Pediatric Emergency Radiology II
Objectives
•Identify the following conditions based on x-ray findings:
• Lobar emphysema
• Vertebral compression
fractures
• Pneumomediastinum
• S aureus pneumonia
• Ingested disk battery
• Pneumatosis
intestinalis - necrotizing
enterocolitis
• Midgut volvulus
• Abdominal abscess
• Bowing fracture
• Toddler fracture
• Retropharyngeal abscess
and phlegmon
• Infant skull sutures
• Infant skull fractures
• Leptomeningeal cyst
• Syphilis of the bone
• Rickets
• Vascular rings
• Discitis
 Congenital Lobar
Emphysema

X-ray diagnosis? 2-week-old boy with respiratory distress.

NoHyperexpanded
Tension
penetrating
pneumothorax
trauma,
left upper
nowas
positive
lobe,
the resembling
initial
pressure
interpretation.
ventilation.
a tension
What
pneumothorax.
No bradycardia,
features speak
This
no hypotension.
against
will not benefit
a tension
Hypoxia
frompneumothorax?
a is
chest
modest.
tube.
 X-rays repeated
8 days later.

8 year old with

Multiple
abdominal
vertebral
pain for 2
body
weeks, back
compression
ache since
fractures.
yesterday’s
Leukemia.
ballet practice.
Vertical air
Air outlining the trachea
densities
(air dissection around
the trachea).

Vertical air densities in

the mediastinum.
Air filled
aorto-
pulmonary
window

Pneumomediastinum 19-year-old with chest

Hamman Sign pain and grating
sound on
auscultation.
 Large right
pleural
effusion.
What clinical
entity is this
mostRapid progression of worsening.
Lower lung shows
consistent
Rapid development of large pleural effusion.
pleural effusion and
with?
infiltrate.
Staphylococcus Aureus Pneumonia
X-ray diagnosis? 6-year-old boy with fever, abdominal
pain, tachypnea, suspected pneumonia.
AnExpect
His Anempyema,
abdominal
respiratoryCT pneumothorax,
abdominal
status
scan series
worsens.
is done: CXRblebs,
is Normal
obtained. fistula.
is appendix.
repeated.
20-month-old girl swallowed a
coin (witnessed by 5-year-old
Ingested
cousin). Brief coughing episode. Disk
No symptoms at this time. Battery

Close-up view
of the “coin.”
Is it a penny?

Coin and battery lineup

3 day oldObvious
premieair
dissecting
with within
hematemesis.
bowel wall in a
Enlarged term infant.
view:
Air dissecting
Pneumatosis
White in
arrows point
atthe
airbowel wall.
dissecting
Intestinalis
within the bowel
DoubleDueoutlining
to
wall. Double density
Necrotizing
(railroad
(“railroad tracks).
tracks”).
Enterocolitis
Bubbles
(NEC)in the
bowel wall.
 This is an upper GI
series using thin
barium.

Standard barium would

demonstrate a “beak
sign” in which the
contrast stops at the
gastric outlet or Midgut Volvulus
proximal duodenum. Complicating a Malrotation
(“guts on a stalk” syndrome)
X-ray diagnosis? 3-month-old with bilious vomiting.
 Enlarged view
(darken the room)
Arrows point to the peritoneal
fatArrows
margins nowwhich
point mark
to edge
the right
This separation
Rupture is most
appendix. likely
of peritoneal
sided cavity. between
separation The bowel the
caused by fluid (pus) on the
Right
should
bowel
right and abdominal
be adjacent
(from the to the fat
theperitoneal
RLQ to the
peritoneal
abscess fat margin
margin. as in
formation.
Also note the
the
liver). The black arrow points
LLQ. Note thatof
scalloping inthe
theliver
RUQedge.
and
at air within this pus.
RLQ, the bowel is separated
from the peritoneal fat margin.

X-ray diagnosis? 4-year-old girl w/ abdominal pain for 3 days.

Bowing Fracture of the Ulna

X-ray diagnosis? 4-year-old girl who fell at

the playground. Her forearm is swollen with
a moderate deformity.
X-ray diagnosis? Toddler Fracture
20 month old
female, refuses to (probably accidental)
stand on her right
leg. No known
trauma except for
falling while
running.
Another view is
obtained.
Child abuse or
dueThin
to aoblique
fall? fracture
of the distal tibia.

White arrows point to the

fracture. Black arrows point
to a vascular groove.
 CT scanning
The
Position False helps
Step-Off
the neck to define
positives
sign to the
sometimes
is sometimes
properly type
avoid of abscess
occur:
helpful
false positives
X-ray diagnosis?
The Phlegmon
7 year oldofmale
back
Prevertebral the
softpharynx
tissue Note that
NeckNeck the back
extension
extension ofresults
the
demonstrates in
with True abscess
should
appears NOT
wide. be in line pharynx is inofline
a normal
persistence thewith the soft
prevertebral
prevertebral
fever, sore throat,
with the trachea. trachea.
tissue widening.
soft tissue appearance.
headache and neck
stiffness, sent to the
ED for possible
meningitis.
An LP is done: normal.
Lateral neck x-ray
Prevertebral
demonstrates bulging
of the prevertebral soft
(retropharyngeal)
tissue, suspected
abscess.abscess
Small, no rim enhancement, Large, rim enhancement with
Normal Step-Off
no anterior bulging. Abnormal:
contrast,Step-Off
anterior is absent
bulging.
 Normal Infant
Skull Sutures:
S=Sagittal,
Normal Infant Skull Sutures:
C=Coronal,
C=coronal, L=lambdoidal, P=parietomastoid,
O=Occipitomastoid L=lambdoidal
 Find the skull fracture - Case 1
Right Parietal Skull Fracture
 Right Occipital Skull Fracture

Find the skull

fracture - Case 2
 Lateral views Skull Fracture
Right Occipito-parietal
AP views

Find the skull fracture - Case 3

Depressed Skull
Lateral viewsFracture

AP views

Find the skull fracture - Case 4

Right Occipital Skull Fracture

Find the skull fracture - Case 5

 AP views
Right Parietal
Lateral Skull
views Fracture

Find the skull fracture - Case 6

Parietal Skull
Lateral
AP Fracture
views
views

Find the skull fracture - Case 7

 AP views
Biparietal Skull
Lateral viewsFracture

Find the skull fracture - Case 8

 Case 9:
10-month-old
boy fell and
sustained a
parietal
skull fracture
3 months
ago. He is
neurologically
normal but
has a Leptomeningeal Cyst
persistent soft
area in (growing skull fracture)
region of
fracture.
 Destructive lytic lesions of the distal radius and ulna.
A skeletal survey is
Periosteal elevation of the radius and ulna.
obtained. Humerus and
elbows are normal.

Both tibiae
Femurs and fibulae
are shown here.
are shown here.
Periosteal
Periostealelevation
elevation
alongalong
the length
the length
of both
of
Syphilis
tibiae.
both
of
Destructive
femurs.
theofBone
lesions the proximal
tibiae and the left fibula.

2-month-old girl who is not using her right arm today.

No history of trauma. Wrist swelling noted 2 days ago.
 Severe Rickets
demineralization:
Mid-radius
(vitamin fracture
D malabsorption)
Ulnar bowing

2-year-old boy with chronic liver disease with persistent

forearm swelling 3 days after falling.
 Lateral Examine
Very
Examine bend the
neck narrow
of trachea near tracheal
radiograph on the
bifurcation. diameter
is obtained. lateral
If it bends on the
Tracheal view.
toward
A barium the left, CXR.
size
this suggests a
swallow
appears to
right-sided
identifies
be normal
aortic
massarch.
ora slightly
posterior
narrow.
Vascular Vascular Ring
to the“rings” encircle the trachea and
(tracheal Two
esophagus.
esopha and esophageal
common types: double
aortic gus
archcompression)
and right sided aortic arch.
6-month-old boy with difficulty breathing.
Frequent noisy breathing episodes since birth.
 An esophagram
identifies a mass
posterior to the
esophagus.

Esophageal Coin
Following coin removal,
His trachea persistent
is narrow stridorCXR.
on the lateral is noted.
With
PMH: a Vascular
frequent Ring
episodes of noisy
This finding persists on abreathing
repeat CXR.since birth.
X-ray diagnosis? 10-month-old boy who swallowed a coin
presents with noisy breathing.
X-ray diagnosis?

8-year-old boy
with chief
complaint of
fever.
On exam, he is
noted to have Narrowed
reproducible inter-
tenderness over vertebral
his upper space.
thoracic spine.

Discitis
Repeat views taken