Apls Pediatric Emergency Radiology 1

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Text of Apls Pediatric Emergency Radiology 1

  • 1. Pediatric Emergency Radiology I

2.

  • 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

3. X-ray diagnosis? 14-month-old girl with vomiting. Identify the target sign in the RUQ again. The crescent sign is formed by the intussusceptum (lead point) protruding into a gas-filled pocket. Identify crescent sign in LUQ again. Intussusception Target sign in RUQ. Target sign in RUQ. Crescent sign in LUQ. Crescent sign in LUQ. Target sign in RUQ. Crescent sign in LUQ. Intussusception 4. X-ray diagnosis? 13-month-old boy with vomiting. The crescent sign may not be crescent shaped. The gas-filled pocket may be large, as in this case. Intussusception Ha5 Crescent sign: Note the intussusceptum lead point ascending into the hepatic flexure.Crescent sign: Note the intussusceptum lead point ascending into the hepatic flexure. 5. X-ray diagnosis? 11-month-old boy with vomiting. Bowel obstruction with right-sided mass effect: Intussusception Right image: Absence of gas in RUQ and RLQ (suggests a mass effect on right). Poor distribution of gas in general (suggests bowel obstruction). Left image: Absence of hepatic angle (suggests RUQ mass). Absence of gas in RLQ (suggests RLQ mass). Two dilated (smooth) bowel segments (suggests bowel obstruction). 6. 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 RUQ target sign. LUQ crescent sign. Absence of the subhepatic angle. RUQ target sign. LUQ crescent sign. Absence of the subhepatic angle. 7. X-ray diagnosis? 7-month-old girl with skull fracture, lethargy, and vomiting. Intussusception Possible target sign in RUQ. Paucity of bowel gas suggestive of right-sided mass and bowel obstruction. 8. X-ray diagnosis? 7-month-old girl with vomiting. Intussusception Target sign Absence of hepatic angle Paucity of gas Target sign Absence of hepatic angle. Paucity of gas. 9. X-ray diagnosis? 7-month-old boy with vomiting. SuspectedI ntussusception RUQ air fluid levels. RUQ bowel loops are smooth (bowel obstruction). Paucity of gas in RLQ. 10. X-ray diagnosis? 17-day-old boy with vomiting. Gas distribution: Good Bowel walls are smooth, hose-like: Distended Bowel Obstruction Bowel obstruction criteria: Gas distribution Bowel distention Air fluid levels Air fluid levels: On upright view Bowel Obstruction

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

11. X-ray diagnosis? 1-month-old girl spitting up. Air fluid levels: None Gas distribution: Good Normal abdominal radiographs Bowel obstruction criteria: Gas distribution Bowel distention Air fluid levels 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. 12. X-ray diagnosis? 9-day-old boy with vomiting. Gas distribution: Fair Bowel distention: No smooth walls Air fluid levels:Many, but they are all small with no J turns ( hairpin loops, candy canes ) ILEUS, No Definite Bowel Obstruction Bowel obstruction criteria: Gas distribution Bowel distention Air fluid levels 13. 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. Radiologist identifies an occult diagnosis.Congenital Dislocated Hip X-ray diagnosis?5-month-old girl discharged yesterday following barium enema reduction ofintussusception. Vomited once today. Shentons arc. A more focused view ofoccult diagnostic finding Congenital dislocated hip (CDH). Shentons arc is discontinuous. 14. 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 Slipped Capital Femoral Epiphysis (SCFE) of the Right Hip Right hip physis appears to be wide compared to the left hip. Kleins line: Superior aspect of the metaphysis to see if it intersects the epiphysis Abnormal: Line misses epiphysis Normal: Line intersects epiphysis 15. X-ray diagnosis? Bilateral SCFE Moderate slip Severe slip 16. X-ray diagnosis? 6-year-old boy with nausea and abdominal pain. Identify it again Appendicitis Fecalith (appendicolith) 17. Find the fecalith(appendicolith) 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. There are two or more potential fecaliths here This fecalith is round with a dense opaque dot in it. This fecalith is fairly large This is the last fecalith on this slide 18. X-ray diagnosis? 6-year-old boy with abdominal pain Pneumonia 19. X-ray diagnosis? 15-month-old boy with fever, coughing, tachypnea. LLL & RML Pneumonia RML infiltrate LLL infiltrate 20. X-ray diagnosis? 2 month old with a VSD presents with recurrent seizures. VSD, Thymic, & Parathyroid Aplasia: DiGeorge Syndrome Cardiomegaly (CHF) No thymic shadow Hypocalcemia found on labs X-ray diagnosis? 2 month old with a VSD presents with recurrent seizures. Normal thymus shadows in young infants Cardiomegaly (CHF) No thymic shadow Normal newborn thymus occupies the space anterior to the heart 21. X-ray diagnosis? Ventilated infant with sudden deterioration PneumopericardiumRevealing the Thymus Sail Sign Air in pericardium reveals shape of infant thymus. 22. X-ray diagnosis? 6-month-old boy with cough and congestion. No fever. O 2Sat 100% on room air. Prominent Thymus Partially Obscuring a RUL Infiltrate: Pneumonia Normal newborn thymus occupies space anterior to heart Prominent asymmetric thymus Infiltrate 23. X-ray diagnosis? 18-month-old girl with mild BPD (former premie). Presents with fever, cough, dyspnea. RML Atelectasis RML atelectasis 24. X-ray diagnosis? 9-year-old boy withfever, headache, nausea, and coughing. Round Pneumonia: Cannonball Pneumonia Round infiltrate. Spherical consolidation. 25. No definite abnormalities X-ray diagnosis? 17-month-old coughing after choking on a chocolate/almond bar Bilateral Air Trapping Bilateral Bronchial Foreign Bodies Nuts + Choking = Bronchoscopy More views: Expiratory view Lateral neck Inspiratory viewExpiratory view 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. 26. X-ray diagnosis?18-month-old girl with fever, noisy breathing, and barking cough. Identify the: Epiglottis Vallecula Vocal cords Trachea Prevertebral soft tissue Retropharyngeal Abscess(also called prevertebral abscess) Clinical symptoms may mimic croup. Epiglottis (E) Vallecula (V) Vocal cords (C) Trachea (T) Prevertebral soft tissue (P) E V C T P Epiglottis - normal Vallecula - normal Trachea - slightly narrow or normal Prevertebral soft tissue (P) - wide and bulging (should be half the width of vertebral body) P 27. X-ray diagnosis?2-year-old boy with fever, stridor, tripoding and NO cough. Identify the: Epiglottis Vallecula Vocal cords Trachea Prevertebral soft tissue Epiglottitis Epiglottis (E) -wide (thumb-like) Vallecula - shallow Trachea - normal Prevertebral soft tissue - normal E E Epiglottis (E) Vallecula (V) Vocal cords (C) Trachea (T)Prevertebral soft tissue (P) V C T P 28. X-ray diagnosis?15-month-old boy with fever, mild stridor, and barking cough. Identify the: Epiglottis Vallecula Vocal cords Trachea Prevertebral soft tissue Croup Epiglottis (E) Vallecula (V) Vocal cords (C) Trachea (T)Prevertebral soft tissue (P) P E V C T Epiglottis - normal Vallecula - normal Trachea (T) - narrow, subglottic edema Prevertebral soft tissue - normal T 29. X-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. Probable C2-C3 Pseudosubluxation 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. C2 C3 C1 Malalignment of C2 and C3. Is it a true subluxation or is it a pseudosubluxation? C2 C3 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. C2 C3 30. 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.Ha30 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. C2 C3 C1 31. X-ray diagnosis? 7-year-old girl unrestrained in a car crash brought in on a spine board.Fracture of the C2 Pedicle Hangman Fracture Ha31 Swischuk line: satisfactory C2 C3 C1 Fracture of C2 pedicle: Despite a satisfactory Swischuk line. There is very slight subluxation of C2 on C3 due to the fracture. 32. 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. Jefferson Fracture (C1 ring) Ha32 Its hard to see anything with this poor odontoid view. The odontoid is not visible. 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. C2 C2 C1 C1 The lateral masses are displaced outward indicating that the ring of C1 has fractured and burst open. LM LM This 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. LM C2 Two normal odontoid views. The lateral masses of C1 are aligned with the base of C2. LM LM LM LM O O C2 C2 C2 C2 Better quality open mouth (odontoid) view demonstrating a Jefferson fracture. 33. X-ray diagnosis? 9-year-old boy who fell onto his forearm. Visible forearm deformity. Mid-ulna angulated fracture.Anything else? Monteggia Injury Ulna fracture often results in radial head dislocation. Check radius-capitellum line confirming alignment. Radius should line up with capitellum (C). Misalignment indicates radial head dislocation. C C Abnormal Normal 34. 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 Joint Effusion Probable occult supracondylar fracture. Anterior fat pad (+) Posterior fat pad (+) Radius-capitellum line (normal) Olecranon Anterior humerus line should bisect capitellum (+) Supracondylar region Radial head 35. X-ray diagnosis? Elbow injury Radial Head Fracture Posterior fat pad Anterior fat pad Both unable to assess (true lateral view required) Anterior humerus line: misses capitellum (not a true lateral view) Radius-capitellum line: normal Radial head: Fracture Olecranon: OK Supracondylar region: OK 36. X-ray diagnosis? Elbow injury Supracondylar Fracture Supracondylar region: cortex disrupted Posterior fat pad (+) Anterior fat pad (+) Olecranon fossa cortex is fractured 37. X-ray diagnosis? Elbow injury Joint Effusion, Olecranon Fracture, Monteggia Injury (radial head dislocation) Posterior fat pad (+) Anterior fat pad (+) Radius-capitellum line is not pointing at capitellum Olecranon fracture 38. X-ray diagnosis? 10-year-old boy, wrist injury Displaced Salter-Harris Type 1 Fracture of the Distal Radius Physis Tenderness is elicited over distal radius Salter-Harris type 1 fracture of distal radius physis should be suspected clinically displa non-displa ced ced The epiphysis is displaced 39. Hey you !! What kind of Salter-Harris fracture type is this?? Who ME? M = metaphysis E = epiphysis WhoME ? SH type II M etaphysis and physis SH type III E piphysis and physis SH type IV Metaphysis 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. 40. X-ray diagnosis?6-week-old boy with sudden left thigh swelling and no history of trauma. Severe femur fracture without explanation. Older forearm and tibia fractures. Child Abuse Ha40 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 and right tibia/fibula are shown here. Elbow/ForearmTib/Fib Proximal radius fracture with periosteal elevation (hard to see). Healing tibia fracture with periosteal elevation. 41. X-ray diagnosis?2 month old who is crying without apparent cause. Osteogenesis imperfecta is suspected. Occult types tend to be autosomal dominant (family history will be positive.) Severe lethal types tend to be recessive. Mid femur fracture. Osteogenesis imperfecta. Family history of frequent fractures may be a useful question in fracture patients. Ha41 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 couldnt have been hard enough to cause a fracture. 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 fractures Crumpled long bones at birth. 42.