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 base.

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 capital femoral epiphysis on the right

Some cases of SCFE are very obvious.

SCFE 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 years.

C – R – I – T – 0 - E 1 – 3 – 5 – 7 – 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 r c 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 tibia. 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 represents 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.

Impression: Osteosarcoma Bone is visible within the mass which has elevated the periosteum of both anterior and posterior cortices of the distal femur (Normal knee)

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 non- specific 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 to some insult to the vascular supply of the femur.

Keys to Remember 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

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