22b radiology ii

8/14/2019 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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AP viewsLateral viewsRight Occipito-parietal Skull Fracture


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AP views

Lateral viewsDepressed Skull Fracture


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Right Occipital Skull Fracture


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AP viewsLateral views


Right Parietal Skull Fracture


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Parietal Skull Fracture


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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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22b radiology ii

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