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Many Instructors verbally describe these as things students will be enabled to do as a result of engaging in the workshop.

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Explicitly ask this, so learners are prompted to and are made comfortable to name their knowledge gaps. Note these down. This prepares facilitator to focus on unmet learner needs as the Workshop unfolds.

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(Allow short discussion, but don’t linger too very long, as the slide that follows graphically clarifies why)

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Here we have graphed Age at Exposure on the X-axis against Cancer risk (Lifetime Attributable Risk) from radiation on the Y-axis.

Q: How much greater is the risk of radiation induced cancer from medical imaging for a newborn compared to the risk for a 50 year old? (give just a moment for them to work this out from graph) A: About five times greater. 500%. That is a LOT.

Q: Why do you think this is true? A: First, children are rapidly growing creatures, so larger fractions of their cells are rapidly dividing (by mitosis). Second, children have much longer to live, and thus they have more “Latency periods” for cancer induction to occur. If the latency period for a radiation induced neoplasm is 20 years, the child is likely to survive to grow that cancer, whereas an 80 year old exposed to the same radiation is not likely to survive long enough for the cancer to develop.

We have to be especially careful when we consider to use imaging with radiation in children. Sobering… Makes you want to use Ultrasound or MR for everything, but that isn’t always best…

ICRP, 1991. 1990 Recommendations of the International Commission on Radiological Protection. ICRP Publication 60. Ann. ICRP 21 (1-3).

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While females have a higher life-time attributable risk of cancer than males at all ages, the difference is greatest in children. Young girls have nearly 2x the Lifetime Attributable Risk (LAR) of cancer from medical imaging radiation than young boys.

Q: How will you ensure the imaging you order for the pediatric patients in your care doesn’t add to the cancer burden needlessly? A: (let them discuss briefly and then see next slide)

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So, we have some resources to help us Image gently and wisely select studies, and we must use those to insure best practice for our youngest patients.

Let’s look at how the ACR Appropriateness Criteria can guide us by applying it to important pediatric clinical cases.

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Q: What do you think?Q: What diagnoses are you considering, from most to least severe? A: volvulus/malrotation, sepsis, gastroenteritis, metabolic disorders, reflux/overfeedingQ: What questions do you need to answer to refine dx? A: What color is the vomitus (i.e. Bilious or non-bilious?) is it a little bit of spit up or a lot? Is it reflux? How much is being fed? What is his feeding? (…Let learners know that vomitus is Greenish in color)Q: What do you think should be done?Q: How will you find this out, if you don’t have the answer at your fingertips?

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ACR Appropriateness Criteria provides widely accepted “Best-Practice” clinical decision support guidelines. So click on Basic view

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This opens a list of disease “Categories”, one of which is PEDIATRICS. Then within the broad “Category” of Pediatrics, we choose the “Clinical Topic”, in this case, “Vomiting in Infants up to 3 months of age”

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So let’s return to our baby with the bilious vomiting… Most appropriate initial exam is abdominal radiograph.

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Task: Compare this normal radiograph to our patient’s radiograph.Q: What do you notice? A: The normal diffuse polygonal pattern of gas is seen in the normal neonate’s bowel. Much less gas in our patient .Q: Are you satisfied with the NG placement? A: Our patient’s NG is within the lumen of gastric body. NG is the reason we DO NOT see the classic “Double Bubble” in this case.Q: What is the next step? A: Well, the baby got an ultrasound of the pylorus.Q: Do you think Ultrasound was the best step for an 8 day old with bilious vomiting. A: No, not an appropriate exam, and doing the US introduced another couple hours of delay to get the needed exam. Pylorus was normal.Q: What is the appropriate next imaging for this baby? A: UGIQ: When? How urgent is this? A: Emergent.Q: What diagnosis are you considering? A: Malrotation and volvulus.

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Task: Compare the Normal Upper GI and the Upper GI in our baby.Q: Is our baby’s UGI normal? Why or why not? (Discussion continues on next slide…)Q: What do you think of the position of the duodenal-jejunal junction? A: It is NOT in the normal location. (normal 2nd portion of duodenum courses posteriorly in retroperitoneum and location of the duodenojejunal junction is at the level of the inferior aspect of the duodenal bulb on the AP). PLUS our baby’s duodenum is dilated.

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Q: What do you think of the position of the duodenal-jejunal junction on these AP images? A: It is NOT in the normal location. (Normal duodenojejunal junction is marked by the red star on Our baby, “to the left of the left-sided pedicles of the vertebral body at the level of the duodenal bulb on frontal”. (Applegate KE Radiographics 2006; 26:1485-1500.)Our baby has the “Corkscrew” sign, which is when the duodenal jejunal junction fails (due to malrotation) to attach in the retroperitoneum behind the stomach. Twisting of small bowel loops causes the corkscrew appearance. In Our baby, the duodenal jejunal junction is down in the pelvis somewhere, because the duodenum just keeps going downward.

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Now lets look at the lateralQ: What do you think of the position of the duodenal-jejunal junction? A: Lateral also shows the abnormal location and course. (normal duodenum courses posteriorly so that 2nd portion of duodenum is retroperitoneal). PLUS our baby’s duodenum is dilated.Q: What does this mean to you? A: this is diagnostic of congenital malrotation. (next slide has annotation…)

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We can again see the “Corkscrew” appearance. (Yellow lines mark corresponding parts of 2nd portion of duodenum, posterior and retroperitonenal in Normal; abnormally far anterior to spine in Our baby)

Q: What is the important clinical association with malrotation and forceful bilious vomiting in the initial week of life? A: High risk of volvulus, which can result in small bowel ischemia and necrosis, which has a fatal outcome.Our baby went emergently from our fluoro to the OR, where the surgeons encountered two full twists of the bowel on itself, but the bowel was pink and viable.

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These are diagrams of the Ladd’s band that crosses over and obstructs the duodenum (causing the duodenal dilatation). The emergent surgical approach in babies with malrotation and midgut volvulus is to untwist the volvulus and to ligate the Ladd’s band

BUT, the opportunity to do this and save the baby from mesenteric ischemia is brief. Prevention of death of the gut (and baby) requires prompt recognition of the clinical scenario as an EMERGENCY, and then quickly to do the necessary imaging to guide the needed surgical care.

Successful surgical treatment requires diagnosis before bowel necrosis occurs.

Image from Petra Lewis, MD

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Q: What is the imaging sign here? A: Double Bubble .

This is a different child with Duodenal Atresia who also has the “Double Bubble” radiographic sign. “Double Bubble” has a differential diagnosis. In this child with duodenal atresia, we see NO gas distal to the atresia, unlike the case with acquired midgut volvulus.

One black bubble is stomach, the other is the duodenum

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Q: What do you want to know? A: Bilious or not, Forceful or not. This was described by mom as very forceful vomiting, even coming out the baby’s nose, and looking similar to formula.Q: What diagnoses might you consider in a child this age? A: learners should say pyloric stenosis as this is typical clinical scenario and ageQ: What might you try to refine the diagnosis? A: 1.) Clinical: If possible and convenient, watch the feeding to get a feel for what happens. 2.) Imaging: Check ACR Appropriateness Criteria for a “Variant” that corresponds to this patient to see how imaging can help.

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Ultrasound imaging is very appropriate and effective for new onset of projectile vomiting.Q: What is an important cause for projectile vomiting in this age baby? A: Pyloric stenosisQ: Why is it important to confirm pyloric stenosis? A: Like volvulus, management of pyloric stenosis requires surgical treatment.

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Before we get to the the 7 week old boy with new projectile vomiting, let’s have a look at NORMAL anatomy by ultrasound. Here is a transverse ultrasound of a normal 7 week old infant. Let us get oriented to the anatomyWho can identify structures for us?(Labeled version next slide)

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White arrows mark the normal short pyloric channel between gastric antrum and duodenal bulb

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This is our 7 week old boy who has developed nonbilious projectile vomiting.

Q: Is it normal? A: No. pylorus is markedly abnormal, both elongated (length >17 mm) and thickened (>3 mm for single wall muscle thickness).

image of pyloric stenosis with gastric antrum filled with hypoechoic fluid.

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This is our 7 week old boy who has developed nonbilious projectile vomiting.This image helps recognize the components of pyloric abnormality.

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If you have an enteric tube and it is not in this area, something is wrong!

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Q: Name and account for these tubes and lines.ETT is between clavicles and carinaNGT is in distal esophagus, but NOT in stomach*, which remains dilatedQ: What is your next management step? A: Adjust NGT (see next slide for result…)

*(NGT shadow terminates over the shadow of the high UA line, and learners may need to have this confounding location pointed out for them, as they are NEW to assessing tubes and lines).(UA and UV line emphasized in later slides…)

3.) UA line4.) UV line

(some bilateral lung airspace opacities and RUL atelectasis, if students ask, but our learning objectives are the tubes and lines)

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Same baby after adjusting NGT.Q: What’s different? A: The markedly air-distended gastric lumen is now decompressed.

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Q: How do you judge if a feeding tube is in the right place? A: We want to trace it pasings through pylorus into duodenum, so the tube needs to course from left to right across midline on frontal, then inferior (MUST cross midline). On the lateral it should course posterior (as the normal duodenum courses in retroperitoneum) and then inferior. Red arrow indicates a sideport in this particular kind of feeding tube.Q: Why does it need to be all the way into duodenum? A: if feeding is delivered distal to pyloric sphincter, chances of reflux and aspiration are greatly reduced compared to delivering feeding just into gastric lumen.

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Q: This patient just had a feeding tube put down. The nurse asks you, “Can we use it to feed this child?”A: No!!! It is looped in his esophagus, kinked, then goes back up and down his airway, finally ending in his right lung. Feeding or administering medications into this tube could cause a serious pneumonia.

(Supplemental Material below, if time allows)

Q: What other tubes/lines do you see? A: Dual lumen RIJ.Q: Other findings you see? A: Subdiaphragmatic air and both walls of a bowel loop in LUQ are visible, signs of some free air, likely residual postoperative air.

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Q: What do we have here? A: Premature neonateQ: How do we know that? A: No visible humeral head ossification centers, skinny.Q: What are the devices, and how do we locate/identify them? A. They each have a typical course. The catheter on the right of midline is an umbilical vein (UV) catheter that terminates in the RA. UV lines should be above the lower liver shadow and not in SVC. Recommended position is to terminate between lower liver margin and inferior cavoatrial junction.Catheter on the left is an umbilical artery (UA) catheter, and these are recognized by their characteristic downward dip into pelvis and course in aorta. UA lines should terminate either between T6-T9 (high line, like this one) or L3-L4 (low line).

(You can appoint learners to discuss each of these; if they falter or are unsure, have them ask a fellow learner for help.)

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This is the proper course for a Umbilical Vein Catheter to take. Any deviation from this should be suspect.

UV catheter should terminate over liver outline or at inferior cavoatrial junction.

(Through the umbilicus, umbilical vein, left portal vein, ductus venosus, middle or left hepatic vein, and into the inferior vena cava. )

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This is the course for a Umbilical Artery Catheter (lateral view). Note: UA line first goes down, then up.Remember the Embryology!!! This is where the embryology of the fetal circulation you learned comes into clinical utility. (Trace out ductus venosus for students)

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So here is a lateral radiograph in a child who has both an Umbilical vein catheter and an Umbilical artery catheter.

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(Trace out ductus venosus for students on X-ray and diagram)

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And the umbilical artery catheter which ends in the aorta.

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Q: Is this premature baby normal? A. Has diffuse hazy granular lung opacities and low lung volumes.Q: What is the diagnosis? A. Surfactant deficiency with respiratory distress syndromeQ: Can you name and account for proper vs improper placement for devices? A: ETT ends above clavicles, too high, (Ask where it should end. About halfway between carina and thoracic inlet.) UV line projects over liver shadow, below the diaphram. UA line fine ending at T6. Position is fine for UA and AV lines.Q: What else can we assess? A: Bowel gas pattern, which has some mildly tubular loops in RLQ to keep an eye on.Q: What do the tubular bowel loops suggest? A: We worry about NEC in the clinical setting of a premature neonate.

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Q: What are the support lines and tubes? (have learners name and assess for proper vs improper position with anatomic location of where these devices terminate) A: ETT is fine, but UV line is misplaced and terminates in main pulmonary artery.Q: Where should the UV line end? A: Between lower ledge of liver and right atrium, as high as the junction of Right atrium and inferior vena cava at level of diaphragm.

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Q. Where are these lines? NGT ok, UV line too high in pulmonary outflow tract.Q. What else should we say about this CXR? May need to prompt learners to compare shades of gray in the right and left hemithorax. (Next slide has this image plus a normal for comparison to make the point)

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Q. Where are these lines? NGT ok, UV line too high in pulmonary outflow tract.Q. What else should we say about this CXR? (May need to prompt learners to compare shades of gray in the right and left hemithorax. Emphasize that this is one of the things they should have on their checklist) A: Hyperlucent left thorax with deep sulcus sign. LLL atelectasis.Q. What does this suggest? A. We worry about pneumothoraxQ. What maneuver can we do to confirm or eliminate pneumothorax as our diagnosis?

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Decubitus view.Q: When doing a decubitus view, how do we choose which side to put down? A: Remember when choosing decubitus views recall that air rises, and water falls, and use that to decide which side goes down.Q: What is next step in this child’s management? A: Thoracostomy catheter, aka chest tube.

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And now he has it. See how the diaphragm has come back up on the left. And lung density is now same. And the UV line is still too far out. The radiologist should be calling the service about this, and if you are on the NICU service, you should expect the call, and then it is courteous professional communication to thank them for the call.

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This neonate with Respiratory Distress syndrome due to RSV infection has an Endotracheal (ETT)Q: What do you think about its position? A: Should be in the mid thoracic trachea (i.e., between bottom of clavicles and carina). Exact position not as important as function, stability.Child also has a Right PICC ending in SVC.(Can point out the mixed interstitial and airspace opacities if asked, but tubes are what we are teaching here)

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Q. What are the important radiographic findings in this child with SDS? A. The ETT is in right mainstem bronchus.Q. What is the result? A. Left lung atelectasis, further respiratory compromise. Note also: Diffuse opacity in both lungs.

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Q: Why did baby’s oxygen saturations not improve after this ETT was placed? (Allow time for students to try and solve, but not too long…see stepwise series on next slides…)

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So, the ETT is a bit high.Q: How can that result in less than effective ventilation?

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So, the ETT is a bit high.Q: How can that result in less than effective ventilation? The lungs ARE hypoinflated.

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This baby has really distended stomach and proximal bowel.Q: How might this be related to the lack of improved Oxygen saturation despite placement of the ETT and mechanical ventilation?

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The esophagus also is dilated. What is going on?

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This is a serious problem, and you CAN sort this out by using what you know from the imaging and the clinical history.

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Q. What is a Salter Harris Fracture? A. Fracture in immature bone that involves the growth plate.Q. Are they all alike? A. No, they are graded by location of osseous fracture line relative to the growth plate, metaphysis, and epiphysis.Q. What is the commonest sort? A. Salter II with involves fracture through the growth plate and also the metaphysis. 75% of Salter Harris (physeal) fractures are Salter-Harris Type II.

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I personally find this mnemonic confusing but many like it.

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This is a Salter Harris III fracture.

(More examples follow the “End” slide if you have time or desire to show)

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Q. How does one do workup for limping child? A. For imaging, use ACR AC for guidance through the variations of presentation. Remember, it is free, and sets the highest quality standard for best practice in imaging.

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This can be confusing, but remember to consult ACR Appropriateness Criteria for Clinical Decision Support.

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ACR to the rescue!Here is an example of how ACR/AC reduces exposure. When ACR/AC followed, only 2 xrays will be done initially. By making the choice to follow ACR Criteria rather than a “search and destroy” mentality you can both protect the child and deliver High Value Care (maximize return for expenditure of health care dollars, minimize harm) , because strong evidence in the medical literature tells us that doing the tib-fib ONLY in this setting will make the diagnosis most of the time, and when it does not, only THEN you get the additional xrays, and ONLY as indicated.

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Here is an 13month old boy youngster who has been a bit cranky

Q: What is a very important clinical question to ask about this patient? A: Has this baby begun walking?

Q: Why is this important in your critical thinking? A: Because, if the child has been walking and then stop, is irritable and cranky, the scenario is right for CAST (childhood accidental spiral tibial) fracture, AKA tibial Toddler’s fracture. These occur between 9 months and 3 years of age. Believed the result of new stresses placed on the bone due to increasing ambulation. Should NOT raise alarm when present in isolation and in the correct age group (i.e ambulating toddlers). Children with CAST typically have vague symptoms, not clearly related to the tibia. Typically they refuse to weight bear, and are irritable. Conventional radiographs are all that are required, however multiple views may be necessary as the fracture is often inapparent on one or more view. The fracture is usually not displaced. Most are LESS conspicuous than this one, which is nice for teaching.

In an alternate scenario, we would elevate our suspicion of Non-accidental trauma if this fracture occurred in a child who had NEVER walked yet.

The spiral nature of this fracture is demonstrated with these two orthogonal views.

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variant 3 for Limping directs us to use ultrasound of the hip. Transient synovitis may be the cause of the limp or a joint effusion of other causes…

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Q: Which hip has an effusion? (after learners assess image and answer, see next slide…)

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Q: Which hip has an effusion? A: The RIGHT hip.

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This is a case with BILATERAL hip effusions.Does anyone want to base this child’s treatment on this radiograph? How confident are you about these effusions? (see next slide)

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This is a case with BILATERAL hip effusions, easily seen on Ultrasound, but NOT reliably detected on the X-ray.

It is much easier to recognize and accurately diagnose an effusion using Ultrasound than by radiography, which is not sensitive, not specific, and delivers radiation dose to the child. Following the ACR Appropriateness Criteria is VERY important to PROTECT the child, as well as ensure an efficient and cost-effective imaging plan.

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This child had a limp, and this was at the initial visit. His doctor chose to manage the problem with radiographs, rather than an ultrasound. This radiograph reveals no abnormality…. Is that the SAME as saying the painful hip is normal???

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Symptoms persisted and the doctor ordered this follow up radiograph 6weeks later.Q: What happened to the thickness of the cartilage separating the femur and the acetabulum? A: Much narrower.Q: What does that mean? A: Cartilage destroyed by infection.

The child turned out to have a septic arthritis. You can see the cartilage space has become abnormally narrow and the femoral neck now is discontinuous…

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Q: What has happened in 3 month follow up? A: Bone is destroyed at femoral head and neck.

The missed initial diagnosis was an infectious hip effusion which became a septic arthritis, and not being properly diagnosed and treated, became an osteomyelitis that destroyed his joint.This is why we care so much about hip effusions and their proper imaging diagnosis and treatment, and one more reason why proper work up for the child with a limp can be so important.

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A 6-month-old female was transferred to the emergency room of a children’s hospital for treatment of a femur fracture. Her mother said she was carrying her down some stairs and fell, landing on the infant. The mother could not give more details of how she was carrying the infant before the fall, how many stairs she fell down, nor the final position of the infant or herself.

Q: What do you think?

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Fractures can be a presenting symptom of abuse but they are also common problems not associated with abuse.Femoral shaft fractures are estimated to account for only 1.6% of all fractures in children, therefore they are potentially more suspicious for child abuse.

After investigation, this was child abuse.Image is from http://pediatriceducation.org/2008/04/28/ and we do have permission to use it.

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Q. What is this injury? A. CML (Classic Metaphyseal Lesion) or corner fracture or “bucket handle” fracture.Q. Why does it occur? A. Fracture through primary spongiosa of metaphysis (weakest newly formed bone). This is the most specific skeletal injury for child abuse.

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Rib fractures, subtle initially then with very obvious callous formation. Most evaluation protocols involve a repeat skeletal survey at 2 weeks, to improve detection. See the ACR/SPR guidelines for how to perform the survey properly.

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Have learners describe types AND clinical scenarios that raise their suspicion for non-accidental trauma. A: Learners should say multiple injuries in different phases of healing, highly specific injuries giving examples, injuries for which the history is not plausible, and other suspicious elements.

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High Classic metaphyseal lesions (<1 year)Specificity Multiple rib fractures (95-99% PPV)

Scapular fracturesSternal fracturesSpinous process fractures

Medium Multiple fracturesSpecificity Fractures of various ages

Epiphyseal separationsVertebral body fracturesDigital fracturesComplex skull fractures

Low Subperiosteal new boneSpecificity Clavicular fractures(but common) Long bone shaft fractures

Linear skull fractures

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Salter Harris I fracture. These may be subtle. Here we can recognize Salter Harris 1 injury on the lateral, where the distal femoral epiphysis has slipped anteriorly relative to the diaphysis. The AP shows widening of the physis compared to the tibia and fibula.

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This is another SH I fracture. They are sometimes seen retrospectively after persistent pain prompts another radiograph that shows healing and physeal widening and fragmentation, as in this case, though the initial film does show enough widening to call the fracture.

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This is a Salter Harris II fracture.

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This is a SH IV. The last image is a follow-up showing the development of a complication: A physeal bar is now tethering a portion of the growth plate and will likely need surgical removal.