22a radiology i

8/14/2019 22a Radiology I

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Pediatric Emergency Radiology I


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ObjectivesIdentify the following conditions based on x-ray findings:

Intussusception Bowel obstruction

Congenital hipdislocation

Slipped capital femoralepiphysis

Pneumonia

Thymus shadow

Appendicitis fecaliths

Bronchial foreign body

Croup

Epiglottitis Retropharyngeal abscess

C-spinepseudosubluxation

Hangman fracture Jefferson fracture

Elbow fractures

Monteggia injury

Salter-Harris fractures Child abuse


3/42

X-ray diagnosis?

14-month-old girl

with vomiting.

Target sign in

RUQ.Identify the target sign

in the RUQ again.

Target sign in

RUQ.

CrescentCrescent

sign in LUQ.sign in LUQ.

The crescent sign is

formed by the

intussusceptum (leadpoint) protruding into

a gas-filled pocket.

Identify crescent sign

in LUQ again.

CrescentCrescent

sign in LUQ.sign in LUQ.

Target signTarget sign

in RUQ.in RUQ.

CrescentCrescent

sign in LUQ.sign in LUQ.IntussusceptionIntussusception


4/42

X-ray diagnosis?

13-month-old boy

with vomiting.

Crescent sign:

Note the

intussusceptum

lead point

ascending into the

hepatic flexure.

The crescent sign may not be crescent shaped.The crescent sign may not be crescent shaped.The gas-filled pocket may be large, as in this case.The gas-filled pocket may be large, as in this case.

Crescent sign:

Note the

intussusceptum

lead point

ascending into the

hepatic flexure.

Intussusception


5/42

X-ray diagnosis? 11-month-old boy with vomiting.

Bowel obstruction with right-sided masseffect: Intussusception

Right image:Right image:

Absence of gas inAbsence of gas in

RUQ and RLQRUQ and RLQ

(suggests a mass(suggests a masseffect on right).effect on right).

Poor distributionPoor distribution

of gas in generalof gas in general

(suggests bowel(suggests bowelobstruction).obstruction).

Left image:Left image:Absence of hepaticAbsence of hepatic

angle (suggests RUQangle (suggests RUQ

mass). Absence ofmass). Absence of

gas in RLQ (suggestsgas in RLQ (suggestsRLQ mass). TwoRLQ mass). Two

dilated (smooth)dilated (smooth)

bowel segmentsbowel segments

(suggests bowel(suggests bowel

obstruction).obstruction).


6/42

X-ray diagnosis?

11-month-old girl

with vomiting.

Identify the target

and crescent signs

again.

RUQ target sign.

LUQ crescent sign.

Absence of thesubhepatic angle.

RUQ target sign.

LUQ crescent sign.

Absence of thesubhepatic angle.

RUQ target sign.

LUQ crescent sign.

Absence of the

subhepatic angle.

Intussusception


7/42

X-ray diagnosis? 7-month-old girl with skull fracture,

lethargy, and vomiting.

Possible

target sign

in RUQ.Paucity of

bowel gas

suggestiveof right-

sided mass

and bowel

obstruction.

Intussusception


8/42

X-ray diagnosis? 7-month-old girl with vomiting.

Target signTarget sign

Absence ofAbsence of

hepatic angle.hepatic angle.

Paucity of gas.Paucity of gas.

IntussusceptionIntussusceptionTarget signTarget sign

Absence of hepaticAbsence of hepatic

angleanglePaucity of gasPaucity of gas


9/42

X-ray diagnosis? 7-month-old boy with vomiting.

Suspected

IntussusceptionRUQ air fluidRUQ air fluidlevels. RUQlevels. RUQbowel loopsbowel loopsare smoothare smooth

(bowel(bowelobstruction).obstruction).

Paucity ofPaucity ofgas in RLQ.gas in RLQ.


10/42

X-ray diagnosis? 17-day-old boy with vomiting.

Bowel obstruction criteria:

Gas distribution

Bowel distention

Air fluid levels

Gas distribution: GoodBowel walls are smooth, hose-like: DistendedAir fluid levels: On upright viewBowel ObstructionBowel Obstruction

Bowel obstruction ddx: AIM A: Adhesions, appendicitis I: Intussusception, incarcerated

inguinal hernia M: Malrotation (midgut volvulus),

Meckels


11/42

X-ray diagnosis? 1-month-old girl spitting up.


Gas distribution

Bowel distention

Air fluid levels

Air fluid levels: NoneGas distribution: GoodNormal abdominal radiographsBowel distention: Lots of gas, but no distention.

Haustra and plicaeare preserved. Lookslike bag of popcorn,instead of bag ofsausages. Bowel wallsare NOT smooth

(hose-like).Distention criterion ismore related tosmoothness of bowel

walls rather thanvolume of gas.


12/42

X-ray diagnosis? 9-day-old boy with vomiting.


Gas distribution

Bowel distention

Air fluid levels

Gas distribution: FairBowel distention: No smooth walls

Air fluid levels: Many, but they are allsmall with no J turns (hairpin loops,candy canes)

ILEUS, No Definite Bowel Obstruction


13/42

X-ray diagnosis? 5-month-oldgirl discharged yesterdayfollowing barium enema

reduction of

Paucity of gas on the right suggestive of a mass.

Residual barium present.

While preparing for an ultrasound, the child

drinks a bottle and her behavior normalizes.

Radiologist identifies an occult diagnosis.

Shentons arc.

A more

focusedview of

occult

diagnosticfinding

Congenital dislocated hip (CDH).

Shentons arc is discontinuous.Congenital Dislocated Hip


14/42

Right hip physis appears to be wide

compared to the left hip.

Thigh or knee pain could originate from a

hip problem. Hip evaluation is required.

X-ray diagnosis? 10-year-old obese

boy with right thigh and knee pain

Kleins line: Superior aspect of the

metaphysis to see if it intersects the

epiphysis

Abnormal: Linemisses epiphysis

Normal: Lineintersects

epiphysis

Slipped Capital Femoral Epiphysis

(SCFE) of the Right Hip


15/42

X-ray diagnosis?

Moderate slip

Severe slip

Bilateral SCFE


16/42

X-ray diagnosis? 6-year-old boy with nausea andabdominal pain.

Fecalith

(appendicolith)Identify it

again

Appendicitis


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Fecaliths

can varyinappeara

nce.

This oneis small

and

opaque.

This

fecalithis faintand

oval inshape

Thisfecalith can

be seenfaintly in

the

radiographof the

appendix

specimen. It

There

aretwo ormore

potential

fecaliths

here

This

fecalith isroundwith a

denseopaque dot

in it.

This

fecalith isfairlylarge

This

is thelastfecalith on

thisslide

Find thefecalith

(appendicolith)


18/42

X-ray diagnosis? 6-year-old boy with abdominal pain

Pneumonia


19/42

X-ray diagnosis? 15-month-old boy

with fever, coughing, tachypnea.

RML

infiltrate

LLL

infiltrate

LLL & RML

Pneumonia


20/42

X-ray

diagnosis?

2 month old

with a VSDpresents with

recurrent

seizures.

VSD, Thymic, &

Parathyroid Aplasia:

DiGeorge Syndrome

Cardiomegaly(CHF)

No

thymic

shadow

Hypocalcemia

found on labs

X-ray

diagnosis?

2 month old

with a VSDpresents with

recurrent

seizures.

Normal thymus shadows

in young infants

Cardiomegaly

(CHF)

No

thymic

shadow

Normal

newborn

thymus

occupies the

space anterior

to the heart


21/42

X-ray

diagnosis?

Ventilated

infant withsudden

deterioration

Air in

pericardium

reveals shape of

infant thymus.

PneumopericardiumRevealing the Thymus

Sail Sign


22/42

X-ray diagnosis? 6-month-old boy with cough andcongestion. No fever. O2 Sat 100% on room air.

Normalnewborn

thymus

occupiesspace

anterior toheart

Prominentasymmetric thymus

InfiltrateInfiltrate

Prominent Thymus Partially

Obscuring a RUL Infiltrate:

Pneumonia


23/42

X-ray diagnosis? 18-month-old girl with mild BPD(former premie). Presents with fever, cough, dyspnea.

RML atelectasis

RML

Atelectasis


24/42

X-ray diagnosis? 9-year-old boy withfever, headache, nausea, and coughing.

Round infiltrate.

Spherical consolidation.

Round

Pneumonia:

Cannonball

Pneumonia


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No definite abnormalities

More views:

Expiratory view

Lateral

neck

Inspiratory view Expiratory view

Insp and Exp views look very similar = air trapping

Right side down Left side down

Heart should move downward. But in both views,

it stays in place, due to bilateral air trapping.

X-ray diagnosis? 17-month-old coughing after

choking on a chocolate/almond bar

Bilateral Air Trapping

Bilateral Bronchial Foreign BodiesNuts + Choking = Bronchoscopy


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X-ray diagnosis?18-month-old girlwith fever, noisybreathing, and

barking cough.

Identify the:

Epiglottis

Vallecula

Vocal cords

Trachea

Prevertebral soft

tissue

Epiglottis (E)

Vallecula (V)

Vocal cords (C)

Trachea (T)Prevertebral soft

tissue (P)

E V

C

T

PEpiglottis - normal

Vallecula - normal

Trachea - slightly

narrow or normalPrevertebral soft

tissue (P) - wide

and bulging (should

be half the width ofvertebral body)

PRetropharyngeal

Abscess

(also calledprevertebral

abscess)Clinical symptoms

may mimic croup.


27/42

X-ray diagnosis?2-year-old boy withfever, stridor,tripoding and NO

cough.

Identify the:

Epiglottis

Vallecula

Vocal cords

Trachea

Prevertebral soft

tissue

Epiglottis (E) -

wide (thumb-like)

Vallecula - shallow

Trachea - normalPrevertebral soft

tissue - normal

EEEpiglottis (E)

Vallecula (V)

Vocal cords (C)

Trachea (T)Prevertebral soft

tissue (P)

V

C

T

P

Epiglottitis


28/42

X-ray diagnosis?15-month-old boy withfever, mild stridor, andbarking cough.

Identify the:

Epiglottis

ValleculaVocal cords

Trachea

Prevertebral soft tissue

Epiglottis (E)

Vallecula (V)

Vocal cords (C)

Trachea (T)

Prevertebral soft tissue (P)

P

E V

C

T

Epiglottis - normal

Vallecula - normalTrachea (T) - narrow,

subglottic edema

Prevertebral soft tissue -

normal

T

Croup


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Probable C2-C3Pseudosubluxation

C2-C3 pseudosubluxation

characteristics:

Minimal / mild trauma Minimal / mild pain No signs of a fracture Neck is positioned inflexion (not lordotic), often

due to a spine board.

Swischuk line criterion.

X-ray diagnosis? 2-year-old

boy who fell off his tricycle

is brought in on a spine

board.

Swischuk line:

Line drawn between the

posterior arch of C1 and

the posterior arch of C3.

The posterior arch of C2

should be within 1 to 2 mm

of this line.

C2

C3

C1


31/42


girl unrestrained in a car

crash brought in on a spine

board.

Swischuk line: satisfactoryC2

C3

C1

Fracture of C2 pedicle:

Despite a satisfactory

Swischuk line.There is very slight

subluxation of C2 on C3

due to the fracture.Fracture of the C2 Pedicle

Hangman Fracture


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boy who fell onto his

forearm. Visible forearm

deformity.

Mid-ulna angulated fracture.

Anything else?

Radius should line up with capitellum (C).

Misalignment indicates radial head dislocation.

C

C

Abnormal

Normal

Monteggia Injury

Ulna fracture often

results in radial headdislocation. Check

radius-capitellum line

confirming alignment.

S d l i


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X-ray diagnosis?

Elbow injury.

Elbow evaluation:

High yield places to look:

Posterior fat padAnterior fat pad

Anterior humerus line

Radius-capitellum line

Supracondylar regionRadial head

Olecranon

Anterior fat pad (+)

Posterior fat pad (+)

Radius-capitellum line

(normal)

Olecranon

Anterior

humerus

line should

bisectcapitellum

(+)

Supracondylar region

Radial head

Elbow Joint Effusion

Probable occult

supracondylar fracture.


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Posterior fat padAnterior fat padBoth unable to

assess (truelateral viewrequired)

Anterior humerus line:

misses capitellum

(not a true lateral view)

Radius-capitellum line:normal

Radial head:

Fracture

Olecranon: OK

Supracondylar region:

OK

X-ray diagnosis?

Elbow injury

Radial Head

Fracture

Ol


36/42

X-ray diagnosis? Elbow injury

Supracondylar region:

cortex disrupted

Posteriorfat pad (+)

Anterior

fat pad (+)

Olecranon

fossa cortex

is fractured

Supracondylar Fracture

A t i


37/42

X-ray diagnosis? Elbow injury

Posteriorfat pad (+)

Anterior

fat pad (+)

Radius-capitellum

line is not pointing

at capitellum

Olecranonfracture

Joint Effusion, Olecranon Fracture,

Monteggia Injury (radial head dislocation)


38/42

X-ray diagnosis? 10-year-old boy, wrist injury

Tenderness

is elicited

over distal

radiusSalter-Harristype 1

fracture of

distal radius

physisshould be

suspected

clinically

disp

la

no

n-dis

pla

ced

ce

d

The epiphysis is displaced

Displaced Salter-Harris Type 1 Fracture of the

Distal Radius Physis

S


39/42

Hey you !!

What kind of

Salter-Harrisfracture type

is this??

Who ME?

M = metaphysis

E = epiphysis

W h o M E ?

SH type II

Metaphysisand physis

SH type III

Epiphysis

and physis

SH type IV

Metaphysis

andEpiphysis

SH type V:

Physis.

Not evident on

X-ray. Relies onclinical

findings and

history of

injury

mechanism.

Tender

Calcaneus fracture

Fell off 2nd floor onto

her feet.

X di i ?


40/42

X-ray diagnosis?

6-week-old boy

with sudden

left thigh swelling

and no history of

trauma.

Obvious oblique

femur fracturewith a thinner

fracture in the

distal half of the

femur.

Child abuse is suspected.

- A skeletal survey is

ordered.

- Left forearm and

right tibia/fibula are shown

here.

Elbow/Forearm Tib/Fib

Proximal radius fracture

with periosteal elevation

(hard to see).

Healing tibia fracture with

periosteal elevation.

Severe femur fracture

without explanation.Older forearm and tibia

fractures.

Child Abuse

X di i ?


41/42

X-ray diagnosis?

2 month old who is

crying without

apparent cause.

Obvious mid

femur fracture is

noted. Child

abuse issuspected.

- Another view shows theoblique fracture line.

- Further questioning abouttrauma is negative exceptfor bumping him against adoor while carrying him in apadded infant carrier. Theparents tell you that thiscouldnt have been hardenough to cause a fracture.

Osteogenesis imperfecta is

suspected.

Occult types tend to be autosomaldominant (family history will be

positive.)

Severe lethal types tend to be

recessive.

Family history:- Father: 4fractures, 2 ofwhich occurredwith minortrauma.- PGF: 4

fractures fromplayingaround- Mother:

Scoliosis- 2 aunts:

A skeletalsurvey isdone

and nootherfracturesare

found.Theupperextremitie

s areshownhere.

Severeosteogenesis

imperfecta.Lethalform in

infancy.Severeosteopenia.

Multiple rib fractures

Crumpledlong bonesat birth.

Mid femur fracture.

Osteogenesis imperfecta.

Family history of frequent

fractures may be a useful

question in fracture patients.


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22a radiology i

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