Frequency of technical success of ultrasound-guided arthrogram injections in children.

BACKGROUND: MR arthrography is an essential diagnostic tool to assess and guide management of labral, ligamentous, fibrocartilaginous, and capsular abnormalities in children. While fluoroscopy is traditionally used for intra-articular contrast administration, ultrasound offers advantages of portability and lack of ionizing radiation exposure for both the patient and proceduralist. OBJECTIVE: The purpose of this retrospective study is to quantify technical success and frequency of complications of ultrasound-guided arthrogram injections at our institution. MATERIALS AND METHODS: This retrospective analysis investigates the results of 217 ultrasound-guided arthrograms of the shoulder, elbow, and hip in patients aged 5-18 years. Successful injection of contrast into the target joint, clinical indication for MR arthrography, and complications were reviewed. RESULTS: Accurate ultrasound-guided intra-articular administration of contrast into the target joint was successful for 100% of shoulder cases (90/90), 97% of elbow cases (77/79), and 98% of hip cases (47/48). Leak of contrast outside the target joint occurred in 1.4% (3/217) of cases. No major side effects including excessive bleeding, paresthesia, allergic reactions, or infection occurred during or after the procedure. Additionally, no major vessel, nerve, or tendon complications were observed on MR images. CONCLUSION: Ultrasound guidance is a reliable, effective, and safe approach to arthrography in children.

Whole-body MRI at initial presentation of pediatric chronic recurrent multifocal osteomyelitis and correlation with clinical assessment.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is a diagnosis of exclusion, relying heavily on whole-body magnetic resonance imaging (WB-MRI) for diagnosing and evaluating response to therapy. Information with respect to disease distribution and imaging correlation with clinical disease severity at initial presentation is lacking. OBJECTIVE: To retrospectively characterize distribution of disease on WB-MRI and to correlate imaging findings with disease severity at initial rheumatology presentation. MATERIALS AND METHODS: Using a modified version of a recently devised imaging-based scoring system, we evaluated disease distribution and correlation between findings on WB-MRI and clinical disease severity in 54 patients presenting for initial evaluation of CRMO. Symptomatic lesion sites were extracted from chart review and physician global assessment was determined by the consensus of two rheumatologists. RESULTS: Sites of CRMO involvement evident on imaging at initial presentation had a strong predilection for the pelvis and lower extremities. There was significant correlation between the number of lesions detected on WB-MRI and total clinical severity score at initial rheumatology presentation (P<0.01). However, no other imaging parameter correlated with disease severity. CONCLUSION: While the overall number of lesions identified on MRI correlates with clinical severity scores at initial imaging, other MR parameters of CRMO lesions may not be reliable indicators of disease severity at initial presentation. Further research is needed to assess whether these parameters are implicated in longitudinal disease severity or overall response to therapy.

Palpable pediatric chest wall masses.

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Normative Values for the Sonographic Measurement of the Pediatric Median and Ulnar Nerves.

RATIONAL AND OBJECTIVES: Ultrasound investigation of peripheral nerves, long used in the adult population, has been shown to be of value in diagnosing a variety of peripheral nerve abnormalities. More recently, nerve sonography has also been shown to be of use in pediatrics. However, normative values for nerve size in children have been lacking. As such, the goal of this research was to establish normative data for cross sectional area (CSA) measurements of the median and ulnar nerves in children. MATERIALS AND METHODS: The median and ulnar nerves of 48 children ranging in age from 2 years to 17 years were imaged by ultrasound. CSA measurements were made at 2 separate sites for each nerve and measured independently by 6 pediatric radiologists. Reliability of ultrasound measurements between the radiologists was assessed by calculating intraclass correlation coefficients. Linear mixed-effects modeling was performed to develop prediction models for nerve cross sectional area for each nerve segment; 95% prediction values were generated from these models to approximate normal ranges. RESULTS: Agreement in nerve cross-sectional area measurements among the 6 radiologists for all nerve segments was good (ICC 0.82, 95% CI 0.78 to 0.85). CSA for both the median and ulnar nerves is larger in older children. However, statistical models to predict CSA using height perform better rather than those using a child's age. The range of normal nerve segment CSA using these prediction models based on child height are reported. CONCLUSION: Median and ulnar nerve CSA can be reliably measured with ultrasound. Normal reference values for ulnar and median nerve CSA correlate with patient age but may be more optimally determined based on a child's height.

Ultrasound assessment of glenohumeral dysplasia in infants.

Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint. As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance as well as providing tips and tricks for identifying and characterizing pathology.

Investigation of occupant kinematics and injury risk in a reclined and rearward-facing seat under various frontal crash velocities.

INTRODUCTION: The availability of highly automated driving functions will vastly change the seating configuration in future vehicles. A reclined and rearward-facing seating position could become one of the popular seating positions. The occupant safety needs to be addressed in these novel seating configurations, as novel occupant loading conditions occur and the current standards as well as regulations are not fully applicable. METHOD: Twelve finite element simulations using a series production seat model and a state of the art 50th percentile male human body model were conducted to investigate the influences of various parameters on the occupant kinematics and injury risk. The varied parameters included the seatback angle, impact speed, and seatback rotational stiffness. RESULTS: The seat model shows a large seatback rotation angle during the frontal crash scenario with high impact speed. A reclining of the seatback angle leads to no significant increase of the injury risk for the assessed injury values. However, the reclining does affect the interaction among the occupant, seatbelt, and seatback. An increase of the seatback rotational stiffness helps reduce brain and chest injury metrics, while neck injury values are higher for the stiffer seatback.

Uniquely pediatric upper extremity injuries.

The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation and fishtail deformity of the distal humerus.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis.

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.

Contemporary imaging of the pediatric shoulder: pearls and pitfalls.

In skeletally immature patients, the presence of growth plates and articular cartilage of the shoulder can create a predisposition for unique injuries not observed in adults. Furthermore, increasing participation in sports by children and adolescents appears to be leading to a corresponding increase in the number of sports-related injuries. The importance of radiologists being familiar with pediatric shoulder imaging and its associated injuries is therefore growing. In this article, we review the normal development and maturation pattern of ossification centers of the shoulder from the early gestational period through adolescence. Brachial plexus birth palsy, physeal injuries, shoulder dislocation, and internal impingement are discussed within the context of the child's age and the mechanism of injury to guide radiologists to a correct diagnosis.

The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Foot and Ankle Musculoskeletal Imaging of Pediatric Patients With Cerebral Palsy.

OBJECTIVE. Any combination of abnormal positioning of the ankle, hindfoot, midfoot, and forefoot is possible in the context of cerebral palsy, but some patterns are more common than others. The purpose of this article is to discuss the radiographic manifestations and surgical management of the following common conditions: equinus, equinoplanovalgus, equinocavovarus, vertical talus, oblique talus, hallux valgus, and ankle valgus. CONCLUSION. CP is defined by abnormalities of the developing fetal or infant brain that result in permanent central motor dysfunction. Foot and ankle deformities are very common in the patients with CP, occurring in up to 93% of such patients as a result of underlying abnormal muscle tone, impaired motor control, and dynamic muscle imbalance. Radiologists must develop knowledge of the most common changes in alignment and basic techniques for correction to better recognize abnormalities and improve communication with orthopedic colleagues.

Development of a Scoring Tool for Chronic Nonbacterial Osteomyelitis Magnetic Resonance Imaging and Evaluation of its Interrater Reliability.

OBJECTIVE: Serial magnetic resonance imaging (MRI) examinations are often needed in chronic nonbacterial osteomyelitis (CNO) to determine the objective response to treatment. Our objectives in this study were (1) to develop a consensus-based MRI scoring tool for clinical and research use in CNO; and (2) to evaluate interrater reliability and agreement using whole-body (WB)-MRI from children with CNO. METHODS: Eleven pediatric radiologists discussed definitions and grading of signal intensity, size of signal abnormality within bone marrow, and associated features on MRI through monthly conference calls and a consensus meeting, using a nominal group technique in July 2017. WB-MRI scans from children with CNO were deidentified for training reading and an interrater reliability study. The reading by each radiologist was conducted in a randomized order. Interrater reliability for abnormal signal and severity were assessed using free-marginal κ statistics. RESULTS: Radiologists reached a consensus on grading CNO-specific MRI findings and on describing bone units based on anatomy. A total of 45 sets of WB-MRI scans, including 4 sets of non-CNO MRI examinations, were selected for the final reading. The mean κ of each category of bones was > 0.7 with majority > 0.9 demonstrating substantial/almost perfect interrater reliability of readings among radiologists. The agreement on signal intensity and the size of signal abnormality within the most commonly affected bones (femur and tibia) were lower than those of other bones. CONCLUSION: The chronic nonbacterial osteomyelitis magnetic resonance imaging scoring (CROMRIS) tool is a comprehensive standardized scoring tool for MRI in children with CNO. Our interrater study demonstrated good interrater reliability and agreement of readings.

Practical considerations when implementing peer learning conferences.

Peer learning represents a shift away from traditional peer review. Peer learning focuses on improvement of diagnostic performance rather than on suboptimal performance. The shift in focus away from random selection and toward identification of cases with valuable teaching points can encourage more active radiologist engagement in the learning process. An effective peer learning program relies on a trusting environment that lessens the fear of embarrassment or punitive action. Here we describe the shortcomings of traditional peer review, and the benefits of peer learning. We also provide tips for a successful peer learning program and examples of implementation.

Documenting your career as an educator electronically.

Academic radiologists on the clinician-educator track are required to provide a teaching portfolio as well as a curriculum vitae (CV) for academic promotion. The specific components of a teaching portfolio vary slightly depending on the institution. Traditionally academicians have collected the necessary documentation in paper format, often stuffing them in a binder or a desk drawer. However in the digital age most academic works are readily available in electronic format and can be accessed online. An electronic portfolio is the ideal method to efficiently organize this digital material. In this article, we describe the specific advantages of an online academic portfolio, explain how to set one up and review many options available to build an online electronic portfolio.

Neonatal Bowel Disorders: Practical Imaging Algorithm for Trainees and General Radiologists.

OBJECTIVE: Neonatal bowel disorders require prompt and accurate diagnosis to avoid potential morbidity and mortality. Symptoms such as feeding intolerance, emesis, or failure to pass meconium may prompt a radiologic evaluation. CONCLUSION: We discuss the most common neonatal bowel disorders and present a practical imaging algorithm for trainees and general radiologists.

Skeletal Dysplasias: Radiologic Approach with Common and Notable Entities.

Skeletal dysplasia is a heterogeneous group of abnormalities affecting growth and development of bone and cartilage characterized by disproportionate shortening of the limbs and/or spine. A systematic radiographic approach combined with pertinent clinical details can help guide specific genetic testing and treatment. We provide a discussion and examples of a few common and notable skeletal dysplasias to help familiarize general, pediatric, and musculoskeletal radiologists who do not commonly encounter children with these entities in their daily practices.

The Pediatric Patella: Normal Development, Anatomical Variants and Malformations, Stability, Imaging, and Injury Patterns.

We discuss the pediatric patella, with an emphasis on diagnostic imaging. Topics include normal patellar development, anatomical variants and their physiologic significance, genetic syndromes that alter the appearance of the patella, physiology of patellar tracking and stability, patellofemoral instability, and injury patterns and classification. Recognition of appropriate development on imaging prevents diagnostic error and unnecessary evaluation. Knowledge of the pertinent features of syndromes associated with morphological patellar abnormalities can aid in generating a succinct and relevant differential diagnosis. In patellofemoral instability, the patient's baseline anatomy, factors that predispose to instability, and the specific injuries that occur as a result are critical considerations for determining the course of treatment. Patellar sleeve fractures are unique to pediatric patients, and timely identification is critical to achieving an optimal treatment outcome.

Nasoduodenal tube placement: Are two views necessary to confirm position?

BACKGROUND: Nasoduodenal tube (NDT) placement is typically performed at the bedside and two-view abdominal radiographs are usually used to confirm tube position. Anecdotally, in most instances the lateral view is unnecessary and utilizes more than twice the radiation than an anteroposterior (AP) view alone. OBJECTIVE: We hypothesize that NDT location can be determined using only the AP view, with the NDT position determined on two views utilized as the gold standard. MATERIALS AND METHODS: A search was performed for all two- or three-view abdominal radiographs from September 2012 to September 2013 with the phrase "ND tube" in the reason field of the requisition. These studies were independently reviewed by two radiologists and scored for anatomical tube position in three different scenarios: AP view alone, the lateral view alone, and both views together, with the latter serving as the gold standard. The anatomical scores were subsequently grouped to reflect clinically significant scenarios. Comparative analysis was performed with the original and clinically grouped scores. RESULTS: A total of 102 patients and 306 separate two-view exams were evaluated. Of the 102 patients, 55 had at least two separate exams. Across raters, concordances of AP and lateral scores relative to the gold standard assessment were 88% and 73% for anatomical scores, and 91.5% and 86.4% for clinically grouped data. Trend differences for fewer errors were found with the AP compared to the lateral view. There were statistically significant group differences with a greater number of false-negative errors in the lateral data set. No clear differences were found when comparing AP and lateral ratings for false-positive errors. Upon review of the common errors, we determined a few imaging findings on AP radiographs that can help assess the need for an additional lateral view. CONCLUSION: A single AP view is sufficient to determine the NDT position in most cases. Two views should be reserved for cases where the NDT position cannot be definitively assessed. Transitioning toward the single AP view to evaluate the NDT position could have immediate consequences for dose reduction.