Apls Pediatric Emergency Radiology 1
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Transcript of Apls 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
X-ray diagnosis? 11-month-old boy with vomiting.
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.
RUQ target sign.LUQ crescent sign.Absence of the subhepatic angle.
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
X-ray diagnosis? 7-month-old boy with vomiting.
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.
Bowel obstruction criteria:Gas distributionBowel distention
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.
Bowel obstruction criteria:Gas distributionBowel distention
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.
Identify the: Epiglottis Vallecula Vocal cords Trachea Prevertebral soft tissue
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.
Identify the: Epiglottis Vallecula Vocal cords Trachea Prevertebral soft tissue
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