[Abscesses after appendectomy due to intraoperative retaining of fecalith]. / Abszesse nach Appendektomie durch intraoperativ verlorene Appendicolithen.

OBJECTIVE: Fecaliths appear to predispose a patient to acute appendicitis, abscess formation, and perforation. The number of preoperative radiological evaluations is increasing, although children with suspected perforation still undergo surgery immediately. We report and discuss imaging findings and implications in children with acute appendicitis and fecaliths. METHODS: Four children (3 girls, 1 boy; mean age 9 years) underwent surgery for acute appendicitis. Three children underwent sonography and plain radiography before surgery, 1 child was operated without radiological evaluation. After readmission, all 4 children underwent sonography and plain radiography before surgery. RESULTS: In 3 patients a fecalith was diagnosed initially. After uneventful recovery all 4 patients had acute abdominal pain and readmission was necessary. In all 4 patients the escaped fecalith was demonstrated with sonography and plain radiography confirmed surgically. CONCLUSION: Discussion about the role of imaging in acute appendicities has concentrated on the diagnostic yield of cross-section techniques. The importance of demonstrating a fecalith, prompting a more thorough intraoperative search has found little attention. The radiologist should also detect and localize a fecalith and should be aware of retained fecaliths as a cause of abscess formation after appendectomy.

The painful hip: evaluation of criteria for clinical decision-making.

UNLABELLED: Children with a painful hip present a diagnostic challenge since clinical differentiation between septic arthritis, transient synovitis and Perthes disease may be difficult. Septic arthritis, a potentially life-threatening and debilitating medical emergency, requires early recognition for successful treatment, while transient synovitis and Perthes disease may be managed conservatively. An "ideal" single test for discrimination between these conditions is currently not available. We assessed the value of clinical examination and simple laboratory tests together with radiography and hip ultrasound in differentiating septic arthritis from transient synovitis and Perthes disease by analyzing the records of 89 children treated at our institution for hip pain. Ultrasound, radiographs, laboratory, clinical, and follow-up data were available for all the children. Diagnoses were made according to established criteria. Transient synovitis was present in 64 patients, septic arthritis in 8 (of whom 2 had additional osteomyelitis), and Perthes disease in 4. All children with septic arthritis had hip effusion shown by ultrasound and at least two of the following criteria: fever, elevation of erythrocyte sedimentation rate (ESR) and of C-reactive protein (CRP). None of the children without effusion on ultrasound or who lacked two or all criteria had septic arthritis. Radiographs had no significant impact on the decision-making in primary evaluation of acute hip pain. CONCLUSION: We conclude that investigation of painful hips in children, based on hip ultrasound, body temperature, ESR and CRP, may allow cases for hip joint aspiration to be selected efficiently and may reduce the number of radiographs and hospital admissions.

"Growing fontanelle": a serious complication of difficult vacuum extraction.

Growing skull fractures in combination with leptomeningeal cysts are well known in childhood. A rare case of a growing fontanelle due to a leptomeningeal cyst is presented. The cyst occurred due to a traumatic delivery with vacuum extraction. Operative repair of the cyst revealed a dural tear at the border of the fontanelle. The imaging findings are discussed.

Fibrous tumours in children: imaging features of a heterogeneous group of disorders.

BACKGROUND: Fibrous tumours are predominantly soft tissue lesions which are relatively frequent in childhood but are little known. Imaging is often used in the evaluation of these tumours but their characteristics, particularly on US or MRI, have not been studied systematically. OBJECTIVES: To provide an overview of the clinical and imaging features of the different disorders, and to correlate them with the currently used classification schemes. MATERIAL AND METHODS: Twenty-five patients with fibrous tumours were evaluated retrospectively. Clinical histories were studied for the histopathological diagnosis, age, signs and symptoms at presentation, mode of therapy and follow-up where available. Imaging findings were analysed for the following variables: number, location, size, margin and architecture of soft tissue and/or visceral lesions and the presence and pattern of osseous involvement. Comparison with the available literature was performed. RESULTS: The following tumour types were encountered: desmoid fibromatosis (n = 9), myofibromatosis (n = 7), fibromatosis colli (n = 2), congenital-infantile fibrosarcoma (n = 2), adult-type fibrosarcoma (n = 2), fibrous hamartoma of infancy (n = 1), angiofibroma (n = 1) and hyaline fibromatosis (n = 1). CONCLUSIONS: While some tumours were non-specific in their clinical and radiological manifestation, others such as myofibromatosis, fibromatosis colli, fibrous hamartoma of infancy and angiofibroma exhibited a characteristic pattern which allowed a diagnosis to be made even without histology.

Late intrauterine Cytomegalovirus infection: clinical and neuroimaging findings.

Fetal Cytomegalovirus (CMV) infection in early pregnancy usually results in severe neurological handicap and sensorineural hearing loss with typical neuroradiological findings of calcification, migrational anomalies, disturbed myelination, and cerebellar hypoplasia. Infections acquired in late pregnancy have less prominent signs, such as microcephaly, hearing deficits, and minor neurological handicap. We report 7 children who presented with a similar clinical complex of signs: microcephaly, sensorineural hearing impairment, behavior problems with hyperactivity, reduced apprehension for pain in 5 of the 7, ataxia in 3, and hypotonia with clumsiness in 3 others. All manifested mild to severe developmental problems. Cranial CT revealed calcification in 4 of 6 patients. MRI in all 7 children showed patchy to confluent nonprogressive dysmyelination. Only 2 children had acute neonatal signs of congenital CMV infection. We assume that these children acquired CMV infection in the third trimester of gestation, leading to microcephaly, hearing loss, and neurological and developmental problems with typical neuroradiological signs.

Metaphyseal peg in geroderma osteodysplasticum: a new genetic bone marker and a specific finding?

We describe two sibs with geroderma osteodysplasticum (GO) who, in addition to the known clinical and radiologic manifestations of the disorder, presented a metaphyseal peg indenting the epiphysis of the long bones, particularly at the knees. The peg was visible only at the age of 4 to 5 years but was invisible in infancy and following physeal closure. This may explain why this anomaly was not described in previous reports of 23 patients in 11 families with GO. The metaphyseal peg is an abnormality of bone development so far unknown to us. We speculate that it represents a primary, agedependent alteration of bone shape and hence a new genetic bone marker apparently specific to GO.

Giant cell tumor in the skull of a 9-year-old child: immunohistochemistry to confirm a diagnosis rare for age and site.

Giant cell tumor of the bone is usually located within the epiphysis of a long bone, the majority of the lesions occurring in the third and fourth decades of life. We report an unusual case of giant cell tumor (GCT) arising in the parietal skull bone of a 9-year-old girl. The tumor exhibited histologic findings typical for GCT, with conspicuous intravascular giant cells. Based on microscopic features, not only conditions like aneurysmal bone cyst or bone changes associated with hyperparathyroidism but also tumors such as chondroblastoma or osteosarcoma had to be considered. Immunohistochemistry revealed strong reactivity of the tumor giant cells and normal bone osteoclasts with CD68 but not Mac-387; tumor stromal cells were uniformly negative for both. The stromal cells exhibited two immunohistochemically distinct phenotypes. One, involving 50-80% of the tumor cells, exhibited negative lysozyme staining with positivity of proliferating cell nuclear antigen (PCNA) in about 30% of the nuclei. The other showed reactivity with lysozyme but negative PCNA staining. Immunohistochemistry thus helped to distinguish chondroblastoma and osteosarcoma, in which lysozyme positivity would reside in macrophages but not within stromal cells. Instead, chondroblastoma would exhibit protein S-100 positivity in the tumor cells. The biological behavior of GCT is difficult to predict based on morphology alone, although the malignant potential seems to rest in the stromal cells rather than the giant cells. Specifically, in reported cases, the intravascular occurrence of giant cells in GCT is not associated with an increased incidence of metastasis.

Juvenile chronic arthritis: imaging of the knees and hips before and after intraarticular steroid injection.

Intraarticular steroid therapy in juvenile chronic arthritis (JCA) is performed because of high local efficacy with few side effects. Imaging is used for initial evaluation and for monitoring of treatment response. The aim of this study was to compare imaging findings in diseased hips and knees before and after therapy. A prospective study was performed on 10 patients (15 joints) scheduled for intraarticular therapy. Pretherapeutic assessment included clinical work-up, radiographs, ultrasound (US), and magnetic resonance imaging (MRI) of affected joints. Following therapy, clinical and sonographic examinations were performed at 1 week and 1 month. MRI was repeated at 1 month. MRI and US demonstrated pannus formation and effusion, but differentiation was less distinct on US. Popliteal cysts and lymph nodes were visible in both modalities. MRI additionally revealed articular cartilage loss and subchondral cysts, not shown by US. Epiphyseal overgrowth and osteopenia were best seen radiographically. At present MRI is the best tool to assess the inflammatory changes of the joints in JCA. Initial staging of the joints may be done with plain films and MRI. US is useful to assess effusion and pannus and may be used to monitor treatment response.

Magnetic resonance imaging of the spine in bone dysplasias and related disorders.

This article discusses the role of magnetic resonance imaging in orthopedic and neurosurgical complications of the spine in developmental disease of bone. The importance of a basic knowledge of spinal deformities in dysplasias and related disorders is stressed, and on the basis of a simple classification, a differential diagnostic list for each category is presented and illustrated with some common disorders.

Pediatric pelvis: radiographic appearance in various congenital disorders.

This article presents the spectrum of pelvic abnormalities in developmental diseases of bone. The pelvis comprises the ilium, ischium and pubis, and the sacrum. Knowledge of pelvic embryology and normal development is essential in recognizing pelvic abnormalities and disorders, which involve the number of bone elements, rate of ossification, density, and size or shape. Anarchic development of bone and dysplasias identifiable at birth must also be considered. The pelvis is important in the evaluation of such disorders because of the frequent, varied, and often specific radiologic abnormalities. The pelvis may also be the first evidence for a congenital malformation syndrome because it is often included in routine radiographic examinations.

Marshall-Smith syndrome: new radiographic, clinical, and pathologic observations.

Radiographic, clinical, and histologic findings in two infants and a neonate with a syndrome of profoundly accelerated skeletal maturation included features closely resembling those of Marshall-Smith (MS) syndrome, but patients had dysmorphic ears as well as distinctive generalized skeletal abnormalities suggestive of a bone dysplasia. Among these was an instability at the craniocervical junction with severe spinal stenosis. These previously unrecognized abnormalities may represent uncommon manifestations within the spectrum of MS syndrome or indicate the existence of a separate disorder.

An unusual case of craniofacial fibrous dysplasia presenting in early infancy.

Fibrous dysplasia (FD) of bone is one of the most frequently encountered anomalies of skeletal development. It may involve one or more bones and, particularly when polyostotic, is sometimes associated with abnormal skin pigmentation and endocrine abnormalities. FD occurs mainly in large limb bones, ribs, and craniofacial bones in older children and young adults. Usually craniofacial involvement is detected because of local swelling or asymmetry of the face or head. Neurological symptoms, primarily due to involvement of the foramina, have been reported but are not common. Infantile fibrous dysplasia of the craniofacial region has rarely been reported.