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6/23/2017
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What do you see?
skull fracture
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Head CTOn soft tissue windows, posterior soft tissues swelling and
hemorrhage, no definite evidence of fracture
Head CTOn bone windows, fracture now seen subjacent to posterior soft tissue swelling
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fpnotebook.com
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NEXT PATIENT
What do you see?
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skullfracture
ANOTHER PATIENT
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What do you see?
skullfracture
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NEXT PATIENT
What do you see?
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skullfracture
SKULL FRACTURES
• Unlike most other healing fractures, skull fractures do not show the subperiosteal new bone formation (SPNBF), a/k/a “periosteal reaction,” on x‐rays that can be readily seen with other healing fractures such as rib fractures
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Metaphyseal corner fractures and bucket handle fractures
Metaphyseal corner fractures
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HEALING FRACTURESPeriosteal Reaction (arrowhead)
NAT, 6‐week‐old
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CASE 4
20‐month‐old girl with a limp
No recent fevers, mom doesn’t relate any specific traumatic event.
Brings her to ED for evaluation, where they got x‐rays and called you for admission.
They tell you it seems weird that she has no fever and that they can’t seem to find anything wrong with her leg. They want her admitted for orthopedics consult and further evaluation for osteomyelitis…or cancer!
Looking at the x‐rays before going to examine the child…
CASE 4
You go and get the best evidence to base care on…a physical exam.
They are tender to palpation on the distal left tibia, with restricted ankle range of motion secondary to guarding from pain.
Look at the x‐ray…
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buckle fracture
Limping Child• First key is pain
– If not painful, when did limp begin• With onset of walking , and normal neuro exam, think orthopedics issue like DDH
• With onset of walking and abnormal neuro exam, think CP, dysraphism, or neuromuscular disease
• Next key is trauma• Then fever• If no fever, the DDx is broad and includes NAT, overuse, AVN, pelvic pathology, etc.
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Keys to the Limping Child
Adapted from Reference 9
Is the limp
painful?
If it began with walking and neuro exam normal, think ortho issue like DDH
If it began with walking and abnormal neuro exam, think CP, spinal dysraphism or
neuromuscular disease
(Variant 1)DDX is very broad from AVN, to
abuse, to tumors, to arthritis, SCFE,pelvic pathology...
(Variant 1)
Labs to look for imflammation or infection
Imaging depending on where you PE guides you
(ACR‐AC are somewhat helpful)(Variant 3)
Image the appropriate area
with plain radiographs(Variant 2)
Was there
trauma?
Was there fever?
NO NO
NO
YES YES
YES
LIMPING CHILD
8 X‐ray tibia and fibula6 Ultrasound hip5 X‐ray pelvis and leg and foot5 X‐ray lumbar spine5 Bone scan lower T‐spine to distal
lower extremities5 MRI lower T‐spine to distal lower
extremities without contrast5 MRI lower T‐spine to distal lower extremities without contrast
Age 0‐5 years old
Variant 1:
No localized pathology on examination and no concern for infection
Adapted from Reference 10
ACR AppropriatnessCriteria®
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LIMPING CHILD
9 X‐ray area of interest
6 MRI area of interest without
contrast
6 MRI area of interest with(out)
contrast
5 Ultrasound area of interest
3 CT area of interest without contrast
2 CT area of interest with contrast
1 CT area of interest with(out) contrast
Age 0‐5 years old
Variant 2:
Isolated area of potential pathology but no concern for infection, i.e., it hurts when I push here!
Adapted from Reference 10
ACR AppropriatnessCriteria®
LIMPING CHILD
9 Hip ultrasound
8 Pelvis x‐ray
7 MRI pelvis without contrast
7 MRI pelvis with(out) contrast
5 Lumbar spine x‐ray
5 Bone scan area of interest
4 CT area of interest with contrast
2 CT area of interest without contrast
1 CT area of interest with(out) contrast
Age 0‐5 years old
Variant 3:
Concern for infection, including septic arthritis
This variant requires you to put on your thinking cap, localize the pathology to the best of your ability, then choose the right imaging study
Adapted from Reference 10
ACR Appropriatness Criteria®
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20‐month‐old with limp
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buckle fracture
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Entire extremity on 1 image
• Reduces # of images,
but not best strategy
when findings may be
subtle
Later that day: Left tibia/fibula, 3‐views
buckle fracture, more obvious on lateral view
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Salter‐Harris Fractures
Common in children!
Salter Harris Fractures Involve the Physis
learnpediatrics.com
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• Salter I: STRAIGHT through the physis
• Salter II: Involves physis and goes ABOVE, into metaphysis
• Salter III: Involves physis and goes LOWER, into epiphysis
• Salter IV: Involves physis and goes TOGETHER,both above, into metaphysis, and lower, into epiphysis
• Salter V: RUINS (crushes) physis
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Salter‐Harris Classification
• Salter I: Straight
• Salter II: Above
• Salter III: Lower
• Salter IV: Together
• Salter V: Ruined
SALTR
Pediatrician’s Keys to Imaging
• Phone a friend and phone often
• Include appropriate history in your request
• Many times the right thing is NO imaging
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SUMMARY
• ALARA principle and principles of evidence‐based imaging
‐Location and use of American College of Radiology
(ACR) Appropriateness Criteria®
SUMMARY
• Evaluation process for determining when an imaging study is indicated and when none is needed
• When indicated, choosing most appropriate imaging study/studies for work‐up of ‐Vomiting in an infant up to 3 months of age‐Suspected malrotation/midgut volvulus‐Suspected intussusception
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SUMMARY
‐Choosing among modified barium swallow (MBS), contrast swallow, e.g., barium swallow, upper GI series (UGI), and small bowel follow‐through (SBFT)
‐When barium can be used and when water‐soluble contrast is indicated
SUMMARY OF FLUOROSCOPY STUDIESProximal to Distal
• MBS: Mechanics of swallow, evaluate for aspiration
• Contrast swallow: Mouth to gastric fundus, does not evaluate for GE reflux
• UGI series: Mouth to duodenojejunal junction/ligament of Treitz, includes duodenum
• SBFT: Entire small bowel, including terminal ileum
• Contrast enema: Colon and rectum
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SUMMARY
‐Head trauma
‐Suspected nonaccidental trauma (NAT)
‐Identification of common fractures seen in NAT
‐Limping child, ages 0‐5 years
‐Mnemonic that aids in classifying Salter fractures
SUMMARY
Best practices, including Image Gently, image collimation, and gonadal shielding
Important considerations including ioninzingradiation exposure, need for sedation, etc.
Relative costs of radiology studies
®
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Practice Changes?
• ALARA‐based protocols?
• ACR Appropriateness Criteria utilization?
• Adopt Image Gently ?
• Create clinical pathways for specific inpatient diagnoses that utilize evidence based imaging?
• Discover who my local experts are?
®
®
References
1. Mettler FA. Essentials of radiology. 3rd ed. Philadelphia: Elsevier/Saunders; 2014.2. Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, et al. The use of computed
tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700‐707.
3. Maul E. Kentucky Medical Services Foundation Financial Database (unpublished data). KMSF; 2014.4. SPR. Image Gently. http://www.imagegently.org/. Published 2017. Accessed January 4, 2017.5. ACR. American College of Radiology Appropriateness Criteria. https://acsearch.acr.org/list. Published 2017.
Accessed January 4, 2017.6. ACR. ACR Appropriateness Criteria‐Suspected Physical Abuse‐Child.
https://acsearch.acr.org/docs/69443/Narrative/. Published 2016. Accessed January 1, 2017.7. CaliforniaACEP. PECARN Head Trauma Prediction Rules. http://californiaacep.org/improving‐health/pecarn/.
Published 2012. Accessed January 3, 2017.8. ACR. ACR Appropriateness Criteria‐Vomiting in Infants Up to 3 Months of Age.
https://acsearch.acr.org/docs/69445/Narrative/. Published 2014. Accessed January 3, 2017.9. Pomeranz AJ, Sabnis S, Busey SL, Kliegman R. Pediatric decision‐making strategies. Second ed. Philadelphia,
PA: Elsevier/Saunders; 2016.10. ACR. ACR Appropriateness Criteria‐Limping Child Ages 0‐5 years.
https://acsearch.acr.org/docs/69361/Narrative/. Published 2012. Accessed January 2, 2017.
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If we can be of assistance, please don’t hesitate to contact us
• Johanne E. Dillon, MD FAAP: (859) 323‐1217
• Erich C. Maul, DO, MPH: (859) 218‐2581
Thank you for the opportunity to speak to you!
