22a Radiology I

Pediatric Emergency Radiology I

Objectives •Identify the following conditions based on x-ray findings: – Intussusception – Bowel obstruction – Congenital hip dislocation – Slipped capital femoral epiphysis – Pneumonia – Thymus shadow – Appendicitis – fecaliths – Bronchial foreign body – Croup

– Epiglottitis – Retropharyngeal abscess – C-spine pseudosubluxation – Hangman fracture – Jefferson fracture – Elbow fractures – Monteggia injury – Salter-Harris fractures – Child abuse

X-ray diagnosis? 14-month-old girl with vomiting. Target sign in Identify the target sign Target sign The crescent sign is inRUQ. the RUQ again. in RUQ. formed by the intussusceptum (lead point) protruding into Intussusceptio a gas-filled pocket. Identify crescent sign n in LUQ again.

Intussusception

Crescent Crescent sign in LUQ. sign in LUQ.

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 gas-filled pocket may be large, as in this case. Intussusception

Left image: Right image: Absence of hepatic Absence of gas in angle (suggests RUQ RUQ and RLQ mass). Absence of (suggests a mass gas in RLQ (suggests effect on right). RLQ mass). Two Poor distribution dilated (smooth) of gas in general bowel segments (suggests bowel (suggests bowel X-ray diagnosis? 11-month-old boy with vomiting. obstruction). obstruction). Bowel obstruction with right-sided mass effect: Intussusception

X-ray diagnosis? 11-month-old girl with vomiting. RUQ target sign. Identify the sign. target RUQ target LUQ crescent sign. and crescent LUQ crescentsigns sign. Absence of the again. of the Absence subhepatic angle. subhepatic angle.

Intussusception

Intussusception

Possible target sign in RUQ.

Paucity of bowel gas suggestive of rightsided mass and bowel obstruction.

X-ray diagnosis? 7-month-old girl with skull fracture, lethargy, and vomiting.

Intussusception Target sign Absence of hepatic angle Paucity of gas

Target sign

Absence of hepatic angle. Paucity of gas.

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

RUQ air fluid Intussusceptionlevels. RUQ bowel loops are smooth (bowel obstruction). Suspected

Paucity of gas in RLQ. X-ray diagnosis? 7-month-old boy with vomiting.

Bowel obstruction ddx: AIM Bowel obstruction criteria: • A: Adhesions, appendicitis Gas distribution • I: Intussusception, incarcerated Bowel distention inguinal hernia Air fluid levels • M: Malrotation (midgut volvulus), Meckel’s

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

Bowel walls Air Gas fluid aredistribution: levels: smooth, Onhose-like: upright Good view Distended Bowel Bowel Obstruction Obstruction

Bowel obstruction criteria: Haustra and plicae Gas distribution preserved. Looks Bowelare distention likelevels bag of popcorn, Air fluid

instead of bag of sausages. Bowel walls are NOT smooth (hose-like). Distention criterion is more related to smoothness of bowel walls rather than volumegirl ofspitting gas. up. X-ray diagnosis? 1-month-old Bowel distention: Lots levels: of gas, but no distention. Gas Air fluid distribution: None Good Normal abdominal radiographs

obstruction criteria: ILEUS, NoBowel Definite Bowel Obstruction Gas distribution Bowel distention Air fluid levels

Air fluid levels: Many, but they are all small with noGas J turns (hairpin loops, Bowel distention: distribution: No smooth Fair walls candy canes) X-ray diagnosis? 9-day-old boy with vomiting.

Radiologist identifies an occult diagnosis. Paucity While preparing ofCongenital gas onfor the andislocated right ultrasound, suggestive hipthe (CDH). of child a mass. Congenital Dislocated Hip Residual drinks a bottle barium Shenton’s and present. her arc behavior is discontinuous. normalizes.

A more focused view of occult diagnostic finding

Shenton’s arc. X-ray diagnosis? 5-month-old girl discharged yesterday following barium enema reduction of

Thigh or knee pain could originate from a Right hip physis appears to be wide Klein’s line: Superior aspect of the hip problem. Hip evaluation iship. required. compared to the left metaphysis to see if it intersects the epiphysis

Abnormal: Line misses epiphysis

Normal: Line intersects epiphysis

X-ray diagnosis? 10-year-old obese Slipped Capital Femoral Epiphysis boy with rightof thigh knee (SCFE) the and Right Hip pain

Moderate slip Severe slip Bilateral SCFE X-ray diagnosis?

Appendicitis

Fecalithit Identify (appendicolith) again

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

Find the fecalith (appendic olith)

This This This Fecaliths There ThisThis fecalith can fecali is fecalit the can vary fecalith are be th last is in two ishis faint or seen faintly fecali fairly round appeara more and in large with thpoten onance. oval in the radiograph dense this This shape tialone of the opaqu slide is small fecalit appendix e dot hsand specimen. It in it. opaque. here

Pneumo nia

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

LLL infiltrate

RML infiltrate X-ray diagnosis? 15-month-old boy with fever, coughing, tachypnea.

LLL & RML Pneumonia

No X-ray Normal diagnosis? thymic newborn 2 month thymus old No shadow with a VSD occupies the presents with thymic space anterior shadow recurrent to the heart seizures. Cardiomegaly (CHF) Cardiomegaly (CHF) Hypocalcemia found on labsNormal thymus shadows VSD, Thymic, & in young infants Parathyroid Aplasia: DiGeorge Syndrome

X-ray diagnosis? Ventilated infant with sudden deterioration

Air in Pneumopericardium pericardium Revealing the Thymus reveals “Sailshape Sign”of infant thymus.

Prominent Prominent Thymus Partially Normal asymmetric thymus Obscuring a RUL Infiltrate: newborn thymus Pneumonia occupies space anterior to heart

Infiltrate

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

RML Atelectasis

RML atelectasis

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

Round infiltrate. Spherical consolidation.

Round Pneumonia: “Cannonball” Pneumonia

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

More views:

Air Trapping Right side Bilateral down Left side down

Inspiratory view

Expiratory view

Lateral Heart should move downward. But in both views, Bilateral Bronchial Foreign Bodies neck it stays in place, due to bilateral air trapping. Expiratory view Nuts + Choking = Bronchoscopy

No definite abnormalities Insp and Exp views look very similar = air trapping X-ray diagnosis? 17-month-old coughing after choking on a chocolate/almond bar

X-ray diagnosis? 18-month-old girl with fever, noisy breathing, and barking cough. Epiglottis Epiglottis - normal (E) Retropharyngeal Identify the: Vallecula Vallecula - normal (V) Epiglottis Abscess Trachea Vocal -cords slightly (C) Vallecula (also called narrow Trachea or (T) normal Vocal cords prevertebral Prevertebral Prevertebral Trachea softsoft abscess) tissue tissue (P) (P)- wide Prevertebral soft Clinical symptoms and bulging (should tissue may mimic be half thecroup. width of vertebral body)

E V

P C

T

X-ray diagnosis? 2-year-old boy with fever, stridor, tripoding and NO cough.

P

E

Epiglottis Epiglottis (E) - (E) Identify the: wide Vallecula (thumb-like) (V) Epiglottitis Epiglottis Vallecula Vocal cords - shallow (C) Vallecula Trachea Trachea - normal (T) Vocal cords Prevertebral Prevertebral soft Trachea soft tissue -tissue normal (P) Prevertebral soft tissue

C

T

V

X-ray diagnosis? 15-month-old boy with fever, mild stridor, and barking cough. IdentifyCroup the: Epiglottis Epiglottis - normal Vallecula Epiglottis (E) Vallecula - normal Vocal cords Vallecula (V) Trachea (T) - narrow, Vocal cords (C) Trachea subglottic edema Trachea (T) Prevertebral soft tissue Prevertebral soft tissue Prevertebral soft tissue (P)normal

P E V C

T

X-ray diagnosis? 6-year-old girl with mild neck pain. Swischuk line criterion: Line drawn between Malalignment C2-C3 pseudosubluxation of C2But andshe C3. No recent trauma. posterior arch of C1 and Is characteristics: itProbable athrown true subluxation or is was intoC2-C3 a posterior arch of C3. it Minimal a pseudosubluxation? / pool mild 30 trauma swimming hours The posterior arch of C2 Pseudosubluxation Minimal / mild pain of ago with no complaint should be within 1 to 2 mm No signs a fracture neck pain atofthat time. She of this line. is positioned in ED isNeck now brought in to the Deviation from this line flexion (notboard. lordotic), often on a spine suggests a C2 pedicle due to a spine board. fracture; however, this Swischuk line criterion. criterion is not perfect.

C1 C2 C2 C3

C3

X-ray diagnosis? 2-year-old boy who fell off his tricycle is brought in on a spine board. C2-C3 pseudosubluxation Swischuk line: characteristics: Line drawn between the  Minimal / mild trauma posterior arch of C1 and  Minimal / mild pain the posterior arch of C3. Probable No signs of C2-C3 a fracture The posterior arch of C2  Neck is positioned in should be within 1 to 2 mm Pseudosubluxation flexion (not lordotic), often of this line. due to a spine board.  Swischuk line criterion.

C1 C2 C3

X-ray diagnosis? 7-year-old girl unrestrained in a car crash brought in on a spine board.

C1 C2

Fracture ofline: Swischuk C2 pedicle: satisfactory Despite a satisfactory Swischuk line. There is very slight subluxation of C2 onC2 C3 Pedicle Fracture of the due to the fracture.

“Hangman Fracture”

C3

This odontoid view is still useful X-ray diagnosis? Two normal odontoid views. It’s hard tothe see anything with The lateral masses are to identify lateral masses 7-year-old boy injured his (ring TheJefferson lateral masses of C2 C1The are Fracture displaced outward indicating of C1) relative to as this poor odontoid view. head and neck diving into outlined aligned with the base C2. ring) that the ring of C1 has fractured here. The LMsof should odontoid is(C1 not visible. shallow water. anddirectly burst open. be over the base of C2. This CT scan shows a C1 C1 O Better quality open Jefferson fracture (C1 LM LM L L No definite abnormalities. ring fracture) sustained mouth (odontoid) L L L M M O His collar is to temporarily when ademonstrating blow the top of view a M C M M C2 C2 C aodontoid removed for an the head places load on C Jefferson fracture. 2 C C (open mouth) view. the long axis of2 the spine, 2 2 2 bursting open the ring of C1.

Radius should line upfracture. with capitellum (C). Mid-ulna angulated Misalignment indicates radial head dislocation. Anything else?

Abnormal

C

X-ray diagnosis? 9-year-old Monteggia Injury boy who fell onto his forearm. Visible forearm Ulna fracture often deformity. results in radial head Normal C dislocation. Check

radius-capitellum line confirming alignment.

Supracondylar region Anterior Elbow evaluation: humerus Posterior fat pad (+) High yield places to look: lineAnterior should fat pad (+) Posterior fat pad bisect Anterior fat pad capitellum humerus line (+) Anterior Radial head Radius-capitellum line Supracondylar region Radial head Radius-capitellum line Olecranon (normal) Olecranon Elbow Joint Effusion X-ray diagnosis? Probable occult Elbow injury.fracture. supracondylar

Posterior fat pad Anterior humerus line: Supracondylar region: Anterior fat pad misses OK capitellum Both unable to (not a true lateral view) assess (true lateral view required) Radius-capitellum line: normal Olecranon: OK

Radial Head Fracture

Radial head: Fracture X-ray diagnosis? Elbow injury

Olecranon fossa cortex is fractured

Supracondylar region: cortex disrupted

Anterior fat pad (+) Posterior fat pad (+)

Supracondylar Fracture X-ray diagnosis? Elbow injury

Anterior fat pad (+) Radius-capitellum line is not pointing at capitellum Posterior fat pad (+)

Olecranon fracture

Joint Effusion, Olecranon Fracture, Monteggia Injury (radial head dislocation) X-ray diagnosis? Elbow injury

non-displa ced

displa ced

Tenderness elicited The epiphysis is is displaced over distal Salter-Harris radius type 1 fracture of distal radius physis should be suspected clinically Displaced Salter-Harris Type 1 Fracture of the X-ray diagnosis? 10-year-old boy, wrist injury Distal Radius Physis

Tender SH type III Hey you !! Epiphysis What kind of and physis Salter-Harris fracture type is this?? Fell off 2nd floor onto W h o Who ME? her feet. M = metaphysis SH type II E = epiphysis Metaphysis and physis Calcaneus fracture

SH type V: SH type IV Physis. Metaphysis Not evident on and X-ray. Relies on Epiphysis clinical findings and history of M E ? injury mechanism.

X-ray diagnosis? 6-week-old boy Elbow/Forearm with “sudden” left thigh swelling and no history of trauma. Proximal radius fracture Child abuse isfracture suspected. Severe femur Obvious oblique with periosteal elevation - A skeletal survey is without explanation. femur fracture (hard see). and tibia ordered. Older to forearm with a thinner Left forearm and fractures. fracture in thefracture Healing tibia with right tibia/fibula are shown distal half ofelevation. the periosteal here. Child Abuse femur.

Tib/Fib

X-ray diagnosis? A skeletal Severe 2 month old who is survey is osteogen crying without done esis apparent cause. and no imperfect Obvious midview otheris a. - Another Osteogenesis imperfecta shows the Family history: femur fracture is fracture. fractures Lethal oblique suspected. fracture line. Mid femur -form Father: 4 noted. Child Multiple rib fractures are in fractures, 2 of abuse is found. infancy. - Further Occult types questioning tend to be autosomal about which occurred imperfecta. Osteogenesis suspected. The Severe trauma dominant is (family negative history except will be with minor upper a osteopen for bumping him against positive.) trauma. Family history of “frequent ia. door while carrying him in a - PGF: 4 fractures” may be a useful extremitie padded Severe lethal infant types carrier. tend to The be fractures from question in you fracture patients. s are Crumpled parents tell recessive. that this “playing shown long bones couldn’t have been hard around” here. at birth. enough to cause a fracture. - Mother: Scoliosis - 2 aunts: