Knee ultrasound in pediatric patients - anatomy, diagnostic pitfalls, common pathologies.

Knee ultrasound in pediatric patients - anatomy, diagnostic pitfalls, common pathologies. Poster No.: C-2434 Congress: ECR 2015 Type: Educational Exhibit Authors: C. M. Olchowy, M. Lasecki, M. Inglot, D. Holownia, K. Moron, 1 1 1 1 1 2 1 2 U. Zaleska-Dorobisz ; Wroclaw/PL, Olesnica/PL Keywords: Pediatric, Musculoskeletal joint, Anatomy, Ultrasound, Elastography, Ultrasound-Power Doppler, Education, Education and training, Trauma DOI: 10.1594/ecr2015/C-2434 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 13

Learning objectives The purpose of this educational exhibit is: 1. to illustrate the normal anatomy and normal apperance of knee compartments depending on age of a patient, 2. to describe a systematic technique (easy to follow check-list protocol) for evaluation of anatomical structures, 3. to present anatomical schemes, x-ray and corresponding sonography images, 4. to present cases of traumatic and oncologic patients as well as Osgood-Schlatter disease Background Ultrasound is well-established as safe, efficient and cost-effective method to evaluate superficial structures of the knee. It also has got it's well known limitations, but because of many advantages it is still one of the most frequently ordered musculoskeletal procedures in diagnosing traumatic and non-traumatic pediatric patients with knee pain (often interpreted together with x-ray). Findings and procedure details Ultrasound examination od knee joint should consist of assesment of: 1: anterior compartment (patella, suprapatellar recess, patellar ligament and it's insertion, quadriceps tendon, cartilage structure) 2: lateral compartment ( lateral colateral ligament, ossification centres, cartilage, lateral meniscus) 3: medial compartment ( medial colateral ligament, ossification centres, cartilage, medial meniscus) 4: posterior compartment (popliteal fossa, vessels) Normal images differ among age groups. It is important to be familiar with ultrasound characteristics od ossification centers. Page 2 of 13

Fig. 5: 5-month-old child. Longitudinal view of anterior knee compartment. Note the ossification center in distal femur and hypoechoic cartilage. References: Department of Radiology. Wroclaw University Hospital Hypoechoic cartilage is often misdiagnosed as fluid. On next images we present normal eppearance of cartilage in knee joint: Page 3 of 13

Fig. 2: Longitudial view. Patellar ligament. Normal ultrasound anatomy in 7-year-old child. References: Department of Radiology. Wroclaw University Hospital Fig. 1: Longitudial view. Suprapatellar recess. Normal ultrasound anatomy in 7-yearold child. Page 4 of 13

References: Department of Radiology. Wroclaw University Hospital Fig. 3: Longitudial view. Medial aspect of knee joint. Normal ultrasound anatomy in 7year-old child. References: Department of Radiology. Wroclaw University Hospital In pediatric trauma patients ultrasound plays an important role in diagnosing fractures. Typical image presented below: Page 5 of 13

Fig. 4: Ultrasonografic findings - fracture. Discontinuity of periosteum is visible. Adjacent soft tissues are hypoechoic - hemartoma. Increased vascularity of this area in PowerDoppler. References: Department of Radiology. Wroclaw University Hospital Osgood Schlatter disease typically occurs in patients between 9 and 16 years old. Male to female ratio - 3:1. Location : ligament-bone junction of the patellar ligament and the tibial tuberosity. Page 6 of 13

Fig. 6: Osgood Schlatter disease - typical ultrasound findings. Arrows show fragmentation of the apophysis (tibial tuberosity) and cartilage swelling (green arrows). References: Department of Radiology. Wroclaw University Hospital Images for this section: Page 7 of 13

Fig. 1: Longitudial view. Suprapatellar recess. Normal ultrasound anatomy in 7-year-old child. Fig. 2: Longitudial view. Patellar ligament. Normal ultrasound anatomy in 7-year-old child. Page 8 of 13

Fig. 3: Longitudial view. Medial aspect of knee joint. Normal ultrasound anatomy in 7year-old child. Page 9 of 13

Fig. 4: Ultrasonografic findings - fracture. Discontinuity of periosteum is visible. Adjacent soft tissues are hypoechoic - hemartoma. Increased vascularity of this area in PowerDoppler. Page 10 of 13

Fig. 5: 5-month-old child. Longitudinal view of anterior knee compartment. Note the ossification center in distal femur and hypoechoic cartilage. Fig. 6: Osgood Schlatter disease - typical ultrasound findings. Arrows show fragmentation of the apophysis (tibial tuberosity) and cartilage swelling (green arrows). Page 11 of 13

Fig. 7: Sinding Larsen Johansen disease. Arrow shows fragmentation od of lowerpole of the patella. Cartilage swelling is also visible. Stars - tendinosis of patellar ligemnt. Page 12 of 13

Conclusion Knowledge of anatomy landmarks is essential for scanning the knee accurately and efficiently. In pediatric patients also the appearance of bony parts differs depending on age: occification centers, articular cartilage, epiphysis. Easy to follow ultrasound examination protocol can be a useful tool in everyday practice of pediatric radiologists. Personal information References 1. 2. 3. 4. 5. 6. 7. Callahan, M. J. (2013). Musculoskeletal ultrasonography of the lower extremities in infants and children. Pediatric radiology, 43(1), 8-22. Navarro, O. M., & Parra, D. A. (2009). Pediatric musculoskeletal ultrasound. Ultrasound Clinics, 4(4), 457-470. Allen, G., & Wilson, D. (2011). Current role for ultrasonography. In Sports Injuries in Children and Adolescents (pp. 83-93). Springer Berlin Heidelberg. Seol, J. G., & Callahan, M. J. (2013). Pediatric Musculoskeletal Ultrasound. Ultrasound Clinics, 8(3), 459-475. Bellah, R. (2001). Ultrasound in pediatric musculoskeletal disease: techniques and applications. Radiologic Clinics of North America, 39(4), 597-618. Harcke, H. T., & Grissom, L. E. (1998). Musculoskeletal ultrasound in pediatrics. In Seminars in musculoskeletal radiology (Vol. 2, No. 03, pp. 321-329). 1998 by Thieme Medical Publishers, Inc.. Mayr, J. M., Grechenig, W., & Höllwarth, M. E. (2004). Musculoskeletal ultrasound in pediatric trauma. European Journal of Trauma, 30(3), 150-160. Page 13 of 13