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Pediatric Emergency Radiology I

Objectives
•Identify the following conditions based on x-ray findings:
– Intussusception – Epiglottitis
– Bowel obstruction – Retropharyngeal abscess
– Congenital hip – C-spine
dislocation pseudosubluxation
– Slipped capital femoral – Hangman fracture
epiphysis – Jefferson fracture
– Pneumonia – Elbow fractures
– Thymus shadow – Monteggia injury
– Appendicitis – fecaliths – Salter-Harris fractures
– Bronchial foreign body – Child abuse
– Croup
X-ray diagnosis?
14-month-old girl
with vomiting.

Target sign
Identify in
the target sign
The crescent sign Target sign
is
inRUQ.
the RUQ again.
formed by the in RUQ.
intussusceptum (lead
point) protruding into Crescent
Intussusceptio
Intussusception
a gas-filled pocket. Crescent
sign in LUQ.
sign in LUQ.
n
Identify crescent sign
in LUQ again.
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 gas-filled pocket may be large, as in this case.
Intussusception
Left image:
Right image: Absence of hepatic
Absence of gas in angle (suggests RUQ
RUQ and RLQ mass). Absence of
(suggests a mass gas in RLQ (suggests
effect on right). RLQ mass). Two
Poor distribution dilated (smooth)
of gas in general bowel segments
(suggests bowel (suggests bowel
X-ray diagnosis? 11-month-old boy with vomiting.
obstruction). obstruction).
Bowel obstruction with right-sided mass
effect: Intussusception
X-ray diagnosis?
11-month-old girl
with vomiting.

RUQ target sign.


Identify
RUQ the sign.
target target
LUQ crescent sign.
and crescent
LUQ crescentsigns
sign.
Absence of the
again. of the
Absence
subhepatic angle.
subhepatic angle.
Intussusception
Intussusception

Possible
target sign Paucity of
in RUQ. bowel gas
suggestive
of right-
sided mass
and bowel
obstruction.
X-ray diagnosis? 7-month-old girl with skull fracture,
lethargy, and vomiting.
Intussusception
Target sign
Absence of hepatic
angle
Paucity of gas
Absence of
hepatic angle.
Paucity of gas.
Target sign

X-ray diagnosis? 7-month-old girl with vomiting.


SuspectedRUQ air fluid
Intussusceptionlevels. RUQ
bowel loops
are smooth
(bowel
obstruction).

Paucity of
gas in RLQ.

X-ray diagnosis? 7-month-old boy with vomiting.


Bowel obstruction
Bowel obstruction ddx: AIM
criteria:
• A: Adhesions, appendicitis
Gas distribution
• I: Intussusception, incarcerated
Bowel distention
inguinal hernia
Air fluid levels
• M: Malrotation (midgut volvulus),
Meckel’s

X-ray diagnosis? 17-day-old boy with vomiting.


Bowel
AirBowel
Gas
Bowel walls
fluid Obstruction
Obstruction
aredistribution:
levels:
smooth, Good
Onhose-like:
upright view
Distended
Bowel obstruction criteria:
Haustra and plicae
Gas distribution
Bowelare preserved. Looks
distention
likelevels
Air fluid 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
volumegirl
X-ray diagnosis? 1-month-old ofspitting
gas. up.
Normal Gasabdominal
Bowel distention:
Air Lots levels:
fluid
distribution:radiographs
of gas, but
None
Goodno distention.
ILEUS, NoBowel
Definite Bowel
obstruction Obstruction
criteria:
Gas distribution
Bowel distention
Air fluid levels

Air fluid levels: Many, but they are all


small with noGas
Bowel J turns (hairpin
distention:
distribution: loops,
No smooth
Fair walls
candy canes)
X-ray diagnosis? 9-day-old boy with vomiting.
Radiologist
Paucity
While identifies
preparing
ofCongenital
gas onfor
the
Congenital an occult
andislocated
right diagnosis.
ultrasound,
suggestive
hipthe
Dislocated (CDH).
of
child
Hip a mass.
Residual
drinks a bottle
barium
Shenton’s
andpresent.
her
arcbehavior
is discontinuous.
normalizes.
A more
focused
view of
occult
diagnostic
finding
Shenton’s arc.

X-ray diagnosis? 5-month-old


girl discharged yesterday
following barium enema
reduction of
Thigh or knee
Right hip pain could
physis originate
appears to be from a
wide
Klein’s line: Superior aspect of the
hip problem. Hip evaluation
compared to the leftiship.
required.
metaphysis to see if it intersects the
epiphysis

Abnormal: Line Normal: Line


misses epiphysis intersects
epiphysis

X-ray diagnosis?
Slipped 10-year-old
Capital Femoral obese
Epiphysis
boy with rightof
(SCFE) thigh
the and knee
Right Hip pain
Moderate slip
Severe slip
Bilateral SCFE
X-ray diagnosis?
Appendicitis

Fecalithit
Identify
(appendicolith)
again

X-ray diagnosis? 6-year-old boy with nausea and


abdominal pain.
Find the
fecalith
(appendic
olith)
This
This
ThisThisThis
Fecaliths
There
fecalith
fecali
is
fecalit
the
can
fecalith
arevarycan
th
last
ishis
two be
or seen
is
faint in
fecali
fairly
round faintly
and in
appeara
more
large
with
thpoten in the
onance.
oval
radiograph
dense
this
Thistialone
shape
opaqu
slide of the
is small
fecalit
appendix
e dot hsand
specimen.
in it.
opaque.
here It
Pneumo
nia

X-ray diagnosis? 6-year-old boy with abdominal pain


LLL
infiltrate

RML
infiltrate
X-ray diagnosis? 15-month-old boy LLL & RML
with fever, coughing, tachypnea. Pneumonia
X-ray Normal No
diagnosis?
newborn thymic
2 month thymus
old No shadow
with a VSD
occupies the
presents with thymic
space anterior
recurrent shadow
to the heart
seizures.
Cardiomegaly
(CHF)
Cardiomegaly
(CHF)
Hypocalcemia
found on labsNormal thymus shadows
VSD, Thymic, &
in young infants
Parathyroid Aplasia:
DiGeorge Syndrome
X-ray
diagnosis?
Ventilated
infant with
sudden
deterioration

Pneumopericardium
Air in
pericardium
Revealing the Thymus
reveals
“Sailshape
Sign”of
infant thymus.
Prominent Prominent Thymus Partially Normal
asymmetric thymus
Obscuring a RUL Infiltrate: newborn
Pneumonia thymus
occupies
space
anterior to
heart

Infiltrate

X-ray diagnosis? 6-month-old boy with cough and


congestion. No fever. O2 Sat 100% on room air.
RML
Atelectasis

RML atelectasis

X-ray diagnosis? 18-month-old girl with mild BPD


(former premie). Presents with fever, cough, dyspnea.
Round infiltrate.
Spherical consolidation.

Round
Pneumonia:
“Cannonball”
Pneumonia

X-ray diagnosis? 9-year-old boy with


fever, headache, nausea, and coughing.
More views:

Right side Bilateral


down Air Trapping
Left side down
Inspiratory view Expiratory view
Bilateral
Lateral
Heart Bronchial
should move downward.Foreign Bodies
But in both views,
neck
it stays in place,
Nuts due to
+ Choking bilateral air trapping.
Expiratory
= Bronchoscopy view
No definite
Insp and Exp views abnormalities
look very similar = air trapping
X-ray diagnosis? 17-month-old coughing after
choking on a chocolate/almond bar
X-ray diagnosis?
18-month-old girl
with fever, noisy
breathing, and
barking cough.
P E V
Epiglottis
Epiglottis
- normal
Retropharyngeal
Identify the: (E)
Vallecula
Vallecula
- normal
(V) C
Epiglottis
Abscess
Trachea
Vocal -cords
Valleculaslightly
(C)
(also called
narrow
Tracheaor (T)
Vocal cords normal
prevertebral
Prevertebral
Prevertebral
Trachea softsoft
abscess)
tissue
tissue(P)
(P)- wide
Prevertebral soft
Clinical symptoms
and bulging
tissue (should T
may mimic
be half thecroup.
width of
vertebral body)
X-ray diagnosis?
2-year-old boy with
fever, stridor,
tripoding and NO
cough.
P
Epiglottis
Epiglottis
Identify (E) - (E)
the: E V
Epiglottitis
wide Vallecula
(thumb-like)
Epiglottis (V)
Vallecula
Vocal cords
Vallecula- shallow
(C)
Trachea
VocalTrachea
- normal
cords (T) C
Prevertebral
Prevertebral
Trachea soft soft
tissue -tissue
normal
Prevertebral (P)
soft
tissue

T
X-ray diagnosis?
15-month-old boy with
fever, mild stridor, and
barking cough.

IdentifyCroup
the: P
Epiglottis
Epiglottis - normal E V
Vallecula Epiglottis (E)
Vallecula - normal
Vocal cords Vallecula (V)
Trachea (T) - narrow, C
Trachea Vocal cords (C)
subglottic edema
Trachea
Prevertebral soft (T)
tissue
Prevertebral soft tissue
Prevertebral soft tissue (P)-
normal

T
X-ray diagnosis? 6-year-old
girl with mild neck pain. C1
Swischuk line criterion:
Line drawn between C2
Malalignment
C2-C3
No recent pseudosubluxation
of C2But
trauma. andshe
C3.
posterior arch of C1 and C2
Is
wasitProbable
characteristics:
athrown intoC2-C3
true subluxation
a or is
posterior arch of C3. C3
it Minimal
a pseudosubluxation?
swimming / pool
mild 30
trauma
hours
Pseudosubluxation
ago
The posterior arch of C2
Minimal
with no / mild pain of
complaint C3
should be within 1 to 2 mm
No signs
neck pain atofthat
a fracture
time. She
of this line.
isNeck is positioned
now brought in ED
in to the
Deviation from this line
flexion
on a spine (notboard.
lordotic), often
suggests a C2 pedicle
due to a spine board.
fracture; however, this
Swischuk line criterion.
criterion is not perfect.
X-ray diagnosis? 2-year-old
C1
boy who fell off his tricycle
is brought in on a spine
board. C2
C2-C3 pseudosubluxation
Swischuk line:
characteristics:
Line drawn between the
 Minimal / mild trauma C3
posterior arch of C1 and
 Minimal / mild pain
the posterior arch of C3.
No signs of C2-C3
Probable a fracture
The posterior arch of C2
 Neck is positioned in
Pseudosubluxation
should be within 1 to 2 mm
flexion (not lordotic), often
of this line.
due to a spine board.
 Swischuk line criterion.
X-ray diagnosis? 7-year-old
girl unrestrained in a car
crash brought in on a spine C1
board.
C2
Fracture ofline:
Swischuk C2 pedicle:
satisfactory
Despite a satisfactory
C3
Swischuk line.
There is very slight
Fracture of
subluxation the
of C2 onC2C3 Pedicle
due to the fracture.
“Hangman Fracture”
This odontoid view is still useful
X-ray diagnosis? Two
It’s
The
to normal
hard tothe
lateral
identify odontoid
see
massesanything
lateralare views.
with
masses
7-year-old boy injured his (ringTheJefferson
this lateral
displaced
of C1)
poor Fracture
masses
outward
relative
odontoid of C2
C1The
are
indicating
to
view. as
head and neck diving into outlined
aligned with the base
LMsof C2.
that
odontoid is(C1
the ring
here.of
not ring)
C1
The has
visible. fractured
should
shallow water. anddirectly
be burst open.
over the base of C2.
This CT scan shows a
Better quality open OC1 C1
Jefferson fracture (C1 LM LM
L L
mouth
ring (odontoid)
No definite
fracture) abnormalities.
sustained L L
L M M O
His collar
when
view blowis to
temporarily
ademonstrating
the top of
a M
C
M C aodontoid C2 C2 M
removed
the head
Jefferson for
placesan load
fracture. on C
2 C
(open
the long axis of2
mouth) view.
the spine, 2 C
bursting open the ring of 2 2
C1.
Radius should
Mid-ulna line upfracture.
angulated with capitellum (C).
Misalignment indicates radial head dislocation.
Anything else?

Abnormal C

X-ray diagnosis? 9-year-old


boy who fell onto his Monteggia Injury
forearm. Visible forearm Ulna fracture often
deformity. results in radial head
Normal C
dislocation. Check
radius-capitellum line
confirming alignment.
Anterior Supracondylar region
Elbow
humerus
Posterior fat pad (+) evaluation:
High yield places to look:
lineAnterior
should fat pad (+)
bisectPosterior fat pad
Anterior fat pad
capitellum
(+) Anterior humerus line
Radial head
Radius-capitellum line
Supracondylar region
Radial head
Radius-capitellum line
Olecranon
(normal)

Olecranon
Elbow Joint Effusion
X-ray diagnosis?
Probable occult
Elbow injury.fracture.
supracondylar
Posterior
Anterior humerus
Supracondylar fat pad
line:
region:
Anterior
misses fat pad
OK capitellum
Both
(not unable
a true to
lateral view)
assess (true
lateral view
required)

Radius-capitellum line:
normal
Olecranon: OK Radial head:
Fracture
Radial Head
Fracture X-ray diagnosis?
Elbow injury
Olecranon Supracondylar region:
fossa cortex cortex disrupted
is fractured

Anterior
fat pad (+)
Posterior
fat pad (+)

Supracondylar Fracture
X-ray diagnosis? Elbow injury
Anterior
fat pad (+)

Radius-capitellum
line is not pointing
at capitellum
Posterior
fat pad (+)

Olecranon
fracture
Joint Effusion, Olecranon Fracture,
Monteggia Injury
X-ray (radial head
diagnosis? dislocation)
Elbow injury
Tenderness
The epiphysis is is elicited
displaced
over distal
Salter-Harris radius

displa ced
type 1

non-displa ced
fracture of
distal radius
physis
should be
suspected
clinically

Displaced Salter-Harris Type 1 Fracture of the


X-ray diagnosis? 10-year-old
Distal Radius boy, wrist injury
Physis
Tender SH type V:
SH type III SH type IV
Hey you !! Physis.
Epiphysis Metaphysis
What kind of Not evident on
and physis and
Salter-Harris X-ray. Relies on
Epiphysis
fracture type clinical
is this?? findings and
Who ME?
W
Fell off 2nd h
floor o
onto M E ?
history of
her feet. injury
mechanism.
M = metaphysis
SH
E = epiphysis type II
Metaphysis
and physis
Calcaneus fracture
X-ray diagnosis?
6-week-old boy Elbow/Forearm Tib/Fib
with “sudden”
left thigh swelling
and no history of
trauma.
Proximal
Child
Severe abuse radius
femur fracture
isfracture
suspected.
Obvious
with oblique
periosteal
- A skeletal elevation
survey is
without explanation.
femur
(hard fracture
Older to
ordered. see). and tibia
forearm
with
- a thinner
Left forearm and
fractures.
fracture
Healing in thefracture
tibia
right tibia/fibula with
are shown
distal half ofelevation.
periosteal
here. the
Child Abuse
femur.
X-ray diagnosis?
Severe A skeletal
2 month old who is
osteogen survey is
crying without
esis done
apparent cause.
imperfect and no
Obvious
a.
- Another midview
Osteogenesis otheris
shows
imperfecta the
Family
femur history:
fracture is fracture.
fractures
LethalMid
oblique
suspected.
-form
Father:
femur
fracture
4
line.
noted. Child
in are Multiple rib fractures
fractures,
abuse
infancy.is 2 of found.
- Further
Occult types questioning
tend to be about
autosomal
Osteogenesis
which
dominant
occurred imperfecta.
suspected.
Severe
trauma is negative
(family The
historyexcept
will be
with minor
osteopen upper a
for bumping him against
positive.)
trauma.
ia. Family history of “frequent
door while carrying him in a
- PGF: 4
fractures” may be a useful
extremitie
padded
Severe infant
lethal typescarrier.
tend to The
be
fractures
question from
in you
fracture patients.
s are
Crumpled
parents tell
recessive. that this
“playing long shown
bones
couldn’t have been hard
around” here.
at birth.
enough to cause a fracture.
- Mother:
Scoliosis
- 2 aunts:

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