Pediatric Radiology

M. Reither

10   Pediatric Radiology

Special Consideration of the Growing Skeleton and Normal Variants

Epiphyseal Ossification of the Proximal Humerus

Ossification Pattern

Image   Newborns: Ossification center rarely present, occasionally a faint calcific rim

Image   Fourth to eighth month: Medial ossification center along the fossa

Image   First to second year: Lateral ossification center in the major tuberosity

Image   Third to fourth year: Ossification center in the minor tuberosity

Image   Fifth to eighth year: Fusion of the tubercular ossification centers

Image   Thirteen to fourteenth year: Fusion of the tubercular ossification centers with the proximal humeral epiphysis

Image   Twentieth year: Osseous connection of the humeral epiphysis with the humeral diaphysis (Fig. 10.1).

Specific Findings

Image   Epiphyseal plate resembles a pitched roof; differential diagnosis (DD): epiphyseal fracture (rare)

Image   Crescentic vacuum phenomenon with the arms elevated and pulled: “True” joint space between glenoid and cartilage of the humeral epiphysis

Image

Fig. 10.1 Image Diagram of the epiphyseal ossifications at the proximal humerus

a  Fourth to eighth month

b  First to second year

c  Fifth to eighth year

Apophyseal Ossification of the Shoulder

Ossification Pattern

Image   First year: Apophyseal ossification center in the coracoid process:

Image   Fifteenth to eighteenth year: Two to three or even more ossification centers in the lateral end of the acromion

Image   Around the twentieth year: Fusion of the apophyseal ossification centers with the scapular spine

Image   Sixteenth to eighteenth year: Apophyseal ossification centers at the superior and inferior angle of the scapula

Specific Findings

Image   Double contour of the intertubercular groove; DD: Neonatal periosteal reaction, nonossifying osseous fibroma (NOF; Fig. 10.3).

Image

Fig. 10.2 Image Apophyseal ossification center in the coracoid process (arrow)

Image

Fig. 10.3 Image Neonatal humerus

Double contour of the intertubercular groove at the proximal humerus in the newborn (arrows).

Configuration of the Medial Clavicular End

Image   First decade of life: Mushroom-like, smooth, or torn contours

Image   Second decade of life: Cup-like, possibly irregularly outlined

Image   Thirteenth to fourteenth year: Appearance of the medial epiphysis

Image   At the end of the second decade of life: Fusion of the ossification center with the clavicle

Image   “Ligament grooves” at the medial end of the clavicle caused by impression of the costoclavicular ligament (Fig. 10.4)

Image

Fig. 10.4 Image “Ligamentous groove” (BG) at the medial end of both clavicles

Impression of the costoclavicular ligament as a linear radiolucency extending craniolaterally to caudalmedially. Incidental finding of a joint (arrows) forming between clavicle and coracoid process (clinically irrelevant anomaly).

Diagnostic Guidelines for Variations of the Growing Skeleton

1  CR (method of choice)

Image   AP projection (comparison with contralateral side)

2  US (supplementary method)

Image   Occasionally the only suitable method, for example, for evaluation of the humeral epiphysis

Therapeutic Principles

Conservative

Image   For minor findings, physical therapy

Surgical

Image   Distal displacement of the scapula (Green, Woodward) in the third to seventh year

Malformations

Congenital High Position of the Shoulder (Sprengel Deformity)

Pathology

Image   Fifth week: Primordial scapula in the lower cervical region

Image   Tenth week: Descent of the scapula to posterior chest wall

Image   If interrupted, “congenital undescended scapula”

Image   Usually unilateral

Image   Scapula wide and shortened

Image   Omovertebral bone: Fibrous, cartilaginous, or osseous connection between cervical spine and scapula

Image   Hook-shaped curvature of the mediosuperior angle

Image   Combination with muscle anomaly

Image   In about 70% of cases, associated anomaly of the vertebrae and ribs (Klippel-Feil syndrome); spinal canal pathologies: diastematomyelia, syringomyelia

Clinical Findings

Image   Asymmetry of the shoulder contour

Image   Restricted mobility (abduction)

Diagnostic Evaluation

Image  (→ Method of choice)

Recommended views

Image   Standard projections:

–   Anteroposterior (AP) projection of the shoulder joint

Image   Special projection:

–   Oblique projection: omovertebral bone

Image  (→ Supplementary method)

Indications

Image   Associated malformations of the spine and bony thorax

Therapeutic Principles

Surgical

Indications:

Image   Pain

Image   Functional impairment

Image   Cosmetic disfiguration

Congenital Clavicular Pseudarthrosis

Pathology

Image   Failed fusion of the clavicular ossification centers

Image   Intrauterine fracture

Image   Erosion: Pressure by the subclavian artery

Clinical Findings

Image   Congenital

Image   Often only discovered in the fourth to sixth year

Image   Usually unilateral

Image   Predominantly on the right

Image   Medial fragment elevated

Image   Lateral fragment pulled down by the weight of the arm

Image   Cosmetic disfiguration

Image   Shoulder function usually not impaired

Image   Rarely painful

Diagnostic Evaluation

Image

Recommended views

Image   AP projection of the shoulder

Findings

Image   Interrupted contour of the clavicular shaft

Image   Clubbing of the ends of the fragments

Image   Fibrous connection (Fig. 10.5)

Image

Fig. 10.5 Image Congenital clavicular pseudarthrosis

Break in the lateral third of the clavicular shaft with terminal clubbing of the clavicle (arrows), with interposed fibrous bridging (B).

Shoulder Deformities in Osteochondrodysplasias

Cleidocranial Dysplasia

Pathology

Image   Generalized skeletal disease

Image   Defect formation

Image   Impaired ossification

Image   Autosomal dominant inheritance

Image   Numerous phenotypic variations

Clinical Findings

Image   Skull, thorax, and pelvis primarily involved

Image   Bell-shaped thorax

Image   Drooping shoulders

Image   No palpable or visible normal clavicle

Image   Hypermotility of the shoulder girdle

Image   Shoulders can touch each other anteriorly

Image   Associated pectus excavatum

Image   Diastatic sagittal suture

Image   Major and minor fontanelle wide open

Image   Short terminal phalanges

Image   Brachymesophalangy

Image   Impaired dentition

Image   Foot deformities

Image   Abnormal gait

Image   Lower limit of body height

Image   Normal life expectancy

Image   Habitual dislocation of shoulder, hip, and radial head

Image   Vertebral deformities

Image   Possibly maternal dystocia

Diagnostic Evaluation

Image

Recommended views

Image   AP shoulder girdle

Image   AP pelvis

Image   Skull in two projections

Image   AP hand and foot

Image   Lateral spine

Findings

Image   AP shoulder girdle:

–   Complete or partial absence of the clavicle

–   Thin, short, inferiorly deviated ribs

–   Small hypoplastic scapulae

–   Narrow tubular bones

Image   AP pelvis:

–   Delayed ossification

–   Hypoplastic iliac wings and pubic bones

–   Wide cartilaginous pubic symphysis

–   Wide sacroiliac (SI) joint spaces

–   Wide acetabular Y-cartilage

–   Valgus deformity of the femoral neck

–   Narrow tubular bones

Image   Skull in two projections:

–   Delayed ossification of the calvarial ossification centers

–   Numerous intercalary bones (“wormian bones”)

Image   AP hand and foot:

–   Pseudoepiphysis

Image   Lateral spine:

Goals of Imaging

“Minimal bone program”:

Image   Lateral skull

Image   Lateral spine

Image   AP pelvis

Image   AP hand

Image   AP knee

Possible supplementary views:

Image   Long tubular bone

Image   Foot

Image   Chest

Therapeutic Principles

Image   Symptomatic orthopedic and dental therapy

Image

Fig. 10.6 Image Cleidocranial dysplasia

Medial and lateral clavicular fragments (F), short, inferiorly deviated anterior ribs, short hypoplastic scapulae.

Image

Fig. 10.7 Image Cleidocranial dysplasia

F

Early ossification of the ossification centers of the femoral head

I

Narrow hypoplastic ilium (I), wide sacroiliac joint space (IF), and Y-cartilage (Y)

OP

Pubic bone that is not yet ossified

SH

Varus position of the femoral neck

Therapeutic Principles

Image   No causative therapy available

Image   Symptomatic therapy of joint contracture and spinal deformity

Mucopolysaccharidoses (MPS) and Mucolipidoses (ML)

Pathology

Image   Mucopolysaccharidosis (MPS):

–   Autosomal recessive

–   Exception: Hurler II diseases (X-chromosomal recessive)

–   Inherited lysosomal enzyme defect

–   Disturbed breakdown of mucopoly-saccharides

Image   Mucolipidosis (ML):

–   Lysosomal storage disease

–   Clinically and biochemically similar to MPS and sphingolipidosis

–   Storage of mucopolysaccharides and lipids in bones, central nervous system (CNS), liver, and heart

Clinical Findings

Image   Strikingly coarse facial features

Image   Short stature

Image   Mental retardation

Image   Facultative: opacified cornea, deafness

Diagnostic Evaluation

Image

Recommended views

Image   Lateral skull

Image   Lateral spine

Image   AP pelvis

Image   AP hand

Image   AP knee

Findings

Image   Thickened, stubby scapulae

Image   Shallow glenoid fossae

Image   Short and thickened clavicles and ribs

Image   Constriction of the proximal humeri (Fig. 10.8)

Image  (→ Supplementary method)

Indications

Image   Storage processes in parenchymal organs

Findings

Image   Heart: thickened myocardium

Image   Liver: diffuse increase in echogenicity

Image   CNS (in newborns): white-matter lesions

Image  (→ Supplementary method)

Indications

Image   Storage processes in parenchymal organs

Technical parameters

Image   T2-weighted spin-echo (SE)/fluid-attenuated inversion recovery (FLAIR) sequences:

Image   Axial and coronal sections

Findings

Image   Heart: thickened myocardium; diffuse signal alteration

Image   Liver: diffuse signal alteration

Image   CNS: white-matter lesions

Image

Fig. 10.8 Image Mucolipidosis II (type “l-cell disease”)

S

Stubby scapula

G

Shallow, hypoplastic glenoid fossa

Black arrow

Thickened clavicle

White and black arrows

Wide ribs with posterior tapering

Image

Fig. 10.9 Image Fibrous dysplasia

Monomelic unilateral manifestation of the humerus. Cystic osteolytic lesions, thinning and bulging of the cortex (C), remaining in part only as osseous bridge.

O

Osteolyses

Fibrous Dysplasia

Pathology

Image   Bone replaced with fibrous connective tissue

Image   “Tumor-like lesion”

Image   Associated with precocious puberty and cutaneous pigmentation: McCune-Albright disease

Clinical Findings

Image   Preferred age: 5–15 years

Image   Solitary lesions:

–   Maxilla, femur, tibia

–   Can remain subclinical

Image   Multiple lesions:

–   Monomelic, unilateral, generalized

–   Initially painful

–   Later, spontaneous fractures

Diagnostic Evaluation

Image

Findings

Image   Bone expansion with loss of normal modelling

Image   Cystic osteolytic patches

Image   Cortical erosions

Image   Scanty spongiosa: hourglass phenomenon

Image   Later, shepherd crook deformity of the proximal femur

Image   After cessation of growth, decreasing activity and increasing stability (Fig. 10.9)

Image  (→ Supplementary method)

Indications

Image   To address the question of possible malignant transformation

Image   For the differential diagnosis

Findings

Image   Hypointensity on T1- and T2 -weighted SE sequences: Fibrous tissue

Image   Exception: Proliferative, expansile tissue:

–   Hypercellular components

–   Increased water content

Therapeutic Principles

Image   Surgical correction if stability at risk

Image   In adults, filling with spongiosa

Image   In children, frequent resorption of the filling material

Osteogenesis Imperfecta

Pathology

Image   Impaired periosteal new bone formation

Image   Impaired collagenous production

Image   Decreased bone density

Image   Increased bone fragility

Clinical Findings

Image   Frequent fractures (following inadequate trauma)

Image   Deformities

Image   Dwarfism

Image   Type I:

–   Blue sclerae

–   Autosomal dominant (former type Lobstein)

Image   Type II:

–   Congenital form

–   New mutation (former type Vrolik)

Image   Type III:

–   Progressive deformity: long tubular bones, skull, spine

Image   Type IV:

–   Like type I but without blue sclerae

Diagnostic Evaluation

Image

Findings

Image   Severe demineralization

Image   Thin cortex

Image   Deficient trabeculation of the spongiosa

Image   Slender tubular shafts

Image   Coexistent old and recent fractures

Image   Deformity caused by healing of malaligned fractures (Fig. 10.10)

Image

Indications

Image   Prenatal diagnosis of type II

Therapeutic Principles

Image   General goal: Upright position of the patient

Image   Orthosis after age two years

Image   Stabilization with intramedullary fixation

Image

Fig. 10.10 Image Osteogenesis imperfecta

Manifestation of osteogenesis imperfecta with extensive osteopenia. Multiple fractures (F) of humeri, ribs, and clavicles, partially healed in malalignment.

Diagnostic Guidelines for Malformations

1  CR (method of choice)

Image   In general AP projection (contralateral comparison)

Image   Specific projections depending on clinical question

Image   “Minimal bone program” in osteochondrodysplasias

2  MRI (supplementary method)

Image   Surrounding soft tissues

Image   Associated malformations: Spine, spinal canal, CNS storage processes

3  US (supplementary method)

Image   Storage processes: Heart, liver, CNS (newborns!)

Image   Prenatal diagnosis

Therapeutic Principles

Conservative

Image   Immobilization

Image   Positioning

Surgical

Image   Internal fixation

Image   Possibly rerotation osteotomy

Traumatology

Epiphyseal Separation Due to Birth Trauma

Pathology

Image   Mechanical separation and/or displacement of the cartilage epiphysis

Image   Accompanying plexus palsy (Erb-Duchenne) possible

Clinical Findings

Image   Painfully restricted mobility

Image   Spontaneous rest position

Diagnostic Evaluation

Image  (→ Method of choice in the acute phase)

Recommended planes

Image   Coronal sections parallel to the humerus (contralateral comparison!)

Indications

Image   Evaluation of epiphyseal displacement

Image   Assessment of perfusion with Doppler sonography

Image   Documentation of ossification centers (Figs. 10.1110.15)

Image

Indications

Image   Selectively during follow-up

Image

Indications

Image   Suitable for follow-up

Image

Fig. 10.11 Image Epiphyseolysis due to birth trauma (Aitken I)

Left image: Longitudinal sonographic section parallel to the proximal humerus, showing a normal finding. The preformed cartilaginous epiphysis is seen along the reflected sound waves, surrounded by the periosteal tube. Interposed growth plate.

Right image: Same section as on the left. Hematoma-induced periosteal thickening of shell-like configuration, small osseous metaphyseal avulsions (arrow), minimally residual epiphyseal displacement after reduction, and internal fixation of the epiphyses. The parallel echogenic structures in the center of the epiphysis correspond to the pin.

E

Epiphysis

H

Humerus

W

Growth plate

E

Epiphysis

PV

Periosteal thickening

S

Pin

Image

Fig. 10.12 Image Epiphyseolysis due to birth trauma

Longitudinal sonographic section along the proximal humerus. Displaced epiphysis, partially immersed in the acoustic shadow (SS) of the osseous humeral shaft.

W

Growth plate

SS

Acoustic shadow

Image

Fig. 10.13 Image Epiphyseolysis due to birth trauma

Radiographic follow-up after reduction and internal fixation: Radiographically invisible epiphysis (!), early, barely discernible callus formation along the lateral border of the metaphysis. In contrast to sonography, the radiograph provides no relevant information for the follow-up at this stage.

E

Epiphysis

K

Callus

Image

Fig. 10.14 Image Epiphyseolysis due to birth trauma

Doppler sonography to visualize the cartilaginous epiphysis (E) and its perfusion, indicative of viability of the ossification center after reduction and internal fixation.

Therapeutic Principles

Conservative

Image   Dressing for pain relief

Image   Desault bandage

Image   For markedly overlapping fractures, knapsack dressing

Surgical

Image   For severely dislocated proximal fractures in older children, open reduction and internal fixation

Clavicular Fractures

Pathology

Image   Fracture usually occurs in the midshaft

Image   Greenstick fractures comprise 50%

Image   Medial fractures (3%):

–   Usually with epiphyseolysis

–   Growth disturbance due to premature closure of the growth plate

–   No functional deficits!

Image   Lateral fractures (5%):

Diagnostic Evaluation

Image  (→ Method of choice)

Recommended views

Image   AP projection as baseline documentation

Image   Generally no follow-up necessary

Image  (→ Supplementary method)

Indications

Image   Substitute for conventional radiography (CR) in classical fractures

Image   No recollection of trauma

Image   Painful swelling (Fig. 10.20)

Image

Fig. 10.16 Image Diagram of clavicular fractures

Image

Fig. 10.17 Image Greenstick fracture of the clavicle

Typical manifestation of a greenstick fracture (F) of the clavicle.

Image

Fig. 10.18 Image Lateral fracture of the clavicle

Lateral fracture (F) of the clavicle, also referred to as pseudodislocation. Incidentally visualized is an ossification center in the coracoid (arrow).

Image

Fig. 10.19 Image Medial fracture of the clavicle

Medial fracture of the clavicle with upward displacement of the lateral fragment (LF) by about one shaft width.

MF

Medial fragment

Image

Fig. 10.20 Image Medial fracture of the clavicle, sonography

Interrupted contour in the medial third without displacement.

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Jan 17, 2016 | Posted by in MUSCULOSKELETAL IMAGING | Comments Off on Pediatric Radiology

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