RD paediatric formatted Flashcards
- Neck mass in 3 month infant. High flow, high velocity, low resistance. Which is most likely
a. Infantile hemangioma
b. Macrocystic lymphatic malformation
c. Arteriovenous malformation
d. Microcystic lymphatic malformation
e. Venolymphatic malformation
.f. Congenital haemangioma
g. Venous malformation
*AJL - This may be either infantile or congenital haemoangioma. There is not enough information to determine which it is. (congenital = present at birth, infantile = not present at birth)
Previous answers:
a. Infantile hemangioma T – see below.
JMIRO 2012 (Mitesh): “Soft tissue mass that is predominantly hypoechoic with high-velocity colour flow, high vessel density and low resistance”. US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).1.
Neck mass in 3 month infant. Growing. High flow, high velocity, low resistance. Which is most likely (Radiographics May-June 2009 p887; JMIRO 2012)
a. Infantile hemangioma T – see below. JMIRO 2012 (Mitesh): “Soft tissue mass that is predominantly hypoechoic with high-velocity colour flow, high vessel density and low resistance”. US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).
b. Macrocystic lymphatic malformation F – low-flow, large cystic spaces at US, grow with child
c. Arteriovenous malformation ? F – enlarge with size of child (present at birth, but usually manifest in childhood or later); high-flow vessels; but usually no definable mass (JMIRO 2012); US Clin 2009: characterized by multiple feeding arteries with increased diastolic flow and high-velocity venous return. Typically high-flow, low resistance. Arterial waveforms in venous structures.
d. Microcystic lymphatic malformation F – low-flow; composed of very small cystic components a few mm in size
e. Venolymphatic malformation. F – low-flow
f. Congenital haemangioma – F? - either involute in infancy (‘rapidly involuting congenital haemangioma’) or grow proportional with child (‘non-involuting haemangioma’); MR appearance similar to infantile haemangioma, although may have ill-defined margins
g. Venous malformation – F - low-flow, do enhance post GdANS = infantile haemangiomao Undergo a characteristic two-stage process of growth & regression:• At birth, typically small & inconspicuous (60% are not visualised at birth)• Shortly after birth, proliferative phase occurs – rapid endothelial growth in 1st few months of life, stabilising in size at ≈ 9-10 months of age• Following this the involuting phase continues slowly for the next several years, being replaced by fibrofatty tissue, and usually complete at 7-10 years of ageo US:• Discrete lobulated mass• Prominent colour Doppler high flowo MRI:• Proliferative phase:➢ Lobulated, well-defined mass➢ Hyperintense on T2W images & isointense to muscle on T1W images➢ Prominent draining veins seen as both central & peripheral flow voids on SE
- 10cm pancreatic cyst (cystic mass) in a young patient (25 years). (Incidental with no calcifications). Most likely is
a. Serous
b. Mucinous
c. Solid pseudopapillary
d. Insulinoma
e. Gastrinoma
c. Solid pseudopapillary T Young age suggests solid pseudopapillary neoplasm with predominate cystic degeneration. RG 2011 – F»M (9:1), young adult (mean age 25); typically large (mean 9cm); 30% have calcifications. Against this is no mention of solid components or haemorrhage.
- 10cm pancreatic cyst (cystic mass) in a young patient (25 years). (Incidental with no calcifications). Most likely is
a. Serous F mean age 65 years
b. Mucinous
c. Solid pseudopapillary T Young age suggests solid pseudopapillary neoplasm with predominate cystic degeneration. RG 2011 – F»M (9:1), young adult (mean age 25); typically large (mean 9cm); 30% have calcifications. Against this is no mention of solid components or haemorrhage.
d. Insulinoma F 4th-6th decades; usually small & hypervascular solid
e. Gastrinoma F 4th-5th decades; usually small & hypervascular solid
- Most likely location of a pulmonary sequestration
a. Right upper lobe
b. Right middle lobe
c. Left upper lobe
d. Right lower lobe
e. Left lower lobe
Left lower lobe•
BPS location: posterobasal segment of LLL is most common siteo LLL > RLLo Posterobasal > mediobasal segment
- NAI injuries. Which is most true?
a. Bucket handle (corner) metaphyseal fractures associated with twisting injury.
b. Long bone diaphyseal injuries are spiral (also recalled as: “Spiral fractures are most often seen in NAI”)
c. Posterior rib fractures more common than lateral
d. Posterior rib fractures less common (frequent) than anterior fractures
e. Bone scan for confirmation of the fracture age is better compared to x-ray
c. Posterior rib fractures more common than lateral T posterior rib fractures most common & most specific for abuse (Donnelly, StatDx)
- NAI injuries. Which is most true? (SK)
a. Bucket handle (corner) metaphyseal fractures associated with twisting injury F shearing injury, usually generated by manual to-and-fro manipulation of extremities (e.g. holding & shaking child)
b. Long bone diaphyseal injuries are spiral T they can be – can also be oblique or transverse. Quite specific for NAI if spiral fracture of long bone occurs in non-ambulatory (< 1 yr) child.Also recalled as: “Spiral fractures are most often seen in NAI” ?? F once a child is walking, spiral fractures of the tibia (Toddler fractures) are quite common, and often have no memorable traumatic antecedent, and by themselves are not suggestive of NAI.
c. Posterior rib fractures more common than lateral T posterior rib fractures most common & most specific for abuse (Donnelly, StatDx)
d. Posterior rib fractures less common than anterior fractures F = adult squeezes infant thorax; causes posterior rib fracture near costovertebral joint, but can also cause anterior & lateral rib fractures
e. Bone scan for confirmation of the fracture age is better compared to x-ray F “Bone scans have no place in fracture dating because they show positive results within 7 hr of injury and can continue to show positive results for as long as 1 year.” AJR April 2005.
- Features of pilocytic astrocytoma (which is false?)
a. The most common posterior fossa tumour
b. Calcify more commonly than medulloblastoma
c. Usually a less aggressive lesion
d. Usually more cystic than solid
e. Show enhancement after contrast administration
b. Calcify more commonly than medulloblastoma F JPA < 10% calcify, while 10-20% of MB’s calcify (NeuroReq); Osborn says up to 20% of MB calcify, while says “uncommon” in JPA; c.f. ependymoma 40-50% calcified at CT (most common PF tumour to calcify) SG reckons about the same
*LW - agrees this is FALSE and therefore correct answer, according to Donnely.
- Features of pilocytic astrocytoma (SK)
a. The most common posterior fossa tumour T in children (although some may MB is); peak age 8-13 years SG MB slightly more common
*LW: Donnelly states Pilocytic astrocytoma most common posterior fossa tumour, thus taken as TRUE.
b. Calcify more commonly than medulloblastoma F JPA < 10% calcify, while 10-20% of MB’s calcify (NeuroReq); Osborn says up to 20% of MB calcify, while says “uncommon” in JPA; c.f. ependymoma 40-50% calcified at CT (most common PF tumour to calcify) SG reckons about the same
*LW as above, FALSE.
c. Usually a less aggressive lesion T WHO grade I tumour:
d. Usually more cystic than solid T typically well-circumscribed cyst-like masses with a discrete mural nodule – one-third are microcystic or solid, esp. in older patients
e. Show enhancement after contrast administration T solid portion (cyst with enhancing mural nodule)
- 11 yo girl with 4th ventricle tumor. Most likely (repeat)
a. Choroid plexus papilloma
b. Oligodendroglioma
c. Ependymoma
d. Haemangioblastoma
e. Medulloblastoma
e. Medulloblastoma T arise from roof of 4th ventricle; older age than ependymoma but usually < 10 years; 2nd most common PF tumour in kids (after JPA) Doesn’t
- Cortically based tumour:
a. Low grade glioma
b. DNET
c. Pilocytic astrocytoma
d. Cavernous haemangioma
e. Ependymoma
b. DNET - T - benign, focal intracortical mass superimposed on background of cortical dysplasia. Arises from secondary germinal layer of CNS, in particular the subpial granular layer.
- Cortically based tumour:
a. Low grade glioma – F typically involve WM. However the pleomorphic xanthoastrocytoma (PXA) is cortically-based.
b. DNET - T - benign, focal intracortical mass superimposed on background of cortical dysplasia. Arises from secondary germinal layer of CNS, in particular the subpial granular layer.
c. Pilocytic astrocytoma - F - arises from astrocytic precursor cell. Typically cerebellar mass (hemisphere) which compresses 4th ventricle
d. Cavernous haemangioma - F
e. Ependymoma - F - floor of 4th ventricle mass, slow-growing tumour of ependymal cells.
Kid in accident. Has lesion that is consistent with angiomyelipoma. Clinical stable.
Next best step.
- MRI
b. DSA
c. family hx
d. renal scintigraphy
e. urgent surgery
ANS• If patient bleeding into AML / retroperitoneum, DSA (B) and transarterial embolisation indicated•
If not bleeding, may have conservative management (e.g. US follow-up) or elective surgical/IR management
Wunderlich syndrome = haemorrhagic shock due to massive bleeding into AML or retroperitoneum (Dahnert).J Trauma. 2005;59:737–741:
SUFE.
a. rarely dx on AP
b. usually 5-10 years of age
c. usually bilateral
d. usually posteromedial slippage
e. in early slippage frog leg view is best
D = T = epiphysis rotated posteriorly & inferomedially
*LW: agrees TRUE.
E ? trueEmedicine: “The lateral radiograph demonstrates slippage earliest because the slippage begins with posterior displacement and progresses with medial rotation.” “Before the femoral epiphysis actually has become displaced, only a slight widening of the affected physis may be evident.”
*LW: agrees also TRUE.
*AJL - agree that both D and E are true (as above)
- Regarding myelination of the brain:
a. As myelination progresses the white matter becomes T1 hypointense.
b. The posterior internal capsule is myelinated at birth.
c. The optic nerves are myelinated by 2 months of age.
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly.
e. At 24-30/12 the white matter is isointense to grey matter on T2.
I guess this question is asking which one is most true
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly. T dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’]
- Regarding myelination of the brain:
a. As myelination progresses the white matter becomes T1 hypointense. F with myelination, deceased amounts of water → T1 hyperintense & T2 hypointense
b. The posterior internal capsule is myelinated at birth. T the posterior portion of the posterior limb of IC is myelinated at birth on T1 (2 mo on T2), anterior part by 1mo (4-7 mo on T2); anterior limb at 2-3mo (5-11 mo on T2)
c. The optic nerves are myelinated by 2 months of age. T optic nerves & tracts myelinated by 1 mo
d. The splenium of the corpus callosum myelinates first, myelination then progresses anteriorly. T dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’]
e. At 24-30/12 the white matter is isointense to grey matter on T2. F
- A 3 year old child has a 1.5cm lesion at the dorsal aspect of the nose. It is bright on T1 and T2 weighted MR, and demonstrates a fibrous band which extends to a pit in the foramen caecum of the frontal bone. It MOST LIKELY represents:
a. Dacrocystocoele
b. Glioma
c. Encephalocoele
d. Choanal atresia
e. Nasal dermal sinus
*AJL - I wonder if this was meant to say nasal dermoid sinus which is bright on both T1 and T2 (contains sebum/fat). Please change the question/answer if you agree.
e. Nasal dermal sinus
B = nasal glioma (F) = T1 mixed-low, T2 hyper-, pedicle of fibrous tissue b/w ING & intracranial cavity
C = encephalocele (F) = connection to intracranial brain parenchyma
E = nasal dermal sinus (?T) = T1 hyper-, T2 intermediate; may have associated sinus tubular tract from tip of nose to apex of crista galli
- Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree
b. Occur in the mediastinum more than the lung
c. Are part of a spectrum of foregut cysts
d. When have a thick contrast enhancing wall indicate infection
e. High T2 signal
a. Communicate with the bronchial tree F – Do not communicate with bronchial tree unless/until they become infected
- Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree F – Do not communicate with bronchial tree unless/until they become infected
b. Occur in the mediastinum more than the lung T – 65-90% occur in middle mediastinum
c. Are part of a spectrum of foregut cysts T aka foregut duplication cyst
d. When have a thick contrast enhancing wall indicate infection T
e. High T2 signal T - Signal is almost always equal to or greater than cerebrospinal fluid (CSF)
- 3 month child with a neck mass which has been present since birth and has grown with the child. Ultrasound shows a compressible lesion with low monophasic flow. Which is MOST likely?
a. Venous malformation
b. Lymphatic malformation
c. Arterial malformation (also recalled as AVM)
d. Infantile haemangioma
e. Cavernous haemangioma
a. Venous malformation T frequently evident at birth & grow proportional to child
- 3 month child with a neck mass which has been present since birth and has grown with the child. Ultrasound shows a compressible lesion with low monophasic flow. Which is MOST likely?
a. Venous malformation T frequently evident at birth & grow proportional to child
b. Lymphatic malformation F no flow in cysts, only in septae
c. Arterial malformation (also recalled as AVM) F would have high flow, pulsatile; do not present as masses
d. Infantile haemangioma – F small & inconspicuous at birth, rapid growth in 1st few months of life, stabilising in size at 9-10 months of age. They then involute slowly, complete by 7-10 years.
e. Cavernous haemangioma – T/F misnomer for venous malformation; frequently evident at birth & grow proportional to child
- 11 yr old female with ataxia and headache has a posterior fossa mass which is hyperdense and enhancing, it is likely to be…
f. Medulloblastoma/PNET
g. Meningioma
h. Pilocytic astrocytoma
i. Ependymoma
a. Medulloblastoma/PNET – typically < 10 yrs, M>F, iso-hyperdense, heterogenous enhancement
- 11 yr old female with ataxia and headache has a posterior fossa mass which is hyperdense and enhancing, it is likely to be..
a. Medulloblastoma/PNET – typically < 10 yrs, M>F, iso-hyperdense, heterogenous enhancement
b. Meningioma – rare in children unless NF-2
c. Pilocytic astrocytoma – 8-13 years (right age), cyst with mural nodule
d. Ependymoma – peak age 1-5 years, hypo-isodense, calcification 40-50%, plastic
Drowsy kid with meningism. Best diagnostic test.
a. CSF
b. CTB non contrast
c. CTB post contrast.
d. MRI brain
B. - if very drowsy
A - if not too drowsy
French guidelines: CNS imaging is indicated if:
• Focal neurology
• GCS ≤ 11
• Seizures if > 5, only if hemiseizure in kids < 5
RCH guidelines on LP & CT:
CT Scans if focal neurological signs
• CT Scans are not helpful in most children with meningitis.
• A normal CT scan does not tell you that the patient does not have raised ICP.
• Herniation may occur even in the presence of a normal scan.
• Don’t delay antibiotics whilst waiting for a CT UK
NICE guidelines:Use clinical assessment and not cranial computed tomography (CT), to decide whether it is safe to perform a lumbar puncture.
CT is unreliable for identifying raised intracranial pressure. In children and young people with a reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect alternative intracranial pathology.
Least supportive of EG in a kid with back pain and loss of vertebral body height at T7
a. mass
b. involvement of posterior elements.
c. wedge shaped compression
*LW:
Favoured answer is involvement of posterior elements:
Radiographic states: EG can initially cause wedge like or uneven lateral compression of vertebral bodies, before developing complete vertebra plana.
Often multifocal
Commonly small para spinal soft tissue mass.
Involvement of posterior elements uncommon / destruction of posterior elements is atypical - hence most unlikely.
Probably B
LCH in spine
- Disc-sparing vertebra plana (collapse of body to thin disc) or anterior wedging
- Destructive lytic lesion (esp. in upper C spine)
- Small paraspinal/epidural soft tissue component common
PedRad 2005 article … Spine LCH section“In the spine, LCH mainly involves the vertebral bodies, with a predilection for the thoracic spine followed by the lumbar and cervical spine. Posterior element involvement is less common. Involvement of the vertebral body may result in anterior wedging or, more commonly, near collapse with a characteristic vertebra plana appearance. Epidural soft-tissue extension may be seen on CT or MR imaging. Partial or almost complete height reconstitution is the usual healing pattern observed in vertebra plana lesions [22]. Neurological deficits usually resolve as osseous healing progresses.”
kid with widened ribs and enlarged vertebral bodies. Most likely
a. marrow hyperplasia
b. sickle
c. anapaestic anaemia
ANS = A = marrow hyperplasia → widening of medullary spaces
ADB–>Original option A) in the hard copy was thalassemia, which would get widened ribs and enlarged vertebral bodies (initially before end plate compression #’s occur)
not associated with renal anomalies
a. turners
b. hemihypertrophy
c. medulloblastoma
PNET-MB = no association foundDahnert
A = Turner = assoc/ w/ horseshoe kidney
B = hemihypertrophy = ? Beckwith-Wiedermann S = assoc/ w/ visceromegaly (incl. kidney), medullary dysplasia, Wilms tumour
C = PNET-MB = no association found
Hemihypertrophy of any aetiology is associated with Wilms tumour. BW is associated with embryo nail tumours in general including Wilms
1) Baby with small mass medial canthus, low T1, high T2. Most likely:
i) Glioma
ii) Nasal Dacrocystocele
iii) Choanal atresia
iv) Encephalocele
ii) Nasal Dacrocystocele T = T1 low, T2 high, minimal if any rim enhancement
2) Regarding holoprosencephaly, which is least correct:
i) Is associated with endocrine abnormalities
ii) Increase in incidence likely secondary to more awareness of mild forms
iii) Caused by mutations in Sonic Hedgehog gene
iv) Lobar form associated with non fusion of central grey matter
ii) Increase in incidence likely secondary to more awareness of mild forms ??F
2) Regarding holoprosencephaly, which is least correct:
i) Is associated with endocrine abnormalities (T - J Pediatr Endocrinol Metab. 2005 Oct;18(10):935-41) Diabetes insipidus (DI) occurred in 70% of patients with classic HPE. The severity of the DI correlated with the grade of HPE and hypothalamic non-separation (p < 0.0001). Anterior pituitary dysfunctions were much less common. Hypothyroidism was identified in 11% of patients, hypocorticism in 7%, and growth hormone deficiency in 5%.
ii) Increase in incidence likely secondary to more awareness of mild forms ??F
iii) Caused by mutations in Sonic Hedgehog gene (T – Robbins)
iv) Lobar form associated with non fusion of central grey matter (T - Unlike semilobar holoprosencephaly, the falx is present, the interhemispheric fissure is fully formed and the thalami are not fused)
3) Best indication of HIE in newborn on MRI is:
i) Increased DWI
ii) Decreased ADC
iii) Increased T2
iv) Decreased T1
v) Decreased NAA on MRS
i) Increased DWI – sensitive (esp. for oedema, seen on DWI before T1/T2), but depends on time since insult. RL: diffusion-weighted imaging scored best for the depiction of infarctions in all groups
3) Best indication of HIE in newborn on MRI is: Radiology Feb 2008 (SK)
i) Increased DWI – sensitive (esp. for oedema, seen on DWI before T1/T2), but depends on time since insult. RL: diffusion-weighted imaging scored best for the depiction of infarctions in all groups
ii) Decreased ADC – does not correlate well with extent of injury or outcome. RL “Normal ADC values thus do not exclude hypoxic-ischemic brain damage in neonates.”
iii) Increased T2 – indicates oedemaiv) Decreased T1 – indicates oedema
v) Decreased NAA on MRS ¬– elevated lactate & decreased NAA (a general MRS marker of necrosis) is a common finding in infants with late neurologic sequelae Radiology Feb 2008: The combination of T1- and T2-weighted imaging and diffusion-weighted imaging is best for the detection of hypoxic-ischemic brain injury in the early neonatal period in term-born infants. Diffusion-weighted imaging is best for depicting infarctions.According to Radiographics, probably best indicator is lactate:choline ratio (elevated, if = 1 then predicts adverse neurodevelopmental outcome)During 1st week → DWIAfter 1st week → pseudonormalisation of DWI, use T1 & T2Indeed, MR spectroscopy and diffusion-weighted MR imaging are the most sensitive imaging modalities for detecting HII in the acute periodStatDx- Use T1WI and PD/Intermediate for identification of deep and periventricular injury - Correlate/verify with DWI and MRS
4) 10yo female. Cystic lesion in midline neck in suprahyoid region. Contains fatty nodules at periphery. Most likely:
i) Thyroglossal duct cyst
ii) 4th branchial cleft cyst
iii) Dermoid
iii) Dermoid
• TGDC = midline when suprahyoid; no fatty nodules
• 4th BCC = against or within superolateral aspect of thyroid gland; off-midline
• Dermoid =Well-defined cyst with fatty material, mixed fluid ± calcification; usually in midline tongue or floor of mouth
• Thymic cyst = lateral infrahyoid neck, almost always on the left.
5) Cystic lesion in child. Feature most supporting lymphangioma over Rannula:
i) Submandibular location
ii) Sublingual location
iii) Parapharyngeal location
iv) Retropharyngeal location
v) Involvement of infrahyoid neck
v) Involvement of infrahyoid neck T – most common site for lymphatic malformation (c.f. Ranula = SLS, involves SMS if ‘diving’)
5) Cystic lesion in child. Feature most supporting lymphangioma over Rannula:
i) Submandibular location F – both can occur here
ii) Sublingual location F lymphatic malformation typically does not involve sublingual space, while ranula always begins in the sublingual space (diving form involves submandibular space) – StatDx
iii) Parapharyngeal location F
iv) Retropharyngeal location F
v) Involvement of infrahyoid neck T – most common site for lymphatic malformation (c.f. Ranula = SLS, involves SMS if ‘diving’)Dahnert
• 75% in posterior triangleStatDx summary:
• Best diagnostic clue: Uni- or multiloculated, non-enhancing, cystic neck mass with imperceptible wall that insinuates between vessels & other normal structures
• Locationo Often found in multiple contiguous spaces, i.e., is trans-spatialo Infrahyoid neck• Posterior cervical space most common spaceo Suprahyoid neck
• Masticator & submandibular spaces most common• Size: Varies from several cm to huge neck mass
• Morphologyo May be unilocular or multilocularo Tends to invaginate between normal structures without mass effect
6) Spondyloepiphyseal dysplasia. NOT a feature:
i) atlanto-occipital instability
ii) kyphosis
iii) normal sized hands and feet
iv) coxa vara
v) normal femoral head ossification
v) normal femoral head ossification F = an “epiphyseal” dysplasia
6) Spondyloepiphyseal dysplasia. NOT a feature:
i) atlanto-occipital instability ?? do get odontoid hypoplasia & atlantoaxial instability
ii) kyphosis T = progressive kyphoscoliosis (Dahnert)
iii) normal sized hands and feet T Short proximal and middle limbs with normal hand and foot size (SED congenita form – StatDx)
iv) coxa vara T = coxa vara, genu valgum, equinovarus foot
v) normal femoral head ossification F = an “epiphyseal” dysplasia
7) 15 yo male. Generalised bone pain. Cardiomegaly. Broad ribs. Flattened thoracic vertebrae. Most likely:
i) Glycogen storage disease
ii) Sickle cell
iii) Thallasaemia
iv) Fibrous dysplasia
v) Mets
iii) Thallasaemia T get cardiomegaly, broad posterior ribs, vertebral compression fractures; joint pain (not sure about generalized bone pain)
7) 15yo male. Generalised bone pain. Cardiomegaly. Broad ribs. Flattened thoracic vertebrae. Most likely (SK/JA):
i) Glycogen storage disease F- GCS affects liver & muscle
ii) Sickle cell F get skeletal pain (osteomyelitis, AVN), cardiomegaly, H-shaped vertebra, rib notching/sclerotic areas (but not listed widening)
iii) Thallasaemia T get cardiomegaly, broad posterior ribs, vertebral compression fractures; joint pain (not sure about generalized bone pain)
iv) Fibrous dysplasia F
v) Mets F
8) Regarding meconium aspiration, which of the following is the most correct?
i) Symmetrical involvement
ii) Increased lung volumes
iii) Confluent opacification
iv) Pneumothorax rare
v) Premature infants
ii) Increased lung volumes T – often hyperinflated, may be asymmetric & patchy
8) Regarding meconium aspiration, which of the following is the most correct?
i) Symmetrical involvement F - asymmetric & patchy
ii) Increased lung volumes T – often hyperinflated, may be asymmetric & patchy
iii) Confluent opacification F - patchy
iv) Pneumothorax rare F 20-40%
v) Premature infants F rare in pre-term, more common in post-dates babies
9) Newborn, term infant, normal karyotype, (? sex). Cephalic presentation. No family hx DDH. Normal examination from paediatrician. Intern rings saying Mum worried about DDH and requests US. You advise her:
i) Not indicated
ii) Do hip US within 2 weeks
iii) Do hip US at 6 weeks
iv) Do hip US at 6 months
v) Do Pelvic XRAY at 6 months
i) Not indicated T – according to AAP guidelines
9) Newborn, term infant, normal karyotype, (? sex). Cephalic presentation. No family hx DDH. Normal examination from paediatrician. Intern rings saying Mum worried about DDH and requests US. You advise her:
i) Not indicated T – according to AAP guidelines
ii) Do hip US within 2 weeks F – ideally wait until 2 weeks, MSK Req says 4-6 weeks
iii) Do hip US at 6 weeks F – but if needed is optimal timing
iv) Do hip US at 6 months F – do US in infants < 4-6 months before femoral head ossified
v) Do Pelvic XRAY at 6 months F – too late, but after 4-6 months do XR not USWA Imaging pathways
• Risk factors that predispose to DDH include - o Family historyo Associated congenital orthopaedic conditions o Oligohydramnioso Breech presentationo High birth weight
• If risk factors present, and screening is indicated ultrasonography is the initial investigation of choice
• Ultrasonography should be performed before 6mnths of age. After this time, plain films of the hip are indicatedWA Imaging pathways
• Risk factors that predispose to DDH include - o Family historyo Associated congenital orthopaedic conditions o Oligohydramnioso Breech presentationo High birth weight
• If risk factors present, and screening is indicated ultrasonography is the initial investigation of choice
• Ultrasonography should be performed before 6mnths of age. After this time, plain films of the hip are indicated
11) Which is the most correct regarding a cortical desmoid?
i) Posteromedial condyle
ii) Lateromedial condyle
iii) Increased signal on STIR imaging
iv) Increased uptake on bone scan in 70%
v) Biopsy required for diagnosis
iii) Increased signal on STIR imaging T – T2 FS hyperintense at site of cortical desmoid
11) Which is the most correct regarding a cortical desmoid?
i) Posteromedial condyle F – posteromedial distal femoral metaphysis (just lateral to adductor tubercle) – occurs at attachment of medial head gastrocnemius or adductor magnus insertion
ii) Lateromedial condyle F
iii) Increased signal on STIR imaging T – T2 FS hyperintense at site of cortical desmoid
iv) Increased uptake on bone scan in 70% F – Normal or slightly increased uptake in lesion
v) Biopsy required for diagnosis F – do not touch lesion
12) A 7 y.o girl comes in with hip pain and fever. Normal x-ray. What would be the next most appropriate examination to perform?
i) Bone scan
ii) MRI
iii) Repeat films in 7 - 10 days time
iv) Bilateral Hip US
iv) Bilateral Hip US
13) Proximal intususseption. Most likely cause:
i) Annular pancreas
ii) Pancreatic agenesis
iii) Ectopic pancreas
iv) Pancreas divisum
iii) Ectopic pancreas T
3mo infant. Mass nasal dorsal on the right. ovoid well defined. Low T1. No intracranial abnormality.
a. NL dacryocystocele
b. nasal dermal sinus
c. encephalocele
d. nasal glioma.
e. choanal atresia
• D = Nasal glioma = (“Sequestered cephalocele”) = Well-circumscribed, solid soft tissue mass off midline at nasal dorsum or within nasal cavity in infant with no CSF connection to brain; T1 mixed-low signal; T2 iso-hyper (?T)
**SCS: Agree. AKA: nasal glial heterotopia. Paramedian. Extra nasal 60% (intra- 30, mixed 10).
Dysplastic glial cells that have lost their intracranial connections.
15% may be connected by stalk of tissue to brain. No fluid filled tract or Subarach space contiguity.
• A = Dacrocystocele = Round-ovoid mass at medial canthus extending along NLD course to inferior meatus; T1 hypo, T2 hyper (T)
• B = Nasal dermal sinus = Ovoid mass ± tubular sinus tract; Epidermoid or dermoid seen from nose tip to apex of crista galli; fat intensity (T1 hyper, T2 intermediate) (F)
• C = Encephalocele = Direct extension of meninges, subarachnoid space ± brain projecting into cephalocele via defect in cribriform plate or frontal bone; isointense to brain with surrounding CSF (F)
• D = Nasal glioma = (“Sequestered cephalocele”) = Well-circumscribed, solid soft tissue mass off midline at nasal dorsum or within nasal cavity in infant with no CSF connection to brain; T1 mixed-low signal; T2 iso-hyper (?T)
• E = Narrow posterior nasal cavity (F)
cc agenesis. false
a. the genus is always present
b. normal cingulate gyrus
• A = false = not present if complete CC agenesis; should be present in partial agenesis
• B = false = abnormal cingulate gyrusPosterior genu and anterior body form first, followed by posterior body, splenium, and finally rostrum.If splenium present & remainder of CC absent → holoprosencephaly (lobar)
3yo. CT calcification in the globe.
a. coats
b. PHPV
c. retinoblastoma
d. neuroblastoma metastases
c. retinoblastoma
• A = Coats = F retinal vascular anomaly = high-density vitreous, but calcification rare
• B = persistent hyperplastic vitreous = F hyperdense small globe; S-shaped Clouqet’s canal; does not calcify
• C = retinoblastoma = T 98% occur in children < 3 yrs (StatDx says 90-95% Dx by 5 years); punctate/speckled calcifications in posterior globe
• D = neuroblastoma = less T typically in children < 2 yrs; ocular involvement in 20% at presentation; calcifications occur
Intuscception
a. SBO contraindication for air reduction
b. duration > 12 hrs is a contraindication
c. viral gastroenteritis is recognised association
d. idiopathic in 50%
• C = T = may be preceded by viral illnessIntussusception
• A = F (assoc/ w/ ↓ success rate, but not contraindication)
• B = F (poor success rate if > 24 hrs symptoms)
• C = T = may be preceded by viral illness
• D = F = 90% idiopathicAir reduction enema
• Contraindications o Peritonitis (clinical exam)o Free intraperitoneal air (XR)• Features assoc/ w/ ↓ success rate but not contraindications:o SBOo Symptoms > 24 hours o Poor clinical condition (lethargy)
- A young girl presents with abdominal pain. Which of the following regarding omental infarction is false?
a. The pathology is usually found on the right.
b. Complications usually include abscess formation and adhesions.
c. The lesion is usually located near the transverse and ascending colon.
d. Omental infarction is a benign and self-limiting disease and usually resolves with conservative measures.
e. US features include a hyperechoic ovoid lesion
b. Complications usually include abscess formation and adhesions. F = complications can include abscess, adhesions, obstruction (but not usual)
- A young girl presents with abdominal pain. Which of the following regarding omental infarction is false?
a. The pathology is usually found on the right. T = 90% found on right
b. Complications usually include abscess formation and adhesions. F = complications can include abscess, adhesions, obstruction (but not usual)
c. The lesion is usually located near the transverse and ascending colon. T = located between anterior abdominal wall and colon
d. Omental infarction is a benign and self-limiting disease and usually resolves with conservative measures. T
e. US features include a hyperechoic ovoid lesion T Hyperechoic, nonmobile, noncompressible fixed mass
meconium aspiration. false
a. hypoinflation
b. coarse markings
c. mixed hyperinflation and atelectasis
d. cord like opacities
a. hypoinflation
Meconium aspiration
• A = F
Features of meconium aspiration
o Hyperinflation (↑ lung volumes) – may be asymmetric & patchy
o Consolidation – asymmetric & patchy (usually no air bronchograms)
o Rope-like perihilar densities
o Subsegmental atelectasis, alternating with areas of hyperinflation/air-trapping
o Pleural effusions may be present
CF in child. Typical CXR. which is false.
a. upper lobe bronchiectasis.
b. bands of atelectasis.
c. hpoinflation.
d. confluent consolidation
Cystic fibrosis
• A = T
• B = T (usually lobar though according to StatDx; Dahnert says subsegmental/segmental/lobar)
• C = F Hyperinflation earliest finding, may be reversible early & then permanent
• D = T = recurrent pneumonias, often difficult to detectNote⇨ Most F is C; most T is A
11 months old. enlarging lump on neck. US showed mass. high flow.
a. infantile haemangioma.
b. congenital haemangioma.
c. AVM
d. lymphatic malformation e. venous malformation
A = infantile haemangioma = ?T JMIRO 2012 – “characterised by a cycle of growth, plateau & involution. The duration of this cycle is variable, yet complete in the majority by 10 years”; high-flow mass; US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).
A = infantile haemangioma = ?T JMIRO 2012 – “characterised by a cycle of growth, plateau & involution. The duration of this cycle is variable, yet complete in the majority by 10 years”; high-flow mass; US Clin 2009: the presence of a distinct mass at sonography, the high vessel density, and the low RI with Doppler are the most important diagnostic criteria of infantile hemangioma. Mean peak arterial flow velocity 28 cm/s. Most common tumour of head & neck in infancy (RadClin 2011).
B = congenital haemangioma = ?F either involute in infancy (‘rapidly involuting congenital haemangioma’) or grow proportional with child (‘non-involuting haemangioma’); MR appearance similar to infantile haemangioma, although may have ill-defined margins.
C = AVM = F do not normally demonstrate a soft tissue mass (JMIRO Feb 2012); enlarge with size of child (present at birth, but usually manifest in childhood or later); high-flow vessels; but usually no definable mass; US Clin 2009: characterized by multiple feeding arteries with increased diastolic flow and high-velocity venous return. Typically high-flow, low resistance.
D = lymphatic malformation = F = low-flow malformation; cystic spaces at US; grow with child
E = venous malformation = F low-flow, do enhance post Gd
- Skeletal surveys for suspected child abuse in infants include a series of radiographs. MOST CORRECT?
a. AP views of axial skeleton and AP views of each extremity
b. AP views of axial skeleton and AP and lateral view of each extremity
c. AP and lateral view of axial skeleton and lateral views of each extremity
d. AP and lateral view of the axial skeleton and AP views of each extremity
e. AP and lateral view of axial skeleton and AP and lateral view of each extremity.
d. AP and lateral view of the axial skeleton and AP views of each extremity ?T controversial & location-specific, this is probably the best answer based on Australian practices (WA Imaging Guidelines, Melbourne RDx review)Imaging approach – suspected NAI
**LJS - this is closes to what we do in Chch
+/- orthogonal views of any suspected fracture
• When clinical or imaging findings are suspicious for potential abuse a radiographic skeletal survey is undertaken: (R-ITI + WA Imaging Pathways + Chapman Imaging04)• Skull: AP & lateral skull• Chest: AP +/- oblique rib views – R-ITI says frontal + obliques• Abdomen: AP with AP pelvis & hips• Spine: Lateral +/- AP entire spine (C/T/L) – R-ITI says lateral only• Long bones: AP +/- lateral of both upper & lower limbs – R-ITI says AP only• Hands & feet: DP • Additional: lateral view of any fracture; coned metaphyseal views• Purpose of skeletal survey is to document the presence of findings of abuse for legal reasons so that the child can be removed from exposure to the abuser• Further imaging:o Repeat skeletal survey in 2 weeks (to look for healing injuries not seen on the initial skeletal survey)o NM bone scan (> 2 years of age)o CT/MRI braino Abdominal CT • Ophthalmologic examination is also neededACR–SPR PRACTICE GUIDELINE FOR SKELETAL SURVEYS IN CHILDRENCOMPLETE SKELETAL SURVEY TABLEAPPENDICULAR SKELETON Humeri (AP) Forearms (AP) Hands (PA) Femurs (AP) Lower legs (AP) Feet (AP) AXIAL SKELETONThorax (AP, lateral, right and left obliques), to include ribs, thoracic and upper lumbar spine Pelvis (AP), to include the mid lumbar spine Lumbosacral spine (lateral) Cervical spine (lateral) Skull (frontal and lateral)
*ESG - Royal Children’s Hospital protocol:
AP Chest (for ribs)
AP Abdomen including Pelvis
AP Femurs
AP Tibias and Fibulae
AP Feet
AP Skull
AP Humerii
AP Forearms
PA Hands
Lateral Spine – all regions – cervical, thoracic and lumbarsacral
Lateral Sternum
Lateral Skull
- Which of the following statements regarding cortical desmoids is MOST correct?
a. Occur only on the posterior medial epicondyle of the femur
b. Occur only on the posterior lateral epicondyle of the femur
c. Occur on the posterior cortex of the
d. They do not exhibit periosteal new bone
e. Biopsy is the only certain method of diagnosis
c. Occur on the posterior cortex of the ?? if posteromedial aspect of distal femoral metaphysis then would be T
• Which of the following statements regarding cortical desmoids is MOST correct?
a. Occur only on the posterior medial epicondyle of the femur F does NOT occur only at the distal femur, can occur at other sites
b. Occur only on the posterior lateral epicondyle of the femur F
c. Occur on the posterior cortex of the ?? if posteromedial aspect of distal femoral metaphysis then would be T
d. They do not exhibit periosteal new bone F
e. Biopsy is the only certain method of diagnosis F do not touch lesion.
Distal femoral metaphyseal irregularity (“cortical desmoid”)
• MSK Req p243
• Occurs in 11% of boys aged 10-15 years
• Related to chronic avulsion at the insertion of the adductor magnus muscle or origin of the medial head of gastrocnemius muscle
• May or may not be painfu
• XR:
o Cortical irregularity along the posteromedial cortex of the distal femoral metaphysis
o Best seen on the lateral view
o May be associated lucency on AP view
o Lamellated periosteal reaction may be present
o Can be confused with aggressive tumours – if unsure, perform views of the contralateral knee, because the process is often bilateral (in 25-100%)• CT/MRI:
o Characteristic scoop-like defect with an irregular but intact cortex
o No associated soft tissue mass
o Contralateral lesion
• NM:
o Can have ↑ uptake on bone scan
• A skeletal “don’t touch” lesion (i.e. biopsy not indicated)
- Pediatric foot, which of the following statements is incorrect?
a. ‘Talipes’ refers to congenital foot deformity
b. ‘Pes’ refers to acquired foot deformity
c. Valgus refers to distal foot angulation medially
d. ‘Equinus’ refers to plantar flexion of the calcaneus
e. ‘Clubfoot’ refers to Talipes equinovarus
c. Valgus refers to distal foot angulation medially F = valgus means lateral angulation
• Pediatric foot, which of the following statements is incorrect?
a. ‘Talipes’ refers to congenital foot deformity T
b. ‘Pes’ refers to acquired foot deformity ??T (pes = foot)
c. Valgus refers to distal foot angulation medially F = valgus means lateral angulation
d. ‘Equinus’ refers to plantar flexion of the calcaneus T
e. ‘Clubfoot’ refers to Talipes equinovarus T
- CCAM, which is the most correct?
a. 5% of all congenital lung disease
b. The lung mass has a well-defined internal bronchial tree
c. The mass often has a number of large air-filled cysts
d. It most commonly appears as a homogeneous lung mass
e. CCAM receives its blood supply from the systemic circulation
c. The mass often has a number of large air-filled cysts T type I lesions have cysts > 2cm
• CCAM, which is the most correct?
a. 5% of all congenital lung disease F 25% of all congenital lung disorders, or 95% of cystic lung disease
b. The lung mass has a well defined internal bronchial tree F classically communicate with bronchial tree, however lung tissue is dysplastic
c. The mass often has a number of large air-filled cysts T type I lesions have cysts > 2cm
d. It most commonly appears as a homogeneous lung mass F variable – 10% are microcystic & can appear solid
e. CCAM receives its blood supply from the systemic circulation F normal pulmonary vascular supply & drainage1 - > 2cm . 70%2 - < 2 cm. 15-20%3 - < 5mm. 10%4 - unlined cyst0 - lethal. global arrest of lung development
- Hypoxic ischaemic injury in the premature neonate characteristically involves?
a. Peri-rolandic regions
b. Hippocampi
c. Cerebral cortex
d. External watershed regions
e. Periventricular watershed regions
e. Periventricular watershed regions affected in preterm (24-36 week) neonate
HIE pattern:
Preterm
- mild/mod: periventricular
- severe : thalamus, brainstem, cerebellum
Term
- mild/mod: watershed zones
- severe : thalamus, brainstem, putamen(posterior), sensorimotor cortex, corticospinal tract,
SCS: before 28 weeks hydrancephaly and porencephaly.
- 10yo male, previously well. 7d Hx of fever and dry cough. CXR patchy airspace opacity at both lung bases with assoc linear atelectasis. No other abnormality. Which of the following is MOST LIKELY Dx?
a. Pneumococcal pneumonia
b. Pneumocystis pneumonia
c. Mycoplasma pneumonia
d. Staphylococcal pneumonia
c. Mycoplasma pneumonia T
Mycoplasma pneumonia
• Causes 30% of pneumonias in school-aged children
• Radiographic findings: variable & can resemble viral LRTI
o Reticulonodular opacification, esp. if confined to a lobeo Hazy or ground-glass consolidation (uncommon to have dense consolidation)o Atelectasis
• Extra-respiratory manifestations: myocarditis, ADEM & cerebral arteriovenous occlusion
- Which of the following is LEAST LIKELY to be associated with increased incidence of urinary tract anomaly?
a. Turners syndrome
b. Single umbilical artery
c. Hemihypertrophy
d. Inperforate anus
e. Medulloblastoma
e. Medulloblastoma
• Which of the following is LEAST LIKELY to be associated with increased incidence of urinary tract anomaly? (Pocket Radiologist Obstetrics, Dahnert)
a. Turners syndrome (renal ectopia and horseshoe kidney)
b. Single umbilical artery – 21% of single UA a/w congenital anomalies, of which GU is a common occurrence (hydronephrosis, dysplastic kidney)
c. Hemihypertrophy – Wilms, MSK and others
d. Inperforate anus (VACTERL)
e. Medulloblastoma
- Congenital cardiac conditions, which is LEAST correct?
a. Ebstein’s anomaly and gross cardiomegaly
b. Earliest CXR finding in neonate with failure is pleural fluid
c. Normal CTR is less than or equal to 0.6 under 3yo
d. VSD and left-to-right shunt is greatest in 1st week of life
e. Majority with TAPVR are not cyanosed
*LW:
Both D and E are in correct… Hopefully incomplete recall.
e. Majority with TAPVR are not cyanosed F A form of cyanotic CHD; some patients with unobstructed TAPVR may not appear to be cyanotic. “The majority of patients with TAPVR have symptoms of cyanosis and congestion within the first year of life.” (Circulation: Cardiovascular Imaging; 2010;3:228-230)
.
• Congenital cardiac conditions, which is LEAST correct?
a. Ebstein’s anomaly and gross cardiomegaly T (box-shaped heart)
b. Earliest CXR finding in neonate with failure is pleural fluid ?F enlarged pulmonary veins
c. Normal CTR is less than or equal to 0.6 under 3yo ? T (should be < 0.55)
d. VSD and left-to-right shunt is greatest in 1st week of life F – worse after 1st 2 weeks of life as pulmonary vascular resistance decreases and left-to-right shunting increases
e. Majority with TAPVR are not cyanosed F A form of cyanotic CHD; some patients with unobstructed TAPVR may not appear to be cyanotic. “The majority of patients with TAPVR have symptoms of cyanosis and congestion within the first year of life.” (Circulation: Cardiovascular Imaging; 2010;3:228-230).
which is not a radiological feature of CF in children.
a. CXR abnormality at birth
b. hyperinflation of lungs
c. upper lobe predominant bronchiectasis.
d. hilar lymphadenopathy.
e. apical cystic airspaces.
⇨ A – F – lungs normal at birth
CXR features of CF:
• Hyperinflation (early sign)
• Atelectasis (early sign): lobar, esp. RUL > segmental & subsegmental
• Multiple, small, ill-defined opacities in lung periphery (small airways mucoid impaction)
• Increased peribronchial markings
• Bronchiectasis – more severe in upper lobes, esp. right side
- Regarding myelination in children, which is of the following is the most correct?
a. Myelination causes reduced / low signal on T1
b. The anterior internal capsule is myelinated at birth.
c. White matter and grey matter appear the same on T2 at 24-30 months
d. Optic nerves myelinated by two months.
e. From the splenium of the corpus callosum forwards
e. From the splenium of the corpus callosum forwards - T - dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’]
- Regarding myelination in children, which is of the following is the most correct? (GC) Dahnert 6e p251 good summary
a. Myelination causes reduced / low signal on T1 - F - bright on T1 (fatty myelin).
b. The anterior internal capsule is myelinated at birth - F - at birth, there is myelination of dorsal WM tracts of brainstem, cerebellar peduncles, dorsomedial tracts of diaencephalon, posterior limb of IC, and WM in the post-central gyrus. The anterior limb and genu of CC myelinate 4 mths later that the posterior limb & splenium. [Clinical MRI 2006]
c. White matter and grey matter appear the same on T2 at 24-30 months - F - adult pattern attained by 18 mths.
d. Optic nerves myelinated by two months - T - assume this means 2 months after birth… The optic nerves and tracts are myelinated by one month, optic radiations at 3 months. [Osborn]
e. From the splenium of the corpus callosum forwards - T - dorsal to ventral, caudad to cephalad, central to peripheral. Splenium bright on T1 at 4 mths, genu at 6 mths; then low on T2 by 6 mths and 8 mths respectively. [Kieran’s ‘rules’] Changed option 2 from “posterior limb” so only one true answer.
- Regarding meconium aspiration, which of the following is the most correct?
a. Symmetrical involvement
b. Increased lung volumes
c. Confluent opacification
d. Pneumothorax rare
e. Premature infants
b. Increased lung volumes - T - aspiration of tenacious meconium causes
- Regarding meconium aspiration, which of the following is the most correct? (GC/SK)
a. Symmetrical involvement - F - often asymmetric & patchy.
b. Increased lung volumes - T - aspiration of tenacious meconium causes obstruction of small airways - hyperinflation.
c. Confluent opacification - F - rope-like perihilar densities, patchy consolidation and atelectasis.
d. Pneumothorax rare - F - occurs in 20-40%.
e. Premature infants - F - more commonly full term or postmature infants. [Pocket paeds]
- Which is the most correct regarding a cortical desmoid?
a. Posteromedial epicondyle
b. Periosteal change in 5%
c. Painful
d. Increased uptake on bone scan in 70%
e. Biopsy required for diagnosis
a. Posteromedial epicondyle - T - posteromedial aspect of the medial femoral epicondyle along the medial ridge of the linea aspera at the attachment of the adductor magnus (Dahnert p61)
- Which is the most correct regarding a cortical desmoid? (JS)
a. Posteromedial epicondyle - T - posteromedial aspect of the medial femoral epicondyle along the medial ridge of the linea aspera at the attachment of the adductor magnus (Dahnert p61)
b. Periosteal change in 5% - F - typically has a lamellated periosteal reaction and can simulate an aggressive lesion radiologically, has a characteristic MRI appearance.
c. Painful – F? - no localising signs of symptoms, may or may not be painful (Helms)
d. Increased uptake on bone scan in 70% - can have increased uptake on bone scan
e. Biopsy required for diagnosis - F - don’t touch lesion - biopsy should be avoided in all cases
- 10yo patient presents with 7 day history of dry cough, febrile. Chest x ray shows bilateral patchy lower lobe airspace opacification with associated subsegmental atelectasis. Most likely diagnosis?
a. Mycoplasma pneumonia
b. Pneumococcus
c. TB
d. Staphylococcus aureus
a. Mycoplasma pneumonia - T - most common in 5-20yo.; dry cough, low fever, malaise; pulmonary infiltrates show significant lag time - focal reticular infiltrate (incl. atelectasis), alveolar infiltrates (patchy inhomogeneous unilateral airspace consolidation in segmental LL in 50%, bilateral in 10-40%); small pleural effusions & hilar LNs in some.
- 10yo patient presents with 7 day history of dry cough, febrile. Chest x ray shows bilateral patchy lower lobe airspace opacification with associated subsegmental atelectasis. Most likely diagnosis? (GC)
a. Mycoplasma pneumonia - T - most common in 5-20yo.; dry cough, low fever, malaise; pulmonary infiltrates show significant lag time - focal reticular infiltrate (incl. atelectasis), alveolar infiltrates (patchy inhomogeneous unilateral airspace consolidation in segmental LL in 50%, bilateral in 10-40%); small pleural effusions & hilar LNs in some.
b. Pneumococcus - F - causes lobar or round pneumonia in children. More common in elderly, debilitated, alcoholics, CHF, COPD etc; usually involves one lobe only (predilection for LL, posterior segment of UL) but may have a bronchopneumonia-like pattern.
c. TB - F - primary TB is most common form in infants and kids, 90% are asymptomatic; one or more areas of homogeneous dense well-defined airspace consolidation 1-7cm in middle/lower/anterior segment upper lobes. Reactivation of focus acquired in childhood (post primary TB) usually occurs in adolescence/adulthood; 85% occurs in apicoposterior UL, 10% in superior segment LL.
d. Staphylococcus aureus - F - in kids causes rapidly developing lobar/multilobar consolidation, pleural effusion/empyema (90%) and pneumatocoele (40-60%). [Dahnert]
- CCAM most likely
a. at least one microcyst
b. solid homogenous
c. 5% congenital lung disease
d. supplied by systemic vessel
e. intact bronchial tree
*LW:
The bronchial tree is dysplastic, so although may connect to the main bronchial tree, I would favour it not being “normally intact”.
Although type 1 CPAM most common with large cysts, these are commonly associated with occasional small cysts.
I would also favour this to be an incomplete recall, where option a) would likely be Macrocyst….
e. intact bronchial tree - T - intralobar mass of disorganised pulmonary tissue communicating with the bronchial tree. [Dahnert] SK – if referring to internal contents, would be false as contains dysplastic tissue.
- CCAM most likely: (GC/SK)
a. at least one microcyst - F - type I single/multiple large cyst(s) >20mm; type II multiple uniform cysts 5-12mm; type III microcystic (3-5mm cysts, appears solid).
b. solid homogenous - F - type III may appear as a homogeneously hyperechoic mass on antenatal US but only accounts for 10%. Type I (50%) +type II (40%) are macrocystic with air-fluid or fluid filled cysts on CT/CXR.
c. 5% congenital lung disease - F - 25% of congenital lung disorders; 95% of congenital cystic lung lesions.
d. supplied by systemic vessel - F - normal vascular supply/drainage (cf. sequestration).
e. intact bronchial tree - T - intralobar mass of disorganised pulmonary tissue communicating with the bronchial tree. [Dahnert] SK – if referring to internal contents, would be false as contains dysplastic tissue.
- Spondyloepiphyseal dysplasia. NOT a feature
a. atlanto-occipital
b. kyphosis
c. normal hands and feet
d. coxa vara
e. normal femoral heads
e. normal femoral heads - F - delayed ossification of capital femoral epiphyses predisposes hip to deformation with flattening, lateral extrusion, hinge abduction, and premature osteoarthrits.
- Spondyloepiphyseal dysplasia. NOT a feature (TW)
a. atlanto-occipital - ?F - have C1-C2 neck instability - wonder if they meant “atlanto-axial”. Ovoid vertebral bodies and severe platyspondyly. Hypoplasia of odontoid process.
b. kyphosis - T - progressive kyphoscoliosis (short trunk) involving thoracic and lumbar spine
c. normal hands and feet - ?F - less incorrect cf e. Hands and feet are relatively normal in length, but have multiple accessory epiphyses.
d. coxa vara - T - severe coxa vara and genu valgum
e. normal femoral heads - F - delayed ossification of capital femoral epiphyses predisposes hip to deformation with flattening, lateral extrusion, hinge abduction, and premature osteoarthrits. AKA spondyloepiphyseal dysplasia: as name indicates: problems with spine, ends of bones, and is present from birth.
- Rickets NOT seen
a. flared metaphyses
b. scoliosis
c. teeth abnormality
d. genu valgus
d. genu valgus – T? - bowed legs - genu varum. SK: usually genu varus (bow legs) but can be genu valgus (esp. in hypophosphataemic rickets – Wheeless, orthonet, emedicine)
- Rickets NOT seen (TW)
a. flared metaphyses – T (?) - axial widening of growth plate (increase in distance between end of shaft and epiphyseal center due to increased osteoid production). Cupping, splaying and fraying of metaphysis with threadlike shadows into epiphyseal cartilage.
b. scoliosis - T – listed in emedicine
c. teeth abnormality - T - delayed dentition
d. genu valgus – T? - bowed legs - genu varum. SK: usually genu varus (bow legs) but can be genu valgus (esp. in hypophosphataemic rickets – Wheeless, orthonet, emedicine)
- Hypoxic injury in premature neonate
a. periventricular watershed
b. external watershed
c. peri rolandic infarction
a. periventricular watershed T - vascular watershed (“border zone”) shifts from periventricular in premature to parasagittal in term infant at about 36wks. Also remember that before 26wks there is no gliosis, vs after 26 wks where develop PVL (vs porencephaly).
- Sequestration
a. RUL
b. RLL
c. LUL
d. RML
e. LLL
e. LLL - T - intralobar sequestration LLL > RLL 60%:40%. Extralobar sequestration almost always LLL. ILS usually presents later than ELS. Patients with ILS usually present in late childhood or adolescence with recurrent pulmonary infections. ELS more apt to present in early life from resp distress / cyanosis / or assoc abnormalities. Both can be an incidental antenatal Dx too. 65% of ELS assoc with other anomalies. ILS not associated with other anomalies.
TTN. which is false.
a. pneumomediastinum.
b. perihilar opacity
c. pleural effusion.
a. pneumomediastinum
HMD (RDS). which is wrong:
a. pleural effusion.
b. loss of lung volume
c. pneumomediastinum.
d. air bronchogram
a. pleural effusion is very uncommon. If present suggest TTN or pneumonia
13 yo male with hip and knee pain. what to do ?
a. x-ray AP and lat hip and knee
b. ap and frog leg of hip.
B = SUFE common in this age group, causes hip/groin/knee pain.
NEC. which needs urgent attention?
a. gas in PV
b. pneumoperitoneum
pneumoperitoneum in NEC is the only radiologic absolute indication for surgery
which needs urgent attention?
a. UVC at region of porta
b. UVC - portal vein with gas
c. UAC at T10
d. UAC dips down below the umbilicus
A = should be repositioned, not really urgent
B = F: AJR April 2003: Air might be introduced inadvertently into the intrahepatic portal venous system at the time of umbilical venous catheter insertion. The air is usually transient and should not be misinterpreted as evidence of necrotizing enterocolitis.
C = should be slightly higher
D = all UACs do this initially, but if it goes down the iliac artery risk of limb ischaemia
UAC – do not position b/w T10-L3 – risk of thrombosis of aorta & branches – ideal is T8-T10 (high line) or below L3 (low line)
UVC – should be at RA/IVC junction at level of hemidiaphragm; PV location risks hepatic haematoma or abscess
One of the most dreaded complications of the UAC placement is thrombosis leading to an ischemic limb.
One of the most dreaded complications of UVCs is perforation of the right atrial or left atrial wall. Rarely the UVC may perforate the portal vein and cause a hematoma within the liver.
CCAM
a. US obstetrics - echogenic thoracic mass.
b. CT. mediastinum shifted towards abnormality
a. US obstetrics - echogenic thoracic mass.
CDH is a/w with (which is false)
a. malrotation
b. persistent fetal circulation associated with bad prognosis
c. renal hypoplasia
d. hernia of the gut associated with bad prognosis
*LW:
Associated anomalies are relatively common and include:
- pulmonary hypoplasia: also a complication
- bronchopulmonary sequestration
- aneuploidy: can be present in up to 50% of cases
trisomy 13
trisomy 18
trisomy 21
- Turner syndrome: monosomy X
- Pallister-Killian syndrome: tetrasomy 12p
- Fryns syndrome
- Cornelia de Lange syndrome
- congenital cardiac anomalies
- neural tube defects
- anencephaly
- spina bifida
- genito-urinary malformations
- Gastro intestinal malformations, including malrotation.
Signs suggesting a poor prognosis include:
large hernia size
early gestational age at diagnosis
intra-thoracic liver
small contralateral lung
the presence of associated abnormalities
bilateral CDH
unfavourable lung: head ratio
a. malrotation: true
b. persistent fetal circulation associated with bad prognosis: true.
c. renal hypoplasia: likely included within genito-urinary malformations,
d. hernia of the gut associated with bad prognosis: likely incorrect answer if referring to bowel vs liver / stomach, however prognosis also affected by size, thus a large hernia containing bowel causing pulmonary hypoplasia will have bad prognosis.
**LJS - agree, liver herniation ass/w bad prognosis
Previous answers:
D = F (herniation of liver or stomach has poorer prognosis)
A = T (30-62%)
B = T
C = T (‘renal anomalies’)
D = F (herniation of liver or stomach has poorer prognosis)
Describe chiari 2
Chiari 2 =
o Small posterior fossa, with caudal displacement of a dysplastic cerebellum & brainstem into an enlarged foramen magnum & upper cervical canal
o Cerebellar tonsils, cerebellar vermis, 4th ventricle & brainstem are herniated thru the foramen magnum
o Superior cerebellum towers superiorly thru a widened tentorial incisura, while the rest of the cerebellum may wrap-around the brainstem
o The 4th ventricle is small, and its outlets are obstructed, resulting in hydrocephalus. The frontal horns of the lateral ventricles are squared off & the aqueduct is stretched inferiorly
o The medulla is elongated & a kink may be present in the cervicomedullary junction
o Torcular low
o Massa intermedia is abnormally enlarged
which is the least use in ? FB aspiration
a. inspiratory and expiratory PA erect CXR
b. PA and lateral CXR
c. lateral debitus
d. fluoro
e. bronchoscopy
B = lateral usually not needed
A = best radiologic test
B = lateral usually not needed
C = lateral decubitus both sides + erect PA if uncooperative child (although a study questions the utility of lat decub films - Pediatr Emerg Care. 2007;23(3):154) → on its own, it may be the least useful
D = fluoroscopy useful for uncooperative child
E = gold standard
14 yo fat boy with 3rd normal knee x-ray in 2 month to investigate pain. What next?
a. MRI knee
b. x-ray hip and thigh
c. bone scan
d. us knee
e. repeat knee xray
b. xray hip and thighlook for sufe
NEC least likely in
a. maternal diabetes
b. T21
c. breech.
d. hirshprungs
e. persistent fetal circulation?
C - breech -> no convincing evidence
Risk factor
- diabetes
- T21
- hirshprung
- umbilical catherisation
- probably persistent fetal circulation ( cardiorespiratory difficulties)
NEC most common in
• Premature (the more premature the higher the risk)
• Occcurs at 1-3 weeks (although Paed Req says 3-5 days & Dahnert says 2-3 days)
• Enteral feeding increases risk
**LJS - variable reports in papers regarding maternal DM as a risk factor for NEC.
Nothing convincing for breech - this is least correct
NEC. which is least likely.
a. born at 36 weeks. day 2 with no oral feeds.
b. born at 32 weeks. day 16
c. 38 weeks
probably C - 38 weeks
NEC most common in
• Premature (the more premature the higher the risk)
• Occcurs at 1-3 weeks (although Paed Req says 3-5 days & Dahnert says 2-3 days)
• Enteral feeding increases risk
