W3F- Workshop #6 Radiology Show and Tell: Do You See What I See

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1 W3F- Workshop #6 Radiology Show and Tell: Do You See What I See Rachel Pevsner, DO Pediatric Radiology Attending Enrique Alvarado, MD Pediatric Radiology Fellow Miami Children s Hospital Miami, Florida

2 Disclosure of Relevant Relationship Drs. Pevsner and Alvarado (or spouse/partner) has not had (in the past 12 months) any conflicts of interest to resolve or relevant financial relationship with the manufacturers of products or services that will be discussed in this CME activity or in his presentation. Drs. Pevsner and Alvarado will support this presentation and clinical recommendations with the best available evidence from medical literature. Drs. Pevsner and Alvarado do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

3 Rachel Pevsner, DO Enrique Alvarado, MD 16 Cases from the ER

6 A. Orbital roof fracture B. Medial orbital wall fracture C. Mandibular dislocation D. Pituitary Mass

7 A. Orbital roof fracture B. Medial orbital wall fracture C. Mandibular dislocation D. Pituitary Mass

10 Lower kvp Decreases dose Decreases scatter radiation Density of bone allows lower tube voltage (kvp) Sagittal and coronal reconstructions from single axial scan

11 Paranasal Sinuses

12 2 patients for evaluation of the paranasal sinuses

13 Calculated effective dose: 0.4 msv Calculated effective dose: 0.5mSv Natural background radiation dose: 3 msv/yr MCH facial bones CT without contrast range: msv

14 PEDIATRICS Volume 126, Number 4, October 201

15 Sinusitis is a clinical diagnosis No sinus XR for child < 6yrs! Limited sinus development. CT high sensitivity Imaging indicated if patient not responding to initial medical management. Immunocompromised patients: CT for acute progression to assess complications: abscess, empyema, osetomyelitis Medina, et al. Evidence-Based Neuroimaging Diagnosis and Treatment. Springer 2013

16 Facial Bone Trauma

18 Towne view-for condyles A. Negative B. Positive

19 Towne view-for condyles NEGATIVE A. Negative X-RAY B. Positive

$Low subcondylar fractures, greenstick fracture, most common mandibular type fracture in kids Kids usually treated non$

21 Mandibular fx 2 nd most common fascial bone fx, nasal bones first < 5yrs crush injury of articular disc more common Usually 2 nd to MVA Condylar fxs-3 types: Intracapsular/condylar head High/ condylar neck above notch, usually dislocated Low subcondylar fractures, greenstick fracture, most common mandibular type fracture in kids Kids usually treated non operatively and managed conservatively If bilateral fx or dislocated open reduction usually required RadioGraphics 2008; 28:

23 A. Pneumothorax B. Dislocation C. AC jt separation D. Avulsion fx

24 A. Pneumothorax B. Dislocation C. AC jt separation D. Avulsion fx

27 A. Benign or B. Malignant

28 A. Benign or B. Malignant

29 Thinning cortex Septations Fallen bone fragment Endosteal scalloping

31 A.Anatomical variant B. Medial epicondyle avulsion C. Normal radiograph D. Supracondylar Fracture

32 A.Anatomical variant B. Medial epicondyle avulsion C. Normal radiograph D. Supracondylar Fracture

33 Capitellum Radial head Internal (medial) epicondyle Trochlea Olecranon External (lateral) epicondyle

35 A.Normal radiograph B. Medial epicondyle avulsion C. Radial neck fracture and joint effusion D. Joint effusion only

$fracture and joint$

36 A.Normal radiograph B. Medial epicondyle avulsion C. Radial neck fracture and joint effusion D. Joint effusion only

37 Normal Joint effusion

39 A.Normal B.Scaphoid fracture C.Chronic stress injury D.Sacpholunate dislocation

$Scaphoid fracture C.$ Chronic stress

40 A.Normal B.Scaphoid fracture C.Chronic stress injury D.Sacpholunate dislocation

42 SEPT DEC A. Pericardial effusion B. Pneumonia C. Pneumothorax D. Pleural effusion

DEC 6 2013 A. Pericardial effusion B. Pneumonia C. Pneumothorax D.

43 DEC A. Pericardial effusion B. Pneumonia C. Pneumothorax D. Pleural effusion 230 cc drained from effusion Hx of Hashimoto thyroiditis & Turner syndrome Echocardiogram 3 months prior was negative Neoplastic & idiopathic most common etiology in children Bottle shaped heart

45 A. Normal B. Pneumothorax C. Consolidation D. Mediastinal Mass

46 A. Normal B. Pneumothorax C. Consolidation D. Mediastinal Mass

47 Ultrasound is a valuable tool! Evaluate pleural effusions: simple vs complex fluid

48 Abscess in kid usually conservative tx only CT if no clinical improvement bronchopleural fistula or empyema

50 A.Abdominal mass B.Pneumatosis C.Bowel obstruction D.Bone mass

51 A.Abdominal mass B.Pneumatosis C.Bowel obstruction D.Bone mass

52 US: LEFT KIDNEY 16 CM LASIX RENOGRAM

53 50% abdominal masses are renal!!!!! NEONATE: Hydronephrosis & MCDK most common INFANT & CHILD: hydronephrosis & wilms tumor most common ABDOMINAL MALIGNANCIES: Wilms (#1) Neuroblastoma (#2) leukemia/lymphoma INFECTION: Appendiceal abscess

55 A. Lateral decubitus film B. Ultrasound C. CT with IV contrast

56 A. Lateral decubitus film B. Ultrasound C. CT with IV contrast

58 Reduced intussuception & reflux of air into bowel

60 A. Bowel obstruction B. Pelvic calcification C. Pelvic Mass D. Constipation

61 A. Bowel obstruction B. Pelvic calcification C. Pelvic Mass D. Constipation Ddx appendicolith gallstone ureteral stone phlebolith

64 A. Appendicitis B. Ulcerative colitis C. Crohn Disease D. Gastroenteritis

65 A. Appendicitis B. Ulcerative colitis C. Crohn Disease D. Gastroenteritis

66 Axial T2 DWI Coronal T1 post-contrast

67 Inflammatory bowel disease Long standing inflammation leads to stricture, fistulas, obstruction, abscess MR enterography & DWI help define active disease prior to tx DWI detects active inflammation MR modality of choice for perianal disease Protocol: Oral and IV contrast

69 A.Positive B. Negative

70 A.Positive B. Negative

Fluid-intensity coronal image Contralateral Synovitis & joint effusion probably due to altered mechanics Sacral Stress Fx: Usually benign in kids

71 Fluid-intensity coronal image Contralateral Synovitis & joint effusion probably due to altered mechanics Sacral Stress Fx: Usually benign in kids Ddx: infection & neoplasm Result mechanical overload, repetitive mico-trauma Usually no hx trauma Sx: low back, buttock, groin, or thigh pain, limping

73 A.Benign B. Malignant

74 A.Benign B. Malignant

75 Mimics osteosarcoma Zonal phenomenom Mature cortex-dense well organized bone at periphery Lucent-less organized center Cleft, but can be adherent to periosteum May contain fat 3-4 weeks for ca+ to develop inside ST mass Wait to resect >12mo otherwise can reoccur Use CT if not sure Histologically can resemble sarcoma in early stages

77 A.Benign or B. Malignant

78 A.Benign or B. Malignant

79 Sunburst periosteal reaction Medullary and cortical destruction Calcified matrix Usually around the knee

80 Ewings sarcoma Osteosarcoma Langerhans cell histiocytosis DO NOT FORGET OSTEOMYELITIS

82 A.First metatarsal B.Second metatarsal C.Third metatarsal D.Fifth metatarsal

83 A.First metatarsal B.Second metatarsal C.Third metatarsal D.Fifth metatarsal

84 Axial Sagittal

85 Comments & Questions Miami Children s Hospital Radiology Department 3100 sw 62 ave (305) Ext Ext. 8440

MRI XR, CT, NM. Principal Modality (2): Case Report # 2. Date accepted: 15 March 2013

MRI XR, CT, NM. Principal Modality (2): Case Report # 2. Date accepted: 15 March 2013 Radiological Category: Musculoskeletal Principal Modality (1): Principal Modality (2): MRI XR, CT, NM Case Report # 2 Submitted by: Hannah Safia Elamir, D.O. Faculty reviewer: Naga R. Chinapuvvula, M.D.