8 Pediatrics


8 Pediatrics

Approach and Analysis

A number of emergent conditions are unique to the pediatric and neonatal age groups, and these are addressed in this chapter. Conditions also seen in adults, such as intussusception and appendicitis, can be found in the corresponding chapters organized by anatomy.

Studies that do not utilize ionizing radiation are preferred in the pediatric age group. Because the lifetime risk of developing a radiation-induced cancer is greater with early exposure, it is prudent to avoid unnecessary X-ray and CT examinations in children and to minimize radiation dose in any necessary study that utilizes ionizing radiation. Fortunately, most practices and equipment manufacturers have protocols and techniques that reduce radiation dose to the minimum needed for accurate diagnosis. Ultrasound and MRI are preferred for cross-sectional imaging, especially in the diagnosis of pediatric abdominal pain and in the often-repeated evaluation of hydro-cephalus in children with ventriculoperitoneal shunts.

In children with suspected appendicitis, ovarian torsion, testicular torsion, intussusception, or pyloric stenosis, ultrasound should be attempted prior to CT. Radio-graphs are the primary imaging modality for acute thoracic disease, ingested foreign bodies, and musculoskeletal injuries, and they can be helpful in evaluating abdominal pain by establishing the diagnosis of severe constipation as well as bowel obstruction. In the emergency setting, CT is generally reserved for significant traumatic injury and for acute abdominal pain that cannot be diagnosed by clinical and laboratory findings, plain radiography, and ultrasound.

Imaging and Anatomy

Skeletal Survey for Nonaccidental Trauma

  • Indications: Suspected child abuse.

    • – AP/lateral skull

    • – AP/lateral cervical and lumbar spine

    • – AP/lateral thorax and abdomen

    • – AP humeri, forearm, hand, femora, tibiae and fibulae, and feet


  • Indications: Appendicitis, acute abdomen.

  • Technique: ~ 175 mA, 120 kV

  • Oral contrast: Dilute Gastrografin (up to 1 liter depending on age and size)

  • IV contrast: 1.5 mL/kg at 3 mL/sec, 90-second delay (symphysis to pubis)

  • Images: 5-mm axial, 0.6-mm reconstruction, 3-mm coronal and sagittal reformation

  • Approximate radiation dose: 400 mGy

Ultrasound—Generalized Abdominal Pain

  • Indications: Pain, mass, hernia.

  • Probe: Linear probe (9 MHz for infants, curved 6 MHz for older children)

  • Views:

    • – Liver—longitudinal and transverse

    • – Porta hepatis—main portal vein and common bile duct

    • – Pancreas/aorta/superior mesenteric artery—midline transverse

    • – Hepatorenal space (demonstrate lack of free fluid)

    • – Kidneys—longitudinal and transverse (measure length)

    • – Spleen—longitudinal and transverse (measure maximal length)

    • – Bladder—midline longitudinal and transverse (demonstrate lack of extravesical free fluid)

    • – Lymph nodes—mesenteric, right lower quadrant, and periaortic

Ultrasound—Suspected Appendicitis

  • Indications: Right lower quadrant pain.

  • Probe: Linear probe (12 MHz or 9 MHz depending on body habitus)

  • Views:

    • – Right psoas muscle—transverse including iliac artery and vein (± color Doppler

    • – Cecum and terminal ileum—longitudinal and transverse

    • – Region of appendix—transverse of region of appendix (± color Doppler)

    • – Bladder—midline longitudinal and transverse (show lack of extravesical free fluid)

    • – Right kidney—longitudinal and transverse

  • Abnormal appendix:

    • – Measure greatest diameter, color Doppler to show hyperemia

    • – Hepatorenal space (demonstrate lack of free fluid)

  • No appendicitis/appendix not seen:

    • – Right kidney (exclude stone or hydronephrosis)

    • – Gallbladder

    • – Ovaries (in girls) document volume and color flow

    • – Adnexal region if ovaries are not seen

Ultrasound—Suspected Intussusception

  • Indications: Abdominal pain.

  • Probe: 12 MHz linear probe (9 MHz may be used for evaluating the right kidney and hepatic flexure)

  • Views:

    • – Transverse images of colon—cecum, ascending, hepatic flexure, transverse, splenic flexure, and descending

    • – Mesenteric, right lower quadrant, and periaortic lymph nodes should be measured if identified

    • – Right kidney—longitudinal and transverse

    • – Hepatorenal space (demonstrate lack of free fluid)

    • – If an intussusception is identified, evaluate flow with color Doppler

    • – Identify any free or loculated peritoneal fluid

Ultrasound—Suspected Hypertrophic Pyloric Stenosis (HPS)

  • Indications: Projectile vomiting in young infant.

  • Probe: 12 MHz linear probe. Patient should be scanned supine and in right posterior oblique positions. It may be necessary to fill the stomach with a small amount of water if gastric air prevents visualization of the antrum

  • Views:

    • – Midline transverse images of pancreas/aorta/superior mesenteric artery

    • – Pylorus—image maximal canal length (normal is less than 17 mm), image maximal wall thickness from outer wall to mucosa (normal is less than 3 mm). Pyloric thickening should be fixed in HPS. If mobile, consider pylorospasm.

Ultrasound—Testicular or Appendix Testis Torsion

  • Indications: Scrotal pain.

  • Probe: Linear probe (12 MHz or higher)

  • Views:

    • – Three transverse views of both testes on one image (upper, lower, mid)

    • – Three longitudinal views of each testicle

    • – Color and arterial flow Doppler both testes (longitudinal and transverse)

    • – Epididymis (longitudinal and transverse ± color Doppler)

    • – Document hydrocele if present

    • – Measure testicular dimensions

Salter-Harris Classification of Pediatric Fractures

Salter-Harris classification of pediatric fractures is seen in Fig. 8.1.

Fig. 8.1 The Salter-Harris classification of pediatric fractures describes five basic fractures that involve the physeal growth plate. Salter-Harris I fractures may be subtle and involve separation of the metaphysis (M) and epiphysis (E) through the physis (P). Salter-Harris II–IV fractures are growth plate fractures that extend to the metaphysis (II), the epiphysis (III), or both (IV). Type V fractures are impaction fractures at the growth plate.

Clinical Presentations and Differential Diagnosis

Clinical Presentations and Appropriate Initial Studies

Cough and Dyspnea

  • Chest X-ray

    • – Bronchiolitis/reactive airway disease (young children)

    • – Pneumonia

    • – Congenital cardiac disease

    • – Tracheoesophageal fistula (newborns)

Vomiting in the Newborn

  • Abdominal plain radiograph

  • Ultrasound

    • – Duodenal or other small-bowel atresia

    • – Midgut volvulus/malrotation

    • – Pyloric stenosis

Abdominal Pain

  • Ultrasound

  • CT or MRI may be necessary if ultrasound not diagnostic

    • – Appendicitis

    • – Testicular or ovarian torsion

    • – Intussusception

    • – Colitis

Hip Pain

  • Pelvis plain radiograph

  • Ultrasound

  • MRI for evaluation of osteomyelitis and bone tumors

    • – Septic arthritis

    • – Toxic synovitis

    • – Osteomyelitis

    • – Eosinophilic granuloma

    • – Slipped capital femoral epiphysis

    • – Avascular necrosis

    • – Legg-Calvé-Perthes disease

    • – Juvenile rheumatoid arthritis

    • – Ewing sarcoma

    • – Osteoid osteoma

Differential Diagnosis

Supratentorial Brain Tumors

  • Astrocytoma

  • Primitive neuroectodermal tumor (PNET)

  • Choroid plexus papilloma (lateral ventricle)

  • Pineal tumors

Infratentorial Brain Tumors

  • Juvenile pilocytic astrocytoma

  • Brainstem glioma (fibrillary astrocytoma)

  • Medulloblastoma (fourth ventricle)

  • Ependymoma (fourth ventricle)

Suprasellar/Parasellar Mass

  • Craniopharyngioma

  • Optic glioma

  • Germinoma

Supraglottic Narrowing

  • Croup

  • Epiglottitis

  • Retropharyngeal abscess

Pulmonary Mass

  • Metastatic tumor (osteosarcoma, Wilms, neuroblastoma)

  • “Round” pneumonia

Focal Pulmonary Opacity in Newborn

  • Pulmonary sequestration

  • Bronchogenic cyst

  • Congenital cystic adenomatoid malformation

Lucent or Cystic Pulmonary Lesion in Newborn

  • Congenital lobar emphysema

  • Cystic adenomatoid malformation

  • Diaphragmatic hernia

Mediastinal Mass

  • Normal thymus (< 2 yrs)

  • Lymphoma

  • Germ cell tumor

  • Bronchogenic or enteric cyst

  • Adenopathy

  • Neuroblastoma (posterior mediastinum)

Abdominal Mass

  • Neuroblastoma

  • Hepatoblastoma

  • Wilms tumor

  • Appendiceal abscess

  • Rhabdomyosarcoma

Intestinal Obstruction in Newborn

  • Duodenal atresia/stenosis/web

  • Annular pancreas

  • Jejunal atresia

  • Meconium plug syndrome/meconium ileus

  • Ileal or anal atresia

  • Hirschsprung disease

Intestinal Obstruction in a Child

  • Intussusception

  • Incarcerated inguinal hernia

  • Adhesions

  • Appendicitis

  • Malrotation/volvulus

  • Meckel diverticulum

Right Lower Quadrant Mass in a Child

  • Appendicitis

  • Intussusception

  • Duplication cyst

Aggressive Bone Lesion in a Child/Adolescent

  • Osteosarcoma

  • Ewing sarcoma

  • Osteomyelitis

  • Eosinophilic granuloma

  • Neuroblastoma metastasis

  • Leukemia/lymphoma

Nonaccidental Trauma

Children who suffer nonaccidental trauma (NAT) are often brought to the emergency department with minor rather than catastrophic injuries. Emergency physicians and radiologists are therefore in a unique position to first identify NAT, and recognition of characteristic injury patterns can potentially avert future abuse or neglect. Common injuries include fractures, intracranial hemorrhage or contusion, and intra-abdominal injuries. Head injury is important to recognize, because it represents a frequent cause of death in abused children below the age of 3.

Suspicious injuries include any fracture in a preambulatory child, any injury incompatible with the clinical history, unusual delay in seeking medical attention, retinal hemorrhage, multiple fractures in the absence of any family history of osteogenesis imperfecta, and subdural hematomas of different ages. A skeletal survey should be performed in cases of suspected abuse to evaluate the location and extent of present and remote osseous injuries.

Certain fractures have been recognized as indicative of NAT: metaphyseal (bucket-handle or corner) fractures, posterior rib fractures, skull fractures, scapular fractures, and sternal fractures. Periosteal reactions and juxtaosseous soft tissue calcifications signify healing fractures and should be carefully documented for medicolegal purposes.

Head CT may identify skull fractures missed by skeletal survey as well as more significant brain injury. Nonparietal skull fractures, diastatic sutures, cross sutures, or depressed fractures should be considered suspicious. MRI can evaluate the brain parenchyma more sensitively and show subdural hematomas of varying ages, hypoxic-ischemic injury, cerebral contusions, and traumatic subarachnoid hemorrhages ( Fig. 8.2 ).

Fig. 8.2a–f a,b Head injury in NAT. Bilateral inferior frontal and anterior temporal cortical encephalomalacia consistent with remote injury; acute right parietal and left frontal vertex subdural hematomas. c,d Bilateral posterior rib fractures. Healing fractures related to squeezing of the infant′s thorax during a past episode of forceful shaking. Right lung consolidation versus contusion is likely a more acute injury. e,f Metaphyseal corner fractures. Fractures of the distal femoral and proximal tibial metaphyses result from a whiplash movement of the arms when shaken.

Lung Disease of Prematurity

Lung disease of prematurity, also known as respiratory distress syndrome (RDS), is an acute lung disease seen in children born before the lungs produce adequate surfactant to maintain alveolar expansion. It is seen in neonates younger than 32 weeks gestational age or who weigh less than 1,200 grams. Symptoms, which are usually evident within hours of delivery, include tachypnea, expiratory grunting, nasal flaring, and substernal and intercostal retractions. In addition to prematurity, other risk factors include maternal gestational diabetes, prenatal asphyxia, and multiple gestations.

Radiographs show a bell-shaped thoracic contour. The lung parenchyma has a fine granular, or “ground glass,” appearance, often with air bronchograms.

Complications of RDS are related to ventilation and barotrauma and include pulmonary interstitial emphysema, pneumothorax, and bronchopulmonary dysplasia.

Treatment consists of administration of artificial pulmonary surfactant and supportive ventilation and oxygen therapy. With the increased use of antenatal steroids to accelerate pulmonary maturity, the incidence and severity of hyaline membrane disease has been declining ( Fig. 8.3 ).

Fig. 8.3a–f a,b Lung disease of prematurity. Diffuse ground glass opacity involving all lung zones. Nasogastric tube. c,d Pulmonary interstitial emphysema. Interval placement of endotracheal tube, umbilical arterial and umbilical venous catheters. The lungs now contain multiple linear lucencies corresponding to air that has dissected from the alveoli into the pulmonary interstitium. e,f Pneumothorax complicating RDS. (e) Initial study showing bell-shaped thorax with diffuse ground glass opacity and endotracheal and nasogastric tubes. (f) Subsequent radiograph with left-sided pneumothorax and interval placement of umbilical arterial and venous catheters.

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Jun 8, 2020 | Posted by in EMERGENCY RADIOLOGY | Comments Off on 8 Pediatrics

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