apls pediatric emergency radiology 2

Hb1

Pediatric Emergency Radiology II

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Objectives•Identify the following 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

Hb3

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

Congenital Lobar Emphysema

Hyperexpanded left upper lobe, resembling a tension pneumothorax. This will not benefit from a chest tube.

Hb4

8 year old with abdominal pain for 2

weeks, back ache since

yesterday’s ballet practice.

8 year old with abdominal pain for 2

weeks, back ache since

yesterday’s ballet practice.

X-rays repeated8 days later.

X-rays repeated8 days later.

Multiple vertebral

body compression

fractures. Leukemia.

Multiple vertebral

body compression

fractures. Leukemia.

Hb5

Vertical air densities

Vertical air densities

Air filled aorto-pulmonarywindow

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

Pneumomediastinum Hamman Sign

Hb6

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.

X-ray diagnosis? 6-year-old boy with fever, abdominal pain, tachypnea, suspected pneumonia.

Staphylococcus Aureus Pneumonia

Expect empyema, pneumothorax, blebs, fistula.

Hb7

Close-up view of the “coin.” Is it a penny?

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.

20-month-old girl swallowed a coin (witnessed by 5-year-old cousin). Brief coughing episode. No symptoms at this time.

Coin and battery lineupCoin and battery lineup

Ingested Disk

Battery

Ingested Disk

Battery

Hb8

Enlarged view: White arrows point at air dissecting within the bowel wall. Double density (“railroad tracks”).

Enlarged view: White arrows point at air dissecting within the bowel wall. Double density (“railroad tracks”).

3 day old premie with hematemesis.3 day old premie with hematemesis.

Air dissecting in the bowel wall.

Double outlining (railroad tracks).

Bubbles in the bowel wall.

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.

Obvious air dissecting within

bowel wall in a term infant.

Pneumatosis Intestinalis

Due to Necrotizing

Enterocolitis (NEC)

Pneumatosis Intestinalis

Due to Necrotizing

Enterocolitis (NEC)

Hb9

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.

X-ray diagnosis? 3-month-old with bilious vomiting.

Midgut Volvulus Complicating a Malrotation

(“guts on a stalk” syndrome)

Midgut Volvulus Complicating a Malrotation

(“guts on a stalk” syndrome)

Hb10

X-ray diagnosis? 4-year-old girl w/ abdominal pain for 3 days.

Enlarged view(darken the room)

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 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.

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.

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.

Rupture appendix. Right abdominal

abscess formation.

Hb11

X-ray diagnosis? 4-year-old girl who fell at the playground. X-ray diagnosis? 4-year-old girl who fell at the playground.

Bowing Fracture of the UlnaBowing Fracture of the Ulna

Her forearm is swollen with a moderate deformity. Her forearm is swollen with a moderate deformity.

Hb12

Another view is obtained.

Another view is obtained.

X-ray diagnosis?20 month old female, refuses to stand on her right leg. No known trauma except for falling while running.

X-ray diagnosis?20 month old female, refuses to stand on her right leg. No known trauma except for falling while running.

Thin oblique fracture of the distal tibia.

Thin oblique fracture of the distal tibia.

White arrows point to the fracture. Black arrows point to a vascular groove.

White arrows point to the fracture. Black arrows point to a vascular groove.

Child abuse or due to a fall? Child abuse or due to a fall?

Toddler Fracture(probably accidental)

Toddler Fracture(probably accidental)

Hb13

X-ray diagnosis?7 year old male with fever, sore throat, headache and neck stiffness, 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.

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.

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.

Note that the back of the pharynx is in line with the trachea.

Normal Step-OffNormal Step-Off Abnormal: Step-Off is absentAbnormal: Step-Off is absent

CT scanning helps to define the type of abscess

Large, rim enhancement with contrast, anterior bulging.

Large, rim enhancement with contrast, anterior bulging.

Small, no rim enhancement, no anterior bulging.

Small, no rim enhancement, no anterior bulging.

True abscessTrue abscessPhlegmonPhlegmon

Prevertebral (retropharyngeal)

abscess

Prevertebral (retropharyngeal)

abscess

Hb14

Normal Infant Skull Sutures:

S=Sagittal, C=Coronal,

L=lambdoidal

Normal Infant Skull Sutures:

S=Sagittal, C=Coronal,

L=lambdoidal

Normal Infant Skull Sutures:C=coronal, L=lambdoidal, P=parietomastoid,

O=Occipitomastoid

Normal Infant Skull Sutures:C=coronal, L=lambdoidal, P=parietomastoid,

O=Occipitomastoid

Hb15

Right Parietal Skull FractureRight Parietal Skull FractureFind the skull fracture - Case 1Find the skull fracture - Case 1

Hb16

Find the skull fracture - Case 2

Find the skull fracture - Case 2

Right Occipital Skull FractureRight Occipital Skull Fracture

Hb17

Find the skull fracture - Case 3Find the skull fracture - Case 3

AP viewsAP viewsLateral viewsLateral viewsRight Occipito-parietal Skull FractureRight Occipito-parietal Skull Fracture

Hb18


AP viewsAP views

Lateral viewsLateral viewsDepressed Skull FractureDepressed Skull Fracture

Hb19


Right Occipital Skull FractureRight Occipital Skull Fracture

Hb20

AP viewsAP viewsLateral viewsLateral views


Right Parietal Skull FractureRight Parietal Skull Fracture

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Parietal Skull FractureParietal Skull Fracture

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Biparietal Skull FractureBiparietal Skull Fracture

Hb23

Case 9:10-month-old

boy fell and sustained a

parietal skull fracture

3 months ago. He is

neurologically normal but

has a persistent soft

area inregion of fracture.

Case 9:10-month-old

boy fell and sustained a

parietal skull fracture

3 months ago. He is

neurologically normal but

has a persistent soft

area inregion of fracture.

Leptomeningeal Cyst(growing skull fracture)Leptomeningeal Cyst

(growing skull fracture)

Hb24

Destructive lytic lesions of the distal radius and ulna. Periosteal elevation of the radius and ulna.

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.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.

A skeletal survey is obtained. Humerus and

elbows are normal.

Femurs are shown here.

Periosteal elevation along the length of

both femurs.

Periosteal elevation along the length of

both femurs.

Both tibiae and fibulae are shown here.

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.

Periosteal elevation along the length of both

tibiae. Destructive lesions of the proximal

tibiae and the left fibula.

Syphilis of the Bone

Syphilis of the Bone

Hb25

2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling.

2-year-old boy with chronic liver disease with persistent forearm swelling 3 days after falling.

Rickets(vitamin D malabsorption)

Rickets(vitamin D malabsorption)

Severe demineralization:Mid-radius fracture

Ulnar bowing

Severe demineralization:Mid-radius fracture

Ulnar bowing

Hb26

6-month-old boy with difficulty breathing.Frequent noisy breathing episodes since birth.

6-month-old boy with difficulty breathing.Frequent noisy breathing episodes since birth.

Lateral neck

radiograph is obtained.

Tracheal size

appears to be normal or slightly

narrow.

Lateral neck

radiograph is obtained.

Tracheal size

appears to be normal or slightly

narrow.

Examine the

tracheal diameter

on the CXR.

Examine the

tracheal diameter

on the CXR.

Very narrow on the lateral view.

Very narrow on the lateral view.

A barium swallow

identifies a mass

posterior to the

esophagus

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.

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.

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)

Vascular Ring(tracheal and esophageal

compression)

Hb27

Following coin removal, persistent stridor is noted. PMH: frequent episodes of noisy breathing since birth.

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.

His trachea is narrow on the lateral CXR.This finding persists on a repeat CXR.

An esophagram identifies a mass posterior to the

esophagus.

An esophagram identifies a mass posterior to the

esophagus.

X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing.

X-ray diagnosis? 10-month-old boy who swallowed a coin presents with noisy breathing.

Esophageal Coin With a Vascular Ring

Esophageal Coin With a Vascular Ring

Hb28

Narrowed inter-vertebral space.

Narrowed inter-vertebral space.

Repeat views takenRepeat views taken

X-ray diagnosis?

8-year-old boy with chief

complaint of fever.

On exam, he is noted to have reproducible

tenderness over his upper

thoracic spine.

X-ray diagnosis?

8-year-old boy with chief

complaint of fever.

On exam, he is noted to have reproducible

tenderness over his upper

thoracic spine.

DiscitisDiscitis

apls pediatric emergency radiology 2

Health & Medicine

xray diagnosis

skull fracture case

parietal skull fracture

occipital skull fracture

oblique fracture

bowel wall

xray findings

trachea air dissection