Aunt Minnies - Paeds

Question 1

Answer 1

Malrotation with midgut volvulus

Top images show partial duodenal obstruction, abnormal DJ flexure position and proximal small bowel.
1.1.3 shows corkscrew of the distal duodenum and proximal jejunum.
1.1.4 shows SMV swirling around the SMA

Bilious vomiting in newborn = Malrotation until proven otherwise.
Check abnormal position of DJ flexure and proximal small bowel on upper GI - gold standard for Dx
Whirlpool sign of twisted mesenteric vessels on CT or US indicates volvulus.
Ladd’s procedure used to reduce the volvulus and resect dead bowel, and lyse any dense Ladd’s bands.

Question 2

Answer 2

Duodenal Atresia

Double Bubble sign with no gas distal to duodenum is diagnostic of duodenal atresia.
30% have downs, 40% have maternal polyhydramnios.
If distal gas present, upper GI series is indicated to investigate for other causes of duodenal obstruction (stenosis, web, annular pancreas, duplication cyst or malrotation)

Question 3

Answer 3

Non-accidental Trauma

CTB - mixed density subdural collection suggesting blood of various ages.
CXR: acute spiral fracture of right humerus, subacute clavicle fractures and multiple healing L rib fractures.
Metaphyseal corner fractures of proximal medial tibia, and bucket handle fracture of distal femoral metaphysis - virtually diagnostic of NAT
follow up CXR - healing posterior rib fractures not seen on previous study.

Question 4

Answer 4

Posterior urethral valve

Voiding cystourethrogram - thick walled, trabeculated bladder during filling (1.4.1) with bullet nosed dilatation of posterior urethra (1.4.2).
1.4.3 shows bilateral pneumothoraces and pulmonary hypoplasia after birth.
US shows thick waled bladder with catheter (1.4.4), bilateral hydronephrosis with loss of cortocimedullary differentiation and cysts.

Bullet nosed posterior urethral dilatation and B/L hydronephrosis in male infant = posterior urethral valves

Question 5

Answer 5

Retroperitonal neuroblastoma with skull mets

IV contrast-enhanced CT images (Figs. 1.5.1 and 1.5.2) through the abdomen demonstrate a calcified right paraspinal mass;
a large calcified retroperitoneal mass that crosses the midline, encasing the aorta and SMA;
and left hydronephrosis.
A delayed image from an metaiodobenzylguanidine (MIBG) scan (Fig. 1.5.3) demonstrates increased uptake in the midabdomen corresponding to the retroperitoneal mass on CT.
Head CT with IV contrast (Fig. 1.5.4) reveals a soft tissue mass, with an epicenter in the right temporal bone, associated with bone destruction and a sunburst periosteal reaction.

A childhood suprarenal mass with calcification, crosses midline and encases mesenteric vasculature or invades neural foramina is almost certainly a neuroblastoma

Question 6

Answer 6

Oesophageal atresia with tracheo-oesophageal fistula and vertebral and cardiac abnormalities (VACTERL)

Babygram demionstrates NG tube terminatingg in gas filled oesophagus, with gas present in bowel.
Cardiac apex is in right chest (dextrocardia).
Vertebral anomalies in upper thoracic and sacral spine.

Always look for VACTERL (Vertebral anomalies, Anorectal malformations, Cardiac anomalies, TE fistula, Radial ray, Limb) in TOF

Question 7

Answer 7

Lap Belt injury complex

Transverse fracture through body (chance fracture) and posterior elements & distraction and separation of posterior elements of L2 without anterior compression.
Axial CT of L2 shows naked facet sign - lack of opposing facets at L2 and bilateral pedical fractures.
Bottom CTs show bowel wall thickening and extensive free fluid in the pelvis.

Lap belt complex - lap belt ecchymosis, distraction fracture of lumbar spine and bowel injury

Question 8

Answer 8

Pneumoperitoneum

Oval shaped lucency overlying the epigastrium with vertical soft tissue density running within (falciform ligament).
Football sign - indicative of massive pneumoperitoneum

Question 9

Answer 9

Retropharyngeal abscess

Lateral XR - thickening of retropharyngeal soft tissue with convex anterior border.
CT: low density rim enhancing lesion in left lateral retropharyngeal soft tissues.

Retropharyngeal soft tissue thickness should be no more than AP diameter of cervical vertebral bodies.
Retropharyngeal soft tissue thickening with gas - diagnostic of retropharyngeal abscess
Fluoro can differentiate it from pseudothickening.

Question 10

Answer 10

Necrotising enterocolitis

10.1 diffuse gaseous distension of bowel, linear and crescentic pneumatosis intestinalis (10.2), branching lucencies of portal venous gas (10.3).
US liver shows echogenic foci bubbling through the lvier (10.4) and sonography reveals free fluid between loops of bowel with echogenic walls (gas, 10.5)

NEC occurs in premature infants or term with congenital heart disease.
Pneumoperitoneum, ascites or both indicate perf and need for urgent surgery

Question 11

Answer 11

Congenital lobar emphysema (RUL)

CXRs day 1-4 of life show initial opacity of the RUL, which becomes interstitial/reticular, then hyperlucent.
Right to left mediastinal shift and progressive right middle and lower lobe collapse also demonstrated.

Progressive air trapping in middle or either upper lobe of newborn = CLE

Question 12

Answer 12

Scimitar syndrome

CXR - heart shifted to right, right hemidiaphragm raised, right heart border indistrinct. Linear density pointing inferomedially to medial right hemidipahragm.
CT shows large vessel draining R pulmonary veins below diaphragm to IVC.

Scimitar syndrome - anomalous right pulmonary venous drainage, right pulmonary hypoplasia, dextroposition of heart.
Infantile form has worse prognosis due to associated abnormalities

Question 13

Answer 13

Meconium ileus

AXR demonstrates numerous dilated loops of bowel.
Contrast enema reveals filling defects in ileum.

Meconium ileus is diagnostic of CF and produces the smallest of microcolons.
Water soluble enema is diagnostic and therapeutic in uncomplicated patients.
Can be complicated by volvulus, atresia, stenosis, perf, peritonitis or pseudocyst formation

Question 14

Answer 14

Meconium peritonitis

Collection of calcifications in RLQ with multiple gas filled, distended loops of bowel. No gas in rectum is consistent with distal obstruction.
Often caused in utero by underlying obstruction or malformation.

Scattered or focal punctate peritoneal calcifications or calcified pseudocyst in newborn = in utero bowel perf and meconium peritonitis.

Question 15

Answer 15

Rickets

Wrist and knees demonstrate metaphyseal cupping and fraying and splaying. Loss of provisional zone calcification is also demonstrated (widening of physes and loss of epiphyseal margins).
Cupping and fraying of costochondral junctions and proximal humeral metaphyses.

Lack of Vit D causes poor osteoid mineralisation and widening of physes

Question 16

Answer 16

SCFE (right)

AP: Widening of right proximal femoral physis, metaphyseal irregularity and regional osteopenia. Klein’s line intersects less of the femoral epiphysis on right vs left.
Frog leg: posterior and medial displacement of the eipihysis

Complications include avascular nectosis, chondrolysis, varus deformity with femoral neck shortening and early degenerative OA.
25% of cases are bilateral.
Surgical emergency. Epiphysis is pinned “as is” to prevent further spillage

Question 17

Answer 17

Foreign body in left main bronchus

Increased lucency of left hemithorax, which during expiration (2nd image) shows left to right mediastinal shift and air trapping

Decub views or fluoro can be done instead of expiratory in uncooperative children.
Bronchoscopy is recommended to further investigate in negative imaging if strong clinical suspicion.

Question 18

Answer 18

Congenital diaphragmatic hernia (Bochladek)

Left to right mediastinal shift with multiple tubular radiolucencies in the left hemithorax and gasless abdomen.

Delayed right sided hernias may be idiopathic or due to previous group B strep.
On prenatal US: stomach bubble adjacent to heart is suggestive of this.

Question 19

Answer 19

Omphalocele

Cardiac apex on right.
Soft tissue mass overlying mid abdomen, with indistinct superior border and sharply defined inferior and lateral margins, containing bowel gas.

Contains bowel and sometimes liver, covered by a sac.
Midline defect, with umbilical cord inserting into sac.
Associated abnormalities (Structural and chromosomal) are very common and mainly determine prognosis

Question 20

Answer 20

Gastroschisis

UVC overlying right atrium.
Paucity of bowel gas in non-distended loops overlying mid abdomen.
No free intraperitoneal air.
Well circumscribed, finger like masses overlying right lower quadrant and pelvis.

Defect in anterior abdominal wall to right of umbilicus, containing bowel with no sac.
Chromosomal abnormalities are cuncommon.
Prognosis determined largely by condition of herniated bowel.

Question 21

Answer 21

Hirschprung disease

Air filled and dilated sigmoid colon with relatively narrow rectum to dilated sigmoid on barium (abnormal rectosigmoid index).

Short segment disease (most common) demonstrates rectosigmoid transition zone. long segment or total colonic agangliosis have longer microcolons.
Enemas performed without bowel prep to prevent false negatives.

Question 22

Answer 22

SBO due to incarcerated right inguinal hernia

Distended small bowel loops with residual contrast in nondilated colon.
US: fluid filled structure herniating through abdominal wall defect and displacing testicle superiorly.

Question 23

Answer 23

Sickle cell disease

Cardiomegaly, H shaped vertebrae and absent splenic shadow.

Findings include small, calcified or absent spleen from progressive infarction, pulmonary opacities from infarction or infection, gallstones, cardiomegaly (high output) and infarction or AVN in bones (spine, humeral and femoral heads)

Question 24

Answer 24

Mediastinal teratoma

AP CXR: Large mediastinal mass, well defined lateral margins and inferolateral lobulations.
Pulmonary vessels and vertebrae are well outlined, but heart border is obscured (anterior mediastinum).
Amorphous calcifications seen projecting over left mid lung.
CT: large, well marginated heterogenous anterior mediastinal mass, mainly fat density with some soft tissue and calcification.

Presence of teeth in anterior mediastinal mass = teratoma
Fat-fluid levels in anterior mediastinal mass almost always = teratoma

Question 25

Answer 25

Ileal duplication cyst ## Footnote Cystic mass with echogenic mucosal lining and hypoechoic rim. Presence of cystic mass with bowel wall signature (inner echogenic mucosal lining and outer hypoechoic rim of smooth muscle) is specific for GI duplication cyst.

Question 26

Answer 26

Acute appendicitis ## Footnote RIF (maximal site of pain) US reveals non-compressible blind ending tubular structure >1cm in diameter, with highly echogenic central focus and acoustic shadowing (appendicolith). Gut signature as per duplication cysts.

Question 27

Answer 27

Achondroplasia ## Footnote AP pelvis: Decreasing lumbar interpedicular distances, short swuared ilia, narrowed sacrosciatic notches and horizontal acetabular roofs. AP lower limbs: short, thick long bones with metaphyseal enlargement. Lateral lumbar spine: Bullet vertebrae with decreased vertebral body height. MRI: Stenosis at foramen magnum causing altered cord signal.

Question 28

Answer 28

Thanatophoric dysplasia ## Footnote Enlargement of calvarium with hypoplasia of frontal bone and depression of nasal bridge. Diffuse spinal platyspondyly, rib hypoplasia and reduced AP thoracic dimension. All extremety bones are shortened, pelvis small with narrowed sacrosciatic notches, bowing of femurs in "telephone receiver pattern". Causes premature closure of the coronal sutures, causing clover like shaped skull. Most common fatal skeletal dysplasia, due to pulmonary hypoplasia.

Question 29

Answer 29

Osteogenesis Imperfecta ## Footnote Marked osteopenia of whole skeleton. Bones are thin, overtubulates (best seen in humerus and femur). Extensive fracturing of all bones, multiple bilateral posterior and anterolateral rib fractures. Bilateral tibias, fibulas, radii and ulnu are deformed, fractured and bowed. Macrosomia with frontal bossing and basilar invagination. Subtle bicomvexity of C spine. Death often due to respiratory failure related to thorax deformity. Milder cases can be mistaken for NAT. Dynamic compression of the skull vault in severe forms on prenatal US.

Question 30

Answer 30

Blount disease (Infantile tibia vara) ## Footnote Beaking, fragmentation and depression of medial tibial metaphyses. Hypoplasia and medial sloping of proximal tibial epiphyses also seen. May be unilateral or bilateral and asymmetric. Often milder in older form present in adolescent, overweight kids. Either form may resolve spontaneously or require osteotomies. Caused by abnormal stress on the medial proximal tibial physis

Question 31

Answer 31

DDH (Developmental Dysplasia of Hip) ## Footnote Lateral and superior displacement of the left femur, increased angulation of left acetabular roof and delayed ossification of L femoral head. Left hip more commonly involved, more often in breech presentation. XR: Persistent increased angulation of acetabular rood and absence of central concavity, distinct lateral edge in acetabulum, lateral and superior displacement and disparity in sizer and ossification of involved femoral head.

Question 32

Answer 32

Medullary osteonecrosis/bone infarcts ## Footnote Coronal T1 and T2 show well defined geographic areas of heterogenous signal abnormalities within the proximal and distal marrow of left femur. Epiphyses and metaphyses of long bones are particularly susceptible due to limited arterial and venous suply. MRI shows double rim sign in subacute or chronic stages on T2: Outer edges of geographic or serpiginous area of infarct, there is inner zone of high signal and peripheral zone of low signal (granulation tissue and sclerotic bone respectively).

Question 33

Answer 33

Pancreas divisum ## Footnote Coronal (33.1-33.2) reveal dorsal accessory pancreatic duct empty into proximal duodenum via minor papilla, separate from distal CBD (33.3) and ventral pancreatic duct (not well seen here) empty into ampulla. Divisum is where main pancreatic duct drains mostly/completely through minor papilla into duodenum. Normally the dorsal and ventral parts fuse and almost all drain into Ampulla of Vater. Divisum can increase risk of recurrent pancreatitis.

Question 34

Answer 34

Hypoperfusion complex ## Footnote Dilated fluid filled bowel, intense bowel wall enhancement, intense enhancement of aorta, IVC, pancreas and kidneys. IVC also demonstrates deminished calibre. This complex is a poor prognostic indicator, but also useful to rule out visceral injury and avoid unneccesary laparotomy.

Question 35

Answer 35

Tuberous Sclerosis ## Footnote 35.1 - enhancing masses in subependymal regions bilaterally. 35.2 - bright, echogenic foci in renal cortex. 35.3 - multiple, low density masses in kidneys bilaterally and large heterogenous soft tissue mass in right kidney Triad of seizures, retardation and adenoma sebaceum. Cysts and hamartomas in kidneys, cardiac rhabdomyomas, tubers of CNS, subependymal calcifications

Question 36

Answer 36

Scaphocephaly or Dolichocephaly (premature sagittal craniosynostosis) ## Footnote Lateral reveals elongated skull. Frontal reveals shortening of sagittal suture and sclerotic ridge of bone at expected location of sagittal suture. Growth along suture edges is impaired, causing narrow boat-like skull. Surgical correction is performed to create a more normal appearance and preven injry to underlying brain

Question 37

Answer 37

Luckenschadel or lacunar skull ## Footnote AP spine shows splaying of posterior elements of lumbar spine consistent with spinal dysraphism. Lateral skull - calvarial fenestrations or lacunae, primarily in parietal bone. Lacunar skull almost always associated sith dysraphisms. Temporary phenomenon, resolves vy 4-6 months. Fenestrations most pronounced in membranous portions of skull (parietal and superior frontal and occipital) and spare endochondral skull (skull base and lower frontal and occipital)

Question 38

Answer 38

Leptomeningeal cyst ## Footnote Lateral view at time of trauma (38.1) - diastatic, linear parietal skull fracture. 2 months later, larger radiolucent defect with smooth sclerotic edges in parietal bone Leptomeningeal cyst or "growing fracture" is an uncommon late complication of skull fracture. If dura is torn, subarachnoid membrane herniates into fracture site, and subarachnoid fluid pulsations produce a smooth edged, gradually widening fracture line. Clinically pulsatile soft tissue mass at site of defect.

Question 39

Answer 39

Vein of galen malformation ## Footnote CXR: Cardiomegaly Sagittal and coronal US brain: Mass in midline, posterior to third ventricle, containing echogenic mobile speckles. Doppler demonstrates vascular lesion with AV shunting. Causes high output cardiac failure through AV shunting. Cau also cause obstructive hydrocephalus. MR or fluoro angiography needed to work up prior to endovascular embolisation. High output cardiac failure with cranial bruit is suggestive of vein of galen malformation.

Question 40

Answer 40

Corpus Callosum Agenesis ## Footnote 40.1 - elevated 3rd ventricle and sulci radiating from 3rd ventricle. 40.2 - horizontal orientation of lateral ventricles producing "longhorn" appearance, with medial indentations caused by thickened Probst bundles. 40.3: t1 MRI reveals absence of corpus callosum and radiating sulci Frequently associated with Dorsal midline cysts and Dandy-Walker malformation

Question 41

Answer 41

Periventricular leukomalacia ## Footnote Sagittal (41.1) and coronal (41.2) show increased echogenicity in periventricular white matter. Sagittal (41.3) and coronal (41.4) 3 weeks later reveal cystic degeneration in these areas and slight lateral ventricle dilatation PVL is a watershed infarction of periventricular white matter, occuring in infants due to hypoxic insult. Coarse, echogenic areas in periventricular matter greater than adjacent choroid plexus (which undergoes cystic degeneration with time) = PVL.\ Scanning through the posterior fontanelle will remove the normal periventricular blush/echogenicity

Question 42

Answer 42

Missed testicular torsion ## Footnote Left testis is enlarged, heterogenous and diffusely hypoechoic, with some thickening of left epididymis. Colour doppler reveals absence of intratesticular flow and ring of increased flow in capsule around the testicle (rim sign). Spontaneous detorsion can occur, resulting in increase in intratesticular flow and clinical resolution of pain.

Question 43

Answer 43

Double aortic arch ## Footnote 1) loss of intrathoracic tracheal air column. 2) frontal and lateral (3) from barium swallow show bilateral and posterior extrinsic impressions on the thoracic oesophagus. 4) CT shows vascular ring surrounding and compressing trachea. 5) AP, PA and 3D recons show double arch Most common symptomatic vascular ring (resp symptoms predominate). X ray shows right arch and generalised overairation. May be displacement or complete loss of tracheal air column on frontal projection. Oesophagram shows reverse S indentation on oesophagus, upper produced by right arch and lower by left arch.

Question 44

Answer 44

Pulmonary artery sling ## Footnote 1) lateral view reveals a mass between trachea and oesophagus, compressing trachea. 2) CT shows left pulmonary artery passing posterior to trachea. 3) LPA arising from RPA 4) Rightward displacement and compression of distal trachea Only vascular ring to pass between trachea and oesophagus. Associated with asymmetric right hyperinflation as it passes around trachea and right main bronchus. Also associated with congenital heart and TOF.

Question 45

Answer 45

Hypertrophic Pyloric stenosis ## Footnote 1) stomach distended with gas 2) and 3) show thickened pyloric musculature and elongation of pyloric channel. Causes nonbilious projectile vomiting in 2-8 weeks US criteria include nonpassage of gastric contents through persistently thickened pyloric channel. Muscle thickness >3mm and elongation of channel >17mm

Question 46

Answer 46

Ileocolic intussusception ## Footnote 1) air scattered in small bowel with soft tissue mass in RUQ 2) Target sign with multiple concentric rings of bowel within bowel. 3) Longitudinal image shows "sandwich" or "pseudokidney" sign 4) Intraluminal soft tissue mass in hepatic flexure on air-contrast enema. Usualy occurs 5 months - 3 years. US is highly sensitive (98-100%). Presence of doppler flow suggests viable bowel --> reducible. Can also identify lead points (meckels, duplication cyst, lymphoma). Air (fluoro) or saline (US) reduction can be used.

Question 47

Answer 47

Ureteropelvic duplication with ectopic ureterocele ## Footnote 1) right upper pole cyst 2) Cystic structure in right inferolateral aspect of bladder 3) filling defect in bladder, right paraureteral diverticulum and right vesicoureteric reflux into lower moiety of duplicated right collecting system (drooping lily sign) Weigert-Meyer rule - Upper pole ireter inserts into the bladder infermedially to the lower pole ureter, which inserts in normal position. Ectopic ureter may insert into urethra, vagina or vestibule in females, causing incontinence. In males, it may insert into posterior urethra, seminal vesicles or prostate (proximal to urethrap sphincter, no incontinence) Upper pole obstructs due to ureterocele, lower pole refluxes. Ureterocele may also obstruct ipsilateral lower pole ureter, contralateral ureter or even bladder outlet

Question 48

Answer 48

Adrenal haemorrhage ## Footnote 1) Right adrenal mass on longitudinal view, with peripheral solid and central cystic component. 2) normal L kidney and adrenal 3) 1 month later, adrenal mass is smaller and more echogenic More common with perinatal stress (sepsis, hypoxia, birth trauma, shock). More common on right. Haemorrhage decreases in size and becomes more homogenous on follow up imaging, unlike neuroblastoma which grows.

Question 49

Answer 49

Right multicystic dysplastic kidney (MCDK) ## Footnote 1) right kidney replaced by multiple cysts of various sizes. 2) Left kidney normal 3) Normal functioning left kidney and absent right renal function on nephrogram Largest cyst is never central, unlike with congenital ureteropelvic junction obstruction, the other common neonatal abdominal mass. NM also differs between these 2 by showing no function in MCDK kidney. Contralateral kidney abnormal in 20%, most comonly VUR and UPJ obstruction. Currently managed non-operatiively unless follow up imaging shows complication (enlargement, atypical cystic renal mass)

Question 50

Answer 50

Choledochal cyst associated with distal extrahepatic biliary atresia ## Footnote 1) longitudinal and 2) transverse through porta hepatis shopw bilobed cystic mass separate from GB. 3) operative cholangiogram (injecting GB) shows communication of cyst with gallbladder and attenuated intrahepatic biliary tree. Absence of contrast in GI tract shows extrahepatic biliary atresia Neonatal choledochal cyst is often associated with extrahepatic biliary atresia. Later presentations don't feature biliary atresia, and present later with mass, pain or jaundice. Early diagnosis of biliary atresia is needed because Kasai procedure (portoenterostmy) before 12 weeks improves prognosis.

Question 51

Answer 51

Bilateral germinal matrix haemorrhage ## Footnote 1) bilateral hyperechoic masses inferolateral to floors of frontal horns and medial to caudate. 2) and 3) sagittal images show hyperechoic masses as a bulge anterior to caudithalamic groove Germinal matric is a bed of highly vascular subependymal tissue, adjacent to lateral ventricles in caudothalamic groove. Stress of delivery and extrauterine life in prematurity can cause bleeding and infarction in delicate germinal matrix. Look for ventricular and parenchymal extension which alters prognosis. Screening US done at days 7 and 14 for premature babies (<32 weeks or <1500g)

Question 52

Answer 52

Perinatal asphyxia/diffuse hypoxic ischaemic injury ## Footnote Diffusely increased brain echogenicity, poor sulcal/gyral differentiation and small ventricles. 90% with abnormal brain echogenicity progress to death or neurologic sequelae. Focal areas of infarction may be seen as increased echogenicity in cerebral artery territories and watershed areas. Late findings include cystic encephalomalacia, parenchymal calcifications and atrophy with ventriculomegaly