22a radiology i
TRANSCRIPT
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Pediatric Emergency Radiology I
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ObjectivesIdentify the following conditions based on x-ray findings:
Intussusception Bowel obstruction
Congenital hipdislocation
Slipped capital femoralepiphysis
Pneumonia
Thymus shadow
Appendicitis fecaliths
Bronchial foreign body
Croup
Epiglottitis Retropharyngeal abscess
C-spinepseudosubluxation
Hangman fracture Jefferson fracture
Elbow fractures
Monteggia injury
Salter-Harris fractures Child abuse
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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.
CrescentCrescent
sign in LUQ.sign in LUQ.
The crescent sign is
formed by the
intussusceptum (leadpoint) protruding into
a gas-filled pocket.
Identify crescent sign
in LUQ again.
CrescentCrescent
sign in LUQ.sign in LUQ.
Target signTarget sign
in RUQ.in RUQ.
CrescentCrescent
sign in LUQ.sign in LUQ.IntussusceptionIntussusception
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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
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X-ray diagnosis? 11-month-old boy with vomiting.
Bowel obstruction with right-sided masseffect: Intussusception
Right image:Right image:
Absence of gas inAbsence of gas in
RUQ and RLQRUQ and RLQ
(suggests a mass(suggests a masseffect on right).effect on right).
Poor distributionPoor distribution
of gas in generalof gas in general
(suggests bowel(suggests bowelobstruction).obstruction).
Left image:Left image:Absence of hepaticAbsence of hepatic
angle (suggests RUQangle (suggests RUQ
mass). Absence ofmass). Absence of
gas in RLQ (suggestsgas in RLQ (suggestsRLQ mass). TwoRLQ mass). Two
dilated (smooth)dilated (smooth)
bowel segmentsbowel segments
(suggests bowel(suggests bowel
obstruction).obstruction).
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X-ray diagnosis?
11-month-old girl
with vomiting.
Identify the target
and crescent signs
again.
RUQ target sign.
LUQ crescent sign.
Absence of thesubhepatic angle.
RUQ target sign.
LUQ crescent sign.
Absence of thesubhepatic angle.
RUQ target sign.
LUQ crescent sign.
Absence of the
subhepatic angle.
Intussusception
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X-ray diagnosis? 7-month-old girl with skull fracture,
lethargy, and vomiting.
Possible
target sign
in RUQ.Paucity of
bowel gas
suggestiveof right-
sided mass
and bowel
obstruction.
Intussusception
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X-ray diagnosis? 7-month-old girl with vomiting.
Target signTarget sign
Absence ofAbsence of
hepatic angle.hepatic angle.
Paucity of gas.Paucity of gas.
IntussusceptionIntussusceptionTarget signTarget sign
Absence of hepaticAbsence of hepatic
angleanglePaucity of gasPaucity of gas
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X-ray diagnosis? 7-month-old boy with vomiting.
Suspected
IntussusceptionRUQ air fluidRUQ air fluidlevels. RUQlevels. RUQbowel loopsbowel loopsare smoothare smooth
(bowel(bowelobstruction).obstruction).
Paucity ofPaucity ofgas in RLQ.gas in RLQ.
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X-ray diagnosis? 17-day-old boy with vomiting.
Bowel obstruction criteria:
Gas distribution
Bowel distention
Air fluid levels
Gas distribution: GoodBowel walls are smooth, hose-like: DistendedAir fluid levels: On upright viewBowel ObstructionBowel Obstruction
Bowel obstruction ddx: AIM A: Adhesions, appendicitis I: Intussusception, incarcerated
inguinal hernia M: Malrotation (midgut volvulus),
Meckels
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X-ray diagnosis? 1-month-old girl spitting up.
Bowel obstruction criteria:
Gas distribution
Bowel distention
Air fluid levels
Air fluid levels: NoneGas distribution: GoodNormal abdominal radiographsBowel distention: Lots of gas, but no distention.
Haustra and plicaeare preserved. Lookslike bag of popcorn,instead of bag ofsausages. Bowel wallsare NOT smooth
(hose-like).Distention criterion ismore related tosmoothness of bowel
walls rather thanvolume of gas.
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X-ray diagnosis? 9-day-old boy with vomiting.
Bowel obstruction criteria:
Gas distribution
Bowel distention
Air fluid levels
Gas distribution: FairBowel distention: No smooth walls
Air fluid levels: Many, but they are allsmall with no J turns (hairpin loops,candy canes)
ILEUS, No Definite Bowel Obstruction
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X-ray diagnosis? 5-month-oldgirl discharged yesterdayfollowing barium enema
reduction of
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.
Shentons arc.
A more
focusedview of
occult
diagnosticfinding
Congenital dislocated hip (CDH).
Shentons arc is discontinuous.Congenital Dislocated Hip
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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.
X-ray diagnosis? 10-year-old obese
boy with right thigh and knee pain
Kleins line: Superior aspect of the
metaphysis to see if it intersects the
epiphysis
Abnormal: Linemisses epiphysis
Normal: Lineintersects
epiphysis
Slipped Capital Femoral Epiphysis
(SCFE) of the Right Hip
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X-ray diagnosis?
Moderate slip
Severe slip
Bilateral SCFE
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X-ray diagnosis? 6-year-old boy with nausea andabdominal pain.
Fecalith
(appendicolith)Identify it
again
Appendicitis
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Fecaliths
can varyinappeara
nce.
This oneis small
and
opaque.
This
fecalithis faintand
oval inshape
Thisfecalith can
be seenfaintly in
the
radiographof the
appendix
specimen. It
There
aretwo ormore
potential
fecaliths
here
This
fecalith isroundwith a
denseopaque dot
in it.
This
fecalith isfairlylarge
This
is thelastfecalith on
thisslide
Find thefecalith
(appendicolith)
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X-ray diagnosis? 6-year-old boy with abdominal pain
Pneumonia
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X-ray diagnosis? 15-month-old boy
with fever, coughing, tachypnea.
RML
infiltrate
LLL
infiltrate
LLL & RML
Pneumonia
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X-ray
diagnosis?
2 month old
with a VSDpresents 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 VSDpresents with
recurrent
seizures.
Normal thymus shadows
in young infants
Cardiomegaly
(CHF)
No
thymic
shadow
Normal
newborn
thymus
occupies the
space anterior
to the heart
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X-ray
diagnosis?
Ventilated
infant withsudden
deterioration
Air in
pericardium
reveals shape of
infant thymus.
PneumopericardiumRevealing the Thymus
Sail Sign
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X-ray diagnosis? 6-month-old boy with cough andcongestion. No fever. O2 Sat 100% on room air.
Normalnewborn
thymus
occupiesspace
anterior toheart
Prominentasymmetric thymus
InfiltrateInfiltrate
Prominent Thymus Partially
Obscuring a RUL Infiltrate:
Pneumonia
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X-ray diagnosis? 18-month-old girl with mild BPD(former premie). Presents with fever, cough, dyspnea.
RML atelectasis
RML
Atelectasis
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X-ray diagnosis? 9-year-old boy withfever, headache, nausea, and coughing.
Round infiltrate.
Spherical consolidation.
Round
Pneumonia:
Cannonball
Pneumonia
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No definite abnormalities
More views:
Expiratory view
Lateral
neck
Inspiratory view Expiratory 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.
X-ray diagnosis? 17-month-old coughing after
choking on a chocolate/almond bar
Bilateral Air Trapping
Bilateral Bronchial Foreign BodiesNuts + Choking = Bronchoscopy
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X-ray diagnosis?18-month-old girlwith fever, noisybreathing, 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)
E V
C
T
PEpiglottis - normal
Vallecula - normal
Trachea - slightly
narrow or normalPrevertebral soft
tissue (P) - wide
and bulging (should
be half the width ofvertebral body)
PRetropharyngeal
Abscess
(also calledprevertebral
abscess)Clinical symptoms
may mimic croup.
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X-ray diagnosis?2-year-old boy withfever, stridor,tripoding and NO
cough.
Identify the:
Epiglottis
Vallecula
Vocal cords
Trachea
Prevertebral soft
tissue
Epiglottis (E) -
wide (thumb-like)
Vallecula - shallow
Trachea - normalPrevertebral soft
tissue - normal
EEEpiglottis (E)
Vallecula (V)
Vocal cords (C)
Trachea (T)Prevertebral soft
tissue (P)
V
C
T
P
Epiglottitis
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X-ray diagnosis?15-month-old boy withfever, mild stridor, andbarking cough.
Identify the:
Epiglottis
ValleculaVocal cords
Trachea
Prevertebral soft tissue
Epiglottis (E)
Vallecula (V)
Vocal cords (C)
Trachea (T)
Prevertebral soft tissue (P)
P
E V
C
T
Epiglottis - normal
Vallecula - normalTrachea (T) - narrow,
subglottic edema
Prevertebral soft tissue -
normal
T
Croup
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Probable C2-C3Pseudosubluxation
C2-C3 pseudosubluxation
characteristics:
Minimal / mild trauma Minimal / mild pain No signs of a fracture Neck is positioned inflexion (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.
C2
C3
C1
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X-ray diagnosis? 7-year-old
girl unrestrained in a car
crash brought in on a spine
board.
Swischuk line: satisfactoryC2
C3
C1
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
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X-ray diagnosis? 9-year-old
boy who fell onto his
forearm. Visible forearm
deformity.
Mid-ulna angulated fracture.
Anything else?
Radius should line up with capitellum (C).
Misalignment indicates radial head dislocation.
C
C
Abnormal
Normal
Monteggia Injury
Ulna fracture often
results in radial headdislocation. Check
radius-capitellum line
confirming alignment.
S d l i
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X-ray diagnosis?
Elbow injury.
Elbow evaluation:
High yield places to look:
Posterior fat padAnterior fat pad
Anterior humerus line
Radius-capitellum line
Supracondylar regionRadial head
Olecranon
Anterior fat pad (+)
Posterior fat pad (+)
Radius-capitellum line
(normal)
Olecranon
Anterior
humerus
line should
bisectcapitellum
(+)
Supracondylar region
Radial head
Elbow Joint Effusion
Probable occult
supracondylar fracture.
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Posterior fat padAnterior fat padBoth unable to
assess (truelateral viewrequired)
Anterior humerus line:
misses capitellum
(not a true lateral view)
Radius-capitellum line:normal
Radial head:
Fracture
Olecranon: OK
Supracondylar region:
OK
X-ray diagnosis?
Elbow injury
Radial Head
Fracture
Ol
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X-ray diagnosis? Elbow injury
Supracondylar region:
cortex disrupted
Posteriorfat pad (+)
Anterior
fat pad (+)
Olecranon
fossa cortex
is fractured
Supracondylar Fracture
A t i
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X-ray diagnosis? Elbow injury
Posteriorfat pad (+)
Anterior
fat pad (+)
Radius-capitellum
line is not pointing
at capitellum
Olecranonfracture
Joint Effusion, Olecranon Fracture,
Monteggia Injury (radial head dislocation)
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X-ray diagnosis? 10-year-old boy, wrist injury
Tenderness
is elicited
over distal
radiusSalter-Harristype 1
fracture of
distal radius
physisshould be
suspected
clinically
disp
la
no
n-dis
pla
ced
ce
d
The epiphysis is displaced
Displaced Salter-Harris Type 1 Fracture of the
Distal Radius Physis
S
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Hey you !!
What kind of
Salter-Harrisfracture type
is this??
Who ME?
M = metaphysis
E = epiphysis
W h o M E ?
SH type II
Metaphysisand physis
SH type III
Epiphysis
and physis
SH type IV
Metaphysis
andEpiphysis
SH type V:
Physis.
Not evident on
X-ray. Relies onclinical
findings and
history of
injury
mechanism.
Tender
Calcaneus fracture
Fell off 2nd floor onto
her feet.
X di i ?
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X-ray diagnosis?
6-week-old boy
with sudden
left thigh swelling
and no history of
trauma.
Obvious oblique
femur fracturewith 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/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
X di i ?
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X-ray diagnosis?
2 month old who is
crying without
apparent cause.
Obvious mid
femur fracture is
noted. Child
abuse issuspected.
- Another view shows theoblique fracture line.
- Further questioning abouttrauma is negative exceptfor bumping him against adoor while carrying him in apadded infant carrier. Theparents tell you that thiscouldnt have been hardenough to cause a fracture.
Osteogenesis imperfecta is
suspected.
Occult types tend to be autosomaldominant (family history will be
positive.)
Severe lethal types tend to be
recessive.
Family history:- Father: 4fractures, 2 ofwhich occurredwith minortrauma.- PGF: 4
fractures fromplayingaround- Mother:
Scoliosis- 2 aunts:
A skeletalsurvey isdone
and nootherfracturesare
found.Theupperextremitie
s areshownhere.
Severeosteogenesis
imperfecta.Lethalform in
infancy.Severeosteopenia.
Multiple rib fractures
Crumpledlong bonesat birth.
Mid femur fracture.
Osteogenesis imperfecta.
Family history of frequent
fractures may be a useful
question in fracture patients.
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