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Hb1 Pediatric Emergency Radiology II

Apls Pediatric Emergency Radiology 2

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Text of Apls Pediatric Emergency Radiology 2

  • 1. Pediatric Emergency Radiology II


  • Objectives
  • Identify the following conditions based on x-ray findings:
  • Lobar emphysema
  • Vertebral compression fractures
  • Pneumomediastinum
  • S aureuspneumonia
  • Ingested disk battery
  • Pneumatosis intestinalis - necrotizing enterocolitis
  • Midgut volvulus
  • Abdominal abscess
  • Bowing fracture
  • Toddler fracture
  • Retropharyngeal abscess and phlegmon
  • Infant skull sutures
  • Infant skull fractures
  • Leptomeningeal cyst
  • Syphilis of the bone
  • Rickets
  • Vascular rings
  • Discitis

3. X-ray diagnosis? 2-week-old boy with respiratory distress. Tension pneumothorax was the initial interpretation. What features speak against a tension pneumothorax? No penetrating trauma, no positive pressure ventilation. No bradycardia, no hypotension. Hypoxia is modest. Congenital Lobar Emphysema Hyperexpanded left upper lobe, resembling a tension pneumothorax. This will not benefit from a chest tube. 4. 8 year old with abdominal pain for 2 weeks, back ache since yesterdays ballet practice.Multiple vertebral body compression fractures.Leukemia. X-rays repeated 8 days later. 5. 19-year-old with chest pain and grating sound on auscultation. PneumomediastinumHamman Sign Vertical air densities Air filled aorto-pulmonarywindow Air outlining the trachea (air dissection around the trachea).Vertical air densities in the mediastinum. 6. X-ray diagnosis? 6-year-old boy with fever, abdominal pain, tachypnea, suspected pneumonia. Staphylococcus AureusPneumonia Expect empyema, pneumothorax, blebs, fistula. An abdominal series is obtained. An abdominal CT scan is done: Normal appendix. Lower lung shows pleural effusion and infiltrate. His respiratory status worsens. CXR is repeated. Large right pleural effusion. What clinical entity is this most consistent with? Rapid progression of worsening. Rapid development of large pleural effusion. 7. 20-month-old girl swallowed a coin (witnessed by 5-year-old cousin). Brief coughing episode. No symptoms at this time. Ingested Disk Battery Close-up view of the coin.Is it a penny? Coin and battery lineup 8. 3 day old premie with hematemesis. Pneumatosis Intestinalis Due to Necrotizing Enterocolitis (NEC) Enlarged view:White arrows point at air dissecting within the bowel wall. Double density (railroad tracks). Air dissecting in the bowel wall. Double outlining (railroad tracks). Bubbles in the bowel wall. Obvious air dissecting within bowel wall in a term infant. 9. X-ray diagnosis? 3-month-old with bilious vomiting. This is an upper GI series using thin barium. Standard barium would demonstrate a beak sign in which the contrast stops at the gastric outlet or proximal duodenum. Midgut Volvulus Complicating a Malrotation (guts on a stalk syndrome) 10. X-ray diagnosis? 4-year-old girl w/ abdominal pain for 3 days. This separation is most likely caused by fluid (pus) on the right (from the RLQ to the liver). The black arrow points at air within this pus.Rupture appendix.Right abdominal abscess formation. Enlarged view (darken the room) Arrows point to the peritoneal fat margins which mark edge of peritoneal cavity. The bowel should be adjacent to the peritoneal fat margin as in the LLQ. Note that in the RUQ and RLQ, the bowel is separated from the peritoneal fat margin. Arrows now point to the right sided separation between the bowel and the peritoneal fat margin. Also note the scalloping of the liver edge. 11. X-ray diagnosis? 4-year-old girl who fell at the playground.Bowing Fracture of the Ulna Her forearm is swollen with a moderate deformity. 12. X-ray diagnosis? 20 month old female, refuses to stand on her right leg. No known trauma except for falling while running. Toddler Fracture (probably accidental) Another view is obtained. Thin oblique fracture of the distal tibia. White arrows point to the fracture. Black arrows point to a vascular groove. Child abuse or due to a fall? 13. X-ray diagnosis? 7 year old male with fever, sore throat, headache and neck stiffness, sent to the ED for possible meningitis.Prevertebral (retropharyngeal)abscess An LP is done: normal.Lateral neck x-ray demonstrates bulging of the prevertebral soft tissue, suspected abscess. False positives sometimes occur: Prevertebral soft tissue appears wide. Neck extension results in a normal prevertebral soft tissue appearance. Position the neck properly to avoid false positives Prevertebral soft tissue appears wide. Neck extension demonstrates persistence of the prevertebral soft tissue widening. The Step-Off sign is sometimes helpful The back of the pharynx should NOT be in line with the trachea. Note that the back of the pharynx is in line with the trachea. Normal Step-Off Abnormal: Step-Off is absent CT scanning helps to define the type of abscess Large, rim enhancement with contrast, anterior bulging. Small, no rim enhancement, no anterior bulging. True abscess Phlegmon 14. Normal Infant Skull Sutures: S=Sagittal, C=Coronal, L=lambdoidal Normal Infant Skull Sutures: C=coronal, L=lambdoidal, P=parietomastoid, O=Occipitomastoid 15. Find the skull fracture - Case 1 Right Parietal Skull Fracture 16. Find the skull fracture - Case 2Right Occipital Skull Fracture 17. Find the skull fracture - Case 3 AP views Right Occipito-parietal Skull Fracture Lateral views 18. Find the skull fracture - Case 4 AP views Depressed Skull Fracture Lateral views 19. Find the skull fracture - Case 5 Right Occipital Skull Fracture 20. AP views Find the skull fracture - Case 6 Right Parietal Skull Fracture Lateral views 21. AP views Find the skull fracture - Case 7 Parietal Skull Fracture Lateral views 22. AP views Find the skull fracture - Case 8 Biparietal Skull Fracture Lateral views 23. Case 9: 10-month-old boy fell and sustained a parietal skull fracture 3 monthsago. He is neurologically normal buthas a persistent soft area in region of fracture. Leptomeningeal Cyst (growing skull fracture) 24. 2-month-old girl who is not using her right arm today.No history of trauma. Wrist swelling noted 2 days ago. Syphilis of the Bone Destructive lytic lesions of the distal radius and ulna.Periosteal elevation of the radius and ulna. A skeletal survey is obtained. Humerus and elbows are normal. Femurs are shown here. Periosteal elevation along the length of both femurs. Both tibiae and fibulae are shown here. Periosteal elevation along the length of both tibiae. Destructive lesions of the proximal tibiae and the left fibula. 25. 2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling. Rickets (vitamin D malabsorption) Severe demineralization: Mid-radius fracture Ulnar bowing 26. 6-month-old boy with difficulty breathing. Frequent noisy breathing episodes since birth. Vascular Ring (tracheal and esophageal compression) Lateral neck radiograph is obtained.Tracheal size appears to be normal or slightly narrow. Examine the tracheal diameter on the CXR. Very narrow on the lateral view. A barium swallow identifies a mass posterior to theesophagus Vascular rings encircle the trachea and esophagus. Two common types: double aortic arch and right sided aortic arch. Examine bend of trachea near bifurcation.If it bends toward the left, this suggests a right-sided aortic arch. 27. Following coin removal, persistent stridor is noted.PMH:frequent episodes of noisy breathing since birth. X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing. Esophageal Coin With a Vascular Ring His trachea is narrow on the lateral CXR. This finding persists on a repeat CXR. An esophagram identifies a mass posterior to the esophagus. 28. X-ray diagnosis? 8-year-old boy with chief complaint of fever.On exam, he is noted to have reproducible tenderness over his upper thoracic spine. Discitis Narrowed inter- vertebral space. Repeat views taken 29.