or more weeks ago
Normal anatomy of a hip ultrasound screening for DDH
- What to look for:
- Is the femoral head within the acetabular joint?
- Alpha angle (how shallow is the acetabulum?)
- Does a line extended from the iliac crest approximately bisect the femoral head?
Alpha angle in DDH screening
- Normal hip joint: alpha > 60o
- Type II: Minor dysplasia: alpha 43-60o
- Type III: Major dysplasia: alpha < 43o
- Type IV: Dislocation
- Note: low alpha angle = shallow acetabulum
Pseudoacetabulum
Bony concavity of the pelvis due to chronic untreated hip dysplasia
Requires surgical osteotomy to correct
Treatment of developmental dysplasia of the hip
Fontanelles and ultrasound
The fontanelles, when open, make ultrasound an extremely useful modality for evaluating the entirety of the intracranial anatomy.
If a fontanelle is sufficiently open, you can use ultrasound regardless of age. However, most infants have closed fontanelles by age 9 months. For these patients, CT or MRI is required to visualize intracranial anatomy.
Normal findings are shown here. Note how small the ventricles normally are.
What is going on in this infant’s brain US?
Hydrocephalus
Note the enlargement of the ventricles, which are normally very small (normal is attached for comparison)
What is going on in this infant’s brain ultrasound?
This infant has intraventricular hemorrhage into the right lateral ventricle.
According to the ACR appropriateness criteria, at what age does the most appropriate test for suspected appendicitis transition from ultrasound to abdominal CT scan?
Age 14
Shown is an image of appendicitis on ultrasound
Intusussception on CT
Only seen in older adults (who get CTs for this purpose)
You may see mesenteric components, such as fat and vessels, within the intussusceptum.
Pseudokidney view
Sign of intussusception
This is the intussusception viewed sagitally
Intussception target sign
What is going on in this lateral film?
Epiglottitis
Note the classic “thumb” sign
