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Course Outline Pediatric Radiology: An Overview of Introduction to imaging the pediatric population Common Conditions Trauma Congenital conditions HEATHER L. MILEY, DC, MS, DACBR Scoliosis overview
Arthritis
Infection
Other musculoskeletal disorders
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Skeletal Development
Bones take many years to grow and mature
Intramembranous ossification
Mesenchymal models of bones form during the Pediatric Imaging embryonic period, and direct ossification of the mesenchyme begins in the fetal period Endochondral ossification
Cartilage models of the bones form from mesenchyme during the fetal period, and bone subsequently replaces most of the cartilage
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Skeletal Development
endochondral ossification
Primary ossification center
The main body of the bone model
Shaft of a bone ossified from the primary ossification center is the diaphysis which grows as the bone develops Secondary ossification centers
Appear in other parts of the developing bone after birth
Parts of bone ossified from these centers are epiphyses
Growth of a long bone at the epiphyseal plates
https://courses.lumenlearning.com/wm-biology2/chapter/bone-growth-and-development/ 5 6
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Skeletal Development
Physis
Appears as a radiolucent line in the skeletally immature
As the metaphysis and epiphysis mature and fuse, the physis thins, disappears, and endochondral ossification ceases
A subchondral bone plate forms with horizontally- oriented trabeculae which appears as a radiopaque transverse fusion line (aka physeal scar)
Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 29729 7 8
Skeletal Development
Apophysis
A normal secondary ossification center located in the non-weight-bearing part of the bone
Eventually fuses over time
Process can be delayed, especially in female athletes
Is a site of tendon or ligament attachment
When unfused, can easily be mistaken for fractures
Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 27354 9 10
Imaging Guidelines
* Epiphysis initially partially or MSK x-ray completely cartilaginous, rapidly Acute trauma – spine or extremity replaced by SOC until only articular cartilage (wavy arrow) remains Limping child up to age 5 Chronic pain
➢ growth plate stays relatively Back or neck pain constant during development; at Inflammatory back pain: known or suspected axial spondyloarthropathy the onset of skeletal maturation, narrows and becomes less Chronic extremity joint pain, suspected inflammatory arthritis hyperintense (straight arrow) and Clinically suspected vascular malformation of extremities then finally closes completely Malignant or aggressive primary musculoskeletal tumor staging and surveillance
Primary bone tumors Can leave behind physeal scar (curved arrow) Soft tissue masses Stress fracture
Suspected osteomyelitis, septic arthritis, or soft tissue infection
Myelopathy or radiculopathy (spine)
Ataxia (spine)
Suspected congenital anomaly
Imaging of Pediatric Growth Plate Disturbances. Jie C. Nguyen, B. Keegan Markhardt, Arnold C. Merrow, and Jerry R. Dwek. RadioGraphics 2017 37:6, 1791-1812 11 12
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Imaging Guidelines
MRI or CT Internal derangement of joints (sports-related injuries) Tumors or infection Bone cancer or bone marrow for leukemia Congenital or acquired abnormalities of the spine or extremities Complex fractures Spinal cord 8 years
https://radsource.us/developmental-variants/ 13 14
Imaging Guidelines Bone Marrow – MRI
MSKUS Red marrow Developmental dysplasia of the hip Cellular, active, myeloid, or hematopoietic marrow Juvenile idiopathic arthritis Composed of cellular elements that include erythrocytes Cartilage/epiphyseal ossification centers that are not visualized on x- ray (red cells), granulocytes (white cells), and thrombocytes (platelets) Muscle hernia
Posttraumatic abnormalities – brachial plexus injury, intramuscular Responsible for satisfying oxygenation needs, immunity, hematoma, myositis ossificans, foreign body, tendon laceration and coagulation
Transient synovitis Osteoarticular and soft tissue infections Yellow marrow Soft tissue masses Fatty or inactive marrow Epidermoid or dermoid cysts Provide surface or nutritional support for red marrow Ganglion cysts elements Peripheral nerve sheath tumors (neurofibromas and schwannomas) Sparse vascular supply
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Bone Marrow – MRI
Amount and distribution of red and yellow marrow change with age
Normal conversion from red to yellow marrow occurs in a predictable and progressive manner
Completed by middle 20s
Conversion proceeds from the extremities to the axial skeleton occurring in the distal bones of the extremities (hands and feet) first, and progressing finally to the proximal bones
Occurs in a roughly symmetric manner on each side
In the long bone, epiphyses and apophyses first, then diaphysis, followed by distal metaphysis, and finally proximal metaphysis
Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 21541 17 18
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Bone Marrow – MRI
Rate of conversion from red to yellow marrow
Age Group Marrow Findings Infants (<1 year) diffuse red marrow, except for ossified epiphyses and apophyses Congenital Conditions Children (1-10 years) yellow marrow below knees and elbows, and in diaphysis of femora and humeri Adolescents (10-20 years) progressive yellow marrow in distal and proximal metaphyses of proximal long bones Adults (>25 years) yellow marrow except in axial skeleton and proximal metaphyses of proximal long bones
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Congenital Disorders of Bone Congenital – Skull
Can be divided into: Parietal foramina Congenital anomalies Result from delayed/incomplete ossification of the Normal skeletal variants posterior aspect of the parietal bone near the Skeletal dysplasias sagittal suture
Commonly encountered in clinical practice Transmits an emissary vein to the superior sagittal Some skeletal variants may simulate disease on x-ray sinus Can occur as a normal variant, or part of a Skeletal dysplasias are the result of faulty development and can congenital syndrome be grouped according to the features of the disease:
Proximal or distal limb shortening Consider further imaging (CT or MRI) if larger than 5
Sclerosis of osseous structures mm as this can be associated with vascular anomalies (especially venous) Specific spinal abnormalities
Agenesis or duplication of specific anatomic structures
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Congenital – Spine
Craniocervical junction (e.g., atlantooccipital assimilation, third occipital condyle, epitransverse and paracondylar process) Spina bifida occulta Block vertebra
Including Klippel-Feil syndrome Odontoid anomalies (e.g., os odontoideum) Agenesis of the posterior neural arch (e.g., C1 posterior arch, articular process, pedicle, etc.) Hemivertebra Butterfly vertebra Cervical ribs Posterior ponticle Transitional segments Sprengel deformity Unfused secondary ossification centers
Case courtesy of Benjamin Pereira Zimmermann, Radiopaedia.org, rID: 72098 23 24
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Congenital – Spine
Atlanto-occipital assimilation
Fusion of the atlas to the occiput = transitional vertebra
0.5% of the population
Typically asymptomatic but symptoms from nerve or vascular compression can occur
Need MRI with additional cuts through C0-C2 to include the transverse ligament
Complete (C1 not identifiable) to incomplete (C1 partially identifiable)
https://radiologykey.com/the-spine-congenital-and-developmental-conditions/ 25 26
Congenital – Spine
Atlanto-occipital assimilation
Associations:
Fusion of C2 and C3 (50% of cases)
Basilar invagination
Cleft palate
Cervical ribs
Urinary tract anomalies
Cranio-cervical instability
https://www.rrnursingschool.biz/syndrome-omim/basilar-impression.html 27 28
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10365 https://www.semanticscholar.org/paper/Congenital-osseous-anomalies-of-the-upper-cervical-Hosalkar-Sankar/87e6da0d1d2e730f7ff81e8334cd99bafcfc978f 29 30
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Congenital – Spine
Klippel-Feil syndrome
A complex heterogenous condition that results in cervical vertebral fusion
Two or more non-segmented cervical vertebrae
Classic triad (50%)
Short neck
Low hairline
Restricted neck motion
https://radiologykey.com/the-spine-congenital-and-developmental-conditions/ 31 32
Congenital – Spine Congenital – Spine
Klippel-Feil syndrome Klippel-Feil syndrome
Associations: Can show fusion of many cervical and upper thoracic vertebrae; fusion of two or three vertebrae Sprengel deformity with associated hemivertebrae, atlanto-occipital Anomalies of the aortic arch and branching vessels fusion, or other cervical spine abnormalities; or Spinal scoliosis cervical fusion with lower thoracic or lumbar
Intervertebral disc herniation vertebral fusion
Cervical spondylosis Classification grouped by patterns of inheritance, associated anomalies, and the axial level of the Renal abnormalities most anterior fusion
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Congenital – Spine
Klippel-Feil syndrome
X-ray: vertebral fusion, hemivertebrae, omovertebral bone, spina bifida, associated scoliosis and Sprengel deformity
CT: may additionally demonstrate canal stenosis secondary to degenerative changes
MRI: indicated in patients with neurologic deficits; excellent in demonstrating canal stenosis and cord compression, as well as disc bulge/herniation; can also reveal associated conditions such as myelomalacia, syrinx, diastematomyelia, and Chiari I malformation 5 yom
Case courtesy of Dr Mostafa El-Feky, Radiopaedia.org, rID: 52725 35 36
6 4/15/2021
Congenital – Hip/Pelvis
Developmental dysplasia of the hip Coxa valga Coxa vara Morphologies that may be associated with femoroacetabular impingement (FAI) Accessory ossicle – os acetabuli
12 yom
https://www.eurorad.org/case/11607 37 38
Congenital – Hip/Pelvis Congenital – Hip/Pelvis
Developmental dysplasia of the hip (DDH) Developmental dysplasia of the hip (DDH) Aberrant development of the hip joint Usually suspected in the early neonatal Results from an abnormal relationship of the femoral period due to routine clinical head to the acetabulum examination (orthopedic tests)
Diagnosis confirmed with ultrasound Female predominance (M:F ratio ~1:8) (femoral epiphysis not visible initially due to lack of ossification; preferred in infant <6 months)
Left hip m/c
Abnormal joint congruity with resulting alterations of both the acetabulum and femoral head
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Congenital – Hip/Pelvis
Developmental dysplasia of the hip (DDH)
Radiographic features: Key is to look for symmetry and defining the relationship of the 13 months female proximal femur to the developing pelvis
Ossification of the superior femoral epiphyses should be symmetric
Delayed ossification is a sign of DDH
Absent or small epiphysis
Lateral displacement of the femur
Shallow, vertically oriented acetabulum with an increased inclination of the acetabular roof
Coxa vara
Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 78984 41 42
7 4/15/2021
16 months female with asymmetric gait and limp on the right with associated pain
30 months female years after acetabular osteotomy
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 26763 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8439 43 44
Congenital – Knee & Ankle/Foot Congenital – Upper Extremity
Os acromiale Bipartite/tripartite/multipartite patella Accessory ossicle – os fabella Radioulnar synostosis
Tarsal coalition Supracondylar process Polydactyly, syndactyly Carpal coalition Accessory ossicles (several) Polydactyly, syndactyly Bipartite sesamoid Madelung deformity Phalangeal synostosis Ulnar variance Accessory ossicles (several)
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Trauma
Acute trauma
Repetitive trauma Pediatric Trauma Non-accidental trauma (abuse)
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Trauma: X-Ray Trauma: X-Ray
Conventional radiography (x-ray) is well suited Stress radiography
to the evaluation of most skeletal injuries Radiographs obtained during the application of manual stress In the evaluation of trauma in children, Used to uncover an articular injury that is not debate has centered around the need to apparent on initial radiographs obtain comparison radiographs of the m/c used to AC joint, knee, and ankle opposite extremity Needs to be accomplished soon after the traumatic event, however, before the appearance of Should be obtained selectively, not routinely, if the diagnosis is in doubt significant muscle spasm that may make the technique less rewarding Most typically in the evaluation of Salter-Harris type I growth plate injuries and hip trauma, as well as bowing fractures and injuries of the elbow
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Trauma: CT/MRI Trauma: CT
Specialized imaging are not generally Able to define the presence and extent of certain fractures or dislocations, detect intraarticular abnormalities (e.g., necessary for proper diagnosis of skeletal cartilage damage and osteocartilaginous loose bodies), and trauma assess nearby soft tissues
Useful in areas of complicated anatomy, such as the spine, bones in the face and pelvis, glenohumeral and Occasionally will allow identification of subtle sternoclavicular joints, and the midfoot and hindfoot fracture lines when initial x-rays are normal Rapid examinations
Not limited by plaster casting
Limited use in certain locations where coronal or sagittal Routine use is not indicated plane images are desired, or when metallic hardware is present
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Trauma: MRI Trauma: MRI
Increasing importance in the analysis of many Is unparalleled in the investigation of traumatically induced musculoskeletal disorders internal derangement of joints
Bone is visible on MR imaging Provides diagnostic information related to integrity of: Articular cartilage Distinct signal characteristics of marrow Menisci Bone marrow edema, bone bruise Labra Also allows information regarding bone cortex and possibly also the periosteal membrane Intraarticular ligaments Periarticular ligamentous and tendinous injuries Is not a suitable substitute for routine radiography or CT in the assessment of complex fractures when Injuries of muscles and other soft tissues information regarding the precise relationship of Osteochondral and stress fractures fracture fragments is required Spinal cord
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Acute Trauma – Fractures Acute Trauma – Fractures
Immature skeleton has growth plates, Likelihood, location, and configuration of a fracture cartilaginous epiphyses, and a thick, strong after injury depend on a number of factors, including age of the person, the type and mechanism of the periosteum injury, and the presence of any predisposing factors
Sports-related activities in an adolescent
Pediatric bone is more elastic than adult Fractures of small bones of hands and feet, as well bone: bowing and bending injuries are m/c as tubular bones of extremities (tibia and humerus) than breaking and splintering and the clavicle predominate in adolescents because of participation recreational activities
Physeal and metaphyseal regions in children and Overall, childhood fractures are less common the epiphyses in teenagers in tubular bones are than adult fractures often injured
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Acute Trauma – Fractures Fracture Terminology
This is due to changing patterns of skeletal strength and Fracture = a break in the weakness continuity of bone or cartilage, or both For example, an identical type of injury such as FOOSH will lead to musculoskeletal consequences that differ in the Chondral fracture – cartilage alone is various age groups: involved
Supracondylar fx of the humerus in young child Osteochondral fracture – fracture composed of cartilage and subjacent Metaphyseal fx of the distal portion of the radius in an older child bone Epiphyseal separation of the radius in an adolescent
Carpal injury in a young adult
Colles type fx of the distal portion of the radius in a middle-aged Each fracture is associated with person soft tissue injury Fx of the surgical neck of the humerus in an elderly person
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Acute Trauma – Fractures Incomplete Fractures
Fracture types: In immature skeleton, fractures that do not
1) Elastic deformation (momentary) completely penetrate the entire shaft of bone
2) Bowing (permanent) Includes:
3) Torus (buckle) fracture Bowing fracture
4) Greenstick fracture Greenstick fracture – incomplete transverse fracture with intact periosteum on the concave side and 5) Complete fracture rupture periosteum on the convex side; more common in elementary school age
Torus fracture – buckling of cortex
Stress fracture (discussed later)
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Incomplete Fractures
Bowing fracture 6 yom, fall while running
Longitudinal compression forces lead to bony forearm deformity, tenderness, deformation with plastic deformation reduced range of motion at occurring as a result of greater force following the elbow an initial elastic deformation; results in permanent bowing of the bone Findings: volar bowing of both Still further increases in stress will lead to the radius and ulna on the fracture lateral view with no visible fracture line m/c in radius and ulna
Abnormality may be subtle and necessitate comparison radiographs of the opposite side
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 44173 61 62
Incomplete Fractures
Greenstick fracture
aka hickory stick, willow
Perforates one cortex and ramifies within the medullary bone
Due to angular force
Commonly become converted to complete fractures because of exaggeration of the deformity as the bone continues to grow
m/c locations: proximal metaphysis or 5 yom trauma diaphysis of tibia, middle third of radius and ulna bowing with incomplete fracture through middle third of radius
Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 65820 63 64
Incomplete Fractures
Torus fracture history of trauma; distal Results from injury insufficient in force to create forearm/wrist pain a complete discontinuity of bone but sufficient to produce buckling of the cortex Findings: buckling of the Longitudinal compressive force distal metadiaphyseal Common in metaphyseal regions of long region of the radius on bones dorsal aspect, volar cortex is intact; mild bowing of radius Oblique and lateral radiographs may be more helpful than frontal projections
Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 10733 65 66
11 4/15/2021
Bone Bruise
Trabecular microfractures or occult intraosseous fractures
Altered signal intensity on MR imaging due to hyperemia, hemorrhage, and edema in the bone
Usually located close to a joint surface
Frequent association with other traumatic abnormalities such as cruciate and collateral ligament injuries of the knee
Case courtesy of Dr Mohammad A. ElBeialy, Radiopaedia.org, rID: 39780 67 68
Stress Fracture
16 yom with left knee pain Can occur in normal or abnormal bone that is and limitation of movement subjected to cyclic loading with the load being less following twisting injury during than that causing acute fracture of bone basketball game
Findings: ruptured ACL, Fatigue fractures – the application of abnormal stress or buckled but intact PCL, small torque on a bone with normal elastic resistance – are vertical tear of posterior horn generally seen in young adults of lateral meniscus, joint effusion, and moderate Features: contusion of the lateral femoral and tibial condyles Activity is new or different for the person The activity is strenuous
The activity is repeated with a frequency that ultimately produces symptoms and signs
Case courtesy of Dr Ahmed Abdrabou, Radiopaedia.org, rID: 24907 69 70
Stress Fracture Stress Fracture
Radiographic abnormalities depend on the location of More children are participating in organized and the fracture and the interval between the time of injury recreational athletics at a younger age and exam Increased athletic specialization and year-round activities have resulted in higher incidences of overuse Initially can be radiographically occult injuries (i.e., stress fractures and stress reactions) Continued stress on the injured bone or cartilage can lead to progressive radiographic changes Factors:
Weaker osteochondral junctions On x-ray may appear as a linear cortical radiolucent Thinner cortices area with periosteal and endosteal cortical thickening Hormonal changes
Decreased mineralization Bone formation can be extreme and obscure the radiolucent defect within the cortex Participation in sports with demanding schedules which may not allow adequate time for recovery Can be similar to an osteoid osteoma or abscess
71 72
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Stress Fracture
9 yom, hx of renal Femur stress fracture transplant on chronic Relatively rare in comparison to those of the tibia, fibula, immunosuppressive and foot therapy presenting with thigh pain m/c in endurance runners, jumpers, and dancers Result from repetitive loading, leading to subperiosteal Findings: linear band of bone resorption and microfractures which are not given sclerosis through the sufficient time to heal distal femoral metaphysis Can present with pain at the groin, hip, or knee and are and periosteal reaction typically aggravated by activity consistent with healing m/c site is femoral neck, but can occur anywhere along stress fracture the femoral diaphysis
X-rays can show linear sclerosis, periosteal elevation, and cortical thickening
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 73 74
Stress Fracture
Diaphyseal stress fracture
Common site for stress fractures in adolescents 3 yof with a limp is the tibia, followed by the fibula Commonly found in children participating in Findings: periosteal reaction football, soccer, tennis, and running along the posteromedial left tibia at the middle third, X-rays demonstrate cortical irregularity and consistent with stress fracture periosteal reaction, typically along the posteromedial proximal third of the tibial shaft MRI can be used in equivocal cases
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 75 76
Stress Fracture
Ankle and foot In children, m/c sites of stress fracture in the foot are the metatarsals and calcaneus, followed by cuboid, talus, and navicular More susceptible following immobilization for other fractures, injuries, or surgeries
two different 12 yof who been immobilized
Findings: stress fractures of the calcaneus (left) and 2nd metatarsal (right)
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 77 78
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Stress Fracture
MRI has high sensitivity and specificity with changes seen earlier than with x-ray 14 yom involved in multiple sports Findings: linear signal abnormality in the distal tibia consistent with Appear m/c as a linear zone of low signal intensity surrounded by a broader, poorly stress fracture (white arrow); multiple additional areas of signal defined area of surrounding bone marrow abnormality (red arrows) also edema consistent with stress reaction
In a tubular bone, however, when there is marrow edema without a visible fracture line, can simulate the appearance of osteomyelitis or a neoplasm
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 79 80
Stress Fracture
Sacral stress fractures Known to have a higher incidence in female athletes, particularly in runners Female athlete triad describes the relationship between caloric imbalance, hormonal dysregulation, and impaired bone health 8 yof with foot pain and limp Injury has components of both a fatigue and insufficiency fracture Findings x-ray: subtle sclerosis in cuboid Radiographs are often normal Findings MRI: linear low T1 signal intensity focus through lateral MRI demonstrates linear low signal intensity on T1-W images with corresponding edema aspect of cuboid with corresponding edema on T2 In endurance athletes, similar findings of a stress fracture can be seen in the inferior pubic rami
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 81 82
Stress Fracture
Not limited to cortical defects and fractures of tubular bones
Stress at the physis and apophysis may result in 18 yof cross country runner with gradually worsening low disruption of endochondral ossification and back pain resulting in physeal widening
Findings: stress fracture of the left sacral ala extending to the sacral foramen
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 83 84
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Stress Fracture
Gymnast’s wrist
Repetitive stress on the upper extremities can lead to physeal injury
Mechanical forces of dorsiflexion and compression triggers physeal injury at the distal radius 11 yo gymnast with ongoing wrist pain Similar forces can lead to the same injury in weightlifters
X-rays can demonstrate widening and fraying or Findings x-ray: unremarkable (no physeal widening, irregularity of the physis, while MRI demonstrates edema irregularity, or fraying) through the metaphysis Findings MRI: marrow edema through distal metaphyses of Severe or chronic injury can lead to premature fusion and positive ulnar variance, TFCC injury, and scapholunate or radius and ulna (white arrows), and to a lesser extent, the lunotriquetral ligament disruption radial and ulnar styloids (red arrows)
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 85 86
Stress Fracture
R L Little leaguer’s shoulder 13 yo baseball pitcher Injury to the proximal humeral physis typically caused by repetitive overhead throwing Findings: diffuse widening of the right proximal Often observed in male baseball pitchers between humeral physis (arrow); ages 11-16 in whom the excessive rotational forces comparison left shoulder of overhead throwing lead to physeal injury demonstrates normal Tend to present with focal pain over the width of the physis anterolateral shoulder that is worse with overhead throwing X-rays demonstrate widening and irregularity MRI reveals similar findings or widening of the physis with marrow edema
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 87 88
Stress Fracture
14 yo baseball pitcher with medial elbow pain for 1 month Little leaguer’s elbow
Injury to the medial epicondylar apophysis Findings x-ray: asymmetric widening of Usually young adolescent pitchers or catchers with medial the right medial elbow pain either with direct palpation or valgus stress to epicondyle physis the elbow (arrow), A; left elbow is Can present with mild flexion contracture at the elbow unremarkable, B secondary to pain Findings MRI: edema Radiographs demonstrate widening or fragmentation of within the medial the apophysis (contralateral asymptomatic elbow can be condyle epiphysis (arrow) used for reference in determining physeal widening or and the adjacent normal apophyseal development) metaphysis of the MRI demonstrates marrow edema and aids in determining humerus the integrity of the common flexor tendon and ulnar collateral ligament
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 89 90
15 4/15/2021
Stress Fracture
collegiate football player with shoulder pain and Acromial apophysiolysis/os acromiale known lesser tuberosity Failure of fusion of the acromion ossification centers (1-4) avulsion in the background of chronic repetitive traction forces from the deltoid = acromial apophysiolysis Findings x-ray: unfused Without healing, this may progress to an os acromiale, apophysis (arrow) at the which can in turn lead to impingement symptoms in the acromion shoulder
Typically present with chronic shoulder pain of insidious Findings MRI: edema at the onset apophysis, consistent with acromial apophysiolysis In younger patients, differentiating from the normal apophyseal development can be challenging as the age range of acromial fusion can vary from 18-25
Irregular cortical margins and abnormal marrow signal with adjacent bony edema favors the dx
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 91 92
Spondylolysis Spondylolysis
Spondylolysis = stress fracture of the neural arch of the More commonly from a fatigue fracture vertebra in the pars interarticularis (stress fracture) after repeated trauma May or may not be associated with slippage of one vertebral body onto the adjacent one = An increase in lumbar lordosis, as well as spondylolisthesis more vertical orientation of the top of the sacrum, may accentuate the stress placed m/c at L5 (90%), unilateral or bilateral on the neural arch Greater frequency in adolescent athletes, particularly: ~65% of patients with spondylolysis will Gymnastics progress to spondylolisthesis occurring before Diving the age of 16 Weight-lifting The defect commonly persists Pole-vaulting
Football Fibrous union and pseudoarthrosis can occur
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Spondylolysis Spondylolysis
Clinical presentation is variable and does not Wiltse classification of lumbar spondylolisthesis: correlate with degree of displacement Type I: dysplastic Type II: isthmic with a defect in the pars interarticularis Spondylolysis can be asymptomatic II-a: fatigue fracture II-b: an elongated but intact pars (d/t repeated, minor trabecular stress fractures of the pars with subsequent Back pain with activity may be present with healing) developing spondylolysis II-c: an acute fracture
Development of spondylolysis in a teenage athlete Type III: degenerative or young adult is usually painful Type IV: traumatic Pain with lumbar extension and/or rotation Type V: pathologic
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Spondylolysis
Radiologic features:
Weight-bearing AP and lateral views
Lateral view most useful for visualizing the pars and assessment of George’s line
However, superimposition of the transverse processes over the pars region may simulate pars defects
Limited sensitivity compared to advanced imaging
AP angulated (tilt-up) lumbosacral spot projection also helpful
The pars region of L5 projects immediately inferior and slightly medial to the pedicle and is particularly difficult at L5 because of the projectional distortion produced by the lumbosacral lordosis
Tube angled 25-30o cephalad with the CR passing through the lumbosacral disc midway between the pubic symphysis and level of the ASIS
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AP lumbar view (cropped) AP lumbosacral spot projection
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Spondylolysis: Spondylolysis: Assessment Assessment
Ullmann’s line George’s line *helpful for evaluation of subtle spondylolisthesis at L5-S1
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Back Pain in Children and Adolescents. Micah Lamb and Joel S. Brenner. Pediatrics in Review November 2020, 41 (11) 557-569; DOI: Haidar, Rachid & Saad, Sara & Khoury, Nabil & Musharrafieh, Umayya. (2011). Practical approach to the child presenting with back pain. European journal of https://doi.org/10.1542/pir.2019-0051 pediatrics. 170. 149-56. 10.1007/s00431-010-1220-9. 103 104
18 yof athlete
22 yof former gymnast
National University of Health Sciences National University of Health Sciences 105 106
pseudospondylolysis results from superimposition of the transverse process due to slight rotation at the time 15 yof athlete of imaging compare to radiograph of a true break in the pars interarticularis with cortical offset and vertebral translation
LSM Chiropractic 107 108
18 4/15/2021
Spondylolysis
Radiologic features: Oblique lumbar projections
Difficulty in positioning
Anterior oblique preferred
Often the pars defect is not tangential to the beam at 45o and defects at L5 may not be identified
Increased radiation exposure
** If a pars interarticularis defect is visible on routine 2-3 view lumbar spine radiographs, then bilateral oblique projections are not indicated
https://learningradiology.com/notes/bonenotes/spondylolysis.htm 109 110
https://www.physio-pedia.com/Spondylolysis_in_Young_Athletes National University of Health Sciences 111 112
Spondylolysis
13 yo basketball player Radiologic features → MRI complaining of low back pain Stress reaction: marrow edema with intact cortical margins Findings: transversely Incomplete stress fracture: marrow edema with oriented low signal through incomplete cortical fracture or fissure the L5 pedicle and pars Acute complete stress fracture: marrow edema with with corresponding edema; complete cortical fracture extending through the pars findings consistent with interarticularis unilateral stress fracture Chronic stress fracture: no marrow edema, fractures through the left pars extending completely through pars interarticularis interarticularis
Sclerosis of the contralateral pedicle if unilateral defect, which could also be seen on x-ray
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. 113 114
19 4/15/2021
16 yo baseball pitcher with recent onset low back pain
Findings: bone marrow edema in the left L3 pedicle, consistent with non-displaced stress fracture
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. https://www.physio-pedia.com/Spondylolysis_in_Young_Athletes 115 116
Salter-Harris Fractures
Epiphyseal plate fractures are analogous to ligamentous injuries in the adult Represent 35% of all skeletal injuries in children Age: 10-15 yoa 75% Physis is injured so permanent deformities may occur; early diagnosis and treatment can prevent significant growth disturbance and deformity Increasing grade of Salter-Harris fracture correlates with increasing risk of deformity Occur acutely as a result of a single episode of trauma or chronically as a consequence of prolonged stress, 15 yom particularly athletics (e.g., gymnastics) Subtle clinical findings may follow the acute traumatic insult: pain, swelling, tenderness, limitation of motion
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 39863 117 118
Salter-Harris Fractures Salter-Harris Fractures
m/c location: Classification
m/c in wrist (50%) and ankle (30%) Mnemonic: “SALTR”
Phalanges Slipped (type 1)
Distal tibial, fibular, ulnar, and radial growth plates Above (type 2)
Proximal humerus Lower (type 3)
Together (type 4)
Ruined (type 5)
119 120
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Salter-Harris Fractures
Type 1 (6%)
Pure epiphyseal separation with the fracture isolated to the growth plate itself
A shearing or avulsion force
m/c location: proximal portions of humerus and femur, and distal portion of humerus
Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 27144 121 122
12 yom fall onto 15 yom little finger shoulder while playing struck by football football
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 22229 Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 30373 123 124
Salter-Harris Fractures
Type 2 (75%) m/c type Shearing or avulsion force that splits the growth plate for a variable distance before entering the metaphyseal bone and separating a small fall, tender ankle fragment of the bone (Thurston Holland fragment or corner sign) Periosteum on opposite side of the metaphyseal fracture is disrupted m/c location: distal ends of the radius, tibia, fibula, femur, and ulna Generally good prognosis, easily reduced
Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 9687 125 126
21 4/15/2021
Salter-Harris Fractures
Type 3 (8%)
Fracture line extends vertically through the epiphysis and growth plate and then horizontally across the growth plate 11 yom fell during a soccer game m/c location: medial or lateral portion of the distal tibia, proximal tibia, distal femur
Displacement generally minimal and growth arrest deformity is rare if care is exercised during reduction
Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 43162 127 128
Salter-Harris Fractures
Type 4 (10%)
Vertically oriented splitting force that fractures across the epiphysis, the growth plate, and the metaphysis
m/c location: distal portions of the humerus and tibia
16 yom fall from bike In younger children where the epiphysis is unossified or only partially ossified, the injury may be mistaken for a type II fx
Type IV may require open reduction and careful realignment so that growth arrest and joint deformity are not encountered later
Arthrography and MR imaging may be needed to further define a possible type IV injury
Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 53308 129 130
ankle pain after 14 yom rugby tackle tackled while playing injury rugby
Case courtesy of Dr Stefan Lazic, Radiopaedia.org, rID: 51225 Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 84964 131 132
22 4/15/2021
Salter-Harris Fractures Salter-Harris Fractures – Hip
Type 5 (1%) Slipped capital femoral epiphysis (SCFE)
A crushing or compressive injury to the end of a m/c 10-17 yoa in boys and 8-15 yoa in girls tubular bone Injury to the vascular supply or the germinal cells of the plate occurs without any immediate Some reports that boys > girls, greater in black radiographic signs; no irregularity or widening of the patients than whites, and especially high in growth plate is seen overweight children Subsequent radiographic examination may indicate focal areas of diminished or absent bony growth, which in the presence of adjacent normal Left side 2x m/c than right in male patients development, can lead to angular deformity m/c location: distal femur and tibia and proximal 20-35% B/L involvement (girls > boys) tibia
133 134
Salter-Harris Fractures – Hip Salter-Harris Fractures – Hip
SCFE – contributing factors: Slipped capital femoral epiphysis (SCFE)
Trauma Radiographic analysis remains essential to the dx
Adolescent growth spurt AP and frog-leg projections are mandatory
A minimal amount of shearing stress is needed to displace Comparison radiographs of the opposite side can be the epiphysis when the growth plate is relatively wide as is very useful, particularly frog-leg view during periods of rapid growth
Further accentuated by its change in configuration from CT, scintigraphy, MR imaging, and ultrasonography have a horizontal to an oblique plane which increases shearing also been used stresses CT and MRI more sensitive to early diagnosis when x- Hormonal influence rays are normal
Weight and activity MRI – subtle physeal widening, synovitis, and marrow edema Obesity increases shearing stress on growth plate
135 136
Salter-Harris Fractures – Hip
SCFE – radiographic signs:
Osteoporosis of the femoral head and neck
Margin of the metaphysis may appear blurred or indistinct
Growth plate may appear increased in width
Epiphyseal height reduced
Abnormal Klein line – a tangential line drawn along the lateral border of the femoral neck may fail to intersect any part of the epiphysis or may cross only a small portion of it 10 yom left sided hip pain, Metaphysis may appear displaced from the acetabulum no trauma Displacement of the epiphysis
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7688 137 138
23 4/15/2021
15 yof
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10357 Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 9298 139 140
Salter-Harris Fractures – Hip Salter-Harris Fractures – Hip
Chronic SCFE – radiographic signs: SCFE sequelae
Reactive bone formation along the medial and Varus deformity posterior portions of the femoral neck (buttressing) Shortening and broadening of the femoral neck
Premature fusion of the growth plate may result in Osteonecrosis (6-15%) femoral shortening Chondrolysis (40%)
DJD age 27 with FAI deformity; ORIF age 13 for SCFE, removed 1.5 yrs later
E. Nectoux, J. Décaudain, F. Accadbled, A. Hamel, N. Bonin, P. Gicquel. Evolution of slipped capital femoral epiphysis after in situ screw fixation at a mean 11years’ follow-up: A 222 case series. Orthopaedics & Traumatology: Surgery & Research, Volume 101, Issue 1, 2015, Pages 51-54. ISSN 1877-0568. 141 142
Salter-Harris Fractures – Knee Salter-Harris Fractures – Knee
Birth, athletic, or automobile injuries At proximal tibial metaphysis, mechanism is
Type II and III especially common usually hyperextension
Includes wagon-wheel fracture resulting when children catch their legs between the spokes of wagon or Partial or complete arrest of growth 20% resulting bicycle wheels in limb length discrepancies and angular Also includes clipping injury of adolescent football deformities players
Prognosis guarded because of possible sequelae of shortening and angulation Associated with anterior compartment syndrome, ligamentous and meniscal abnormalities, and In hyperextension injury may damage popliteal artery, peroneal nerve palsy and with varus angulation there may be peroneal nerve damage; ACL may be disrupted in some cases
143 144
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Salter-Harris Fractures – Ankle Salter-Harris Fractures – Ankle
Distal tibial growth plate injuries common Triplane fracture
Represent approximately 5-10% of all injuries in the ankle
Adolescents m/c type II MOI – external rotation of foot
Several variations to the resulting injury:
10-12% growth disturbance Two plane fx (Tillaux or Kleiger fx) which involves only the epiphysis
Three plane fx with additional metaphyseal fx
Presents as appearance of two different types of Salter-Harris injury (type III on AP and type II on lateral) but is actually a variation of a type IV injury
Complex fracture – CT best evaluation
145 146
Salter-Harris Fractures – Shoulder
Disruption of proximal humeral epiphysis and physis relatively uncommon m/c in boys 11-16 yoa Variable mechanism Occurrence in adolescent baseball pitchers as an epiphysiolysis = little league shoulder syndrome
Residual shortening of the extremity in 10%
14 yom football injury
Case courtesy of Dr Hisham Alwakkaa, Radiopaedia.org, rID: 55779 147 148
Salter-Harris Fractures – Shoulder Salter-Harris Fractures – Elbow
Epiphysis at medial end of clavicle Accurate diagnosis of elbow injury in an immature skeleton is complicated by multiple Last one in the body to merge with the adjacent shaft of the bone ossification centers
Epiphysis ossifies at approximately 18-20 yoa At birth, entire distal portion of the humerus is Merges with closure of growth plate at approximately cartilaginous and no centers of ossification are 25 yoa present Injury to the medial end of clavicle (type I or II) can produce an epiphyseal separation that may be First secondary ossification center to appear is misdiagnosed as a sternoclavicular joint dislocation capitulum which begins to ossify during the first year of life CRITOE
149 150
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Salter-Harris Fractures – Elbow
Capitulum → 1 Radial head → 3-6 Internal (medial) epicondyle → 4-7 Trochlea → 8-10 Olecranon → 8-10 External (lateral) epicondyle → 10-13
Fuse with the shaft between ages 14-16 except for medial epicondyle which may not fuse until 18-19 yoa
Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 80555 151 152
Salter-Harris Fractures – Elbow
Many types of epiphyseal injuries in the pediatric elbow
Lateral condyle of humerus (Salter-Harris type IV)
Fracture-separation of the distal humeral epiphysis
From FOOSH or from lifting an infant by grasping the forearm
Separation of medial epicondyle ossification center as a result of stress placed on the flexor pronator tendon that leads to a transverse fracture or inferior displacement of the epicondyle (10% of all elbow injuries)
In some cases, the epicondyle may become entrapped within the joint which can simulate a normal trochlear center and the dx may be missed
The appearance of a “trochlear” center without a medial epicondylar center is inconsistent with the normal sequence of ossification
https://epomedicine.com/medical-students/mnemonic-approach-to-elbow-xray-fool/ 153 154
Chondral and Osteochondral Fractures
Shearing, rotational, or tangentially aligned impaction forces generated by abnormal joint motion may produce fractures of one or both of the two apposing joint surfaces
Can produce fragments of cartilage alone (chondral fracture) or cartilage and underlying bone (osteochondral fracture)
After injury, the detached portion of the articular surface can remain in situ, be slightly displaced, or become loose/free within the joint cavity
12 yom dislocated elbow while playing baseball May be visible with x-ray but MR imaging is the preferred examination
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9450 155 156
26 4/15/2021
15 yof twisting injury, pain and intermittent locking
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8442 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8442 157 158
Chondral and Osteochondral Fractures Chondral and Osteochondral Fractures
Osteochondritis dissecans Osteochondritis dissecans – femoral condyle
Fragmentation and possible separation of a portion of Presence and degree of displacement of the the articular surface with gradual fragmentation chondral or osteochondral fragment can vary
Onset in adolescence is most common Purely chondral lesions require arthrography, MRI, or arthroscopy Asymptomatic or symptomatic (pain aggravated by movement, limitation of motion, clicking, locking, and The osseous component is detectable with x-ray or CT swelling) May also see a femoral defect Femoral condyles – one of the m/c locations
Male > female
Age 15-20 yo
Significant history of trauma in about 50% of cases
159 160
16 yom
Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 9246 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8299 161 162
27 4/15/2021
Chondral and Osteochondral Fractures
Osteochondritis dissecans – capitulum of humerus
Adolescents, especially those involved in throwing activities (e.g., baseball pitchers)
d/t valgus force and immature articular surface
Pain, swelling, and limitation of elbow motion
Radiographic appearance:
Flattening, cystic, and sclerotic changes
Fragmentation of the capitulum normal developmental OCD with marrow edema, variation thinning of cartilage, and Bone fragments may remain at their site or become extension to intercondylar notch partially or completely detached
https://radsource.us/developmental-variants/ 163 164
Avulsion Fractures
Abnormal tensile stresses on ligaments and tendons caused by a single violent injury or repetitive injuries may lead to avulsions at sites of attachment to bone
In children or adolescents, and entire apophysis may undergo avulsion
Degree of displacement is variable
Most frequently encountered in the pelvis and hips
Particularly in young athletes
Uchida, Soshi & Utsunomiya, Hajime & Taketa, Tomonori & Sakoda, Shinsuke & Hatakeyama, Akihisa & Nakamura, Toshitaka & Sakai, Akinori. (2015). Arthroscopic Fragment Fixation Using Hydroxyapatite/Poly-L-Lactate Acid Thread Pins for Treating Elbow Osteochondritis Dissecans. The American journal of sports medicine. 43. 10.1177/0363546515570871. 165 166
Avulsion Fractures – Pelvis
ASIS sprinters at origin of the tensor fasciae femoris or sartorius muscle AIIS straight and reflected heads of the rectus femoris muscle lesser trochanter apophysis psoas major muscle during strenuous hip flexion ischial tuberosity apophysis violent contraction of hamstring muscles (soccer players and hurdlers) greater trochanter gluteal muscle contraction iliac crest apophysis severe contraction of abdominal muscles assoc. with abrupt directional change during running symphysis pubis adductor muscle
https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children 167 168
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Avulsion Fractures – Pelvis
Clinically: local pain, tenderness, and swelling Radiographs may appear normal or reveal irregularity at the site of avulsion Displaced pieces of bone of variable size
MR is more sensitive method; however, associated changes in periosseous soft tissue may simulate the appearance of a tumor or infection
Follow-up radiographs may show new bone formation or healing with incorporation of the fragment into the parent bone, which in some cases is associated with bizarre skeletal overgrowth or deformity simulating neoplasm
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8920 169 170
15 yom acute football trauma 16 yom soccer injury
Case courtesy of Dr Mark Holland, Radiopaedia.org, rID: 16820 Case courtesy of Dr Mark Holland, Radiopaedia.org, rID: 19164 171 172
13 yom, hamstring injury?
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 30012 Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 47175 173 174
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Spinal Trauma Spinal Trauma
Spinal column trauma in children is variable depending on Lumbosacral injuries are more common than cervical in age, frequency of injury, causes of injury, vertebral level, pediatric patients and the specific pattern of injury However, injuries of the upper and lower cervical spine Decreasing trend in annual incidences of both spinal more frequently result in spinal cord injury column and spinal cord injury among pediatric patients In general, the net effect of the anatomical and MVCs account for 50% of spinal column injuries in physiological differences from the mature adult spine is adolescents and 32% in children that the pediatric spine is much more flexible to external forces but is far more susceptible to damage to the Falls 10% of spinal column injuries in adolescents and 18.3% underlying spinal cord in children Developing pediatric spine, particularly the cervical spine, Also includes penetrating injuries, pedestrian injuries, and reaches adult biomechanical maturity between ages 8-10 non-accidental trauma
175 176
Spinal Trauma Spinal Trauma
Craniovertebral junction (O-C2) is the most Four patterns of injury:
susceptible zone of the pediatric spine to injury 1) Fracture with subluxation
2) Fracture without subluxation Thoracolumbar spine also has more likelihood of 3) Subluxation without fracture (purely ligamentous injury) fracture and dislocations vs. ligamentous injury 4) Spinal cord injury without CT evidence of trauma due to increased ligamentous laxity, incomplete ossification, and more horizontally oriented facet joints in children (less stability and more mobility)
177 178
Spinal Trauma Cervical Spine Trauma
During initial evaluation, immobilization is critical to prevent Jefferson (C1) fractures with minimal ligamentous disruption further injury and an intact transverse ligament
Younger children and infants have larger heads in proportion Acute and subacute atlantoaxial rotary to their torsos, resulting in cervical flexion when placed supine subluxation/fixation on a flat surface Minimally displaced or angulated odontoid fractures and Specific MOIs are associated with underlying spinal cord hangman (C2) pedicle fractures injuries: Minor ligamentous injuries without instability Diving injuries “clothes-line” injuries Fracture dislocation High-risk motor vehicle injuries Burst fracture Seat-belt-type injuries Compression fractures with deformity Falls Atlanto-occipital dislocation Suspected non-accidental trauma
179 180
30 4/15/2021
4 yom s/p MVC with head strike presenting with diffuse upper and lower extremity weakness
Findings: C3 burst fracture with kyphotic deformity
14 yom with neck pain and transient paresthesias after snowboarding accident Findings: C5 fracture with kyphosis and ligamentous injury
Pediatric Spine Trauma: A Brief Review, Neurosurgery Pediatric Spine Trauma: A Brief Review, Neurosurgery 181 182
Cervical Spine Trauma Cervical Spine Trauma
Atlantoaxial rotary fixation (AARF) Atlantoaxial rotary fixation (AARF)
Rotational subluxation or dislocation of C1 on C2 Type I: atlas rotated on the odontoid with no anterior Resulting from osseous or ligamentous abnormalities – displacement congenital or acquired Type II: atlas rotated on one lateral articular process with As a result of instability, excessive motion and spinal cord 3-5 mm of anterior displacement compression may occur at the atlantoaxial joint Type III: comprises rotation of the atlas on both lateral articular processes with anterior displacement greater Etiology than 5 mm Grisel syndrome (retropharyngeal irritation secondary to URI) m/c Type IV: rotation and posterior displacement of the atlas Trauma
Postoperative (e.g., tonsillectomy)
Down syndrome, RA, AS, Klippel-Feil syndrome, odontoid congenital anomalies
183 184
https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS) https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS) 185 186
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Cervical Spine Trauma Cervical Spine Trauma
Atlantoaxial rotary fixation (AARF) clinical Atlantoaxial rotary fixation (AARF) x-ray:
findings: APLC and APOM views
Cock-robin head position (rotation and contralateral Asymmetric distance between the lateral mass and dens tilt of the head in relation to the lateral mass of C1) Anteriorly displaced lateral mass will appear wider and Neck pain (increased with attempted passive closer to midline correction in acute cases) Lateral view
Headache Lateral facet translated anteriorly and appears wedged SCM spasticity on the side to which the chin is rotated instead of oval shaped
Decreased cervical ROM Flexion-extension views Can be used to measure ADI and prove instability
May not be useful acutely in the presence of pain and muscle spasm
187 188
Cervical Spine Trauma
Atlantoaxial rotary fixation (AARF) CT and MRI: CT
Will clearly demonstrate rotatory subluxation and remains gold standard
MRI
Possible spinal cord compression, disruption of • APOM → asymmetry between lateral masses and dens, transverse atlantal ligament, bone or soft tissue head tilt to right infection • CT confirms rotation of atlas with continued asymmetry in paraodontoid space • MRI shows hemorrhage at the alar ligament
https://radiologykey.com/the-spine-congenital-and-developmental-conditions/ 189 190
8 yof with chronic AARF secondary to retropharyngeal abscess
Sferopoulos NK. Atlantoaxial rotatory subluxation in children: A review. J Radiol Med Imaging. 2018; 2: 1009. https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS) 191 192
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Cervical Spine Trauma Thoracolumbar Spine Trauma
Atlantoaxial rotary fixation (AARF) Compression, burst, and chance fractures
Treatment is non-operative Vertebral apophysis fractures Soft collar, therapy, NSAIDs, stretching exercise Traumatic spondylolisthesis program, traction, muscle relaxants, soft collar, halo traction
May necessitate open reduction with posterior spinal instrumentation and fusion if chronic with neuro deficits or failure of previous management
193 194
Osteochondroses
Osteochondrosis = describes a group of disorders that share a predilection for: 16 yof jumped out of a 3-story window The immature skeleton Involvement of an epiphysis, apophysis, or epiphysioid bone A radiographic picture that is dominated by fragmentation, L2 burst fracture with 3-column collapse, sclerosis (“mixed sclerosis, lucency, fragmentation, and injury without significant canal collapse”** is hallmark of AVN of bone, but can be seen in all osteochondroses) compromise Frequently, reossification with reconstitution of the osseous contour
It represents a heterogenous group of unrelated lesions Some of the osteochondroses are not disorders at all but represent variations in normal ossification
Pediatric Spine Trauma: A Brief Review, Neurosurgery ** Jeff Rich, DC, DACBR 195 196
Osteochondroses Osteochondroses
Age Disorder Site Probable Mechanism (Years) Articular osteochondroses are characterized by initial Legg-Calve-Perthes disease femoral head 4-8 osteonecrosis, perhaps from trauma deformity of the developing epiphysis with the Freiberg infraction metatarsal head 13-18 osteonecrosis from trauma potential for subsequent alteration in the joint itself Kienbock disease carpal lunate 20-40 osteonecrosis from trauma osteonecrosis or altered sequence of Kohler disease tarsal navicular 3-7 ossification capitulum of Nonarticular osteochondroses involve tendinous and Panner disease 5-10 osteonecrosis from trauma humerus ligamentous attachments to apophyses, or in Thiemann disease phalanges of hand 11-19 osteonecrosis, perhaps from trauma Osgood-Schlatter disease tibial tuberosity 11-15 trauma response to abnormal pressure or chronic stress proximal tibial Blount disease 1-3 or 8-15 trauma epiphysis discovertebral Scheuermann disease 13-17 trauma junction Both alter normal chondrogenesis and osteogenesis Sinding-Larsen-Johansson patella 10-14 trauma disease Sever’s phenomenon calcaneus 9-11 normal variation in ossification ischiopubic Van Neck’s phenomenon 4-11 normal variation in ossification synchondrosis
197 198
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Osteochondroses – Trauma Osgood-Schlatter Disease
Many become apparent in the first decade of life Occurs in adolescents, usually 11-15 yoa Usually a history of participation in Almost always more frequent in boys than girls sports, particularly those that involve kicking, jumping, and squatting In epiphyseal disorders, the ossifying portion of May also include a rapid growth spurt before the onset of symptoms and bone within the cartilage is especially vulnerable signs to mechanical pressure superimposed on Local pain and tenderness hormonal or nutritional changes Pain may be aggravated with activity, relieved with rest Some occur during the adolescent growth spurt Soft tissue swelling and palpable firm (e.g., Osgood-Schlatter disease or Scheuermann masses disease) Generally unilateral
199 200
Osgood-Schlatter Disease
Tibial tuberosity lies slightly lateral to the midline, so a lateral projection with the knee in slight rotation should be used Careful to not overpenetrate the image so soft tissue alterations are not missed May include two lateral radiographs with bone technique and soft tissue technique Diagnosis requires knowledge of the normal pattern of ossification of the tibial tuberosity Several ossific nodules anterior to the tibial metaphysis is normal and should not be misinterpreted as fragmentation 11 yom 13 yom 15 yom of bone Bony fusion of the tuberosity to the tibial metaphysis not before age 15 in girls and 17 in boys
https://bonexray.com/
https://bonepit.com/ 201 202
Osgood-Schlatter Disease
Radiographic features:
Soft tissue swelling in front of the tuberosity
Margins of patellar tendon may be indistinct 10 yom Increased radiodensity of the infrapatellar fat pad Avulsed fragments of cartilage and bone
May include fragmentation of the inferior pole of the patella
After acute stage, displaced pieces of bone may increase in size or may reunite; eventually appearance may result to normal or may have persistent ossific fragment(s)
https://bonepit.com/ 203 204
34 4/15/2021
R L
18 yom with pain and swelling over tibial tuberosity, exacerbated with exercise
adolescent male with pain and swelling of anterior right knee and infrapatellar region
Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 10135 Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 20861 205 206
Osgood-Schlatter Disease
Musculoskeletal ultrasound
Development and structure of the ossification center
Integrity of the nonossified cartilage and superficial soft tissues
MRI
Evidence of patellar tendinosis
Infrapatellar bursitis two different patients demonstrating Osgood-Schlatter disease
Case courtesy of Dr Nasir Siddiqui, Radiopaedia.org, rID: 12417 Case courtesy of Dr Maxime St-Amant, Radiopaedia.org, rID: 18930 207 208
Scheuermann Disease Scheuermann Disease
aka juvenile kyphosis, juvenile discogenic Etiology disease, or vertebral epiphysitis Cartilaginous node formation through the Results in kyphosis of the thoracic or cartilaginous endplates which are thinner than thoracolumbar spine normal Dx usually made on x-ray The congenital weakness of the endplates predisposes to intraosseous disc displacement during periods of excessive physical stress
5% of general population Traumatically induced growth arrest with secondary nuclear degeneration → Typical age presentation 12-17 years adolescent endplate injury Slight male predominance Nodes, as well as vertebral body irregularity and wedging identified with increased frequency in athletic adolescents
209 210
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Scheuermann Disease Scheuermann Disease
Clinical Radiographic features Highly variable Irregularity in vertebral contour – undulant superior and inferior surface Some totally asymptomatic to prominent signs and symptoms Schmorl nodes
Middle and lower thoracic spine m/c Can be accompanied by loss of intervertebral disc height Fatigue, defective posture, aching Wedging or reduction in height of the anterior portion pain aggravated by physical of the vertebral bodies can be seen exertion, tenderness to palpation Small or moderately-sized osteophytes with narrowed Kyphotic deformity, may be intervertebral discs associated with mild scoliosis Increased kyphosis Neurologic complaints not common Limbus vertebrae
211 212
22 yof with mild changes
18 yom with back pain
Case courtesy of Dr Dalia Ibrahim, Radiopaedia.org, rID: 58862 LSM Chiropractic 213 214
19 yom
15 yof post-MVC
LSM Chiropractic Case courtesy of Dr Andrew Van, Radiopaedia.org, rID: 45407 215 216
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Scheuermann Disease
Treatment
Management largely dependent on degree of kyphosis
teenager <50o: conservative, stretching, postural changes
15 yof post-MVC 50-75o: brace >75o: surgery
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6075 217 218
Juvenile Lumbar Osteochondrosis Juvenile Lumbar Osteochondrosis
Shares some features of Scheuermann disease Radiographs show prominent depression of the but localized to the lower thoracic and lumbar vertebral endplates with wedging and increased spine AP dimension of affected vertebral bodies Pain, often severe, appearing during Decreased height of lumbar intervertebral discs adolescence Retrolisthesis of lumbar vertebrae Boys > girls Spinal stenosis – CT or MRI can confirm presence
Thoracic deformity absent May also reveal posterior disc extension into the spinal Occurs with higher frequency in persons canal involved in competitive athletics
219 220
@article{Palazzo2014ScheuermannsDA, title={Scheuermann's disease: an update.}, author={C. Palazzo and F. Sailhan and M. Revel}, journal={Joint, bone, spine : revue du rhumatisme}, year={2014}, volume={81 3}, pages={ 209-14 } } West, E.Y., Jaramillo, D. Imaging of osteochondrosis. Pediatr Radiol 49, 1610–1616 (2019). https://doi.org/10.1007/s00247-019-04556-5 221 222
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Osteochondroses – Other
Legg-Calve-Perthes disease
Osteonecrosis, perhaps from trauma
Kohler disease
Osteonecrosis or altered sequence of ossification
Sever phenomenon
Normal variation in ossification
Van Neck’s phenomenon
Normal variation in ossification
LSM Chiropractic 223 224
idiopathic avascular necrosis of the left femoral epiphysis: small, mixed sclerosis and lucency, fragmented, blurring of physeal plate
5 yom with foot pain, painful gait
Findings: sclerosis, fragmentation, collapse of navicular consistent with Kohler disease, a childhood-onset AVN
Case courtesy of Dr Muhanad Jaff, Radiopaedia.org, rID: 21954 Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 13686 225 226
8 yof with posterior heel pain for one month duration
true calcaneal apophysitis demonstrating bone all normal 8-13 yom marrow edema of the calcaneal apophysis, extending into the adjacent calcaneal tuberosity
x-rays are usually normal
https://bonepit.com/ Case courtesy of Dr Paulo A Noronha, Radiopaedia.org, rID: 63302 227 228
38 4/15/2021
12 yom with left-sided hip pain
Findings: asymmetry of the ischiopubic synchondrosis with marked prominence on the left
consistent with van Neck phenomenon, an anatomic variant
normal, 3 mos.
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 24279 https://epos.myesr.org/ 229 230
14 yof, normal development at the ischiopubic junction Non-accidental Trauma
normal, not asymmetry or variant
Child abuse
Radiographic abnormalities can be detected in 50-75% of cases
LSM Chiropractic 231 232
Non-accidental Trauma
Elevation of periosteal membrane, which is loosely attached to the diaphysis of tubular bones
Periostitis is a delayed radiographic finding
Firm attachment of the periosteal membrane to the metaphyses of the tubular bones can lead to immediate visualization of single or multiple metaphyseal bone fragments (corner fx)
Physeal injuries
Radiolucent zones appearing in the metaphyses with healing
Single or multiple fractures in different stages of healing, particularly the ribs, or bilateral acute fractures
Skull fractures that are multiple or that cross sutures 1 yo Transverse diaphyseal or metaphyseal fractures
Unusual fractures – sternum, lateral clavicle, scapula, vertebral bodies
Fractures in the lower extremities in infants or young children who are not walking
Rib fractures that are bilateral and paravertebral
Case courtesy of Rad_doc, Radiopaedia.org, rID: 47998 233 234
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Non-accidental Trauma
Radiographic survey of all the long bones, the pelvis, the spine, the ribs, and the skull is recommended in the proper workup of a child suspected of having been physically abused
Bone scintigraphy may be a useful addition
4 mos. In Wisconsin, chiropractors are mandated reporters Both suspected abuse or neglect of a child, or that abuse or neglect will occur Reports should be made to the county where the child resides or where the possible abuse and/or neglect occurred https://dcf.wisconsin.gov/reportabuse
Case courtesy of Dr Augusto César Vieira Teixeira, Radiopaedia.org, rID: 23537 235 236
6-week female brough to hospital after noticed her to be irritable after Scoliosis inadvertent forceful twisting of the thigh when changing diaper; spiral midshaft femur fx seen
follow-up skeletal survey negative, but bone scan showed focal increased uptake in posterior 4th-7th ribs consistent with fxs
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 10321 237 238
Scoliosis Scoliosis
Abnormal lateral curvature of the spine Terminology >10o Dextroscoliosis – curve convex to the right Levoscoliosis – curve convex to the left Kyphoscoliosis – scoliosis with a component of kyphosis Signs/symptoms
Visible physical deformities C-curve – a single curve (may be long or short in Adam’s test span) Generally asymptomatic – but may progress rapidly S-curve – two adjacent curves, one to the right and during growth spurts one to the left If painful, the scoliosis is assumed to be secondary Primary curve – the curve with the greatest angulation to a different issue and, therefore, requires advanced imaging Secondary or compensatory curve – the smaller curve which balances the primary curve
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Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 49513 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10358 241 242
Scoliosis: Classification Scoliosis: Classification
Classification based on location of apex: Classification based on etiology:
Cervical → C1-C6 Structural
Cervicothoracic → C7 or T1 A lateral curvature that is fixed Fails to correct with side-bending radiographic studies Thoracic → between T2-T11 Rib humping will be seen on the convex side Thoracolumbar → T12 or L1
Lumbar → L1-L4 Non-structural Lumbosacral → L5 or below aka functional
A scoliosis with no structural alteration
Will lessen or disappear (correct) with lateral bending radiographic studies
Rib humping will disappear with forward flexion
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Scoliosis: Classification
Structural Non-structural (functional)
Idiopathic Postural
Neuromuscular (e.g., CP, syrinx, Nerve root irritation (e.g., HNP, poliomyelitis, muscular dystrophy) tumors)
Congenital Inflammatory (e.g., appendicitis)
Neurofibromatosis Leg length discrepancy
Mesenchymal disorders (e.g., Hip contractures Marfan, Ehlers-Danlos)
Rheumatoid disease
Trauma
Infection of bone
Vertebral or spinal cord tumor
Metabolic disorders (e.g., rickets, OI)
Osteochondrodystrophies (e.g., dwarfisms and dysplasias)
C. Hirsch, B. Ilharreborde, K. Mazda. Flexibility analysis in adolescent idiopathic scoliosis on side-bending images using the EOS imaging system, Orthopaedics & Traumatology: Surgery & Research, Volume 102, Issue 4, 2016, Pages 495-500. ISSN 1877-0568. https://doi.org/10.1016/j.otsr.2016.01.021. 245 246
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Idiopathic Scoliosis Scoliosis
Undetermined etiology without underlying bony or neuromuscular disease Imaging X-ray is still the gold standard in evaluating an Onset abnormal curvature Infantile (<3) – m/c in males, usually left convex thoracic For an initial evaluation, should include AP and lateral Childhood (3-10) – aka juvenile, m/c in females, dextroscoliosis m/c projections of either 1, 2, or all 3 sections of the spine Adolescent (>10) – m/c type, m/c in females Lateral views should be convex side towards the IR
Common; m/c in females (F:M 7:1) Follow-up evaluations can be just frontal projections
m/c pattern is thoracic dextroscoliosis with a compensatory o lumbar levoscoliosis Cobb angle has a margin of error +/- 3-7 A thoracic levoscoliosis has a higher incidence of underlying syrinx and spinal cord tumors Advanced imaging will play a role in the evaluation of Also, any idiopathic scoliosis of 15o or more that occurs before the age of 11 years should be viewed with a high index of suspicion secondary causes or associations to the scoliosis as evidence of the presence of a significant intraspinal pathology, particularly left-sided thoracic curves
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incorrect correct
B B U U C C K K Y tube Y tube
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10 yof
12o right thoracic with apex at T8 using T4 and T11
21o left thoracolumbar with apex at L1, measured using T11 and L3
Case courtesy of Dr Sachintha Hapugoda, Radiopaedia.org, rID: 64183 LSM Chiropractic 251 252
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14 yof
49o right thoracic with apex at T7 using T4 and T11
15 yof
91o right thoracic and 85o left thoracolumbar
LSM Chiropractic LSM Chiropractic 253 254
child with asymmetric abdominal reflexes
a pronounced C-shaped levoscoliosis present centered in the thoracic spine
follow-up MRI performed MRI demonstrates a Chiari I malformation with associated extensive syrinx
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10358 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10358 255 256
Juvenile Idiopathic Arthritis (JIA)
aka juvenile rheumatoid arthritis
The m/c chronic arthritic disease of childhood Arthritis Must start before 16 yoa, females m/c (F:M 2:1)
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Juvenile Idiopathic Arthritis (JIA) Juvenile Idiopathic Arthritis (JIA)
Clinical presentation Subtypes:
Oligoarticular or polyarticular arthritis with a duration of Oligoarticular JIA 6 weeks or longer <4 joints in first 6 months of illness
Peak age 1-6 years Acute onset of symptoms or more gradual Mainly affects medium and large joints Symptoms often worse in the morning but typically persist to some extent throughout the day Polyarticular JIA >5 joints affected
Systemic onset (Still disease) – intermittent spiking fevers, Peak age 1-4 years, 7-10 years
rash involving trunk and/or extremities, Mainly affects small and medium joints hepatosplenomegaly Systemic onset JIA (Still disease)
A proportion have serum RF Arthritis may present weeks to months after onset of systemic symptoms
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Juvenile Idiopathic Arthritis (JIA) Juvenile Idiopathic Arthritis (JIA)
Imaging shows a varied spectrum of involvement X-ray cervical spine based on the severity and duration of the disease Atlantoaxial subluxation Odontoid erosions Predilection for large joints rather than small Ankylosis, especially of the facet joints X-ray Soft tissue swelling Osteopenia Loss of joint space Erosions Growth disturbances (epiphyseal overgrowth or “ballooning”) Joint subluxation
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11 yof with stiffness and pain in both wrists, limitation in movement of bilateral wrist joints, right > left 14 yo with long-standing polyarticular JIA demonstrating Findings: severe erosions in B/L ankylosis of the posterior MCP and PIP joints, soft tissue elements of the cervical spine swelling, periarticular with narrowed vertebral bodies osteoporosis, subluxation of 1st and disc space narrowing MCP joint, ulnar deviation of right fifth finger, severe destruction and fusion of right sided carpal bones, destruction of distal epiphysis of right radius and ulna
Imaging of Juvenile Idiopathic Arthritis: A Multimodality Approach Elizabeth F. Sheybani, Geetika Khanna, Andrew J. White, and Jennifer L. Demertzis Case courtesy of Dr Prashant Mudgal, Radiopaedia.org, rID: 30383 RadioGraphics 2013 33:5, 1253-1273 263 264
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child with late-stage JIA child with JIA showing soft demonstrating growth arrest due to tissue swelling, displacement premature closure of most physes in of periarticular fat planes, the elbows, marked periarticular and osteoporosis osteoporosis, and increased size of the humeral epiphyses
https://radiologykey.com/juvenile-idiopathic-arthritis-2/ https://radiologykey.com/juvenile-idiopathic-arthritis-2/ 265 266
Infection
15 yom
Findings: erosions and joint space reduction of bilateral glenohumeral and hip joints with protrusion acetabuli
Case courtesy of Dr Wael Nemattalla, Radiopaedia.org, rID: 7416 267 268
Pediatric MSK Infection Pediatric MSK Infection
A diagnostic challenge Staphylococcus aureus continues to be the Difficult to recognize in the early stages leading cause of musculoskeletal infection in
Can be confused with other osseous pathology (e.g., children tumors, trauma) MRSA associated with a higher rate of complications
Incidence higher in infants and young children Tuberculosis Risk factors: Fungal Premature birth
UTI
Immunodeficiency
Other preexisting disease
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Pediatric MSK Infection Osteomyelitis
Earlier diagnosis and treatment help to reduce Osteomyelitis = inflammation of bone due to complications infection, typically bacterial
Even when successfully treated, there may be m/c between the ages of 2-12 years, m/c in significant long-term effects on growth males (M:F of 3:1)
Imaging studies play a critical role in the diagnosis and management
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Osteomyelitis Pediatric MSK Infection
Imaging Location of osteomyelitis within a bone varies X-ray usually the first study performed with age: Other imaging modalities used, as needed Neonates – metaphysis and/or epiphysis Ultrasound is helpful in detecting joint effusions and fluid Children – metaphysis collections in the soft tissue and subperiosteal regions
CT can demonstrate osseous and soft tissue abnormalities and is ideal for detecting gas in soft tissues
Nuclear scintigraphy and MR imaging are valuable because of high sensitivity
Scintigraphy for multifocal involvement
MRI provides accurate information on both the soft tissues and bones and is the imaging study of choice for evaluating the local extent of musculoskeletal infections
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Osteomyelitis Osteomyelitis
X-ray Ddx: Earliest changes in soft tissues with swelling and loss/blurring of normal fat planes, effusion may be seen in adjacent joint Metastases In general, must extend at least 1 cm and compromise 30-50% of Primary bone neoplasm – Ewing sarcoma, bone to produce noticeable changes on x-ray osteosarcoma, lymphoma Early findings are subtle and changes may not be obvious until 5-7 days from onset in children (10-14 days in adults); after this time: Langerhans cell histiocytosis
Regional osteopenia
Periosteal reaction/thickening (periostitis); may be aggressive
Focal bony lysis or cortical loss
Endosteal scalloping
Loss of trabecular bone architecture
Eventual peripheral sclerosis
In chronic/untreated cases, eventual formation of a sequestrum, involucrum, and/or cloaca may be seen
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12 yo with osteomyelitis of distal radius osteomyelitis of the first distal phalanx due to chronic thumb sucking
https://blog.cincinnatichildrens.org/radiology Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7526 277 278
pain and swelling in the calf 15 yof +fever
diffuse soft • diffuse intramedullary tissue swelling altered signal with with suspicious periosteal reaction in tibia erosion of distal • interosseous and fibular cortex circumferential soft tissue abscess • diffuse circumferential myositis
Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 10046 Case courtesy of Dr Ashutosh Gandhi, Radiopaedia.org, rID: 19684 279 280
Brodie Abscess
Brodie abscess = an intraosseous abscess related to a focus of subacute or chronic pyogenic osteomyelitis
Typically present in children with unfused epiphyseal plates, m/c in boys 12 yo with calf swelling for 2 mos. after traumatic Predilection for metaphysis of tubular bones football injury Proximal/distal tibial metaphysis m/c demonstrating chronic osteomyelitis Femur Carpal and tarsal bones
Case courtesy of Dr Fabien Ho, Radiopaedia.org, rID: 61327 281 282
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Brodie Abscess Brodie Abscess
X-ray Ddx:
Lytic lesion, oval, oriented along the long axis of the Osteoid osteoma bone Eosinophilic granuloma Surrounded by a thick dense rim of reactive sclerosis that Sarcoma fades imperceptibly into surrounding bone Skeletal metastasis Lucent channel extending toward growth plate (pathognomonic)
Periosteal new bone formation +/- adjacent soft tissue swelling
May persist for months
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12 yom with pain and swelling of the ankle with limp and fever
Cossio, A., Graci, J., Lombardo, A.S. et al. Bilateral tibial Brodie’s abscess in a young patient treated with BAG-S53P4: case report. Ital J Pediatr 45, 91 (2019). T. Moser, M. Ehlinger, M. Chelli Bouaziz, M. Fethi Ladeb, J. Durckel, J.-C. Dosch, Pitfalls in osteoarticular imaging: How to distinguish bone infection from tumour?, https://doi.org/10.1186/s13052-019-0685-z Diagnostic and Interventional Imaging, Volume 93, Issue 5, 2012, Pages 351-359. 285 286
Septic Arthritis
Septic arthritis = infection in a joint
Destructive arthropathy
Severe symptoms such as pain, decreased range of motion, and fever
May occur in isolation or as a secondary process related to underlying osteomyelitis
https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children 287 288
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Septic Arthritis
Radiography may be normal in the acute setting Joint effusion may be seen Juxta-articular osteoporosis due to hyperemia Narrowing of joint space due to cartilage destruction followed by destruction of subchondral bone on both sides of a joint If left untreated or a severe case, ankylosis will develop
https://www.orthobullets.com/spine/2028/disk-space-infection--pediatric 289 290
10 yom evaluated for kidney stone shows narrowing and irregularity of L2-L3 disc space on x-ray; CT shows subtle hypoattenuation at superior endplate of Transient Synovitis of the Hip L3; MRI demonstrates loss of disc space at L2-L3 with high T2 signal and contrast enhancement of L3 superior endplate A self-limiting acute inflammatory condition affecting the synovial lining of the hip Usually has no residual sequelae Typically affects young children (3-8 yoa); male predilection Exact pathogenesis is not well known but a viral etiology has been suggested
Clinical presentation: hip pain for 1-3 days, associated with limping or the refusal to bear weight
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 23514 291 292
Transient Synovitis of the Hip
X-ray Non-specific but there may be an increase in medial joint space US 6 yom with one-week history of Useful to demonstrate joint effusion right groin pain MRI Hip joint effusion with synovial enhancement (+C), synovial thickening, and signal alterations in surrounding soft tissue
ddx septic arthritis another patient, 6 yom, left hip pain Septic arthritis will often demonstrate signal abnormality in marrow and “affects children younger than 4 yoa with a hx of fever”
https://radsource.us/pediatric-hip-disorders/ 293 294
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5 yof with 2-week history of limping and suspicion for osteomyelitis
Findings: large left hip joint effusion and medial joint Other MSK Disorders space widening; no additional findings
https://radsource.us/pediatric-hip-disorders/ 295 296
Langerhans Cell Histiocytosis
A rare multisystem disease with a wide and heterogenous clinical spectrum and variable Findings: amorphous area of sclerosis extent of involvement in the proximal humeral diaphysis
ddx? m/c in the pediatric population, peak incidence 1-3 yoa; male predilection (M:F 1.5:1)
Due to uncontrolled monoclonal proliferation of Langerhans cells (monocyte-macrophage radiograph one year earlier shows a non-ossifying fibroma lineage) Considered a malignancy
https://blog.cincinnatichildrens.org/radiology 297 298
Langerhans Cell Histiocytosis Langerhans Cell Histiocytosis
Any part of the body can be affected so clinical Three forms:
presentation will depend on specific involvement Letterer-Siwe disease
Skeletal Hand-Schuller-Christian disease
CNS Eosinophilic granuloma (EG)
Hepatobiliary 70% affect bone
Pulmonary Best prognosis
Salivary gland
GI
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Langerhans Cell Histiocytosis Langerhans Cell Histiocytosis
The skeleton is the most common involved organ Skeletal location: system in LCH and is by far the most common Skull ~50% location for single-lesion LCH (often referred to as EG) Pelvis 23% Femur 17%
Ribs 8% Skeletal lesions may be asymptomatic and discovered as an incidental radiographic finding Humerus 7% Mandible 7%
When symptomatic: pain, swelling, and Spine tenderness around the lesion; systemic symptoms may also be present
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Langerhans Cell Histiocytosis
Radiographic appearance:
Skull – solitary or multiple punched out lytic lesions without a sclerotic rim, beveled edge appearance
Mandible – irregular radiolucent areas, floating tooth
Spine – vertebra plana (m/c cause of vertebra plana in children, more often in thoracic spine)
Long bones – permeative and aggressive appearing lesion, mainly diaphysis or metadiaphysis and respects growth plates, endosteal scalloping, periosteal reaction 5 yof with painful swelling of the skull
Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 61259 303 304
9 yof
4 yof with limp
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 8062 305 306
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References
ACR Appropriateness Criteria
American Journal of Roentgenology
http://www.bonepit.com
Diagnosis of Bone and Joint Disorders. Resnick. 2002
Essentials of Skeletal Radiology. Tochum, Rowe.
Musculoskeletal MRI. Kaplan, et al. 2001
http://www.radiopaedia.org
Alexiades N., et al. Pediatric Spine Trauma: A Brief Review, Neurosurgery, Volume 87, Issue 1, July 2020, Pages E1-E9.
Nguyen J., et al. Imaging of Pediatric Growth Plate Disturbances, Musculoskeletal Imaging, October 11, 2017.
Shelat NH, et al. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146.
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