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Pediatric Radiology
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Indications for Pediatric Radiographic Examination
HistoryWill the imaging give you any added clinical
data?Benefits vs. riskAmerican College of Radiology (ACR)
Appropriateness Criteria available at www.acr.org
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All radiological exams carry riskgonadsbreastthyroidlungBone
The concept of ALARA (as low as reasonably achievable) should be
applied to all patients
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Radiation Exposure - ChildrenConsiderably more sensitive to
radiation than adults Also have a longer life expectancya larger
window of opportunity for expressing radiation damage
Compared with a 40-year old, the same radiation dose given to a
neonate is several times more likely to produce a cancer over the
patients lifetimeRetrieved 01-17-05 from
http://www.cancer.gov/cancertopics/causes/radiation-risks-pediatric-CT
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Never radiograph routinely!Will the results change my
management?Will the study confirm my clinical suspicions?Is this
the appropriate study for what Im trying to confirm?
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Technical Issues
Instructional complianceMotionThe child should be stabilized by
the parentRecumbent radiographs a necessity in young childrenacute
fractures
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uprightrecumbent
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Radiographic InterpretationMust know the normal radiographic
appearance at each age for accurate interpretationAtlas of normal
developmental anatomyConsult a DACCBR?
Chiropractic line analysisChildren are not small adults Does the
technique recognize this?
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Normal Pediatric Variants
PseudosubluxationPseudospread of C1 on C2ADI spaceAbsence of
cervical lordosisNormal appearance of ossification centers and
epiphyses
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Pseudosubluxation
Normal variantOccurs most commonly at C2/C340% of normal
children
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Swischuk's line distinguishes pseudosubluxation from
pathological subluxationA line drawn connecting the anterior
cortices of the spinous processes of C1 and C3 should intersect or
lie within 1 mm of the anterior cortex of the spinous process of
C2If C2 is >2mm off of this line = true
injuryhttp://www.uth.tmc.edu/radiology/test/er_primer/spine/images/csp40.htmlhttp://www.medcyclopaedia.com/library/topics/volume_vii/p/pseudosubluxation.aspx
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Pseudospread of C1 on C2
Normal variantLateral mass displacement relative to the dens Up
to 6mm is common
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Pseudospread of C1 on C2
Lustrin ES, Karakas SP, Ortiz AO et al. Pediatric Cervical
Spine: Normal Anatomy, Variants and Trauma. RadioGraphics 2003;
23:539-60.
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Other Common Variants
ADI spaceMaximum of 4mm (new literature) in childrenAbsence of
cervical lordosisCan be seen in children up to 16 yoaOval/wedge
shaped vertebrae are normalNot to be confused with compression
fxNormal appearance of ossification centers and epiphyses can
simulate fracturesLustrin ES, Karakas SP, Ortiz AO et al. Pediatric
Cervical Spine: Normal Anatomy, Variants and Trauma. RadioGraphics
2003; 23:539-60.
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Copyright Radiological Society of North America, 2003Lustrin, E.
S. et al. Radiographics 2003;23:539-560Figure 1bsynchondrosis
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Copyright Radiological Society of North America, 2003Lustrin, E.
S. et al. Radiographics 2003;23:539-560Figure 4
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The spaces between the sacral segments are synchondroses
composed of fibrocartilage, not discsBone starts to be deposited in
the fibrocartilage starting at puberty
*They do not move like vertebraeGray, Henry. Anatomy of the
Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com,
2000. www.bartleby.com/107/. [January 20, 2006].
http://www.bio.psu.edu/people/faculty/strauss/anatomy/skel/sacrum2.htm
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Where is the anomaly?
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Os Odontoideum
Results from injury at the odontoid synchondrosis
Flexion/extension radiographsNeurological
deficit?Neurologist/orthopedist consult
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Epiphyseal Plate Injuries
Salter-Harris Classification
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http://xray.20m.com/photo4.html
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Child AbusePhysical, sexual, nutritional abuse or neglect
Must report to appropriate agency!
Remain professional and objectiveBe non-judgemental toward
parents
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Radiography plays an important part in documenting physical
abuse
Technical considerationsreveal soft tissues wellhigh detail
radiographs sectionals, not babygram
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Battered child syndromeMetaphyseal corner fracturesMultiple
fractures at various stages of healingRibs, scapulaHead injuries
Skull fx, subdural hematoma, shearing injuries*MC cause of death +
disability in child abuseSoft tissue swelling and injuries i.e.
contusions, burns, etc.
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Oblique fracturePeriosteal reactionMetaphyseal corner fx
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Linear skull fracturesMultiple metacarpal fractures
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Rib fracturesEspecially posterior aspect
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Hx: 2 yo with vomiting and diarrheaInitial abdomen and chest
films normalIncreased WBCElevated ESRFindings: -decreased disc
height-abnormal signal in two adjacent VB-paraspinal massDx:
discitisSwischuk LE. Vomiting, diarrhea and--oh! oh! what is that?
Pediatr Emerg Care. 2004 Jan;20(1):54-6
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Spinal infection
DiscitisA common problem in infantsMC lumbar region, lower
thoracics
S/S: back pain (often cant directly communicate) and difficulty
walking or limping
Therefore, when one has exhausted all of the more common causes
of limping, one should look to the lower thoracic and lumbar spine
regions for the presence of discitis.Swischuk LE. Vomiting,
diarrhea and--oh! oh! what is that? Pediatr Emerg Care. 2004
Jan;20(1):54-6
