====== Pedi Neuro ====== {{:pediatric_astrocytomas.jpg|:pediatric_astrocytomas.jpg}} {{:pediatric_misc_supratentorial.jpg|:pediatric_misc_supratentorial.jpg}} {{:pediatric_extraaxial.jpg|:pediatric_extraaxial.jpg}} ===== External Hydrocephalus ===== * Benign extraaxial collections of infancy ===== Cholesteatoma Types ===== * Primary/Congenital * Epitympanum * Secondary/Acquired * Mesotympanum ===== Mineralizing Vasculopathy ===== * Branched-linear pattern of echogenicity in the region of the basal ganglia and thalami on echoencephalogram * Follow the course of the lenticulostriate branches of the middle cerebral arteries * Secondary to a cerebrovasculitic response to congenital infection (most often ascribed to rubella, CMV, and syphilis), anoxia, or rarely trisomy 13 ===== DDx Scalp Fluid Collection ===== * Cephalohematoma * Caput succedaneum * Leptomeningeal cyst * related to dural tear * Subgaleal hematoma ===== DDx Stenosis @ Aqueduct Level ===== * Aqueductal stenosis * Tectal glioma ===== Craniosynostosis ===== {{headshapes.gif}} * Scaphocephaly - Early fusion of the sagittal suture * Anterior plagiocephaly - Early fusion of 1 coronal suture * Brachycephaly - Early bilateral coronal suture fusion * Posterior plagiocephaly - Early closure of 1 lambdoid suture * Trigonocephaly - Early fusion of the metopic suture (metopic suture fuses between 6-8 months and sometimes as early as 3 months) ====== Pedi Cardiac ====== * Proper location for umbilical artery catheter = T8 - T12; alternative at L3 - L4 * Umbilical vein catheter tip should be at the right atrium ===== Pedi Cardiac DDx ===== ^Acyanotic, normal vascularity ^Acyanotic, increased vascularity ^Cyanotic, decreased vascularity ^Cyanotic, increased vascularity ^ |Aortic Stenosis |ASD (no LAE) |Tets (normal heart size, boot shaped)|TAPVR (Type 3 has nl heart size) | |Pulmonic Stenosis |ECD (no LAE) |Ebstein |Transpostion | |Coarctation |VSD |Pulmonic Atresia\\ (w/ intact ventricular septum) |Truncus Arteriosis | |Interrupted Aortic Arch |PDA |Tricuspid Atresia w/ PS |Tricuspid Atresia w/o PS | |Cardiomyopathy/Pericardial Eff.| | |Single Ventricle/Double Outlet RV| * I classify Pulmonic Atresia w/ VSD as a severe form of tetralogy * Right Arch common w/ TGV, Truncus, Tets, Tricuspid Atresia (basically the cyanotic, increased vascularity ddx plus tets and minus TAPVR) * Increased pulmonary flow, a right arch and cardiomegaly (biventricular) is classic for truncus arteriosus * Hypoplastic Left Heart Syndrome has cardiomegaly, pulmonary edema, a small aorta, and is cyanotic ===== Cardiac Tumors in Children ===== * Rhabdomyoma (small, multiple) * Fibroma * Myxoma ===== Dilitation of Aortic Root ===== * Connective tissue disorders * Takayasu's * Syphilitic aortitis * Neurofibromatosis * FMD * Giant cell arteritis * Williams Syndrome ===== Tetralogy of Fallot ===== - Overriding Aorta - VSD - Pulmonary Stenosis - Right Ventricular Hypertrophy ===== Types of TAPVR ===== * Type 1 * cardiomegaly and increased pulmonary vascularity * widened mediastinum ("snowman heart") due to vertical vein * Type 2 * cardiomegaly and increased pulmonary vascularity * simulates shunt physiology * blood returns via pulmonary veins -> coronary sinus -> RA * Type 3 * normal heart size, increased pulmonary vascularity * blood returns via infradiaphragmatic systemic venous connection (IVC, hepatic vein, portal vein, etc.) ===== Newborn w/ CHF ===== * Aortic Anomalies * aortic stenosis * coarctation * LV dysfxn * **aberrant L coronary artery** * myocarditis * hypoplastic L heart syndrome * Glycogen Storage Disease (Pompe) * High Flow States * **vein of galen** * **hemangioendothelioma** * anemia * polycythemia ===== Most Common Vascular Rings ===== ^ Double Aortic Arch ^ Right Arch w/ Aberrant L Subclavian ^ Right Arch w/ Mirror Image Branching\\ (Not a vascular ring) ^ | {{ double_arch.jpg |Double Aortic Arch}} | {{ rarch_aberrant_lsub.jpg |Right Arch w/ Aberrant L Subclavian}} | {{ rarch_mirror_image.jpg |Right Arch w/ Mirror Image Branching}} | ==== L Arch w/ Aberrant R Subclavian ==== * dysphagia lusoria * low association w/ congenital heart disease * not a true ring ====== Pedi Chest ====== ===== Lung Lesions ===== ==== Lucent ==== * CCAM (Type 1) * CLE * CDH * PIE ==== Solid ==== * CCAM (Type 3) * sequestration * bronchgenic cyst ===== Complications of Cystic Fibrosis ===== * Recurrent Infections -> Pseudomonas and Staph * Lung Fibrosis * Progressive Respiratory Failure * Clubbing * Pancreatic Insufficiency * Liver Cirrhosis * Rectal Prolapse * Meconium Ileus, Meconium Peritonitis, Intussusception * Sinusitis * Infertility in Males ===== Hyperlucent Lung ===== * foreign body * PTX * congenital lobar emphysema * most common LUL > RML > RUL * pulmonary artery hypoplasia * compensatory hyperinflation b/c of bad c/l lung ===== Neonatal Lung Infiltrates ===== ^ ^ Surfactant Deficiency ^ TTN ^ Meconium Aspiration ^ Neonatal Pneumonia ^ | Typical Patient | Preemie | Term/C-section | Post-term | PROM | | Time Course | < 6 hrs | 24-48 hrs | 12-24 hrs | <6 hrs | | Lung Volume | Decreased | Increased | Increased | Increased | | Imaging | Ground-glass | Interstitial Edema | Coarse, Nodular, Asymmetric | Streaky, Perihilar | ==== TTN ==== * early (2-6 hr) prominent vascular markings with patchy round alveolar opacities and pleural fluid * normal to large lung volumes, mild CM, rapid clearance by 42-78hrs, starting by 10-12hrs ==== RDS/HMD/Surfactant Deficiency ==== * Low lung volumes * Ground-glass opacities ==== Meconium Aspiration ==== * patchy, bilateral, asymmetric coarse opacities, representing areas of SSA * marked hyperaeration - 25% get PTX and pneumomediastinum * CXR clearing takes several weeks & lags clinical improvement * treatment is ECMO if severe ==== Neonatal PNA ==== * GBS looks like RDS, with bilateral granular, symmetric opacities and low lung volumes * GBS usually has effusions and RDS rarely does * other pneumonias resemble meconium aspiration, w/ patchy, asymmetric opacities and hyperaeration * organisms - Group B Strep, CMV (viral pneumonitis), Chlamydia ===== Low Volume Pulmonary Opacification ===== * Pneumonia * Hyaline Membrane Disease * Neurogenic (Brain Damage) ===== DDx Retrocardiac Mass ===== * Neuroblastoma * Sequestration * Pneumonia * Nerve Sheath Tumors ===== Tracheoesophageal Fistulas ===== {{tefistulas.jpg}} ====== Pedi GI/GU ====== ===== Normal Spleen Size ===== ^ Age ^ Spleen Length (cm) ^ | 0-3 mo | <6 cm | | 3-6 mo | <6.5 cm | | 6-12 mo | <7 cm | | 1-2 yr | <8 cm | | 2-4 yr | <9 cm | | 4-6 yr | <9.5 cm | | 6-8 yr | <10 cm | | 8-10 yr | <11 cm | | 10-12 yr | <11.5 cm | | 12-15 yr | <12 cm | | 15-20 yr | <12 cm (female) | | 15-20 yr | <13 cm (male) | * Rosenberg, et.al. AJR 1991 ===== Pediatric Liver Masses ===== ==== <5 yr old ==== * hepatoblastoma * most common primary malignant liver tumor of childhood, M > F, elevated AFP * inhomogeneous appearance * associated with Beckwith-Wiedemann syndrome * hemangioendothelioma * same CT appearance as adult hemangiomas; 50% calcify * MR - low T1, very high T2, large flow voids, Gd enhancement like CT * often presents w/ CHF or Kasabach-Meritt * mesenchymal hamartoma * large multilocular cystic mass with thin internal septations * septa and any solid portions will enhance * neuroblastoma mets ==== >5 yr old ==== * HCC * mesenchymal sarcomas * mets * lymphoma * adenoma ===== Abdominal Cyst ===== * Mesenteric Cyst * Urachal Cyst * Duplication Cyst * Choledochal Cyst * Abscess * Hydronephrosis * Multicystic Dysplastic Kidney * Cystic Ovarian Mass ===== Bilateral Dilated Ureters ===== * Posterior Urethral Valves * Prune-Belly Syndrome * Bilateral Megaureter ===== Wilms vs Neuroblastoma ===== Mnemonics: * Neuroblastoma encases and calcifies (NEC) * Wilms invades and lung mets (WILM) ^ ^ Wilms ^ Neuroblastoma ^ | Origin | Kidney | Adrenal or Sympathetic chain | | Calcification | Uncommon (<15%) | Common (85%) | | Appearance | Cystic/Solid | Solid | | Vessels | Displaces & Invades | Encases | | Mets | Lung | Early (bone, neural foramina, nodes) | | Peak Age | 3 years | <2 years | * Drash syndrome - Wilms, pseudohermaphroditism, glomerulonephritis ==== Neuroblastoma Staging ==== * 1 - confined to the organ of origin * 2 - extension beyond the organ but not crossing midline * 3 - extension across midline * 4 - distal mets * 4S - age <1 year, mets confined to skin, liver, and bone marrow (SLiM) ==== Wilms Staging ==== * 1 - confined to kidney, completely excised * 2 - local extension, completely resected * 3 - incomplete resection, no distant mets * 4 - distant mets to lung, liver, bone, or brain * 5 - bilateral synchronous tumors ===== Hypoperfusion Complex ===== * decreased calibur of aorta and IVC * intense enhancement of bowel wall, aorta, IVC, pancreas, and kidneys * dilated, fluid-filled bowel * suggests tenuous hemodynamic state ===== Eagle-Barrett Syndrome ===== * abdominal wall muscle deficiency ("prune belly") * nonobstructed, but markedly dilated redundant ureters ± hydronephrosis ± renal dysplasia * bilateral cryptorchidism ===== Vesicoureteral Reflux ===== {{:gradesofreflux.jpg|Reflux Grades}} * Grade I: Urine backs up into the ureter only, and the renal pelvis appears healthy, with sharp calyces. * Grade II: Urine backs up into the ureter, renal pelvis, and calyces. The renal pelvis appears healthy and has sharp calyces. * Grade III: Urine backs up into the ureter and collecting system. The ureter and pelvis appear mildly dilated, and the calyces are mildly blunted. * Grade IV: Urine backs up into the ureter and collecting system. The ureter and pelvis appear moderately dilated, and the calyces are moderately blunted. * Grade V: Urine backs up into the ureter and collecting system. The pelvis severely dilates, the ureter appears tortuous, and the calyces are severely blunted. ===== DDx Bladder Thickening ===== * hemorrhagic cystitis * rhabdomyosarcoma ====== Pedi MSK ====== * Kohler's disease, if asymptomatic, is normal variant called Karp Dysplasia * Blount's Disease = Tibia Vara * The tarda form of hypophosphatasia mimics rickets radiographically * Toddler's Fx - nondisplaced spiral fx of distal tibia ===== Scoliosis ===== ==== Risser Grades ==== {{:risser.gif|:risser.gif}} * Ossification of the iliac apophysis starts at the anterior superior iliac spine and progresses posteromedially. * The iliac crest is divided into quadrants, and the stage of maturity is designated as the number of ossified quadrants. For example, 50 percent ossified is a Risser grade 2. On the anatomic left (right side of the figure), all quadrants are ossified and the apophysis is fused to the iliac crest, for a Risser grade 5. ==== DDx ==== * Idiopathic (adolescent) * usually females * R thoracic ± L lumbar curve * Juvenile (3-10 years) * idiopathic * 2:1 female predominance * Infantile * convex to L * boys ===== Developmental Dysplasia of the Hip ===== ==== Risk Factors ==== * left hip is more often involved (? due to fetal positioning) * females: 80% of cases * breech birth (may account for 25-45% of DDH cases) * first born * fixed positions of extension and adduction * Down's syndrome ==== Plain Film ==== {{pelvisddh.jpg|AP pelvis demonstrating superior and lateral displacement of the femoral heads. Note Hilgenreiner's line, Perkin's line, and acetabular angle.}} * Hilgenreiner's line is drawn thru the triradiate cartilages * Perkins line is perpendicular to that, drawn from the anterior inferior iliac spine * Femoral head should be in the lower inner quadrant fromed by the lines ==== Ultrasound ==== * Alpha Angle * measurement of acetabular concavity * angle between the baseline and the roofline * Beta Angle * measured between the baseline and the inclination line * indicates the acetabular cartilaginous roof coverage * Type I hips * alpha angle > 60° * normal * require no treatment and no follow-up * Type II hips * alpha angle = 50-59 degrees * hip is normally located, but the bony acetabulum is immature * if < 3mos -> physiologic immaturity * if > 3mos -> mild dysplasia * no treatment but should be closely observed clinically and with US until they meet type I criteria * small risk of delayed displacement or acetabular dysplasia * Type III hips (low displacement) and type IV hips (high displacement) * beta angle < 55 degrees * usually very apparent clinically * both require immediate treatment ===== AVM of Hip ===== * causes coxa magna & coxa plana ===== Dense Metaphyseal Bands ===== * Lead Poisoning * Heavy Metals * Healing Phase of Rickets ===== Lucent Metaphyseal Bands ===== * Blue Cell Tumor (Ewings/Neuroblastoma) * Leukemia/Lymphoma * Ricketts * Rubella * Congenital Syphillis -> Wimberger Sign ===== DDx Fragmented Epiphyses (HAMS) ===== * hypothyroidism * delayed skeletal maturity (bone age more than 2 SD below the mean) * small stature * wormian bones * enlarged sella * fragmented epiphyses * delayed closure of cranial sutures * AVN (few epiphyses involved) * multiple epiphyseal dysaplsia * spondyloepiphyseal dysplasia ===== DDx Metaphyseal Fraying (CHARMS) ===== * Congenital infections (Syphilis, CMV, Rubella) * Hypophosphatasia * Achondroplasia * Ricketts * Metaphyseal dysostosis * Scurvy ===== DDx Erlenmeyer Flask (TOP DOG) ===== * Thalassemia (or other severe anemias) * Osteopetrosis * Pyle's disease (metaphyseal dysplasia) * Diaphyseal aclasis (multiple osteochondromas) * Ollier disease (multiple enchondromas) * Gaucher disease ===== Mucopolysaccharidoses (Hunter/Hurler/Morquio) ===== * J-shaped Sella * Dense Skull/Dense Bones * Vertebral Body Beaking * Canoe Paddle Ribs * Basilar Invagination * Dural Ectasia * Proximal Metacarpal Tapering ===== Dwarfism ===== ==== General ==== * Rhizomelic -> proximal shortening (humerus or femur) * Mesomelic -> middle shortening (tibia/fibula or radius/ulna) * Acromelic -> distal shortening (hand) * Micromelic -> entire limb shortened ==== Achondroplasia ==== * Rhizomelic * Increased craniofacial ratio * Small skull base/foramen magnum * Short vertebral bodies and large disc space * **Interpediculate distance decreases at more inferior levels in the L spine** * Pedicles are short and there is posterior vertebral body scalloping * Metaphyses of long bones are flared * **Trident hand** due to increased space between the middle fingers * Iliac bones are short and rounded * Decreased acetabular angles * **Champagne glass shaped true pelvis** * Lower extremities are short and thick * Growth plates are “V” shaped ==== Thanatophoric ==== * Rhizomelic * Severe platyspondyly, but with enlarged disc space, such that the overall thorax is nl in length * **Bowing and widening of femurs which look like telephone recievers** * Metaphyses are flared * Small iliac wings and decreased acetabular angles * May be a trident acetabulum * Ribs are very short * Tubular bones of the hands are feet and short and broad * Interpediculate distance may be narrowed * **Cloverleaf skull** ==== Jeune syndrome (asphyxiating thoracic dystrophy) and Ellis van Creveld ==== * Both are acromelic * Very short ribs (especially Jeune) resulting in a very narrow chest, with a large appearing heart * Trident acetabulum and decreased acetabular angle * Premature ossification of the prox femoral epiphysis * Skull and spine are normal, which helps distinguish from other dwarfisms * Carpal bone fusions * Polydactyly and an extra carpal bone are found much more commonly in ellis van creveld * Could ask if the pt is Amish (ellis van creveld) ==== Camptomelic ==== * Main feature is bowing of the long bones of the lower extremity, with the apex pointing toward a skin dimple * Also hypoplastic scapulae, small face vs skull, and dysplastic pelvic bones ===== Child Abuse ===== ==== Suspicious Fractures for Child Abuse (MR SSS) ==== * Metaphyseal * Rib * Scapula * Sternum * Spinous process ==== Other Causes of Multiple Fxs ==== * osteogenesis imperfecta (look for osteopenia and wormian bones) * neuromuscular disorders * Menkes syndrome (also causes osteopenia and wormian bones plus WM hypomyelination, cerebral atrophy and subdural collections due to decreased copper absorption in GI tract) * congenital insensitivity to pain ===== Periosteal Reaction ===== * physiologic/nl variant - should be only diaphyseal, smooth, symmetric, mostly along medial prox femur * prostaglnadin txt * Caffey’s * neuroblastoma mets * TORCH infections * syphilis ====== Miscellaneous ====== ===== Normal Umbilical Vein Catheter ===== * Goes from Umbilicus to Right Atrium ===== Normal Umbilical Artery Catheter ===== * Goes from Umbilicus to T6-10 or below L3 ^Hemangioma ^Lymphatic Malformations ^Vascular Malformations ^ |discrete masses |cystic, fluid-fluid levels |AV fistula, AVM | |prominent enhancement |rim, septal, or no enhancement |capillary malformation | |grow 1-2 years then involute|grows as child grows |venous malformation (may have calcification)| ===== Prostaglandin ===== * Keeps PDA Open * Causes Mucosal Pyloric Hypertrophy * Causes Periostitis ===== DDx for Thanatophoric Dwarf ===== * Jeune Syndrome (asphyxiating thoracic dysplasia) * Homozygous Achondroplasia ===== DDx Wormian Bones (CHOP DIK) ===== * Cleidocranial Dysostosis * Hypothyroidism/Hypophosphatasia * Osteogenesis Imperfecta * Pyknodysostosis/Progeria * Down Syndrome * Idiopathic * Kinky Hair Syndrome