Common Pediatric Rads

Question 1

Imaging workup for bilious vomiting

Answer 1

1. Three view abdominal series
2. Upper GI fluoroscopic series

Question 2

Transverse view of pyloric stenosis

Answer 2

On axial you see the classic donut sign

Question 3

Midgut volvulus “small intestinal beak” sign

Answer 3

Question 4

Results of a normal upper GI fluroscopy study

Answer 4

Question 5

Anatomy of malrotation (as seen on barium enema)

Answer 5

Question 6

Double bubble sign on fetal ultrasound

Answer 6

Presence of a gastric bubble is important, but there should not be two discrete bubbles

Question 7

Results of upper GI fluoroscopy in a child with malrotation-volvulus

Answer 7

Corkscrew jejunum is also often seen

Question 8

What is the key to diagnosing malrotation?

Answer 8

Identification of the location of the ligament of Treitz

Usually, it is on the left side of the abdomen underneath the stomach.

In malrotation, it is attached to the right abdominal wall and crosses over the cecum. (Ladd’s bands)

Question 9

The appendix in a Ladd procedure

Answer 9

To avoid future diagnostic confusion, the appendix is usually removed as the intestinal anatomy is so altered.

Question 10

What is going on in this infant’s radiograph?

Answer 10

There is hyperinflation and increased perivascular markings. It can be fairly subtle, the perivascular markings are the biggets tell. Sometimes complete RUL collapse is observed.

On the lateral radiograph associated with this case you can better appreciate the hyperinflation via the flattening of the diaphragm.

In the right clinical context, this is suggestive of bronchiolitis, particularly RSV.

Question 11

How frequently should a baby have CXRs when intubated to assess tube placement?

Answer 11

As infrequently as possible

Question 12

Bronchus intermedius

Answer 12

Where the lesion is here

After the take-off of the RUL bronchi, before the separation of the RLL and RLM bronchi.

Question 13

What is going on in this hand/wrist x-ray?

Answer 13

Taurus fracture or Buckle fracture

Common in kids and adolescents where the periosteum is stronger than the bone. More than half of these fractures involve the metaphysis only.

Any cortical “bump” should be considered a Taurus fracture if the kid has symptoms at the site.

Tx for nondisplaced fractures: splint of < 48 hours old, cast for 2-4 weeks if > 48 hours old. Repeat radiography is not indicated if symptoms improve.

Question 14

Salter-Harris system

Answer 14

Graded in terms of increasing risk for growth disturbance (so 5 is the highest risk!)

Question 15

Nomenclature of bone components

Answer 15

Question 16

What is going on in this radiograph?

Answer 16

Greenstick fracture of the radius and ulna

Usually seen in pediatric patients (strong periosteum)

Question 17

What is going on in this radiograph?

Answer 17

Greenstick fracture of the radius with associated plastic deformation (but not fracture!) of the ulna.

Question 18

What is going on in this radiograph?

Answer 18

This is a Toddler’s fracture

The mechanism/traumatic event is often not witnessed. Radiographs may reveal a non-displaced spiral fracture of the tibia without fibular involvement.

However, initial radiographs may be negative and only after there has been time for periosteal reaction (~1 week, maybe more) will you be able to see the fracture.

Question 19

What is the most likely site of elbow fracture in pediatric patients?

Answer 19

Supracondylar

Unfortunately, they also tend to be hard to see on films. We often have to rely on elevation of the fat pads on plain films.

Question 20

Where should you see a fat pad in a healthy elbow joint?

Answer 20

Question 21

SCFE lesion

Answer 21

Question 22

Osgood-Schlatter disease aka Osteochondrosis

Answer 22

• Condition of painful inflammation of the tibial tubercle, caused by traction apophysitis of the tibial tubercle
• Occurs in active children and adolescents between ages 9 and 17
• Diagnosis may be made clinically
• Treatment consists of decreased activity, ice after exercise, and NSAIDs
  
  • In severe cases, immobilization of the knee and use of crutches may be required
• Symptoms may recur until ossification is complete (~17 years)
• Long-term prognosis is excellent

Question 23

Patellofemoral pain syndrome

Answer 23

• Broad term used to describe pain in the front of the knee and around the patella
• Also called “runner’s knee” or “jumper’s knee”
• Characterized by anterior knee pain and stiffness with motion, popping or cracking sound when climbing stairs or standing after a long period of sitting, and tenderness of the inferior patella

Question 24

Slipped capital femoral epiphysis (SCFE)

Answer 24

• Occurs in adolescents during the growth spurt. Most common in overweight adolescents. No history of trauma.
• Leads to a limp and groin or thigh pain, however hip pain may be referred to the knee.
• On exam, there is limited hip flexion, internal rotation, and abduction
• Frog leg X-ray reveal widening of the femoral epiphysis and osteopoenia.
• These inviduals are at risk for avascular necrosis of the femoral epiphysis and require orthopedic evaluation
• Treat w/ surgery

Question 25

Iliotibial band friction

Answer 25

* Frequent cause of lateral knee pain in runners and bicyclists

Question 26

Legg-Calve-Perthes disease

Answer 26

* Age ~6 years old * Insidious onset of antalgic gate, unable to bear weight on foot * Avascular necrosis of femoral head in acetabulum * Diagnose w/ x-ray * Treat w/ cast

Question 28

Osteosarcoma

Answer 28

* Distal femur is typical presentation * Associated w/ pRB mutation, may have had retinoblastoma * "Sunburst" pattern on x-ray, confirm with MRI, then biopsy * **Focal, atraumatic bone pain** * Treatment is resection

Question 33

Ewing sarcoma

Answer 33

* Translocation 11:22 * Mid-shaft of bone * X-ray described as onion-skin or periostial elevation, confirm with MRI, then biopsy * **Focal, atraumatic bone pain** * Treatment is resection

Question 34

Stages of avascular necrosis of the femoral head

Answer 34

Note the subtle periosteal elevation in stage 1 in comparison to the degenerative change and loss of bone mass in stage 4

Question 35

Transient synovitis

Answer 35

* Post-infectious or idiopathic, self-limited joint pain in kids * Will appear with a joint effusion detectable on ultrasound, which is helpful in diagnosis * Common cause of limp in kids * Treat with NSAIDs and rest. No follow-up needed if symptoms resolve.

Question 36

What is going on in this radiograph?

Answer 36

This is a metaphyseal corner fracture, or a **"bucket handle" fracture** This occurs when a small piece of bone is avulsed due to shearing on the growth plate. The mechanism of these fractures is thought to be an **acceleration/deceleration force during shaking or grabbing.** This is **pathognomonic for child abuse**

Question 37

Types of injury pathognomonic for child abuse

Answer 37

* Metaphyseal corner fracture * Posterior rib fracture * Salter Harris Type V fractures * Multiple fractures of different ages or in a pattern not related to the supposed mechanism of injury * Femoral fracture in a child that cannot walk yet (\< 1 year, typically)

Question 38

What is going on in this child's radiograph?

Answer 38

There is callus formation around multiple posterior ribs This is highly suggestive of child abuse with injury to posterior ribs that occurred one or more weeks ago

Question 39

How and at what time is imaging for development hip dysplasia performed?

Answer 39

* **How:** Ultrasound * X-ray becomes more reliable at ~6 months-1 year * **What time:** 4-6 weeks of age *for:* * ​Infants with history of positive Ortolani/Barlow on exam * Infants with family history * Infants with history of breech presentation

Question 40

Risk factors for Developmental Dysplasia of the Hip

Answer 40

* Female Sex * First born child * Certain racial backgrounds * **Breech presentation** * **Family history** * Note: **bolded** is a risk factor that is an independent indication for US screening at 4-6 weeks

Question 41

Normal anatomy of a hip ultrasound screening for DDH

Answer 41

* What to look for: * Is the femoral head within the acetabular joint? * Alpha angle (how shallow is the acetabulum?) * Does a line extended from the iliac crest approximately bisect the femoral head?

Question 42

Alpha angle in DDH screening

Answer 42

* Normal hip joint: alpha \> 60^o * Type II: Minor dysplasia: alpha 43-60^o * Type III: Major dysplasia: alpha \< 43^o * Type IV: Dislocation * Note: **low alpha angle = shallow acetabulum**

Question 43

Pseudoacetabulum

Answer 43

Bony concavity of the pelvis due to chronic untreated hip dysplasia Requires surgical osteotomy to correct

Question 44

Treatment of developmental dysplasia of the hip

Answer 44

Question 45

Fontanelles and ultrasound

Answer 45

The fontanelles, when open, make ultrasound an extremely useful modality for evaluating the entirety of the intracranial anatomy. If a fontanelle is sufficiently open, you can use ultrasound regardless of age. However, most infants have closed fontanelles by age 9 months. For these patients, CT or MRI is required to visualize intracranial anatomy. Normal findings are shown here. Note how small the ventricles normally are.

Question 46

What is going on in this infant's brain US?

Answer 46

Hydrocephalus Note the enlargement of the ventricles, which are normally very small (normal is attached for comparison)

Question 47

What is going on in this infant's brain ultrasound?

Answer 47

This infant has intraventricular hemorrhage into the right lateral ventricle.

Question 48

Meckel's diverticulum rule of 2's

Answer 48

* 2% of the population * 2 feet from the ileocecal valve * Presents at age 2 (usually as painless rectal bleeding)

Question 49

According to the ACR appropriateness criteria, at what age does the most appropriate test for suspected appendicitis transition from ultrasound to abdominal CT scan?

Answer 49

Age 14 Shown is an image of appendicitis on ultrasound

Question 50

Studies that may be used if intussusception is suspected

Answer 50

* First-line: * **Ultrasound** OR **air enema** (depending upon center) * Other: * KUB (usually second-line if the above fail, basically just demonsrtates obstruction but cannot tell you the etiology)

Question 51

Air enemas and intussusception

Answer 51

Contrast enemas have largely been replaced by air enemas for this purpose. Air enema still has therapeutic value. It is contraindicated in cases of peritonitis and/or suspected perforation and patients who are hemodynamically unstable.

Question 52

Etiology of intussusception by age

Answer 52

In patients age **3 months - 3 years,** the lead point is **presumed to be an inflamed Peyer's patch** If the patient is **older than 5 years,** another mechanical lead point must be suspected. This may include: Foreign bodies, **intestinal lipomas,** **Henoch-Schonlein Purpura**, intestinal polyps, Meckel's diverticulum, hemangioma, hematoma, etc.

Question 53

Intusussception on CT

Answer 53

Only seen in older adults (who get CTs for this purpose) You may see mesenteric components, such as fat and vessels, within the intussusceptum.

Question 54

Pseudokidney view

Answer 54

Sign of intussusception This is the intussusception viewed sagitally

Question 55

Intussception target sign

Answer 55

Question 56

Risk of recurrence in intusussception

Answer 56

Nearly 10% of patients will have a recurrence within 24 hours after reduction For this reason, they are kept in the hospital for *at least* 24 hours following reduction procedure.

Question 57

What imaging do you order if you are concerned for epiglottitis

Answer 57

*After* stabilization in the ED, a lateral neck soft tissue x-ray is indicated. This should be done erect, as lying supine can close the airway.

Question 58

What is going on in this lateral film?

Answer 58

Epiglottitis Note the classic "thumb" sign

Question 59

Almost any mass that *looks* like a soft tissue tumor on CXR in a child or adolescent is probably. . .

Answer 59

. . . **round pneumonia** **or round atelectasis** Of course, in the proper clinical setting, it *could* be cancer. But common things are common.