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SPR 2016 Pediatric MSK Imaging: Beyond the Basics Reloaded Course January 15-17, 2016 SAM Questionnaire

SESSION FIVE

Pediatric Fracture Complications Arthur B. Meyers, MD

1. What it the typical cause of a deformity after a supracondylar fracture? A. Injury to the distal humeral physis and peripheral physeal bridge formation. B. Incomplete reduction and malunion. C. Osteonecrosis of the trochlea. D. Cubitus varus does not typically occur after supracondylar fractures.

Correct Answer: B

Reference Ecklund K, Jaramillo D. Imaging of growth disturbance in children. Radiol Clin North Am. 2001 Jul;39(4):823-41. Dai L. Radiographic evaluation of Baumann angle in Chinese children and its clinical relevance. J Pediatr Orthop B. 1999 Jul;8(3):197-9.

Rationale Answer is B. – Cubitus varus is the most common complication after supracondylar fractures and is typically due to persistent angulation of the distal fragment and malunion, not a growth disturbance. Answer A and C are not correct. Cubitus varus after supracondylar fractures is typically secondary to malunion not an osseous bridge or osteonecrosis. Answer D is not correct. Cubitus varus is the most common complication encountered after supracondylar fractures.

2. In a child with a post traumatic physeal bridge, in which of the following situations would bridge resection be considered? A. Bridge occupies > 50% of the physis, < 2 years of expected growth B. Bridge occupies > 75% of the physis, > 3 years of expected growth C. Bridge occupies < 2% of the physis, < 1 year of expected growth D. Bridge occupies < 50% of the physis, > 2 years of expected growth

Correct Answer: D

References Inoue T, Naito M, Fujii T, et al. Partial physeal growth arrest treated by bridge resection and artificial dura substitute interposition. J Pediatr Orthop B. 2006 Jan;15(1):65-9. Khoshhal KI,

Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):47-58. Williamson RV, Staheli LT. Partial physeal growth arrest: treatment by bridge resection and fat interposition. J Pediatr Orthop. 1990 Nov-Dec;10(6):769-76.

Rationale Answer is D. When a bridge occupies less than 50% of the area of the physis and the child is expected to have greater than two years of growth, this is the clinical scenario when bridge resection is considered. A and B are not correct. If a bridge occupies greater than 50% of the physis, then bridge resection is not typically considered. C is not correct. A bridge which occupies <2% of the physis with less than 1 year of expected growth is not likely to cause a substantial growth disturbance and would not typically be resected.

3. Which of the following scenarios has the highest risk for developing a clinically significant growth disturbance after a physeal injury? A. 15 year-old with a distal femoral fracture involving the germinal zone of the physis. B. 14 year-old with a distal radial fracture involving the hypertrophic zone of the physis. C. 10 year-old with a distal femoral fracture involving the germinal zone of the physis. D. 10 year-old with a distal radial fracture involving the hypertrophic zone of the physis.

Correct Answer: C

Reference Khoshhal KI, Kiefer GN. Physeal bridge resection. J Am Acad Orthop Surg. 2005 Jan- Feb;13(1):47-58. Ecklund K, Jaramillo D. Imaging of growth disturbance in children. Radiol Clin North Am. 2001 Jul;39(4):823-41.

Rationale Answer is C. Distal femoral physeal fractures are at high risk of post-traumatic bridges. Extension into the germinal zone of the physis increases the risk of bridge. Also younger patients with more expected growth are more likely to form bridges. Answers A and D are not correct. Distal radial fractures are common but bridge formation is less likely to occur at this location versus the distal femoral physis. Answer B is not correct. While distal femoral fractures are at high risk for physeal bridges the older age of the patient and involvement of the hypertrophic zone rather than the germinal zone make this patient at less risk than the patient in answer C.

MRI Anatomy and Injuries of the J. Herman Kan, MD

1. Which of the following are positive risk factors for recurrent anterior shoulder dislocation? A. Hill-Sachs lesion B. Under 20 years of age for first time dislocation C. >25% loss of the glenoid width (osseous Bankart) D. All of the above

Correct Answer: B

Reference Kinsella et al. Traumatic shoulder dislocation among adolescents: Hill-Sachs lesion volume and recurrent instability. JPO 2015 35:5, 455-61.

2. Which of the following is most commonly identified on MR arthrography in patients with multidirectional instability? A. Normal shoulder findings B. Chondral injury C. Hills-Sachs fracture and Bankart injury D. Patulous axillary recess

Correct Answer: A

Reference Milewski MD et al. Pediatric and adolescent shoulder instability. Clin Sports Med 2013 32:761- 79.

3. At what age does the glenoid secondary ossification centers first appear? A. At birth B. 5 years C. 11 years D. 18 years

Correct Answer: C

Reference Zember JS. Normal skeletal maturation and imaging pitfalls in the pediatric shoulder. Radiographics. 2015 35:1108-22.

4. Which of the following statements are true regarding rotator cuff tears in children? A. Full thickness tears are more common than partial thickness tears B. 90% of labral tears have associated rotator cuff tears C. Unlike adult patients, MR arthrography has low sensitivity for rotator cuff tears in children D. All the above are true statements

Correct Answer: C

Reference Edmonds EW et al. Diagnostic shortcomings of magnetic resonance Arthrography to evaluate partial rotator cuff tears in adolescents. J Pediatr Orthop 2015 35:4 p407-11.

Orthopedic Perspective: The Shoulder Scott B. Rosenfeld, MD

1. A patient undergoes an MRI arthrogram for recurrent shoulder instability. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. What is the most likely diagnosis? A. Glenolabral articular disruption (GLAD) B. Humeral avulsion of the glenohumeral ligament (HAGL) C. Superior labrum tear from anterior and posterior (SLAP) D. Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)

Correct Answer: B

References Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. PMID:12368791

Neviaser TJ. The GLAD lesion: Another cause of anterior shoulder . Arthroscopy 1993;9:22- 23. PMID:8442825

Rationale Humeral avulsion of the glenohumeral ligament (HAGL) occurs when the IGHL tears away from its humeral insertion without an associated subscapular tear. HAGL lesions are known to contribute to shoulder instability and is a likely culprit for recurrent dislocation. The classic teaching is that HAGL lesions requires open repair of the capsule, whereas the other lesions listed are felt to be better addressed with an arthroscopic approach.

According to the literature review by Stein et al., patients with significant glenoid bone loss, attenuated capsulolabral tissue, engaging Hill-Sachs lesions, and HAGL lesions are contraindicated for arthroscopic repair. They state that while arthroscopy has better cosmesis, decreased perioperative morbidity, decrease loss of external rotation, and is valuable in the confirmation of the extent and severity of shoulder instability, for these lesions open techniques are the gold standard.

2. A 21-year-old rugby player has recurrent pain and instability of the right shoulder recalcitrant to conservative management. Figure A is an image taken during diagnostic arthroscopy in the lateral decubitus position viewing from the posterior portal with instrument through a rotator interval anterior portal. In addition to a Bankart lesion, what other associated intra-articular condition is most likely present? A. B. SLAP tear C. Posterior labral tear D. Hill-Sachs lesion

Correct Answer: D

References Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002 Jan-Feb;30(1):116-20. PMID:11799007

Hintermann B, Gachter A,: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551 PMID:8526268

Rationale Bankart lesions frequently result from traumatic anterior shoulder dislocations and may result in recurrent instability, especially in younger patients. Because of the violent mechanism of injury, compression fractures of the posterolateral humeral head (Hill-Sachs lesions) may also result as the soft humeral head impacts against the relatively hard anterior glenoid. It is important to note that the presence of a Hill-Sachs lesion may destabilize the GH joint and predispose to subsequent dislocation if it engages the glenoid.

Hintermann et al conducted a prospective study to evaluate the arthroscopic findings of the unstable shoulder to provide insights in the causes and mechanisms of shoulder instability. In 212 patients who had at least 1 documented shoulder dislocation; 87% had anterior glenoid labral tears (Bankart lesion), 79% had ventral capsule insufficiency, 68% had Hill-Sachs compression fractures, 55% had glenohumeral ligament insufficiency, 14% had complete rotator cuff tears, 12% had posterior glenoid labral tears, and 7% had SLAP tears. Thus, of the choices, Hill-Sachs lesions are the most common finding.

3. Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? A. Humeral length inequality B. Glenoid hypoplasia and retroversion C. Scapular winging D. Anterior shoulder instability

Correct Answer: B

Reference Waters PM, Bae DS. Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am. 2005 Feb;87(2):320-5. PMID:15687154

Pearl ML. Shoulder problems in children with brachial plexus birth palsy: evaluation and management. J Am Acad Orthop Surg. 2009 Apr;17(4):242-54. Review. PMID:19307673

Rationale With or without nerve repair or transfer, internal rotation of the shoulder is the most common problem requiring treatment in children with incomplete brachial plexus palsy recovery. This contracture results from an imbalance between the strength of the relatively unaffected internal rotators and the paralytic external rotators. Untreated, it usually leads to progressive glenohumeral deformity characterized by posterior displacement of the humeral head on an increasingly dysplastic and retroverted glenoid.

Waters et al. performed a study to determine the effects of correction of external rotation weakness and internal rotation on glenohumeral development in patients with brachial plexus birth palsy. Twenty-five patients who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff were evaluated clinically and radiographically before the operation and at a minimum 2 years postoperatively. Soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a 2-5 year follow-up.

Pearl et al. completed a review article on shoulder problems related to children with brachial plexus palsy. They discuss the clinical workup, imaging studies, and surgical interventions used to treat these difficult clinical problems. They also state that evaluating the status of glenohumeral development is critical throughout the treatment of these palsies

SESSION SIX

MRI Anatomy and Injuries of the Nancy A. Chauvin, MD

1. In throwing athletes, what structure is the primary passive stabilizer to valgus stress at the elbow? A. Common flexor tendon B. Lateral ulnar collateral ligament C. Posterior bundle of the ulnar collateral ligament D. Anterior bundle of the ulnar collateral ligament

Correction Answer: D

Reference Conway JE, Jobe FW, Gousman RE, Pink M. Medial instability of the elbow in throwing athletes. J Bone Joint Surg Am 1992; 74: 67-83. Dwek JR, Chung CB. A systematic method for evaluation of pediatric sports injuries of the elbow. Pediatr Radiol 2013;43(Suppl 1): S120-128.

Rationale The anterior bundle of the ulnar collateral ligament is the primary passive stabilizer to valgus stress while the posterior bundle of the ulnar collateral ligament is a minor stabilizer. The common flexor tendon is an active stabilizer. The lateral ulnar collateral ligament functions as a stabilizer to varus stress.

2. Of the following, what preoperative MRI feature is least likely to be associated with unstable dissecans of the capitellum? A. Displaced osteochondral fragment B. Focal high-signal T2-weighted line crossing the articular cartilage C. Fluid-filled osteochondral defect D. High-signal fluid interface between the articular cartilage and the subchondral bone

Correct Answer: B

References Satake H, Takahara M, Harada M, Maruyama M. Preoperative imaging criteria for unstable osteochondritis dissecans of the capitellum. Clin Orthop Relat Res. 2013; 471: 1137-1143. Jans

LBO, Ditchfield M, Anna G, Jaremko JL, Verstraete KL. MR imaging findings and MR criteria for instability in ostechondritis dissecans of the elbow in children. Eur J Radiol. 2012; 81(6): 1306- 10.

Rationale A high-signal T2-weighted line that crosses the articular cartilage indicates a focal cartilage defect/fissure. The other findings directly or indirectly indicate motion of the osteochondral fragment.

3. Fishtail deformities of the distal are delayed complications due to: A. Panner's disease B. of the proximal C. Distal humeral fractures D. Radial head dislocations

Correct Answer: C

Reference Narayanan S, Shailam R, Grotthai BE, Nimkin K. Fishtail deformity – a delayed complication of distal humeral fractures in children. Pediatr Radiol 2015; 45: 814-819.

Rationale Fishtail deformities of the distal humerus are rare delayed complications of distal humeral fractures in children. The deformity likely results from post-traumatic avascular necrosis of the trochlear cartilage which gives rise to a fishtail configuration of the distal humerus. The other responses involve the medial compartment and are not associated with fishtail deformities.

4. Which is the optimal MR sequence to diagnose Panner's disease? A. T1-weighted imaging B. T2-weighted fat suppressed imaging C. Gradient imaging D. T1-weighted fat suppressed post-contrast imaging

Correct Answer: A

Reference Dwek JR, Chung CB. A systematic method for evaluation of pediatric sports injuries of the elbow. Pediatr Radiol 2013;43(Suppl 1): S120-128.

Rationale Panner's disease is typically low on T1-weighted imaging. It can have variable signal on T2- weighted imaging due to viability of the tissue and stage of the disease. While the capitellum can appear fragmented on gradient imaging, it is the low T1-weighted signal which is most diagnostic. Gadolinium is not necessary to make the diagnosis.

Anatomy and Abnormalities of the Wrist Mahesh M. Thapa, MD

1. Which carpal bone is the first to demonstrate an ossific center? A. Lunate B. Capitate C. Hamate D. Scaphoid

Correct Answer: B

References Radiographics. 2014 Mar-Apr;34(2):472-90. doi: 10.1148/rg.342135073. Pediatric distal forearm and wrist injury: an imaging review. Little JT, Klionsky NB, Chaturvedi A, Soral A, Chaturvedi A.

Greulich WW, Pyle S. Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. Stan- ford, Calif: Stanford University Press, 1959.

2. Galeazzi-equivalent fracture differs from a Galeazzi fracture in that a Galeazzi- equivalent fracture involves the ______. A. Ulnar physis B. TFCC C. DRUJ D. Extensor carpi ulnaris

Correct Answer: A

References Eberl R, Singer G, Schalamon J, Petnehazy T, Hoell- warth ME. Galeazzi lesions in children and ado- lescents: treatment and outcome. Clin Orthop Relat Res 2008;466(7):1705–1709.

Atesok KI, Jupiter JB,Weiss AP. Galeazzi fracture. J Am Acad Orthop Surg 2011;19(10):623–633.

Letts M, Rowhani N. Galeazzi-equivalent injuries of the wrist in children. J Pediatr Orthop 1993;13(5): 561–566.

3. In gymnast’s wrist, the distal radial physis is affected much more commonly than the distal ulnar physis. Which of the following is a likely contributing factor for this phenomenon? A. Cross-sectional area of the distal radial physis is larger B. Children normally tend to have ulnar positive-variance C. Axial loading affects the distal more D. Radial physis loses its growth potential earlier

Correct Answer: A

Reference Pediatr Radiol. 2009 Dec; 39(12): 1310–1316. Published online 2009 Oct 22. doi: 10.1007/s00247-009-1428-x PMCID: PMC2776148. MR imaging of overuse injuries in the skeletally immature gymnast: spectrum of soft-tissue and osseous lesions in the hand and wrist. Jerry R. Dwek, Fabiano Cardoso, and Christine B. Chung

Unknown Cases 3 Erica K. Schallert, MD

1. The percentage of giant cell tumors of bone diagnosed in skeletally immature patients(< 14 years of age) is: A. <1% B. 1-3% C. 4-6% D. 7-10 %

Correct Answer: B

Reference Murphey MD et al. Imaging of Giant Cell Tumor and Giant Cell Reparative Granuloma of Bone: Radiologic-Pathologic Correlation. RadioGraphics 2001; 21: 1283-1309. Chakarun CJ et al. Giant Cell Tumor of Bone: Review, Mimics, and New Developments in Treatment. RadioGraphics 2013; 33: 197-211.

2. Which of the following is the LEAST common location for chronic recurrent multifocal (CRMO) at initial presentation? A. Lower extremities B. Spine C. Pelvic D. Mandible

Correct Answer: D

Reference Khanna G, Takashi SP, Ferguson P. Imaging of Chronic Recurrent Multifocal Osteomyelitis. RadioGraphics 2009; 29: 1159-1177.

Rationale In the three year institutional experience detailed in the reference below, the most common sites of CRMO at initial presentation were the lower extremities at 39.7%, followed by the spine at 25.9% and the pelvis at 20.7%.

3. Synovial(intra-articular) venous vascular malformations can cause which of the following bony abnormailities? A. Overgrowth B. Hypoplasia C. Early physeal closure D. All of the above

Correct Answer: D

Reference Quinn SF. Venous Malformations. MRI Web Clinic - November 2007. www.radsource.us Kan JH, Kleinman PK. Pediatric and Adolescent Musculoskeletal MRI: A Case-Based Approach. Springer 2007.

Rationale Synovial venous malformations cause a wide range of bony abnormalities including hypoplasia, demineralization, overgrowth, sclerosis, erosion, , early growth plate fusion and advanced epiphyseal maturation.

SESSION SEVEN

MRI Anatomy and Injuries of the Hand Andrew M. Zbojniewicz, MD

1. A Stener lesion refers to a ligamentous injury to the thumb metacarpophalangeal joint in which: A. The radial collateral ligament retracts superficial to the abductor pollicis brevis tendon B. The ulnar collateral ligament retracts superficial to the abductor pollicis brevis tendon C. The ulnar collateral ligament retracts superficial to the adductor pollicis aponeurosis D. The radial collateral ligament retracts superficial to the adductor pollicis aponeurosis

Correct Answer: C

Reference Hinke DH, Erickson SJ, Chamoy L, Timins ME. Ulnar Collateral Ligament of the Thumb: MR Findings in Cadavers, Volunteers, and Patients with Ligamentous Injury (Gamekeeper’s Thumb). AJR 1994;13:1431-1434.

2. Jersey finger refers to: A. Injury to the extensor mechanism at the distal interphalangeal joint B. Injury to the flexor digitorum profundus at the distal interphalangeal joint C. Injury to the flexor digitorum superficialis at the distal interphalangeal joint D. Volar plate avulsion injury at the proximal interphalangeal joint

Correct Answer: B

Reference: Clavero JA, Alomar X, Monill JM, et al. MR Imaging of Ligament and Tendon Injuries of the Fingers. Radiographics 2002; 22:237-256.

3. Which of the following is true regarding bizarre parosteal osteochondromatous proliferation (BPOP): A. Presence of corticomedullary continuity and a cartilage cap are diagnostic B. Most commonly involves the long bones C. Strong potential for malignant degeneration and metastasis D. May mimic chondrosarcoma on histology

Correct Answer: D

Reference Kransdorf MJ and Murphey MD. Extraskeletal Osseous and Cartilaginous Tumors. In: McAllister L and Barrett K, eds. Imaging of Soft Tissue Tumors, 2nd ed. Philadelphia, PA. Lippincott Williams & Wilkins; 2006:449-452.

Rationale Option A is not correct. Presence of corticomedullary continuity is diagnostic of an osteochondroma, but not present in BPOP. Option B is not correct. The hands are most commonly involved. Option C is not correct. BPOP has not been shown to undergo malignant degeneration or metastasis.

Update on Vascular Anomalies Arnold Carl Merrow, MD

1. Which of the following is NOT a recognized complication of extremity venous malformations? A. Hemarthrosis with joint degeneration B. Limb length discrepancy C. Thrombosis D. Malignant degeneration

Correct Answer: D

References Dasgupta R, Patel M. Venous malformations. Semin Pediatr Surg. 2014 Aug;23(4):198- 202.

Spencer SA, Sorger J. Orthopedic issues in vascular anomalies. Semin Pediatr Surg. 2014 Aug;23(4):227-32.

Rationale

Malignant degeneration. Degeneration of a preexisting vascular anomaly into malignancy has rarely been reported with infantile hemangiomas and lymphatic malformations but has not been reported with venous malformations. (D)

Venous and lymphatic malformations may have intra-articular extension with synovial involvement. Such lesions can cause recurrent hemarthrosis with erosions of cartilage and bone. (A)

Vascular malformations of the extremity can cause overgrowth or undergrowth, either of which may lead to a limb length discrepancy. (B)

Venous malformations may have an intralesional (or “localized intravascular”) coagulopathy, leading to internal thrombi. (C)

2. Which of the following lesions is NOT associated with a coagulopathy? A. Congenital hemangioma B. Infantile hemangioma C. Venous malformation D. Kaposiform hemangioendothelioma

Correct Answer: B

References http://issva.org/content.aspx?page_id=22&club_id=298433&module_id=152904

Enjolras O, Wassef M, Mazoyer E, Frieden IJ, Rieu PN, Drouet L, Taïeb A, Stalder JF, Escande JP. Infants with Kasabach-Merritt syndrome do not have "true" hemangiomas. J Pediatr. 1997 Apr;130(4):631-40.

Rationale Infantile hemangioma. The term “infantile hemangioma” will sometimes be misapplied to lesions that can cause a coagulopathy, such as the large solitary congenital hemangiomas of the liver or soft tissue, visceral, or bony venous malformations. (B)

Congenital hemangioma. The rapidly involuting subtype of congenital hemangioma (RICH) may cause a mild to moderate transient thrombocytopenia with or without a consumptive coagulopathy and elevated D-dimer. This coagulopathy is sometimes confused with the Kasabach-Merritt phenomenon. (A)

Venous malformation. These congenital anomalies cause a chronic localized intravascular/intralesional coagulopathy with elevated D-dimer and mild to moderate thrombocytopenia. (C)

Kaposiform hemangioendothelioma (KHE). KHE is an intermediate grade, locally invasive neoplasm typically found in infants. This lesion causes the true Kasabach- Merritt phenomenon (KMP), which consists of a consumptive coagulopathy with a severe and sustained thrombocytopenia and hypofibrinogenemia with elevated D- dimer. (D)

3. Which imaging feature separates Gorham-Stout disease from Generalized Lymphatic Anomaly (GLA)? A. Splenic lesions B. Pleural effusions C. Bone lesions D. Cortical bone destruction

Correct Answer: D

References Lala S, Mulliken JB, Alomari AI, Fishman SJ, Kozakewich HP, Chaudry G. Gorham-Stout disease and generalized lymphatic anomaly--clinical, radiologic, and histologic differentiation. Skeletal Radiol. 2013 Jul;42(7):917-24.

Trenor CC 3rd, Chaudry G. Complex lymphatic anomalies. Semin Pediatr Surg. 2014 Aug;23(4):186-90.

Rationale Splenic lesions, B) pleural effusions, and C) bone lesions can be seen with either Gorham-Stout disease or GLA, though involvement of the spleen and pleura occurs more frequently in GLA.

4. Which characteristic imaging finding is NOT paired correctly with the vascular anomaly in which it is commonly seen? A. Phleboliths, low flow vessels: Infantile hemangioma B. Fatty mass with high flow vessels: PHOST C. Septa in cysts + fluid-fluid levels: Lymphatic malformation D. Solid, enhancing, infiltrating mass: Kaposiform hemangioendothelioma

Correct Answer: A

References Kollipara R, Odhav A, Rentas KE, Rivard DC, Lowe LH, Dinneen L. Vascular anomalies in pediatric patients: updated classification, imaging, and therapy. Radiol Clin North Am. 2013 Jul;51(4):659-72.

Dasgupta R, Patel M. Venous malformations. Semin Pediatr Surg. 2014 Aug;23(4):198- 202.

Kurek KC, Howard E, Tennant LB, Upton J, Alomari AI, Burrows PE, Chalache K,Harris DJ, Trenor CC 3rd, Eng C, Fishman SJ, Mulliken JB, Perez-Atayde AR, Kozakewich HP. PTEN hamartoma of soft tissue: a distinctive lesion in PTEN syndromes. Am J Surg Pathol. 2012 May;36(5):671-87.

Restrepo R, Palani R, Cervantes LF, Duarte AM, Amjad I, Altman NR. Hemangiomas revisited: the useful, the unusual and the new. Part 1: overview and clinical and imaging characteristics. Pediatr Radiol. 2011 Jul;41(7):895-904.

Adams DM, Hammill A. Other vascular tumors. Semin Pediatr Surg. 2014 Aug;23(4):173-7.

Rationale A) Phleboliths, low flow vessels: Infantile hemangioma. Phleboliths associated with vascular anomalies are almost always within venous malformations. Rarely, they may also be seen in spindle cell hemangiomas (not infantile hemangiomas).

Incorrect answers: B) Fatty mass with high flow vessels: PHOST, C) Septa in cysts + fluid-fluid levels: Lymphatic malformation, and D) Solid, enhancing, infiltrating mass: Kaposiform hemangioendothelioma are all correct pairings between characteristic imaging findings and the vascular anomalies in which they are frequently seen.

Update on Pediatric Musculoskeletal Intervention John H. Naheedy, MD

1. All of the following are acceptable therapeutic regimens for the treatment of an Osteoid Osteoma, EXCEPT: A. Medical management with Oral NSAIDs B. Surgical Excision C. Sclerotherapy with Doxycycline D. Radiofrequency Ablation

Correct Answer: C

Reference Ghanem I. The management of osteoid osteoma: updates and controversies. Current Opinion in Pediatrics: February 2006 - Volume 18 - Issue 1 - pp 36-41

2. All of the following lesions may potentially be amenable to percutaneous sclerotherapy, EXCEPT: A. Venous Malformations B. Fibrous Dysplasia C. Arteriovenous Malformations D. Primary Aneurysmal Bone Cysts

Correct Answer: B

Reference Shiels WE, Mayerson JL. Percutaneous Doxycycline Treatment of Aneurysmal Bone Cysts With Low Recurrence Rate: A Preliminary Report

3. All of the following are FDA approved for intra-articular use in children, EXCEPT: A. Aristospan (Triamcinolone hexacetonide) B. Synvisc-One (Hylan G-F 20) C. Kenalog-40 (Triamcinolone acetonide) D. Depo-Medrol (Methylprednisolone acetate)

Correct Answer: B

Reference http://products.sanofi.us/synviscone/synviscone.html

SESSION EIGHT

Scoliosis and Other Spine Abnormalities Jerry R. Dwek, MD

1. Markers for a which requires further neurosurgical imaging includes A. Thoracic hyperkyphosis B. Dextroscoliosis with a single major curve C. Stable thoracic levoscoliosis D. Non painful curvature

Correct: A

Reference Diab M, Landman Z, Lubicky J, Dormans J, Erickson M, Richards BS, et al. Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36(8):667-71

Rationale There are many studies documenting the need for preoperative neurosurgical imaging in the scoliosis. Although many risk factors have been assessed, increased thoracic hyperkyphosis has been shown to be one risk predictor(1). Others include a pain (answer 4 is wrong), and juvenile onset curves(1). While some studies have suggested a leftward curve is atypical and should be imaged, the largest studies have not if the curve is a stable thoracic leftward curve (answer 3 is wrong). Simple single major thoracic curves are the most typical types of scoliosis and unless there are other risk factors, do not require imaging(2).

2. When using the Cobb angle measurement: A. The measurement is taken from one vertebral body above the most tilted vertebral body superiorly to one vertebral body below the most tilted vertebral body. B. The measurement is taken from the most tilted vertebral body superiorly to the most tilted vertebral body inferiorly. C. The measurement is taken from one vertebral body below the most tilted vertebral body superiorly to one vertebral body above the most tilted vertebral body. D. The measurement is taken between the two vertebral bodies at the apex of the curve.

Correct: B

Reference Pahys JM, Samdani AF, Betz RR. Intraspinal anomalies in infantile idiopathic scoliosis: prevalence and role of magnetic resonance imaging. Spine (Phila Pa 1976). 2009;34(12):E434-8.

Rationale When measuring curvature in scoliosis, the Cobb angle system of measurement is overwhelmingly the most common in use. The taken most tilted vertebral body superiorly and the most tilted vertebral body inferiorly are taken as the end vertebral bodies of the curve and are the ones used for measurement. Essentially the curvature is measured at its maximum. Neither the body above of the body below the most tilted bodies are used for measurement as that would underestimate the curvature (answer 1 and 3 are wrong). While the bodies at the apex of the curvature can be used to indicate the level of maximum curvature they are not used for curve measurement (answer 4 is wrong) (3).

3. A structural curve: A. Will correct to a Cobb angle of less than 25 degrees with ipsilateral bending B. Will not correct to a Cobb angle of less than 25 degrees with ipsilateral bending C. Should not be included in the fusion segment as it will correct over time D. Is generally the compensatory curve and latest to develop

Correct Answer: B

Reference Kim H, Kim HS, Moon ES, Yoon CS, Chung TS, Song HT, et al. Scoliosis imaging: what radiologists should know. Radiographics. 2010;30(7):1823-42.

Rationale A structural curve is a curve which does not correct adequately with ipsilateral bending. These structural curves do not straighten with ipsilateral bending to a Cobb angle of less than 25 degrees (answer is wrong). Structural curves do not “bend out” to less than 25 degrees due to changes in vertebral body morphology and rotation. They are thus the major focus of fusion surgery and should be included in the fusion levels. They will not correct over time (answer 3 is wrong). In contrast a non-structural curve is compensatory and latest to develop. They should correct if the main structural curve is addressed (answer 4 is wrong) (3).

4. The following are possible options for scoliosis treatment A. Observation B. Bracing C. Spinal fixation D. All of the above

Correct Answer: D

Reference AAOS. What Are the Treatment Options for Scoliosis?2015; 2015(november 17 2015). Available from: http://orthoinfo.aaos.org/topic.cfm?topic=A00636.

Rationale There are many options for scoliosis treatment. Minor curves may be observed especially closer to skeletal maturity. Bracing may be effective in younger patients though patient compliance is a large problem since the brace must be worn most of each day. The mainstay of spinal curvature treatment in the current day when neither observation is not viable and bracing not an appropriate option (4).

Unknown Case 4 Mahesh M. Thapa, MD

1. A 12-year-old boy presents with right shoulder pain. What’s the most likely diagnosis?

A. Ewing Sarcoma B. Osteosarcoma C. Langerhans Cell Histiocytosis D. Chronic Noninfectious Osteomyelitis

Correct Answer: A

References Kapoor S, Tiwari A, Kapoor S. Primary tumours and tumorous lesions of . Int Orthop. 2008;32 (6): 829-34. doi:10.1007/s00264-007-0397-7

Zietz H, Berrak S, Ried H et-al. The clavicle: a vulnerable bone in pediatric oncology. Int. J. Oncol. 2001;18 (4): 689-95

2. An 11-year-old boy presents with left shoulder pain. What’s the most likely diagnosis?

A. Ewing Sarcoma B. Osteosarcoma C. Langerhans Cell Histiocytosis D. Chronic Noninfectious Osteomyelitis

Correct Answer: D

References Kapoor S, Tiwari A, Kapoor S. Primary tumours and tumorous lesions of clavicle. Int Orthop. 2008;32 (6): 829-34. doi:10.1007/s00264-007-0397-7

Zietz H, Berrak S, Ried H et-al. The clavicle: a vulnerable bone in pediatric oncology. Int. J. Oncol. 2001;18 (4): 689-95

3. The arrows point to what finding in this 15-yr-old girl with Juvenile Idiopathic Arthritis?

A. Synovial Osteochondromas B. Rice Bodies C. Steroid injection Granulomas D. Sequela of Infection

Correct Answer: B

Reference Imaging of juvenile idiopathic arthritis: a multimodality approach. Sheybani EF, Khanna G, White AJ, Demertzis JL. Radiographics. 2013 Sep-Oct;33(5):1253-73. doi: 10.1148/rg.335125178.