22b Radiology II
Transcript of 22b Radiology II
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Pediatric Emergency Radiology II
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ObjectivesIdentify the following conditions based on x-ray findings:
Lobar emphysema
Vertebral compressionfractures
Pneumomediastinum
S aureus pneumonia
Ingested disk battery Pneumatosis
intestinalis - necrotizingenterocolitis
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
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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.
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8 year old with
abdominal
pain for 2
weeks, backache since
yesterdays
ballet practice.
X-rays repeated
8 days later.
Multiple
vertebral
body
compressionfractures.
Leukemia.
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Vertical air
densities
Air filled
aorto-
pulmonarywindow
Air outlining the trachea
(air dissection around
the trachea).
Vertical air densities in
the mediastinum.
19-year-old with chest
pain and grating
sound on
auscultation.
Pneumomediastinum
Hamman Sign
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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 thismost
consistent
with?
Rapid progression of worsening.
Rapid development of large pleural effusion.
X-ray diagnosis? 6-year-old boy with fever, abdominal
pain, tachypnea, suspected pneumonia.
Staphylococcus Aureus Pneumonia
Expect empyema, pneumothorax, blebs, fistula.
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Close-up view
of the coin.Is it a penny?
20-month-old girl swallowed a
coin (witnessed by 5-year-old
cousin). Brief coughing episode.
No symptoms at this time.
Coin and battery lineup
Ingested
Disk
Battery
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Enlarged view:
White arrows point
at air dissecting
within the bowelwall. Double density
(railroad tracks).
3 day old premie
with hematemesis.
Air dissecting in
the bowel wall.
Double outlining
(railroad tracks).
Bubbles in thebowel wall.
Obvious air
dissecting within
bowel wall in a
term infant.
Pneumatosis
Intestinalis
Due toNecrotizing
Enterocolitis
(NEC)
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This is an upper GI
series using thin
barium.
Standard barium would
demonstrate a beak
sign in which thecontrast stops at the
gastric outlet or
proximal duodenum.
X-ray diagnosis? 3-month-old with bilious vomiting.
Midgut Volvulus
Complicating a Malrotation
(guts on a stalk syndrome)
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X-ray diagnosis? 4-year-old girl w/ abdominal pain for 3 days.
Enlarged view
(darken the room)
Arrows point to the peritoneal
fat margins which mark edgeof peritoneal cavity. The bowel
should be adjacent to the
peritoneal fat margin as in the
LLQ. Note that in the RUQ andRLQ, 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.
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.
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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.
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Another view is
obtained.
X-ray diagnosis?
20 month old
female, refuses to
stand on her rightleg. No known
trauma except for
falling while
running.
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?
Toddler Fracture
(probably accidental)
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X-ray diagnosis?
7 year old male with
fever, sore throat,
headache and neckstiffness, sent to the
ED for possible
meningitis.
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 abscessPhlegmon
Prevertebral
(retropharyngeal)
abscess
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Normal Infant
Skull Sutures:S=Sagittal,
C=Coronal,
L=lambdoidal
Normal Infant Skull Sutures:
C=coronal, L=lambdoidal, P=parietomastoid,
O=Occipitomastoid
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Right Parietal Skull Fracture
Find the skull fracture - Case 1
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Find the skull
fracture - Case 2
Right Occipital Skull Fracture
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Find the skull fracture - Case 3
AP viewsLateral viewsRight Occipito-parietal Skull Fracture
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Find the skull fracture - Case 4
AP views
Lateral viewsDepressed Skull Fracture
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Find the skull fracture - Case 5
Right Occipital Skull Fracture
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AP viewsLateral views
Find the skull fracture - Case 6
Right Parietal Skull Fracture
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AP viewsLateral views
Find the skull fracture - Case 7
Parietal Skull Fracture
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AP viewsLateral views
Find the skull fracture - Case 8
Biparietal Skull Fracture
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Case 9:
10-month-old
boy fell and
sustained aparietal
skull fracture
3 months
ago. He isneurologically
normal but
has a
persistent soft
area in
region of
fracture.
Leptomeningeal Cyst
(growing skull fracture)
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Destructive lytic lesions of the distal radius and ulna.
Periosteal elevation of the radius and ulna.
2-month-old girl who is not using her right arm today.
No history of trauma. Wrist swelling noted 2 days ago.
A skeletal survey is
obtained. Humerus and
elbows are normal.
Femurs are shown here.
Periosteal elevationalong the length of
both femurs.
Both tibiae and fibulae
are shown here.
Periosteal elevationalong the length of both
tibiae. Destructive
lesions of the proximal
tibiae and the left fibula.
Syphilis of
the Bone
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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
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6-month-old boy with difficulty breathing.
Frequent noisy breathing episodes since birth.
Lateral
neck
radiograph
is obtained.Tracheal
size
appears to
be normalor slightly
narrow.
Examine
the
tracheal
diameteron the
CXR.
Very
narrow
on the
lateralview.
A barium
swallow
identifies
a mass
posterior
to the
esopha
gus
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.
Vascular Ring(tracheal and esophageal
compression)
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Following coin removal, persistent stridor is noted.
PMH: frequent episodes of noisy breathing since birth.
His trachea is narrow on the lateral CXR.
This finding persists on a repeat CXR.
An esophagram
identifies a mass
posterior to theesophagus.
X-ray diagnosis? 10-month-old boy who swallowed a coin
presents with noisy breathing.
Esophageal Coin
With a Vascular Ring
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Narrowedinter-
vertebral
space.
Repeat views taken
X-ray diagnosis?
8-year-old boy
with chiefcomplaint of
fever.
On exam, he is
noted to havereproducible
tenderness over
his upper
thoracic spine.
Discitis
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