Transcript Pediatric Radiology

Pediatric Radiology
A Case Study Approach
Bucky Boaz, ARNP
Case 1: Chest
• This is a 6-week old male infant. His
parents brought him to the E.D.
because of coughing and congestion.
He had a 20 minute episode of frequent
coughing, but now seems to be better.
He is feeding well. There is no history of
fever or cyanosis. His vital signs are
normal. Oxygen saturation is 100% in
room air. Auscultation is clear.
The upper mediastinum shows the usual prominent
thymus for this age.
Impression: Normal Chest x-ray
Case 2: Chest
• 15-month old male with fever, coughing,
and tachypnea
Bilateral central pulmonary infiltrates, but most marked
in the right middle and left lower lobes.
Impression: Right middle and left lower lobe infiltrates
Case 3: Chest
• 3 year old female whose parents do not
speak English well. Her chief complaint is
coughing and difficulty breathing. There
is mild bilateral stridor on exam. Her
cough sounds slightly bronchospastic,
but not barking in nature.
No infiltrates are noted. The right side is more
lucent (darker)compared to the left. The right
hemidiaphragm is slightly higher than the left,
however it should be higher than this.
Impression: Right sided hyperexpansion
• More clinical history through a translator
indicated that she was jumping on a bed
while eating some food (thought to be
meat), when she began choking. Since
that time, she has experienced
respiratory difficulty. Further
radiographs revealed bilateral air
trapping. Bronchoscopy revealed
bilateral bronchial peanut fragment
foreign bodies
Case 4: Chest
• A 3-month old female with fever and
coughing.
There is a faintly visible infiltrate in the right
upper lobe. Subtle findings may be more difficult
to appreciate on dark films.
Impression: Right upper lobe infiltrate.
Case 5: Chest
• This is an 11-year old female with a
history of fever and coughing for 5 days.
VS T39.1 (oral), P122, R 20, BP 107/76.
Oxygen saturation 99% in room air.
Auscultation is significant for moist
rhonchi in the left base.
There is a patchy infiltrate at the left lung base.
This is seen on the lateral view obliquely over the
heart and on the PA view as haziness in the left
lower lung.
Impression: Patchy area of consolidation at the left lung b
The prominence of the right perihilar region is probably
due to rotation. Note the asymmetry of the spinal column
and the ribs. This rotation exposes more of the right hilum
in the radiograph, making it appear more prominent.
Case 6: Chest
• This is a 9-year old male with a history
of fever, headache, nausea, and
coughing.
There is a circular density in the right lung. This is
the superior segment of the right lower lobe. Although
this has the appearance of a mass, it is most likely an
infectious process.
Impression: Spherical consolidation in the right
lower lobe (round pneumonia).
Case 7: Ortho
• This is a large 10-year old male who
presents to the acute care clinic with a
two week history of right thigh and knee
pain. He states that the pain is mainly in
his thigh (points to his upper thigh) but
radiates down to his knee. He was
playing basketball when he collided with
another player and fell.
Physical Exam
• Right lower extremity: Moderate
tenderness in the upper anterior thigh.
Severely tender in the hip. Pubic
symphysis non tender. Mid thigh and
knee non-tender. Tibia/fibula and foot
non-tender. No joint swelling noted.
Range of motion about the hip is not
done. Range of motion of the right knee
is good.
A common pitfall is to focus on the patient's chief complaint.
In this case, focusing on the thigh may lead one to focus on the
mid thigh and ignore the hip. His exam clearly points to his hip
as the source of his pain.
The history of his collision and fall suggests an acute
injury
such as a non-displaced fracture.
Impression: His hip radiographs show a slipped capita
femoral epiphysis on the right
Some cases of SCFE are very obvious.
SCFE
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Most SCFE patients prefer to keep their hip
externally rotated
A major clinical finding in SCFE is their inability to
fully internally rotate their hip
In subtle cases, the epiphyseal plate (physis) may
be widened or irregular compared to the normal
side
In other subtle cases, the physis may appear to be
thinner than the normal side
Treatment is largely the responsibility of the
orthopedic surgeon
Case 8: elbow
• 3 yr male with complaints of right elbow
pain after falling off bed while jumping.
Now guarding elbow. Refusing range of
motion
C-R-I-T-O-E
• The mnemonic of the order of
appearance of the individual ossification
centers is C-R-I-T-O-E: Capitellum,
Radial head, Internal (medial)
epicondyle, Trochlea, Olecranon,
External (lateral) epicondyle.
• The ages at which these ossification
centers appear are highly variable, but
as a general guide, remember 1-3-5-7-
C–R–I–T–0-E
1 – 3 – 5 – 7 – 9 - 11
Knowing the C-R-I-T-O-E mnemonic is helpful in determining
whether a small piece of bone about the elbow joint represents an
avulsion fragment or an ossification center.
c
c
r
r
Both anterior fad pad (with sail sign) and posterior fat
pads are present.
Impression: No visible fracture. Possible radial head fracture
Case 9: Ortho
• 14-year old male with an ankle injury.
AP, mortise, and lateral views are displayed. There is a vertical
lucency through the distal tibial epiphysis extending from the
physis to the mortise joint space.
Impression: Salter Harris Type III fracture of the distal tib
Tillaux Fracture
Case 10: Ortho
• This is a 3-year old female who
sustained an inversion injury while
running downhill. She is limping and has
tenderness over her lateral malleolus.
There are no definite bony abnormalities seen on these radiographs
• On closer examination, her pain is
mostly over the fibular physis rather
than the tip of the fibula. Because of
this, she is suspected as having a Salter
Harris Type I fracture through the fibular
physis or the fracture of the fibular
metaphysis. She is placed in a splint
and is followed clinically.
Case 11: Ortho
• This is a 4 year old female who
presents to the emergency department
with a forearm injury after falling off the
jungle gym (playground bars) at the
park. Her mother noted that her forearm
was deformed and she was complaining
of persistent pain. She denies trauma or
pain elsewhere.
Radiographs of her left forearm
Although there is an obvious deformity of her forearm on exam,
no fracture is evident here. Her elbow does not demonstrate a
joint effusion and her radial head is of normal contour and is
well aligned with the capitellum
Note the curvature of the ulna which is excessive. This represent
a "bowing fracture" of the ulna.
View comparison of the other forearm.
Arrows point to the bowing deformity of the ulna.
Case 12: Ortho
• A 16 year old girl presents with increasing
knee pain and posterior swelling.
Bone is visible within the mass which has elevated the periosteum
of both anterior and posterior cortices of the distal femur
(Normal knee)
Impression: Osteosarcoma
Case 13: Ortho
• A 2 year old boy falls out of bed and
afterward refuses to use his right hand.
Impression: There is a buckle fracture of both the distal
radius and ulna. The fractures are not displaced.
Case 14: Ortho
• This is a 6-year old male who presents with a
chief complaint of a limp which began 6
months ago. There is no history of trauma,
fever, swelling or pain. Recently, he began
complaining of right hip pain and the limping
became more noticeable. He was seen by
his physician on two occasions in the last six
months for this complaint. Mother was
advised to administer ibuprofen on both visits.
He was diagnosed as having toxic synovitis of
the hip joint on the first encounter and a nonspecific soft tissue injury at the second visit.
The right hip (left on the image) shows widening of the
joint space. The femoral epiphysis is fragmented and flattened
The physis appears narrow. The femoral neck is short and
wide (Coxa magna). There is flattening of the femoral
capitellum (Coxa plana).
Impression: Avascular necrosis (AVN) of the femoral head
may be idiopathic (Legg-Calve-Perthe's Disease) or due
some insult to the vascular supply of the femur.
Keys to Remember
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Evaluate quality of film, if poor, repeat
Always think 3D
Look for clues (fat pads, comparison views)
When clinically you think fracture, splint
and refer to ortho
WebSite for Practice
• http://www2.hawaii.edu/medicine/pediatrics
/pemxray/pemxray.html