SPR 2017 General Pediatric Radiology Categorical Course: Musculoskeletal May 16, 2017 SAM References
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1 Elbow: Don't be a FOOL Kiery Braithwaite, MD SPR 2017 General Pediatric Radiology Categorical Course: Musculoskeletal May 16, 2017 SAM 1. Which pediatric elbow fracture is most commonly seen in the absence of a joint effusion? A. Supracondylar B. Lateral condyle C. Radial neck D. Olecranon In the absence of a joint effusion, the two most common pediatric fractures identified include radial neck and medial epicondyle fractures. The radial neck is partly extra-articular and the medial epicondyle is extra-articular. Thus, effusions are not always seen unless there are additional fractures and/or associated dislocation. Answer A is incorrect. Explanation: Supracondylar factures are typically associated with a joint effusion. Answer B is incorrect. Explanation: Lateral condylar factures are typically associated with a joint effusion. Answer D is incorrect. Explanation: Olecranon fractures are typically associated with a joint effusion. 1. Emery, Kathleen H., et al. "Pediatric elbow fractures: a new angle on an old topic." Pediatric radiology 46.1 (2016): John, Susan D., et al. "Improving detection of pediatric elbow fractures by understanding their mechanics." Radiographics 16.6 (1996): Which of the following is true regarding supracondylar fractures? A. In a 2014 study by Bisset & Crowe, the least commonly missed elbow fracture by pediatric radiologists was a supracondylar fracture. B. The anterior humeral line normally passes through the anterior 1/3 of the capitellum in the majority of children. C. Supracondylar fractures are the second most common pediatric elbow fractures. D. The anterior humeral line may not be as accurate in younger children. The anterior humeral line may not be as accurate in younger children. In children < 5 years old, the anterior humeral line may normally intersect either the anterior or middle 1/3 of the capitellum.
2 Answer A is incorrect. Explanation: In a 2014 study by Bisset & Crowe, the most commonly missed elbow fracture by pediatric radiologists was a supracondylar fracture Answer B is incorrect. Explanation: The anterior humeral line normally passes through the middle 1/3 of the capitellum in the majority of normal children. Answer C is incorrect. Explanation: Supracondylar fractures are the most common pediatric elbow fracture. 1. Bisset, George S., and James Crowe. "Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites." Pediatric radiology 44.5 (2014): Emery, Kathleen H., et al. "Pediatric elbow fractures: a new angle on an old topic." Pediatric radiology 46.1 (2016): Herman, Martin J., et al. "Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age." J Bone Joint Surg Am 91.9 (2009): Mistakes by Pediatric Radiologists in MSK Interpretations James E. Crowe, MD 3. In cases of Monteggia fracture-dislocation which is the most frequently missed fracture? A. Angulated fracture proximal ulna B. Angulated fracture of the radius C. Angulated fractures of both bones D. Bowing fracture of the ulna Answers A, B and C are incorrect. Angulated fractures are not missed 1. Bisset GS 3rd, Crowe JE. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Pediatr Radiol May.44(5): Lateur LM, Van Hoe LR, Van Ghillewe KV, et al. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology Dec. 193(3): Oestreich AE, Mize WA, Crawford AH, Morgan RC Jr. The "anteater nose": a direct sign of calcaneonavicular coalition on the lateral radiograph. J Pediatr Orthop Nov-Dec. 7(6): Which of the following is unlikely to be obvious on a lateral view of the ankle? A. Subtalar coalition B. Calcaneonavicular coalition C. Osteochondral lesion of the talus D. Calcaneal cyst
3 Answer A is incorrect. Explanation: C sign & talar beak. Answer B is incorrect. Explanation: Anteater nose sign & talar beak. Answer D is incorrect. Explanation: Calcaneal cysts are best shown on lateral view. 1. Bisset GS 3rd, Crowe JE. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Pediatr Radiol May.44(5): Lateur LM, Van Hoe LR, Van Ghillewe KV, et al. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology Dec. 193(3): Oestreich AE, Mize WA, Crawford AH, Morgan RC Jr. The "anteater nose": a direct sign of calcaneonavicular coalition on the lateral radiograph. J Pediatr Orthop Nov-Dec. 7(6): Bone Age: Beyond G+P David B. Larson, MD, MBA 5. Which of the following methods should be used to assess bone age for patients under 3 years of age? A. Greulich and Pyle method B. Tanner-Whitehouse method C. Hemi-skeleton method D. BoneXpert method Hemi-skeleton methods are more accurate than hand-based methods in children under 3 years. Answer A is incorrect. Explanation: The Greulich and Pyle method is less reliable in children under 3 because of lack of and variability in ossification centers of the hand. Answer B is incorrect. Explanation: The Tanner-Whitehouse method, also based on hand radiographs, is not reliable in children under 3 years of age for the same reason. Answer C is incorrect. Explanation: BoneXpert is an automated bone age assessment tool, based on the Tanner- Whitehouse method. 1. Breen MA, Tsai A, Stamm A, Kleinman PK. Bone age assessment practices in infants and older children among Society for Pediatric Radiology members. Pediatr Radiol Aug;46(9): Thodberg HH, Kreiborg S, Juul A, Pedersen KD. The BoneXpert method for automated determination of skeletal maturity. IEEE Trans Med Imaging Jan;28(1): Which of the following methods requires the radiologist to score twenty different ossification centers in the hand and wrist? A. Greulich and Pyle method B. Tanner-Whitehouse method C. Hemi-skeleton method D. BoneXpert method Correct Answer: B
4 Answer A is incorrect. Explanation: The Greulich and Pyle method is based on a visual comparison to standard radiographs of the hand and wrist. Answer C is incorrect. Explanation: The hemi-skeleton method is based on summing the ossification centers of the left hemiskeleton in young children. Answer D is incorrect. Explanation: BoneXpert is an automated bone age assessment tool, based on the Tanner-Whitehouse method, that requires no manual data entry. 1. Tanner JM, Healy MJR, Goldstein H, Cameron N. Assessment of skeletal maturity and prediction of adult height (TW3 method), 3rd ed. WB Saunders: London, UK, Breen MA, Tsai A, Stamm A, Kleinman PK. Bone age assessment practices in infants and older children among Society for Pediatric Radiology members. Pediatr Radiol Aug;46(9): Thodberg HH, Kreiborg S, Juul A, Pedersen KD. The BoneXpert method for automated determination of skeletal maturity. IEEE Trans Med Imaging Jan;28(1): Bone Density: Is DR Adequate? Jeannette M. Perez-Rossello, MD 7. Quantitative computed tomography densitometry (QCT)? A. Is a 2-Dimentional technique B. Quantifies areal BMD C. Measures cortical and trabecular compartments separately D. Reported in g/cm2 QCT measures cortical and trabecular compartments separately. Answer A is incorrect. Explanation: QCT is a 3-Dimentional technique. Answer B is incorrect. Explanation: QCT measures true volumetric BMD. Answer D is incorrect. Explanation: Reported in g/cm3 1. JE. Adams et al. Quantitative Computer Tomography in Children and Adolescents: The 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014;17(2): Dual-energy X-ray absorptiometry (DXA): A. Relatively high radiation exposure B. 3-Dimensional measurement C. Not affected by soft-tissue composition or body fat D. Does not account for growth related variations Explanation: DXA does not account for growth related variations, this is a limitation in the pediatric population, where bones are growing and changing in shape. Answer A is incorrect. Explanation: DXA has low radiation exposure. Answer B is incorrect. Explanation: DXA is a 2- dimentional, areal measurement. Answer C is incorrect. Explanation: Soft tissues and fat affect DXA results.
5 1. Binkovitz LA, Henwood, MJ. Pediatric DXA: technique and interpretation. Pediatr Radiol 2007;37:21-31 How to Read a Pediatric DEXA Adina Alazraki, MD, FAAP 9. Regarding Dual Xray Absorptiometry: A. The diagnosis of osteoporosis can be made based on the DXA result alone. B. The T score is reported in pediatric DXA as a measure of the bone density loss since birth. C. DXA is a volumetric density measurement. D. The DXA-derived bone mineral density (BMD) is based on the two-dimensional projected area of a three-dimensional structure. The DXA-derived bone mineral density (BMD) is based on the two-dimensional projected area of a three-dimensional structure. Answer A is incorrect. Explanation: The diagnosis must take into account other factors including normative databases, age, gender, height, etc. Answer B is incorrect. Explanation: The T score is used in adults as a measure of bone loss since adulthood and is not applicable to pediatric patients. Answer C is incorrect. Explanation: DXA is a two dimensional representation of a three dimensional structure and is therefore an areal measurement rather than a true volumetric measure. 1. Binkovitz, Pediatr Radiol Jan; 37(1): Factors that influence BMD for in the development of normative pediatric datasets include age, gender, ethnicity and physiologic maturity. The most common causes for misdiagnosis include all BUT: A. Use of T-scores B. Inappropriate normative datasets C. Inattention to short stature D. Scoliosis Answer A is incorrect. Explanation: T scores compare bone loss from adulthood and should not be used in pediatrics. The Z score compares BMD to age matched controls. Answer B is incorrect. Explanation: Age matched controls and normative data matched to the patient is very important for accurate measurements. Answer C is incorrect. Explanation: Height should be recorded for all patients and accounted for in the reporting. 1. Binkovitz, Pediatr Radiol Jan; 37(1):
6 If Only I Would Have Known (Or Listened!) A Twenty Year Reflection Kelley W. Marshall, MD 11. The line marked in blue on the left image and marked with the arrow on the right image represents A. The median ridge B. The trochlear floor C. The crossing line D. The terminal sulcus Correct Answer: B Answer A is incorrect. Explanation: The median ridge is the ventral margin of the medial femoral condyle. Answer C is incorrect. Explanation: The crossing line occurs when the trochlear floor intersects the ventral margin of the femoral condyle. Answer D is incorrect. Explanation: The terminal sulcus is the normal contour indentation of the lateral femoral condyle. 1. RadSource MRI Web Clinic- June Trochlear Dysplasia. Steven S. Ngai, MD, Edward Smitaman, MD, Donald Resnick, MD 12. Which of these is not a radiographic finding seen with acetabular retroversion? A. The crossover sign B. The ischial spine sign C. Medial posterior wall sign D. Lateral displacement of the physeal scar Answers A, B, and C are incorrect. Explanation: The crossover sign, ischial spine sign, and medial posterior wall sign are all indicators of acetabular retroversion. 1. Tannast et al., AJR 2007; 188:
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