Breast carcinoma bone metastasis first presenting to single middle phalanx.

Phalangeal bone metastasis is rare. Breast cancer is known to metastasise to bone but rarely to fingers. This case presents the first site of breast cancer metastasis found on a single proximal phalanx causing pain and affecting hand function. For surgical symptomatic treatment the patient had a ray resection. Post-operatively the patient was pain free with excellent hand function.

Role of intravenous urogram in investigation of urinary tract infection: an observational study.

OBJECTIVES: To examine the value of an intravenous urogram (i.v.U) in patients with abnormal differential (99m)Tc dimercaptosuccinic acid (DMSA) uptake without scarring or ultrasound abnormality. STUDY DESIGN: Forty patients (age 0-19 years) were identified over a two year period in whom the differential renal uptake was >10%, who had smooth renal outlines, and had no evidence of scarring. All patients had an ultrasound examination. Two had marked urological abnormalities on ultrasound and eight had a duplex system in the kidney with greater DMSA uptake. In 18 patients where no explanation was apparent for the discrepant DMSA uptake, an i.v.U was performed. RESULTS: Eight patients had a normal i.v.U. In the remaining 10 patients, six had duplex systems without scarring and four had appearances of scarring in the kidney with reduced DMSA uptake. CONCLUSIONS: In this small selected group an i.v.U will identify a significant number of patients with normal kidneys, unrecognised simple duplex systems, or scarring where the DMSA scan has been inconclusive. This will help in planning long term follow up.

Paediatric emergencies: non-traumatic abdominal emergencies.

Presentation with acute abdominal pain or abdominal symptopathology is a very common cause of presentation of children to hospital. The causes are dependent in part on the age of the child, in part on the presence of previous surgery, and can be divided into those that relate to congenital abnormalities at whatever age they present, acquired disease and infection. Children, particularly young children are often poor historians, and therefore the clinical examination and the laboratory investigations are important in helping to come to a diagnosis. Primary imaging of abdominal emergencies in childhood is a radiograph of the abdomen, followed by ultrasound. Further imaging depends on the results of these studies. An ordered review of the abdomen radiograph is important if the salient features on X-ray are not to be missed. Practitioners should be competent with abdominal ultrasound in children and know where to seek the causes of disease, as these are different from those that are obtained in many instances in adults. Familiarity with the likely causes is important. The three commonest causes of acute abdominal pain in childhood are, in young infants, intussusception, appendicitis and mesenteric adenitis. In older children, inflammatory bowel disease and ovarian pathology are also included. This article details the approach to imaging and the salient features of some of the conditions.

Iodixanol in paediatric gastrointestinal imaging: safety and efficacy comparison with iohexol.

Iodixanol (Visipaque) is a dimeric, non-ionic iodinated contrast medium that is isotonic with blood at all clinically relevant concentrations. Iodixanol was compared in a randomized, double blind, parallel group, phase III multicentre trial with a monomeric, non-ionic contrast medium, iohexol (Omnipaque), at two concentrations assessing safety, tolerability and radiographic efficacy during contrast enhanced gastrointestinal radiography examinations of children. 154 children entered the trial; 152 formed the safety population and 147 the efficacy population. All examinations were performed following standard departmental practice. Children were assigned into either a high or low concentration group (iodixanol, 150 mgI ml(-1) and 320 mgI ml(-1) vs iohexol, 140 mgI ml(-1) and 300 mgI ml(-1)). The primary outcome measure for efficacy was the overall quality of visualization, which was assessed using a 100 mm visual analogue scale (VAS). The secondary efficacy variables assessed were quality of contrast opacification, mucosal coating and overall quality of diagnostic information. Safety evaluation involved patient follow-up for at least 48 h. Taste acceptance was also assessed. There was no statistically significant difference between the two contrast media with regard to the primary and secondary efficacy variables assessed, although higher ratings were observed for iodixanol. The 100 mm VAS score overall was 86 mm for iodixanol and 82 mm for iohexol (95% confidence interval -2.56, 10.42). The frequency of adverse events was lower for patients receiving iodixanol. Adverse events, mainly diarrhoea, occurred in 12 patients (16.2%) in the iodixanol group and 28 patients (35.9%) in the iohexol group. This reached statistical significance (p=0.006). Overall, iodixanol is well suited for examinations of the gastrointestinal tract, giving good efficacy results and fewer adverse events than iohexol.

Cystic retroperitoneal lymphangioma: treatment by image-guided percutaneous catheter drainage and sclerotherapy.

Retroperitoneal cystic lymphangiomas are extremely rare and the majority are symptomatic during childhood. Although benign, they can compress and infiltrate vital structures. Surgery is curative but is associated with a high complication rate. An alternative treatment strategy is image-guided percutaneous catheter drainage of the lymphangioma followed by sclerotherapy. Resolution of a large retroperitoneal cystic lymphangioma in a 4-year-old child treated by this technique is reported. To our knowledge, this technique has not been previously described in this condition and we believe that it offers significant advantages over surgery.

A pictorial review of atlanto-axial rotatory fixation: key points for the radiologist.

Atlanto-axial rotatory fixation (AARF) is a rare condition which occurs more commonly in children than in adults. The terminology can be confusing and the condition is also known as 'atlanto-axial rotatory subluxation' and 'atlanto-axial rotary dislocation'. Rotatory fixation is the preferred term, however, as in most cases the fixation occurs within the normal range of rotation of the joint. By definition, therefore, the joint is neither subluxed nor dislocated. AARF is a cause of acquired torticollis. Diagnosis can be difficult and is often delayed. The radiologist plays a key role in confirming the diagnosis. The classification system proposed by Fielding in 1977 is most frequently used and will be discussed in detail. Given that this classification system was devised in the days before computed tomography (CT), as well as the fact that combined atlanto-axial and atlanto-occipital rotatory subluxation (AORF) is omitted from the classification, we propose a modification to the classification of this rare but significant disorder. The radiological findings in six cases of AARF will be illustrated, including a case with associated atlanto-occipital subluxation. The pertinent literature is reviewed and a more comprehensive classification system proposed. The imaging approach to diagnosis and the orthopaedic approach to management will be discussed.

Paediatric Crohn's disease: a radiological review.

Paediatric Crohn's disease can be a serious and complex condition which is not always easy to diagnose if it presents in an atypical manner. Although the pathological processes are the same in adults and children, the clinical presentation and disease distribution can be different in children. The impact of the disease can also be much more significant in a growing and developing child than in an adult. Numerous investigations are available to establish the diagnosis, define the complications and to demonstrate the extra-intestinal manifestations. Close cooperation is required between the clinician and radiologist when investigating a child suspected of having Crohn's disease or its symptoms to minimise the radiation dose and the psychological and physical trauma. We review the clinical and radiological aspects of Crohn's disease and discuss the imaging modalities available in diagnosing Crohn's disease and its complications and suggest an investigation pathway as used in our institution.

Evolving experience in the management of empyema thoracis.

The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty-seven patients presenting to a paediatric surgical centre were studied in three consecutive 6-y periods during 1980-97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1-42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n = 2), scoliosis (n = 2), restrictive lung disease (n = 1), bronchopleural fistula (n = 1) and sympathetic pericardial effusion (n = 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome. Whilst fibrinolytics and thoracoscopy may provide attractive options for early empyema, thoracotomy can hasten patient recovery regardless of the stage of disease. Prospective randomized trials are required to assess the ideal therapy for childhood empyema.

Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children.

BACKGROUND: The use of oral contrast in evaluating children by computed tomography (CT) following blunt trauma is controversial. The aim of this study was to evaluate retrospectively the use of oral contrast with abdominal CT in children with suspected abdominal injury. METHODS: The medical records of 101 children who underwent CT for abdominal trauma between 1993 and 1997 were reviewed for data pertaining to the mechanism of injury, clinical findings and management. Scans were reviewed by a paediatric radiologist and criteria of intestinal injury on CT described by Cox and Kuhn were used: (1) extraluminal air or contrast material, (2) focal area of thickening of bowel wall and mesentery, and (3) free intraperitoneal fluid in the absence of solid organ injury. RESULTS: CT was performed within a median time of 2.4 (range 1-48) h after the injury. On 37 (62 per cent) of 60 scans in children who had oral contrast, the duodenum was not opacified after a mean delay of 30 min. Intestinal injury was suspected on CT in four children. In two children with CT evidence of intestinal injury (with/without oral contrast) rupture of the duodenojejunal flexure (n = 1) or ileal perforation (n = 1) was found at laparotomy. Two children had a false-positive scan, leading to negative laparotomy; one scan with oral contrast incorrectly suggested a duodenal leak and in another child CT without oral contrast showed thickening of bowel wall with free intraperitoneal fluid but no specific intestinal injury was identified at laparotomy. One patient had two negative CT scans (with and without oral contrast) and underwent laparotomy for clinical suspicion of bowel injury; rupture of the splenic flexure of the colon was found at laparotomy. CONCLUSION: CT is not reliable for diagnosing intestinal injuries and this is not improved by use of oral contrast. Omission of oral contrast was not associated with delay in the diagnosis of intestinal injury. Since intestinal injuries are uncommon in children, a prospective multicentre study would determine more precisely the role of the routine use of oral contrast.

Digital radiography in paediatrics: radiation dose considerations and magnitude of possible dose reduction.

The purpose of this study was to evaluate the radiation doses received by paediatric patients examined using a digital radiography unit, and to compare these doses with those received from conventional screen-film systems. In this way, guidelines could be drawn up concerning the magnitude of possible dose reductions achievable using digital radiography. The study was undertaken on approximately 900 patients undergoing abdomen, chest, pelvis and skull examinations. Patients were categorized into the following age groups: 0-1 month, 1-12 months, 1-5 years, 5-10 years and 10-15 years. Approximately half were X-rayed using a Fuji computed radiography system and half using a conventional screen-film system. Entrance surface dose was calculated from the recorded exposure parameters and measured X-ray tube outputs. Dose-area product was recorded directly. Image quality was assessed clinically using criteria recommended by a working group of the Commission of the European Communities. Apart from chest examinations, it was found possible to reduce doses by about 40% on average, by using a computed radiography system instead of a 600 speed screen-film combination. There was no significant difference in the dose for chest examinations. Satisfactory image quality can therefore be achieved by using computed radiography as a 1000 speed system for abdomen, pelvis and skull examinations, and as a 600 speed system for chests. Since very few departments appear to use screen-film systems of speeds greater than 400, then, for most departments, the use of computed radiography would result in dose reductions of at least 60%, or 33% for chests.

Isolated H-type recto-vaginal fistula associated with a vulval abscess.

Recto-vaginal fistula is well known to occur in association with imperforate anus. We describe the case of an isolated "H-type" recto-vaginal fistula with no other anorectal abnormalities. The patient presented at 2 months of age with a vulval abscess and passing faeces per vaginum. Unilateral renal agenesis was also seen in this patient. We are unaware of any previous reports in the English-language literature of this isolated abnormality.

Magnetic resonance imaging of knee injuries in children.

The purpose of this study was to evaluate the significance of meniscal appearances and determine the frequency of abnormalities seen on magnetic resonance (MR) imaging in children with knee injuries. We reviewed 78 consecutive MR imaging studies of 74 children aged 5-16 years with unfused epiphyses. Menisci were evaluated using conventional grading techniques. We used chi2 to compare the frequencies of medial and lateral meniscus and anterior cruciate ligament (ACL) tears with each other and with published data for children. Similarly, we compared the proportions of tears of these structures with published data. Arthroscopy results from 26 children were used to calculate sensitivity and specificity of MR imaging for meniscal tears, which were 100% (8/8) and 89% (16/18), respectively. The majority of studies (82%) had grade I or II signal intensity in one or both menisci. Arthroscopy results available in 33% of this group revealed normal menisci. Tears of the medial and lateral menisci were significantly more common than of the ACL. Injuries of the ACL were seen significantly less frequently than previously reported. Grade I or II meniscal signal intensity in children with knee injuries is consistent with a normal meniscus. Tears of the menisci are more common than ACL tears. MR imaging in this context appears reliable.

Ultrasound in children with osteomyelitis.

Ultrasound (US) is a proven method of identifying subperiosteal abscess formation in osteomyelitis, but its precise role in the management of children with the condition is contentious. We reviewed nine children in whom US was used in the management of long bone osteomyelitis, including ribs. US was helpful in confirming the presence of a subperiosteal abscess in those children with an appropriate history and localizing signs. In these circumstances a bone scan is unnecessary. Problems were encountered when US failed to identify a subperiosteal abscess, because of the early stage of the disease process, and in multifocal abnormalities. In these circumstances a bone scan should still be performed.

Imaging strategies in the first 12 months after reduction of developmental dislocation of the hip.

We have reviewed the records of 32 infants whose developmental dislocation of the hip (DDH) was treated by reduction and immobilization in a plaster cast. We examined 50 CT scans from 22 patients. The postreduction radiological studies led to a change of cast in 10 patients and, in five of them, the subluxation shown on CT scan was not seen in an earlier radiograph. Where reduction has been undertaken at the time of arthrography or in an older child, a plain radiograph may be adequate to confirm the position in the cast. In an infant, CT scans give superior information, have acceptable risks, and should be used in association with radiation protection measures.

The swollen leg and primary lymphoedema.

Children who present with unilateral or bilateral swelling of the legs are often suspected of having a deep venous thrombosis. The incidence of deep venous thrombosis in children is low and lymphoedema may be a more appropriate diagnosis. Lymphoedema can be primary or secondary. In childhood, primary lymphoedema is more common and may be seen associated with other congenital abnormalities, such as cardiac anomalies or gonadal dysgenesis. Primary hypoplastic lymphoedema is the most often encountered type. It is more common in girls, especially around puberty, and is typically painless. Atypical presentations produce diagnostic confusion and may require imaging to confirm the presence, extent, and precise anatomical nature of the lymphatic dysplasia. This article describes four patients presenting with limb pain and reviews the clinical features and imaging options in children with suspected lymphoedema.

Current imaging of childhood urinary infections: prospective survey.

OBJECTIVES: To assess whether ultrasonography alone is adequate for routine screening of childhood urinary infection, whether clinical features determine the need for further investigations, and which investigations are most appropriate. DESIGN: Prospective survey of children with proved urinary infection and a preinvestigation record of clinical features. Ultrasonography and intravenous urography were routine, with choice of further studies determined by ultrasonographic findings. SETTING: A children's hospital and two district general hospitals in Mersey region. MAIN OUTCOME MEASURES: Sensitivity and specificity of ultrasonography both generally and in relation to clinical features. Accuracy of intravenous urography compared with radioisotope examinations. RESULTS: Specificity of ultrasonography was good (99% (95% confidence interval 96% to 100%)) but sensitivity modest (43% (32% to 55%)), principally with respect to detecting vesicoureteric reflux and renal scarring. Among older children (aged 2-10 years) with positive ultrasound results and fever or vomiting the sensitivity in detecting reflux (with and without renal scarring) was 78% (62% to 89%) and the specificity 69% (60% to 78%); in detecting renal scarring (with and without reflux) the sensitivity was 100% (80% to 100%) and specificity 65% (56% to 74%). Renal scarring and obstructive uropathies were better assessed by radioisotope examinations than by intravenous urography. CONCLUSIONS: Ultrasonography alone is inadequate for routine screening of childhood urinary infection. Though further investigations remain advisable in infants, in older children they can be restricted to a minority who have positive ultrasound examinations or have had fever or vomiting. Radioisotope examinations largely eliminate the need for intravenous urography.

Transient gyriform brightness on non-contrast enhanced computed tomography (CT) brain scan of seven infants.

Spontaneous gyriform brightness seen on CT scan is an unusual finding unless associated with arteriovenous malformations (AVM). There are sporadic case reports in the literature of its occurrence in association with herpex simplex virus encephalitis (HSVE), purulent meningitis, following chemotherapy for leukaemia, in a child with chronic renal failure, and in a child with folic acid deficiency. We present a series of seven cases exhibiting this phenomenon, none of whom have AVMs, who have been scanned at this hospital in the first 2 1/2 years following the installation of a CT scanner. Four of the cases had congenital heart disease requiring corrective surgery or cardiac catheterisation. The other three had probable meningo-encephalitis. In all cases the gyriform brightness followed an ischaemic insult to the child's brain. We hypothesise that this phenomenon is an ischaemic response in the immature brain and that its occurrence is not so rare as the literature may suggest.