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Apls Pediatric Emergency Radiology 2
This document provides objectives and case descriptions for identifying various pediatric conditions based on x-ray findings, including lobar emphysema, vertebral fractures, pneumomediastinum, pneumonia, ingested disk battery, necrotizing enterocolitis, midgut volvulus, abdominal abscess, fractures, retropharyngeal abscess, infant skull sutures and fractures, leptomeningeal cyst, syphilis of the bone, rickets, and vascular rings. Each case includes an x-ray image and description of findings to aid in diagnosis.
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Apls Pediatric Emergency Radiology 2
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- 2. Objectives Identify thefollowing conditions based on x-ray findings: Lobar emphysema Vertebral compression fractures Pneumomediastinum S aureus pneumonia Ingested disk battery Pneumatosis intestinalis - necrotizing enterocolitis 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
- 3. X-ray diagnosis? 2-week-oldboy 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.
- 4. 8 year oldwith abdominal pain for 2 weeks, back ache since yesterday’s ballet practice. Multiple vertebral body compression fractures. Leukemia. X-rays repeated 8 days later.
- 5. 19-year-old with chestpain and grating sound on auscultation. Pneumomediastinum Hamman Sign Vertical air densities Air filled aorto-pulmonarywindow Air outlining the trachea (air dissection around the trachea). Vertical air densities in the mediastinum.
- 6. X-ray diagnosis? 6-year-oldboy with fever, abdominal pain, tachypnea, suspected pneumonia. Staphylococcus Aureus Pneumonia Expect empyema, pneumothorax, blebs, fistula. 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 this most consistent with? Rapid progression of worsening. Rapid development of large pleural effusion.
- 7. 20-month-old girl swalloweda coin (witnessed by 5-year-old cousin). Brief coughing episode. No symptoms at this time. Ingested Disk Battery Close-up view of the “coin.” Is it a penny? Coin and battery lineup
- 8. 3 day oldpremie with hematemesis. Pneumatosis Intestinalis Due to Necrotizing Enterocolitis (NEC) Enlarged view: White arrows point at air dissecting within the bowel wall. Double density (“railroad tracks”). Air dissecting in the bowel wall. Double outlining (railroad tracks). Bubbles in the bowel wall. Obvious air dissecting within bowel wall in a term infant.
- 9. X-ray diagnosis? 3-month-oldwith bilious vomiting. This is an upper GI series using thin barium. Standard barium would demonstrate a “beak sign” in which the contrast stops at the gastric outlet or proximal duodenum. Midgut Volvulus Complicating a Malrotation (“guts on a stalk” syndrome)
- 10. X-ray diagnosis? 4-year-oldgirl w/ abdominal pain for 3 days. 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. Enlarged view (darken the room) Arrows point to the peritoneal fat margins which mark edge of peritoneal cavity. The bowel should be adjacent to the peritoneal fat margin as in the LLQ. Note that in the RUQ and RLQ, 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.
- 11. X-ray diagnosis? 4-year-oldgirl who fell at the playground. Bowing Fracture of the Ulna Her forearm is swollen with a moderate deformity.
- 12. X-ray diagnosis? 20month old female, refuses to stand on her right leg. No known trauma except for falling while running. Toddler Fracture (probably accidental) Another view is obtained. 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?
- 13. X-ray diagnosis? 7year old male with fever, sore throat, headache and neck stiffness, sent to the ED for possible meningitis. Prevertebral (retropharyngeal)abscess 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 abscess Phlegmon
- 14. Normal Infant SkullSutures: S=Sagittal, C=Coronal, L=lambdoidal Normal Infant Skull Sutures: C=coronal, L=lambdoidal, P=parietomastoid, O=Occipitomastoid
- 15. Find the skullfracture - Case 1 Right Parietal Skull Fracture
- 16. Find the skullfracture - Case 2 Right Occipital Skull Fracture
- 17. Find the skullfracture - Case 3 AP views Right Occipito-parietal Skull Fracture Lateral views
- 18. Find the skullfracture - Case 4 AP views Depressed Skull Fracture Lateral views
- 19. Find the skullfracture - Case 5 Right Occipital Skull Fracture
- 20. AP views Findthe skull fracture - Case 6 Right Parietal Skull Fracture Lateral views
- 21. AP views Findthe skull fracture - Case 7 Parietal Skull Fracture Lateral views
- 22. AP views Findthe skull fracture - Case 8 Biparietal Skull Fracture Lateral views
- 23. Case 9: 10-month-oldboy fell and sustained a parietal skull fracture 3 months ago. He is neurologically normal but has a persistent soft area in region of fracture. Leptomeningeal Cyst (growing skull fracture)
- 24. 2-month-old girl whois not using her right arm today. No history of trauma. Wrist swelling noted 2 days ago. Syphilis of the Bone Destructive lytic lesions of the distal radius and ulna. Periosteal elevation of the radius and ulna. A skeletal survey is obtained. Humerus and elbows are normal. Femurs are shown here. Periosteal elevation along the length of both femurs. Both tibiae and fibulae are shown here. Periosteal elevation along the length of both tibiae. Destructive lesions of the proximal tibiae and the left fibula.
- 25. 2-year-old boy withchronic liver disease with persistent forearm swelling 3 days after falling. Rickets (vitamin D malabsorption) Severe demineralization: Mid-radius fracture Ulnar bowing
- 26. 6-month-old boy withdifficulty breathing. Frequent noisy breathing episodes since birth. Vascular Ring (tracheal and esophageal compression) Lateral neck radiograph is obtained. Tracheal size appears to be normal or slightly narrow. Examine the tracheal diameter on the CXR. Very narrow on the lateral view. A barium swallow identifies a mass posterior to the esophagus 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.
- 27. Following coin removal,persistent stridor is noted. PMH: frequent episodes of noisy breathing since birth. X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing. Esophageal Coin With a Vascular Ring His trachea is narrow on the lateral CXR. This finding persists on a repeat CXR. An esophagram identifies a mass posterior to the esophagus.
- 28. X-ray diagnosis? 8-year-oldboy with chief complaint of fever. On exam, he is noted to have reproducible tenderness over his upper thoracic spine. Discitis Narrowed inter- vertebral space. Repeat views taken
- 29.
Editor's Notes
- #2 Pediatric Emergency Radiology II Note to instructor: Each slide contains multiple “clicks.” Each click is identified by number in the lecture notes. The last click on each slide is indicated by yellow type.
- #3 Objectives: Lobar emphysema, vertebral compression fractures, pneumomediastinum, S aureus pneumonia, ingested disk battery, pneumatosis intestinalis, necrotizing enterocolitis, 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
- #4 X-ray diagnosis? 2-week-old boy with respiratory distress. 1) Tension pneumothorax was the initial interpretation. What features speak against a tension pneumothorax? 2) Most tension pneumothoraces are associated with penetrating chest trauma or positive pressure ventilation. The patient is in respiratory distress but is more stable than what would be expected with a tension pneumothorax. Most patients with a tension pneumothorax will have bradycardia, hypotension, and severe hypoxemia, all of which are rapidly worsening. 3) This is a chest x-ray with congenital lobar emphysema of the left upper lobe. The LUL is hyperexpanded, resembling a tension pneumothorax, but this will NOT benefit from a chest tube.
- #5 X-ray diagnosis? 8-year-old girl with abdominal pain for 2 weeks. She also has a backache since ballet practice the day before. This abdominal film was initially read as normal. 1) X-rays of her chest, abdomen, and spine are repeated 8 days later. 2) Multiple vertebral body compression fractures indicative of leukemia. Note the lateral and AP views demonstrate severe compression fractures.
- #6 X-ray diagnosis? 19-year-old with chest pain and a grating sound on auscultation. The sound can be described as walking on snow, or the separation of Velcro. 1) On the PA view, vertical air densities are visible in the left neck. A triangular air density is visible where the aorta and left pulmonary artery cross. This is an aorto-pulmonary window. 2) The lateral view demonstrates air dissecting around the trachea. The trachea usually appears as a single solid air column, but in this view, there is air outlining the trachea. There are also vertical air densities in the mediastinum. 3) This chest x-ray shows a pneumomediastinum. The grating sound is known as Hamman sign, which is a transient sign associated with air leaks (pneumomediastinum and pneumothorax).
- #7 X-ray diagnosis? 6-year-old boy with fever, abdominal pain, tachypnea, and suspected pneumonia. This chest x-ray is nonspecific, with a poor inspiratory effort. 1) An abdominal series is obtained because of the abdominal pain. No specific findings are noted here. 2) A CT scan of the abdomen is done to rule out appendicitis. The appendix is normal, but the upper abdominal cuts note pulmonary infiltrates and a small pleural effusion in the lower aspect of the right lung. Antibiotics were previously given. At this point, the patient is hospitalized for further management. 3) Four hours later, his respiratory status worsens. Chest x-ray is repeated. A large right pleural effusion is noted. What clinical entity is this most consistent with? 4) The image on the left is his initial chest x-ray. The image on the right is the current chest x-ray showing the rapid development of a large pleural effusion. 5) This clinical course is most compatible with S aureus pneumonia. Expected complications include sepsis, empyema, pneumothorax, pulmonary blebs, and bronchopleural fistulae.
- #8 X-ray diagnosis? 20-month-old girl swallowed a "coin," which was witnessed by a 5-year-old cousin. There was a brief coughing episode, but there are no symptoms at this time. 1) A close-up view of the coin is shown here. Any special characteristics of this "coin?" 2) This circular density is actually a disk battery. Note the lucent ring just inside the circumference of the density identifying this as a battery. The battery–coin lineup on the right demonstrates some of the characteristics of disk batteries compared to coins. When viewed on its side, the battery might have a "frosting on the cake" appearance. When viewed as a flat circle, the inner lucent ring is visible sometimes if the battery is thin enough. 3) Ingested disk battery
- #9 X-ray diagnosis? 3-day-old premie with hematemesis. 1) An enlarged view of this abdominal radiograph is shown here. The white arrows point to air dissecting within the bowel walls, forming a parallel double density, called railroad tracks (without the ties). 2) Another abdominal radiograph shows the same thing. Note the cigar-shaped bowel segment in the LLQ. Bubble-shaped air densities can be seen outlining the bowel (orange arrows). 3) This abdominal radiograph is from a term infant. Obvious air dissection within the bowel wall is visible in the right abdomen. 4) Pneumatosis intestinalis due to necrotizing enterocolitis
- #10 X-ray diagnosis? 3-month-old with bilious vomiting. The stomach is dilated with a large fluid level. The rest of the bowel is relatively gasless. 1) This is an upper GI series using thin barium. This barium would demonstrate a "beak sign," in which the barium contrast stops at the gastric outlet or proximal duodenum. 2) This barium study demonstrates a spiral corkscrew pattern of a midgut volvulus complicating a malrotation.
- #11 X-ray diagnosis? 4-year-old girl with abdominal pain for 3 days. 1) An enlarged view of the pertinent findings is shown here. (The subtle findings require that the room be darkened.) The black arrow points at a small air pocket. Is this within bowel? 2) Arrows point to the peritoneal fat margins (also called the peritoneal fat stripe) that demarcate the edge of the peritoneal cavity. The bowel should lie adjacent to the peritoneal fat margins, as can be seen in the LLQ. Note that in the RUQ and RLQ, the bowel is separated from the peritoneal fat margin. 3) The arrows now point to the right-sided separation between the bowel and the peritoneal fat margin. Note that the liver edge is scalloped. What accounts for these findings? 4) Most likely, this separation is caused by fluid (pus) on the right (RLQ to the liver). The black arrow points at air within this pus. 5) Ruptured appendix. Right abdominal abscess formation.
- #12 X-ray diagnosis? 4-year-old girl who fell at the playground. Her forearm is swollen with a moderate deformity. 1) Note the contour of her ulna. It is bent, but no fracture line or disruption of the cortex is seen. 2) Bowing fracture of the ulna. This type of fracture usually requires reduction by an orthopedic surgeon.
- #13 X-ray diagnosis? 20-month-old girl who refuses to stand on her right leg. There is no known history of trauma except for falling while running. 1) Another view is obtained. 2) There is a thin oblique fracture of the distal tibia. 3) The original x-ray is on the left. The additional film is on the right. The white arrows point to the fracture. The black arrows point to a vascular groove. 4) Is this fracture due to child abuse or due to a fall? 5) This is a toddler fracture, which is most likely accidental. Large fractures of the distal tibia are less likely to be accidental.
- #14 X-ray diagnosis? 7-year-old boy with fever, sore throat, headache, and neck stiffness. He is referred to the ED for possible meningitis. 1) An LP is done (normal). Lateral neck x-ray demonstrates bulging of the prevertebral soft tissue. A prevertebral abscess is suspected. 2) False-positives sometimes occur. The prevertebral soft tissue width should be roughly half the width of a vertebral body. In the x-ray on the left, the patient's neck is poorly positioned, resulting in redundancy of the prevertebral soft tissue and making it appear to be widened. In the x-ray on the right, the patient's neck is extended properly, showing the prevertebral soft tissue with a normal width. 3) Malpositioning was thought to be the reason for the prevertebral soft tissue widening in the x-ray on the left. However, good neck extension in the repeat x-ray on the right shows persistence of the prevertebral soft tissue widening. 4) The step-off sign is sometimes helpful. The x-ray on the left shows that the back of the pharynx should not be in line with the trachea. It is normally in line with the esophagus, while the trachea is anterior to the esophagus. This results in the normal step-off seen between the back of the pharynx and the posterior border of the trachea. In a retropharyngeal abscess, the prevertebral soft tissue is widened, displacing it anteriorly. Thus, the back of the pharynx and the posterior margin of the trachea are nearly parallel (absence of the step-off). 5) CT scanning helps to define the type of abscess that is present. The left image shows a small lesion with no rim enhancement and no bulging anteriorly. This is more consistent with a phlegmon, a type of pyogenic cellulitis that can usually be treated with antibiotics alone. The right image shows a large lesion with rim enhancement and bulging anteriorly. This is more consistent with a true abscess that requires surgical drainage. 6) Prevertebral abscess (also called retropharyngeal abscess)
- #15 Normal infant skull sutures are shown on these AP views. S=sagittal, C=coronal, L=lambdoidal. 1) The lateral views shows the C=coronal, L=lambdoidal, P=parietomastoid, O=occipitomastoid sutures.
- #16 Find the skull fracture - Case 1 1) Right parietal skull fracture
- #17 Find the skull fracture - Case 2 1) Right occipital skull fracture
- #18 Find the skull fracture - Case 3 1) Arrows point out the fracture line on the AP views. 2) Lateral views are shown here. 3) The arrows point out the fracture lines on these lateral views. 4) Right occipito-parietal skull fracture
- #19 Find the skull fracture - Case 4. AP views are shown. 1) Lateral views are shown. 2) Arrows point to a lucent area surrounded by a hyperdense rim. 3) Depressed skull fracture
- #20 Find the skull fracture - Case 5 1) Arrows point to the fracture line. 2) Right occipital skull fracture
- #21 Find the skull fracture - Case 6. AP views are shown here. 1) Arrow points to the fracture line. 2) Lateral views are shown here. 3) Arrows point to the fracture line. 4) Right parietal skull fracture
- #22 Find the skull fracture - Case 7. AP views are shown here. 1) Lateral views are shown here. 2) Arrows point to the fracture line. 3) Parietal skull fracture
- #23 Find the skull fracture - Case 8. AP views are shown here. 1) Lateral views are shown here. 2) Arrows point to the fracture line, which extends from one side of the skull, over the top, to the other side of the skull. 3) Biparietal skull fracture
- #24 Find the skull fracture - Case 9 A 10-month-old boy fell and sustained a skull fracture 3 months ago. He is neurologically normal, but he has a persistent soft area in the region of the fracture. 1) Leptomeningeal cyst (growing skull fracture)
- #25 X-ray diagnosis? 2-month-old girl who is not using her right arm today. No history of trauma. Wrist swelling was noted 2 days ago. 1) Destructive lytic lesions of the distal radius and ulna. Periosteal elevation of the radius and ulna. 2) A skeletal survey is obtained. Humerus and elbows are normal. Femurs are shown here. 3) Extensive periosteal elevation along the length of both femurs. 4) Both tibiae and fibulae are shown here. 5) Periosteal elevation along the length of both tibiae. Destructive lytic lesions of the proximal tibiae and the left fibula. 6) Syphilis of the bone
- #26 X-ray diagnosis? 2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling. 1) Severe demineralization (osteopenia). A mid-radius fracture is noted along with ulnar bowing. 2) His femurs show bowing and prominent flaring of the distal femur metaphysis. 3) Both tibiae are demineralized with bowing. 4) Rickets due to vitamin D malabsorption (chronic liver disease and lack of bile and fat-soluble vitamin malabsorption)
- #27 X-ray diagnosis? 6-month-old boy with difficulty breathing. He has had frequent noisy breathing episodes since birth. 1) Lateral neck radiograph is obtained. The tracheal size appears to be normal or slightly narrow. 2) Examine the tracheal diameter on the chest x-ray. It looks relatively normal on the PA view, but the lateral view demonstrates a very narrow trachea. 3) A barium swallow identifies a mass posterior to the esophagus. 4) Vascular "rings" encircle the trachea and esophagus. The two most common types are the double aortic arch and the right-sided aortic arch. 5) Examine the bend of the trachea near the bifurcation. If it bends toward the left, this suggests a right-sided aortic arch. 6) Vascular ring with tracheal and esophageal compression
- #28 X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing. 1) Following coin removal, persistent stridor is noted. His PMH is significant for frequent episodes of noisy breathing since birth. 2) His trachea is narrow on the lateral chest x-ray. This finding persists on a repeat chest x-ray. 3) An esophagram identifies a mass posterior to the esophagus. 4) Esophageal coin with a vascular ring
- #29 X-ray diagnosis? 8-year-old boy with a chief complaint of fever. On exam, he is noted to have reproducible tenderness over his upper thoracic spine. 1) Note the narrowed intervertebral disk space best seen on the AP view. 2) Repeat x-rays are taken and confirm the narrow disk space on both AP and lateral views. 3) Discitis