1. Pediatric Radiology

2. Indications for Pediatric Radiographic Examination History Will the imaging give you any added clinical data? Benefits vs. risk –American College of Radiology (ACR) Appropriateness Criteria available at www.acr.org www.acr.org

3. All radiological exams carry risk gonads breast thyroid lung Bone The concept of ALARA (as low as reasonably achievable) should be applied to all patients…

4. Radiation Exposure - Children Considerably more sensitive to radiation than adults Also have a longer life expectancy –a larger window of opportunity for expressing radiation damage Compared with a 40-year old, the same radiation dose given to a neonate is several times more likely to produce a cancer over the patient’s lifetime Retrieved 01-17-05 from http://www.cancer.gov/cancertopics/causes/radiation- risks-pediatric-CT

5. Never radiograph routinely! Will the results change my management? Will the study confirm my clinical suspicions? Is this the appropriate study for what I’m trying to confirm?

6. Technical Issues Instructional compliance Motion –The child should be stabilized by the parent Recumbent radiographs a necessity in young children –acute fractures

7. uprightrecumbent

8. Must know the normal radiographic appearance at each age for accurate interpretation –Atlas of normal developmental anatomy –Consult a DACCBR? Chiropractic line analysis –Children are not small adults… Does the technique recognize this? Radiographic Interpretation

9. Normal Pediatric Variants Pseudosubluxation Pseudospread of C1 on C2 ADI space Absence of cervical lordosis Normal appearance of ossification centers and epiphyses

10. Pseudosubluxation Normal variant Occurs most commonly at C2/C3 –40% of normal children <7 years of age –24% of those under 16 years Also occurs at C3/C4 –20% of those <7 years; 9% <16 years http://www.medcyclopaedia.com/library/topics/volume_vii/p/pseudosubluxation.aspx

11. A line drawn connecting the anterior cortices of the spinous processes of C1 and C3 should intersect or lie within 1 mm of the anterior cortex of the spinous process of C2 If C2 is >2mm off of this line = true injury http://www.uth.tmc.edu/radiology/test/er_primer/spine/images/csp40.html http://www.medcyclopaedia.com/library/topics/volume_vii/p/pseudosubluxation.aspx Swischuk's line distinguishes pseudosubluxation from pathological subluxation

13. Pseudospread of C1 on C2 Normal variant Lateral mass displacement relative to the dens –Up to 6mm is common <4 yoa –Can be seen up to 7 yoa Lustrin ES, Karakas SP, Ortiz AO et al. Pediatric Cervical Spine: Normal Anatomy, Variants and Trauma. RadioGraphics 2003; 23:539-60.

14. Pseudospread of C1 on C2 Lustrin ES, Karakas SP, Ortiz AO et al. Pediatric Cervical Spine: Normal Anatomy, Variants and Trauma. RadioGraphics 2003; 23:539-60.

15. Other Common Variants ADI space –Maximum of 4mm (new literature) in children Absence of cervical lordosis –Can be seen in children up to 16 yoa Oval/wedge shaped vertebrae are normal –Not to be confused with compression fx Normal appearance of ossification centers and epiphyses can simulate fractures… Lustrin ES, Karakas SP, Ortiz AO et al. Pediatric Cervical Spine: Normal Anatomy, Variants and Trauma. RadioGraphics 2003; 23:539-60.

16. Copyright ©Radiological Society of North America, 2003 Lustrin, E. S. et al. Radiographics 2003;23:539-560 Figure 1b synchondrosis

17. Copyright ©Radiological Society of North America, 2003 Lustrin, E. S. et al. Radiographics 2003;23:539-560 Figure 4

18. The spaces between the sacral segments are synchondroses composed of fibrocartilage, not discs –Bone starts to be deposited in the fibrocartilage starting at puberty *They do not move like vertebrae… Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. [January 20, 2006].www.bartleby.com/107/ http://www.bio.psu.edu/people/faculty/strauss/anatomy/skel/sacrum2.htm

19. Where is the anomaly?

20. Os Odontoideum Results from injury at the odontoid synchondrosis Flexion/extension radiographs Neurological deficit? Neurologist/orthopedist consult

21. Epiphyseal Plate Injuries Salter-Harris Classification

22. http://xray.20m.com/photo4.html

23. Child Abuse Physical, sexual, nutritional abuse or neglect Must report to appropriate agency! –Remain professional and objective –Be non-judgemental toward parents

24. Radiography plays an important part in documenting physical abuse Technical considerations –reveal soft tissues well –high detail radiographs –sectionals, not “babygram”

25. Battered child syndrome Metaphyseal “corner” fractures Multiple fractures at various stages of healing Ribs, scapula Head injuries –Skull fx, subdural hematoma, shearing injuries *MC cause of death + disability in child abuse Soft tissue swelling and injuries –i.e. contusions, burns, etc.

26. Oblique fracture Periosteal reaction Metaphyseal corner fx

27. Linear skull fractures Multiple metacarpal fractures

28. Rib fractures –Especially posterior aspect

29. Hx: 2 yo with vomiting and diarrhea Initial abdomen and chest films normal Increased WBC Elevated ESR Findings: -decreased disc height -abnormal signal in two adjacent VB -paraspinal mass Dx: discitis Swischuk LE. Vomiting, diarrhea and--oh! oh! what is that? Pediatr Emerg Care. 2004 Jan;20(1):54-6

30. Spinal infection Discitis A common problem in infants MC lumbar region, lower thoracics S/S: back pain (often can’t directly communicate) and difficulty walking or limping Therefore, when one has exhausted all of the more common causes of limping, one should look to the lower thoracic and lumbar spine regions for the presence of discitis. Swischuk LE. Vomiting, diarrhea and--oh! oh! what is that? Pediatr Emerg Care. 2004 Jan;20(1):54-6