This document provides an overview of pediatric x-ray interpretation and summarizes key points to consider when commenting on different types of pediatric x-rays, including chest, abdominal, bone, and other specialized x-rays. It outlines important anatomical landmarks and pathological findings to identify on x-rays of various body regions. The objectives are to enable identification of proper radiological film comments and distinguish pathological findings across different pediatric x-ray types and views.

1. Pediatric
X-Ray
Marwa Elhady
Ass Prof of pediatrics
Al-Azhar University
2019

2. Chest
X-Ray

3. Objectives
On completion of this lecture, you will be able to:
• Identify proper comment to different radiological x-ray films in
pediatrics
• Describe and distinguish different pathological findings in different
forms of X-ray in pediatrics with examples.

4. To comment on x-ray you must fulfill:
1. Quality.
2. Centralization.
3. Type.
4. View.
5. Bone
6. Tracheal air column.
6. Cardiac shadow.
7. Cardiothoraxic ratio
8. Lung field
9. Mediastinum
10. Costophrenic angle
11. Diaphragm
12. Any device
Centralization when the
medial ends of both
clavicles at same level
If Not Centralized: so we
Can not comment on
Position of Mediastinum.

5. Quality: determined by intervertebral disk & Soft tissue of the axilla
Good quality if can differentiate Intervertebral disks behind the heart
Soft x-ray: Intervertebral disks not seen.
Hard x-ray: Intervertebral disks hardly seen

6. •Bone deformity ≠ interpretation

7. Type:
• Plain CHEST X-Ray
• Barium swallows
• X-ray with contrast
(bronchography)
View:
• Posteroanterior
• Lateral

9. Tracheal air column: Normally central or slightly to the right.
Brocho-vascular makings:-
• Clearly seen in the medial 1/3.
• May be seen (hazy) in the middle 1/3.
• Not seen in the lateral 1/3.

10. Pulmonary congestion =
increased
bronchvascular marking
Pulmonary oligemia =
decreased
bronchvascular marking

11. Prominent bronchovascular
marking = pulmonary
congestion or plethora =
cardiac pathology
Reticulation = thick
bronchial tree wall
= lung pathology
Normal

13. Deep inspiration
Right copula of
diaphragm at
anterior rib 6-7 left copula of
diaphragm at
anterior rib 7-8

14. Cardiac shadow:-
• Normally to the left.
• 2/3 to the left, Less than 1/3
to the right side.
• Cardio-thorathic ratio ≤50%
(higher if recumbent or AP view)

15. Thymus (Sail sign)

16. Rt upper lobe suggest
aspiration
Lt upper lobe
pneumonia

17. • Upper lobe pneumonia
• Trachea central
• Lower border concave
• Upper mediastinal
mass
• Trachea shifted to
opposite side
• Rounded border
• Upper lope collapse
• Triangular opacity
• Trachea shifted to
same side
• Lower border convex

18. Middle lobe pneumonia

19. Lower lobe pneumonia

20. Pneumatocele with left
lobe consolidation =
staph pneumonia

21. • Scattered bilat
opacities =
bronchopneumonia

22. • Homogenous opacity obliterate costophrenic angle Rising to axilla with Shift of
mediastinum to opposite side
• Pleural effusion

23. Lung collapse with mediastinal
shift to same side + compensatory
emphysema
Massive effusion with mediastinal
shift to opposite side

24. • Jet black with no pulmonary
tissue = pneumothorax
• Homogenous opacity obliterate
costophrenic angle = Pleural
effusion
• Air fluid level = hydro-
pneumothorax

25. Lung abscess/ cyst

26. Lung abscess/ infected cyst

27. Lung abscess/ infected cyst

28. • Rt up lobe pneumonia
complicated by lung abscess
suggesting underlining FB

29. Normal Mild RDS Moderate RDS

30. White lung = Severe RDS

31. Full term = group B
strept infection
Preterm = RDS

32. • Jet black with shift of
mediastinum to opposite side
• Pneumothorax

33. • Hyperlucent with mediastinal
shift but contain lung tissue
• Emphysema
• Either congenital or
compensatory to other lung
pathology or ball valve effect
(suggest FB)

34. Emphysema Pneumothorax

35. Encysted pneumothorax

36. Interstitial emphysema

37. Interstitial emphysema
with pneumothorax
Interstitial emphysema
with pneumomediastinum

38. Diaphragmatic hernia
with mediastinum shift

39. •Rt diaphragmatic hernia,
Lf pneumothorax
•Hepatic UVC

40. Diaphragmatic hernia
Congenital cystic adamantoid
malformation

41. Mediastinal/
Rt mediastinal/ hilar mass

42. Mass in the posterior mediastinum.

43. Hilar LN Calcified LN

44. Eventration of the diaphragm Phrenic nerve paralysis

45. Pulmonary edema, kerley B
line (fluid in lung fissures)
Ground glass appearance
Pulmonary edema

46. ARDS

48. Pulmonary edema Bronchopneumonia ARDS

49. Miliary TB

50. Nasogastric tube
ETT
UVC
UAC
Chest tube
Central line
Devices

52. Low position ETT High position ETT Esophageal ETT

53. Fracture rib

54. Bone
X-Ray

55. Bone age = number of carpal bones - 1

56. Broadening, fraying ,
cubing = Active rickets
Broadening, fraying, cubing
+ line of calcification =
healing rickets
No broadening + line of
calcification = healed rickets

57. Green stick
fracture in rickets

58. Blount disease

59. Achondroplasia

60. • Multiple fracture with malunion
• Osteogenesis imperfecta

61. Osteopetrosis

62. Spatulated ribs = MPS
Flat vertebrae
(fish mouth)

63. Absent radius

64. Lead poisoning

65. Zebra stripe sing in
osteogenesis imperfecta
treated by intermittent
medication

66. Congenital rubella

67. Narrow joint space = JRANormal

68. Cardiology
X ray

69. In PA view
• Cardiac shape
• Cardio-phrinic angle
• Cardiothoracic ratio
• Cardiac borders
• Broncho vascular marking
In barium swallow
Esophageal displacement
Esophageal indentation
In lateral view
• Retrosternal space
• Retrocardiac space

71. Cardiomegaly

72. Cardiomegaly for DD
• If smooth borders with narrow base = flask shaped = pericardial effusion
• If angulated / irregular borders = champers enlargement

73. • Cardio-thorathic ratio>50%
• Cardiomegaly for DD
• Smooth cardiac borders
• Flask shape
• Pericardial effusion

74. Cardiomegaly +
heterogeneous lung opacity
(bronchopneumonia)
Cardiomegaly + increased
pulmonary vascular
marking

75. Lf ventricular enlargement
Apex down, out
Cardio-phrinic angle obtuse
Rt ventricular enlargement
Apex out
Cardio-phrinic angle acute
Bi ventricular enlargement
Apex out, out
Cardio-phrinic angle acute

76. Prominent aortic knuckle RT atrium enlargement=
obliteration of waist
Prominent pulmonary artery

77. Mass confirm by lateral view , CT , echo

78. Pneumopericardium Pneumomediastinum

79. Pneumopericardium + pneumomedistinum

80. Egg on side appearance = TGA

81. Fallot tetralogy

82. The largest heart = side to side = Ebetain anomaly

83. snowman sign = Figure 8 appearance = TAPVR

84. Rib notching in
coarctation of aorta

85. Situs inversus totals

86. Dextrocardia Dextroposition

87. Esophageal displacement by
Lf atrium enlargement
Esophageal compression by double
aortic arch or vascular ring

88. Abdominal
X ray

89. • Indications for plain abdominal X‐ray
Suspected obstruction/ perforation / FB / stone (UT/GB)
• Indications for Abdominal X-ray with contrast:
To evaluate: Filling time, motility, filling defect, malposition, stenosis
GIT: barium swallow, barium meal, barium follow through, barium enema
Urinary: IVP, ascending cystourethrography
• Abdominal X-ray not indicated:
If abdominal trauma/ pain/ mass/ bleeding

90. • "double bubble" sign =
Duodenal atresia

91. • triple bubble = Jejunal atresia

92. • No gas in pelvis = anal atresia

94. Bilateral inguinal hernia

95. Esophageal atresia NG tube not pass

96. • Abnormal passage of NG tube =
esophageal perforation

97. FB

98. • Errect Abd x ray
• Multiple fluid level
• Intestinal obstruction

99. • Air under diaphragm =
intestinal perforation

100. Bilateral renal calcification = nephrocalcenosis

101. Stone

102. • Air under diaphragm

103. • NEC with thick intestinal wall,
pnematosis intestinalis , Portal
venous gas

104. • NEC with perforated viscus

105. Barium swallow:
esophagus
displaced right and
posteriorly due to
enlarged left atrium.

106. Achalasia

107. Hypertrophic Pyloric
Stenosis

108. barium enema→ narrow
segment involving recto-
sigmoid junction =
Hirschsprung Disease

109. Loss of stria with
strengthening of colon
suggest IBD (UC)
Dilated colon with
irregular mucosa suggest
IBD (chon's disease)
Aganglionic segment
(Hirschsprung disease)

110. IVP
• Filling time reflect renal function (replaced by DMSA)
• Empty to urinary bladder (reflect narrowing of ureter or PU junction)
• Renal calyceal system (displaced , ballooning)
• Renal pelvis (dilatation or filling defect)
• Ureter (displaced, dilated, tortious, abnormal insersion)
• Bladder (if can hold urine = filling defect, diverticulum)

111. An x-ray image of the upper abdomen 10 minutes after
the injection of contrast material shows normal
kidneys, collecting systems and upper ureters.

112. IVP hydronephrosis

113. Hydroureter
hydronephrosis

114. Pelvi-ureteric
junction stenosis =
hydronephrosis

115. Double ureter

116. Ascending cystourethrogram
• Urinary catheter
• Assess urethra: (stenosis, fracture, tear, posterior urethral valve)
• Assess urinary bladder (must be completely full): diverticulum,
filling defect (stone/mass), irregular surface)
• Assess ureter: vasicoureteric valve for VUR

117. Ascending
cystourethrogram
= Rt VUR

118. Posterior urethral
valve

119. Skull X ray

120. Normal

121. Fissure fracture

122. Hair on top appearance
= chronic hemolytic
anemia

123. Silver beaten
appearance =
↑ICT after
suture closure

124. • Skull bone defect
(osteolytic lesion)
• Histiocytosis X

125. Osteopetrosis

126. Lateral neck &
Nasopharynx X ray

127. Thumb sign = EpiglottitisNormal

128. Normal Steel sign = Subglottic
narrowing = Croup

129. Normal Adenoid enlargement