On Thursday, four presenters used a case-based approach to offer expert guidance in the diagnosis of emergent pediatric disorders. The radiologists described key imaging features of disorders affecting the abdomen, brain and spine, chest and the musculoskeletal system.
Harriet J. Paltiel, MD, a radiologist at Boston Children’s Hospital and Harvard Medical School, discussed the key diagnostic imaging features of eight pediatric emergency conditions of the abdomen. She noted that acute appendicitis is the most common pediatric surgical emergency. It is diagnosed with ultrasound, but cross-sectional imaging may also be used, she said, depending on patient size and whether there is a lot of bowel gas.
“By ultrasound, we’re looking for a non-compressible tubular structure more than 6 mm in diameter,” Dr. Paltiel said. “A negative ultrasound examination does not exclude appendicitis unless you actually see the appendix. So, we find cross-sectional imaging can be very useful in imaging a retrocecal appendix and in documenting fluid collections in the setting of perforation.”
Sundgren
Pia C. Maly Sundgren, MD, PhD, professor of radiology and senior consultant in neuroradiology at the Institution of Clinical Sciences/Radiology at Lund University in Lund, Sweden, discussed emergent conditions of the head and spine in children, including infections and associated brain and spine lesions.
Dr. Sundgren emphasized the importance of obtaining all clinical information so that the right imaging protocol can be used. She also urged radiologists to review bone windows on CT for all patients, a point she emphasized by sharing the case of a 10-year-old girl whose mastoiditis was missed initially on CT because the bone windows were not reviewed. The girl, who also had sinus thrombosis and pneumococcal meningitis, did not survive.
Edward Y. Lee, MD, MPH, associate professor of radiology at Boston Children’s Hospital and Harvard Medical School, discussed the diagnosis of thoracic disorders in children.
“Imaging evaluation is critical for the diagnosis, treatment and follow-up of many emergencies involving the pediatric chest,” said Dr. Lee. “Pediatric chest emergencies can arise from various causes. It’s important to remember signs such as the thumb sign for epiglottitis, and the candle dripping sign for bacterial croup.”
Matthew R. Wanner, MD, associate professor of clinical radiology and imaging sciences at Indiana University School of Medicine, focused on the musculoskeletal system. In particular, he explored the diagnosis of slipped capital femoral epiphysis (SCFE) and fractures resulting from child abuse.
Dr. Wanner emphasized the importance of obtaining both AP and frog-lateral views of the pelvis (including both hips) as part of a SCFE diagnosis. It’s also crucial to identify the signs of epiphyseal slippage – and, most importantly, the so-called "pre-slip," where the alignment is correct but the growth plate is widened – which is the earliest indicator on radiographs.
With child abuse findings, the focus is mostly on radiographs. When diagnosing child abuse, Dr. Wanner said, it’s important to look for the classic metaphyseal lesion (CML) and rib fractures. He also emphasized the importance of two-week follow-up skeletal surveys if there is high clinical suspicion.
Access the presentation, “Pediatric Emergencies: Must Know Diagnoses,” (R3-CMS21) on demand at Meeting.RSNA.org.
