A P L S Pediatric Emergency Radiology 1

Ha1

Pediatric Emergency Radiology I

Ha2

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

Ha3

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.

Crescent Crescent sign in LUQ.sign in LUQ.

The crescent sign is formed by the intussusceptum (lead point) protruding into a gas-filled pocket. Identify crescent sign in LUQ again.

Crescent Crescent sign in LUQ.sign in LUQ.

Target sign Target sign in RUQ.in RUQ.

Crescent Crescent sign in LUQ.sign in LUQ.IntussusceptionIntussusception

Ha4

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

Ha5

Ha5


Bowel obstruction with right-sided mass effect: Intussusception

Right image:Right image: Absence of gas in RUQ Absence of gas in RUQ

and RLQ (suggests a and RLQ (suggests a mass effect on right). Poor mass effect on right). Poor

distribution of gas in distribution of gas in general (suggests bowel general (suggests bowel

obstruction).obstruction).

Left image:Left image: Absence of hepatic angle Absence of hepatic angle

(suggests RUQ mass). (suggests RUQ mass). Absence of gas in RLQ Absence of gas in RLQ

(suggests RLQ mass). Two (suggests RLQ mass). Two dilated (smooth) bowel dilated (smooth) bowel

segments (suggests bowel segments (suggests bowel obstruction). obstruction).

Ha6

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

Identify the target and crescent signs again.

RUQ target sign.LUQ crescent sign.Absence of the subhepatic angle.



Intussusception

Ha 6

Ha7

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

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

Possible target sign in RUQ.

Possible target sign in RUQ.

Paucity of bowel gas suggestive of right-sided mass and bowel obstruction.

Paucity of bowel gas suggestive of right-sided mass and bowel obstruction.

Intussusception

Ha8

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

Target signTarget sign

Absence ofAbsence ofhepatic angle.hepatic angle.Paucity of gas.Paucity of gas.

IntussusceptionIntussusceptionTarget signTarget sign

Absence of hepatic angleAbsence of hepatic anglePaucity of gasPaucity of gas

Ha9


Suspected Intussusception

Suspected Intussusception

RUQ air fluid RUQ air fluid levels. RUQ levels. RUQ bowel loops bowel loops are smooth are smooth

(bowel (bowel obstruction).obstruction).

RUQ air fluid RUQ air fluid levels. RUQ levels. RUQ bowel loops bowel loops are smooth are smooth

(bowel (bowel obstruction).obstruction).

Paucity of Paucity of gas in RLQ.gas in RLQ.Paucity of Paucity of

gas in RLQ.gas in RLQ.

Ha10

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

Bowel obstruction criteria:Gas distributionBowel distention

Air fluid levels

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

Bowel obstruction ddx: AIM• A: Adhesions, appendicitis• I: Intussusception, incarcerated inguinal hernia• M: Malrotation (midgut volvulus), Meckel’s

Ha11

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


Air fluid levels

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

Haustra and plicae are preserved. Looks like bag of popcorn, instead of bag of sausages. Bowel walls are NOT smooth (hose-like). Distention criterion is more related to smoothness of bowel walls rather than volume of gas.

Haustra and plicae are preserved. Looks like bag of popcorn, instead of bag of sausages. Bowel walls are NOT smooth (hose-like). Distention criterion is more related to smoothness of bowel walls rather than volume of gas.

Ha12

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


Air fluid levels

Gas distribution: FairGas distribution: FairBowel distention: No smooth wallsBowel distention: No smooth wallsAir fluid levels: Many, but they are all small with no J turns (hairpin loops, candy canes)Air fluid levels: Many, but they are all small with no J turns (hairpin loops, candy canes)

ILEUS, No Definite Bowel ObstructionILEUS, No Definite Bowel Obstruction

Ha13

Paucity of gas on the right suggestive of a mass.Residual barium present.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.While preparing for an ultrasound, the child drinks a bottle and her behavior normalizes.Radiologist identifies an occult diagnosis. Radiologist identifies an occult diagnosis.

Shenton’s arc.Shenton’s arc.

A more focused view of

occult diagnostic

finding

A more focused view of

occult diagnostic

finding

Congenital dislocated hip (CDH).Shenton’s arc is discontinuous.Congenital dislocated hip (CDH).Shenton’s arc is discontinuous.Congenital Dislocated HipCongenital Dislocated Hip

X-ray diagnosis? 5-month-old girl discharged yesterday following barium enema reduction of intussusception. Vomited once today.

Ha14

Right hip physis appears to be wide compared to the left hip.

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.

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

X-ray diagnosis? 10-year-old obese boy with right thigh and knee pain

Klein’s line: Superior aspect of the metaphysis to see if it intersects the

epiphysis

Klein’s line: Superior aspect of the metaphysis to see if it intersects the

epiphysis

Abnormal: Line misses epiphysisAbnormal: Line

misses epiphysisNormal: Line

intersects epiphysis

Normal: Line intersects epiphysis

Slipped Capital Femoral Epiphysis (SCFE) of the Right Hip

Slipped Capital Femoral Epiphysis (SCFE) of the Right Hip

Ha15

X-ray diagnosis?X-ray diagnosis?

Moderate slipModerate slip

Severe slipSevere slipBilateral SCFEBilateral SCFE

Ha16

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

Fecalith (appendicolith)

Fecalith (appendicolith)

Identify it again

Identify it again

Appendicitis

Ha17

Fecaliths can vary in

appearance. This one is

small and opaque.

This fecalith is faint and

oval in shape

This fecalith can be seen faintly in the radiograph of

the appendix specimen. It is

very faint on the abdominal film.

This fecalith can be seen faintly in the radiograph of

the appendix specimen. It is

very faint on the abdominal film.

There are two or more

potential fecaliths

here

This fecalith

is round with a dense

opaque dot in it.

This fecalith

is round with a dense

opaque dot in it.

This fecalith is fairly

large

This fecalith is fairly

large

This is the last fecalith on this

slide

This is the last fecalith on this

slide

Find the fecalith

(appendicolith)

Find the fecalith

(appendicolith)

Ha18

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

PneumoniaPneumonia

Ha19

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

RML infiltrateRML infiltrate

LLL infiltrate

LLL infiltrate

LLL & RML PneumoniaLLL & RML Pneumonia

Ha20

X-ray diagnosis?2 month old with a VSD presents with recurrent seizures.

VSD, Thymic, & Parathyroid Aplasia: DiGeorge Syndrome

VSD, Thymic, & Parathyroid Aplasia: DiGeorge Syndrome

Cardiomegaly (CHF)

Cardiomegaly (CHF)

No thymic shadow

No thymic shadow

Hypocalcemia found on labsHypocalcemia found on labs

X-ray diagnosis?2 month old with a VSD presents with recurrent seizures.

Normal thymus shadows in young infants

Normal thymus shadows in young infants

Cardiomegaly (CHF)

Cardiomegaly (CHF)

No thymic shadow

No thymic shadow

Normal newborn

thymus occupies the

space anterior to the heart

Normal newborn

thymus occupies the

space anterior to the heart

Ha21

X-ray diagnosis? Ventilated infant with sudden deterioration

X-ray diagnosis? Ventilated infant with sudden deterioration

Air in pericardium reveals shape of infant thymus.

Air in pericardium reveals shape of infant thymus.

Pneumopericardium Revealing the Thymus

“Sail Sign”

Pneumopericardium Revealing the Thymus

“Sail Sign”

Ha22

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

Normal newborn

thymus occupies

space anterior to

heart

Normal newborn

thymus occupies

space anterior to

heart

Prominent asymmetric thymusProminent asymmetric thymus

InfiltrateInfiltrate

Prominent Thymus Partially Obscuring a RUL Infiltrate:

Pneumonia

Prominent Thymus Partially Obscuring a RUL Infiltrate:

Pneumonia

Ha23

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

RML atelectasisRML atelectasis

RML Atelectasis

RML Atelectasis

Ha24

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

Round infiltrate.Spherical consolidation.

Round infiltrate.Spherical consolidation.

Round Pneumonia:“Cannonball” Pneumonia

Round Pneumonia:“Cannonball” Pneumonia

Ha25

No definite abnormalitiesNo definite abnormalities

More views:More views:

Expiratory viewExpiratory view

LateralneckLateralneck

Inspiratory view Expiratory viewInspiratory view Expiratory view

Insp and Exp views look very similar = air trapping 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 afterchoking on a chocolate/almond bar

X-ray diagnosis? 17-month-old coughing afterchoking on a chocolate/almond bar

Bilateral Air Trapping

Bilateral Bronchial Foreign BodiesNuts + Choking = Bronchoscopy

Ha26

X-ray diagnosis? 18-month-old girl with fever, noisy breathing, 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)

EE VV

CC

TT

PPEpiglottis - normalVallecula - normalTrachea - slightly narrow or normalPrevertebral soft tissue (P) - wide and bulging (should be half the width of vertebral body)

PPRetropharyngeal Abscess (also called prevertebral abscess)Clinical symptoms may mimic croup.

Ha27

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


Epiglottis (E) - wide (thumb-like)Vallecula - shallowTrachea - normalPrevertebral soft tissue - normal

EEEEEpiglottis (E)Vallecula (V)

Vocal cords (C)Trachea (T)

Prevertebral soft tissue (P)

VV

CC

TT

PP

Epiglottitis

Ha28

X-ray diagnosis? 15-month-old boy with fever, mild stridor, and barking cough.


Epiglottis (E)Vallecula (V)

Vocal cords (C)Trachea (T)

Prevertebral soft tissue (P)

PP

EE VV

CC

TT

Epiglottis - normalVallecula - normalTrachea (T) - narrow, subglottic edemaPrevertebral soft tissue - normal

TT

Croup

Ha29

Swischuk line criterion: Line drawn between posterior arch of C1 and posterior arch of C3. The posterior arch of C2 should be within 1 to 2 mm of this line. Deviation from this line suggests a C2 pedicle fracture; however, this criterion is not perfect.

C2C2

C3C3

C1C1X-ray diagnosis? 6-year-old girl with mild neck pain.

No recent trauma. But she was thrown into a swimming pool 30 hours ago with no complaint of neck pain at that time. She is now brought in to the ED on a spine board.

Malalignment of C2 and C3. Is it a true subluxation or is it a pseudosubluxation?

C2C2

C3C3

C2-C3 pseudosubluxation characteristics: Minimal / mild trauma Minimal / mild pain No signs of a fracture Neck is positioned in flexion (not lordotic), often due to a spine board. Swischuk line criterion.

C2C2

C3C3

Probable C2-C3 Pseudosubluxation

Ha29

Ha30

Probable C2-C3 Pseudosubluxation

C2-C3 pseudosubluxation characteristics: Minimal / mild trauma Minimal / mild pain No signs of a fracture Neck is positioned in flexion (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.

C2C2

C3C3

C1C1

Ha30

Ha31

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

Swischuk line: satisfactoryC2C2

C3C3

C1C1

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”

Ha31

Ha32

It’s hard to see anything with this poor odontoid view. The odontoid is not visible.

X-ray diagnosis? 7-year-old boy injured his head and neck diving into shallow water.

No definite abnormalities. His collar is temporarily removed for an odontoid (open mouth) view.

This odontoid view is still useful to identify the lateral masses (ring of C1) relative to C2 as outlined here. The LMs should be directly over the base of C2.

C2C2 C2C2

C1C1 C1C1

The lateral masses are displaced outward indicating that the ring of C1 has fractured and burst open.

LMLM LMLMThis CT scan shows a Jefferson fracture (C1 ring fracture) sustained when a blow to the top of the head places a load on the long axis of the spine, bursting open the ring of C1.

Two normal odontoid views. The lateral masses of C1 are aligned with the base of C2.

LMLMC2C2

Two normal odontoid views. The lateral masses of C1 are aligned with the base of C2.

LMLM LMLMLMLM LMLM

OO

OO

C2C2 C2C2C2C2

C2C2

Jefferson Fracture (C1 ring)

Better quality open mouth (odontoid) view demonstrating a Jefferson fracture.

Ha32

Ha33

X-ray diagnosis? 9-year-old boy who fell onto his forearm. Visible forearm deformity.

Mid-ulna angulated fracture. Anything else?Mid-ulna angulated fracture. Anything else?

Radius should line up with capitellum (C). Misalignment indicates radial head dislocation.Radius should line up with capitellum (C). Misalignment indicates radial head dislocation.

CC

CC

AbnormalAbnormal

NormalNormal

Monteggia InjuryUlna fracture often results in radial head dislocation. Check radius-capitellum line confirming alignment.

Ha34

X-ray diagnosis? Elbow injury.

Elbow evaluation: High yield places to look: Posterior fat pad Anterior fat pad Anterior humerus line Radius-capitellum line Supracondylar region Radial head Olecranon

Elbow evaluation: High yield places to look: Posterior fat pad Anterior fat pad Anterior humerus line Radius-capitellum line Supracondylar region Radial head Olecranon

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

Radius-capitellum line(normal)Radius-capitellum line(normal)

OlecranonOlecranon

Anterior humerus line should bisect capitellum (+)

Anterior humerus line should bisect capitellum (+)

Supracondylar regionSupracondylar region

Radial headRadial head

Elbow Joint Effusion Probable occult supracondylar fracture.

Ha35

Posterior fat padAnterior fat padBoth unable to assess (true lateral view required)

Posterior fat padAnterior fat padBoth unable to assess (true lateral view required)

Anterior humerus line: misses capitellum (not a true lateral view)

Anterior humerus line: misses capitellum (not a true lateral view)

Radius-capitellum line: normalRadius-capitellum line: normal

Radial head: FractureRadial head: Fracture

Olecranon: OKOlecranon: OK

Supracondylar region: OKSupracondylar region: OK

X-ray diagnosis?Elbow injuryX-ray diagnosis?Elbow injury

Radial Head FractureRadial Head Fracture

Ha36

X-ray diagnosis? Elbow injuryX-ray diagnosis? Elbow injury

Supracondylar region: cortex disruptedSupracondylar region: cortex disrupted

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

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

Olecranon fossa cortex is fractured

Olecranon fossa cortex is fractured

Supracondylar FractureSupracondylar Fracture

Ha37

X-ray diagnosis? Elbow injuryX-ray diagnosis? Elbow injury

Posterior fat pad (+)Posterior

fat pad (+)

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

Radius-capitellum line is not pointing at capitellum

Radius-capitellum line is not pointing at capitellum

Olecranon fractureOlecranon fractureJoint Effusion, Olecranon Fracture,

Monteggia Injury (radial head dislocation)Joint Effusion, Olecranon Fracture,

Monteggia Injury (radial head dislocation)

Ha38

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

Tenderness is elicited

over distal radius

Tenderness is elicited

over distal radiusSalter-Harris

type 1 fracture of distal radius physis should be suspected clinically

Salter-Harris type 1 fracture of distal radius physis should be suspected clinically

dis

pla

dis

pla

no

n-d

isp

la c

edn

on

-dis

pla

cedce

dce

d

The epiphysis is displacedThe epiphysis is displaced

Displaced Salter-Harris Type 1 Fracture of the Distal Radius Physis

Displaced Salter-Harris Type 1 Fracture of the Distal Radius Physis

Ha39

Hey you !!What kind of Salter-Harris fracture type

is this??

Who ME?

M = metaphysisE = epiphysis

W h o M E ?

SH type IIMetaphysis and physis

SH type IIMetaphysis and physis

SH type IIIEpiphysis and physis

SH type IIIEpiphysis and physis

SH type IVMetaphysis and Epiphysis

SH type IVMetaphysis and Epiphysis

SH type V:Physis.Not evident on X-ray. Relies on clinical findings and history of injury mechanism.

Tender

Calcaneus fracture

Fell off 2nd floor onto her feet.

Ha40

X-ray diagnosis? 6-week-old boy with “sudden” left thigh swelling and no history of trauma.

Obvious oblique femur fracture with a thinner fracture in the distal half of the femur.

Child abuse is suspected. - A skeletal survey is ordered. - Left forearm andright tibia/fibula are shown here.

Elbow/Forearm Tib/FibElbow/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

Ha40

Ha41

X-ray diagnosis? 2 month old who is crying without apparent cause.

Obvious mid femur fracture is noted. Child abuse is suspected.

- Another view shows the oblique fracture line.

- Further questioning about trauma is negative except for bumping him against a door while carrying him in a padded infant carrier. The parents tell you that this couldn’t have been hard enough to cause a fracture.

Osteogenesis imperfecta is suspected.

Occult types tend to be autosomal dominant (family history will be positive.)

Severe lethal types tend to be recessive.

Family history:- Father: 4 fractures, 2 of which occurred with minor trauma.- PGF: 4 fractures from “playing around”- Mother: Scoliosis- 2 aunts: Scoliosis

A skeletal survey is done and no other fractures are found. The upper extremities are shown here.

Ostepenia is NOT evident.

Severe osteogenesis imperfecta.Lethal form in infancy.Severe osteopenia. Multiple rib fracturesMultiple rib fractures

Crumpled long bones at birth.

Mid femur fracture.

Osteogenesis imperfecta.

Family history of “frequent fractures” may be a useful

question in fracture patients.

Ha41

Ha42

Health & Medicine

A P L S Pediatric Emergency Radiology 1