Miley Ped - Radiology

4/15/2021
Course Outline
Pediatric Radiology:
An Overview of  Introduction to imaging the pediatric population
Common Conditions  Trauma
 Congenital conditions
HEATHER L. MILEY, DC, MS, DACBR
 Scoliosis overview
 Arthritis
 Infection
 Other musculoskeletal disorders
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Skeletal Development
 Bones take many years to grow and mature
 Intramembranous ossification
Pediatric Imaging  Mesenchymal models of bones form during the
embryonic period, and direct ossification of the
mesenchyme begins in the fetal period
 Endochondral ossification
 Cartilage models of the bones form from
mesenchyme during the fetal period, and bone
subsequently replaces most of the cartilage
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endochondral ossification
 Primary ossification center

 The main body of the bone model
 Shaft of a bone ossified from the primary ossification
center is the diaphysis which grows as the bone
develops
 Secondary ossification centers
 Appear in other parts of the developing bone after
birth
 Parts of bone ossified from these centers are epiphyses
 Growth of a long bone at the epiphyseal plates
https://courses.lumenlearning.com/wm-biology2/chapter/bone-growth-and-development/
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 Physis
 Appears as a radiolucent line in the skeletally
immature
 As the metaphysis and epiphysis mature and fuse,
the physis thins, disappears, and endochondral
ossification ceases
 A subchondral bone plate forms with horizontally-
oriented trabeculae which appears as a
radiopaque transverse fusion line (aka physeal scar)
Case courtesy of Dr M att Skalski, Radiopaedia.org, rID: 29729
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 Apophysis
 A normal secondary ossification center located in
the non-weight-bearing part of the bone
 Eventually fuses over time
 Process can be delayed, especially in female athletes
 Is a site of tendon or ligament attachment
 When unfused, can easily be mistaken for fractures
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Imaging Guidelines
* Epiphysis initially partially or  MSK x-ray

completely cartilaginous, rapidly  Acute trauma – spine or extremity
replaced by SOC until only articular
 Limping child up to age 5
cartilage (wavy arrow) remains
 Chronic pain
➢ growth plate stays relatively  Back or neck pain
constant during development; at  Inflammatory back pain: known or suspected axial spondyloarthropathy
the onset of skeletal maturation,
 Chronic extremity joint pain, suspected inflammatory arthritis
narrows and becomes less
hyperintense (straight arrow) and  Clinically suspected vascular malformation of extremities
then finally closes completely  Malignant or aggressive primary musculoskeletal tumor staging and surveillance
 Primary bone tumors
Can leave behind physeal scar
 Soft tissue masses
(curved arrow)
 Stress fracture
 Suspected osteomyelitis, septic arthritis, or soft tissue infection
 Myelopathy or radiculopathy (spine)
 Ataxia (spine)
 Suspected congenital anomaly
Imaging of Pediatric Growth Plate Disturbances. Jie C. Nguyen, B. Keegan Markhardt, Arnold C. Merrow, and Jerry R. Dwek. RadioGraphics 2017 37:6, 1791-1812
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Imaging Guidelines
 MRI or CT
 Internal derangement of joints (sports-related
injuries)
 Tumors or infection
 Bone cancer or bone marrow for leukemia
 Congenital or acquired abnormalities of the
spine or extremities
 Complex fractures
 Spinal cord
8 years
https://radsource.us/developmental-variants/
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Imaging Guidelines Bone Marrow – MRI
 MSKUS  Red marrow

 Developmental dysplasia of the hip
 Cellular, active, myeloid, or hematopoietic marrow
 Juvenile idiopathic arthritis
 Composed of cellular elements that include erythrocytes
 Cartilage/epiphyseal ossification centers that are not visualized on x-
ray (red cells), granulocytes (white cells), and thrombocytes
(platelets)
 Muscle hernia
 Posttraumatic abnormalities – brachial plexus injury, intramuscular  Responsible for satisfying oxygenation needs, immunity,
hematoma, myositis ossificans, foreign body, tendon laceration and coagulation
 Transient synovitis
 Osteoarticular and soft tissue infections  Yellow marrow
 Soft tissue masses
 Fatty or inactive marrow
 Epidermoid or dermoid cysts
 Provide surface or nutritional support for red marrow
 Ganglion cysts
elements
 Peripheral nerve sheath tumors (neurofibromas and schwannomas)
 Sparse vascular supply
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Bone Marrow – MRI
 Amount and distribution of red and yellow marrow change

with age
 Normal conversion from red to yellow marrow occurs in a
predictable and progressive manner
 Completed by middle 20s
 Conversion proceeds from the extremities to the axial
skeleton occurring in the distal bones of the extremities
(hands and feet) first, and progressing finally to the proximal
bones
 Occurs in a roughly symmetric manner on each side
 In the long bone, epiphyses and apophyses first, then
diaphysis, followed by distal metaphysis, and finally proximal
metaphysis
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Bone Marrow – MRI
 Rate of conversion from red to yellow marrow
Age Group Marrow Findings

Infants (<1 year) diffuse red marrow, except for ossified
epiphyses and apophyses Congenital Conditions
Children (1-10 years) yellow marrow below knees and elbows, and
in diaphysis of femora and humeri
Adolescents (10-20 years) progressive yellow marrow in distal and
proximal metaphyses of proximal long bones
Adults (>25 years) yellow marrow except in axial skeleton and
proximal metaphyses of proximal long bones
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Congenital Disorders of Bone Congenital – Skull
 Can be divided into:  Parietal foramina

 Congenital anomalies
 Normal skeletal variants
 Result from delayed/incomplete ossification of the
posterior aspect of the parietal bone near the
 Skeletal dysplasias
sagittal suture
 Commonly encountered in clinical practice  Transmits an emissary vein to the superior sagittal
 Some skeletal variants may simulate disease on x-ray sinus
 Can occur as a normal variant, or part of a
 Skeletal dysplasias are the result of faulty development and can congenital syndrome
be grouped according to the features of the disease:
 Proximal or distal limb shortening  Consider further imaging (CT or MRI) if larger than 5
 Sclerosis of osseous structures mm as this can be associated with vascular
 Specific spinal abnormalities
anomalies (especially venous)
 Agenesis or duplication of specific anatomic structures
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Congenital – Spine
 Craniocervical junction (e.g., atlantooccipital assimilation, third

occipital condyle, epitransverse and paracondylar process)
 Spina bifida occulta
 Block vertebra
 Including Klippel-Feil syndrome
 Odontoid anomalies (e.g., os odontoideum)
 Agenesis of the posterior neural arch (e.g., C1 posterior arch, articular
process, pedicle, etc.)
 Hemivertebra
 Butterfly vertebra
 Cervical ribs
 Posterior ponticle
 Transitional segments
 Sprengel deformity
 Unfused secondary ossification centers
Case courtesy of Benjamin Pereira Zimmermann, Radiopaedia.org, rID: 72098
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 Atlanto-occipital assimilation
 Fusion of the atlas to the occiput = transitional vertebra
 0.5% of the population
 Typically asymptomatic but symptoms from nerve or

vascular compression can occur
 Need MRI with additional cuts through C0-C2 to
include the transverse ligament
 Complete (C1 not identifiable) to incomplete (C1 partially

identifiable)
https://radiologykey.com/the-spine-congenital-and-developmental-conditions/
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 Atlanto-occipital assimilation
 Associations:
 Fusion of C2 and C3 (50% of cases)
 Basilar invagination
 Cleft palate
 Cervical ribs
 Urinary tract anomalies
 Cranio-cervical instability
https://www.rrnursingschool.biz/syndrome-omim/basilar-impression.html
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Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10365 https://www.semanticscholar.org/paper/Congenital-osseous-anomalies-of-the-upper-cervical-Hosalkar-Sankar/87e6da0d1d2e730f7ff81e8334cd99bafcfc978f
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 Klippel-Feil syndrome
 A complex heterogenous condition that results in
cervical vertebral fusion
 Two or more non-segmented cervical vertebrae
 Classic triad (50%)

 Short neck
 Low hairline
 Restricted neck motion
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Congenital – Spine Congenital – Spine
 Klippel-Feil syndrome  Klippel-Feil syndrome

 Associations:  Can show fusion of many cervical and upper
 Sprengel deformity thoracic vertebrae; fusion of two or three vertebrae
with associated hemivertebrae, atlanto-occipital
 Anomalies of the aortic arch and branching vessels fusion, or other cervical spine abnormalities; or
 Spinal scoliosis cervical fusion with lower thoracic or lumbar
 Intervertebral disc herniation vertebral fusion
 Cervical spondylosis  Classification grouped by patterns of inheritance,
associated anomalies, and the axial level of the
 Renal abnormalities
most anterior fusion
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 Klippel-Feil syndrome
 X-ray: vertebral fusion, hemivertebrae, omovertebral
bone, spina bifida, associated scoliosis and Sprengel
deformity
 CT: may additionally demonstrate canal stenosis

secondary to degenerative changes
 MRI: indicated in patients with neurologic deficits;

excellent in demonstrating canal stenosis and cord
compression, as well as disc bulge/herniation; can also
reveal associated conditions such as myelomalacia,
syrinx, diastematomyelia, and Chiari I malformation 5 yom
Case courtesy of Dr M ostafa El-Feky, Radiopaedia.org, rID: 52725
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Congenital – Hip/Pelvis
 Developmental dysplasia of the hip

 Coxa valga
 Coxa vara
 Morphologies that may be associated with
femoroacetabular impingement (FAI)
 Accessory ossicle – os acetabuli
12 yom
https://www.eurorad.org/case/11607
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Congenital – Hip/Pelvis Congenital – Hip/Pelvis
 Developmental dysplasia of the hip (DDH)  Developmental dysplasia of the hip

 Aberrant development of the hip joint
(DDH)
 Usually suspected in the early neonatal
 Results from an abnormal relationship of the femoral period due to routine clinical
head to the acetabulum examination (orthopedic tests)
 Diagnosis confirmed with ultrasound
 Female predominance (M:F ratio ~1:8) (femoral epiphysis not visible initially due
to lack of ossification; preferred in infant
<6 months)
 Left hip m/c
 Abnormal joint congruity with resulting
alterations of both the acetabulum and
femoral head
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Congenital – Hip/Pelvis
 Developmental dysplasia of the hip (DDH)

 Radiographic features:
 Key is to look for symmetry and defining the relationship of the 13 months female
proximal femur to the developing pelvis
 Ossification of the superior femoral epiphyses should be
symmetric
 Delayed ossification is a sign of DDH
 Absent or small epiphysis
 Lateral displacement of the femur
 Shallow, vertically oriented acetabulum with an increased
inclination of the acetabular roof
 Coxa vara
Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 78984
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16 months female
with asymmetric
gait and limp on
the right with
associated pain
30 months female years after acetabular osteotomy
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 26763 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8439
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Congenital – Knee & Ankle/Foot Congenital – Upper Extremity
 Os acromiale
 Bipartite/tripartite/multipartite patella
 Accessory ossicle – os fabella  Radioulnar synostosis
 Tarsal coalition  Supracondylar process
 Polydactyly, syndactyly
 Carpal coalition
 Accessory ossicles (several)
 Polydactyly, syndactyly
 Bipartite sesamoid  Madelung deformity
 Phalangeal synostosis  Ulnar variance
 Accessory ossicles (several)
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Trauma
 Acute trauma
 Repetitive trauma
Pediatric Trauma
 Non-accidental trauma (abuse)
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Trauma: X-Ray Trauma: X-Ray
 Conventional radiography (x-ray) is well suited  Stress radiography

to the evaluation of most skeletal injuries  Radiographs obtained during the application of
manual stress
 In the evaluation of trauma in children,  Used to uncover an articular injury that is not
debate has centered around the need to apparent on initial radiographs
obtain comparison radiographs of the  m/c used to AC joint, knee, and ankle
opposite extremity  Needs to be accomplished soon after the traumatic
 Should be obtained selectively, not routinely, if the event, however, before the appearance of
diagnosis is in doubt significant muscle spasm that may make the
technique less rewarding
 Most typically in the evaluation of Salter-Harris type I
growth plate injuries and hip trauma, as well as
bowing fractures and injuries of the elbow
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Trauma: CT/MRI Trauma: CT
 Specialized imaging are not generally  Able to define the presence and extent of certain fractures
or dislocations, detect intraarticular abnormalities (e.g.,
necessary for proper diagnosis of skeletal cartilage damage and osteocartilaginous loose bodies), and
trauma assess nearby soft tissues
 Useful in areas of complicated anatomy, such as the spine,
bones in the face and pelvis, glenohumeral and
 Occasionally will allow identification of subtle sternoclavicular joints, and the midfoot and hindfoot
fracture lines when initial x-rays are normal  Rapid examinations
 Not limited by plaster casting
 Limited use in certain locations where coronal or sagittal
 Routine use is not indicated plane images are desired, or when metallic hardware is
present
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Trauma: MRI Trauma: MRI
 Increasing importance in the analysis of many  Is unparalleled in the investigation of traumatically induced
musculoskeletal disorders internal derangement of joints
 Bone is visible on MR imaging  Provides diagnostic information related to integrity of:

 Articular cartilage
 Distinct signal characteristics of marrow
 Menisci
 Bone marrow edema, bone bruise
 Labra
 Also allows information regarding bone cortex and
 Intraarticular ligaments
possibly also the periosteal membrane
 Periarticular ligamentous and tendinous injuries
 Is not a suitable substitute for routine radiography or CT
 Injuries of muscles and other soft tissues
in the assessment of complex fractures when
information regarding the precise relationship of  Osteochondral and stress fractures
fracture fragments is required  Spinal cord
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Acute Trauma – Fractures Acute Trauma – Fractures
 Immature skeleton has growth plates,  Likelihood, location, and configuration of a fracture
cartilaginous epiphyses, and a thick, strong after injury depend on a number of factors, including
age of the person, the type and mechanism of the
periosteum injury, and the presence of any predisposing factors
 Sports-related activities in an adolescent
 Pediatric bone is more elastic than adult  Fractures of small bones of hands and feet, as well
bone: bowing and bending injuries are m/c as tubular bones of extremities (tibia and humerus)
than breaking and splintering and the clavicle predominate in adolescents
because of participation recreational activities
 Physeal and metaphyseal regions in children and
 Overall, childhood fractures are less common the epiphyses in teenagers in tubular bones are
than adult fractures often injured
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Acute Trauma – Fractures Fracture Terminology
 This is due to changing patterns of skeletal strength and  Fracture = a break in the
weakness
continuity of bone or cartilage, or
both
 For example, an identical type of injury such as FOOSH will
lead to musculoskeletal consequences that differ in the  Chondral fracture – cartilage alone is
various age groups: involved
 Supracondylar fx of the humerus in young child  Osteochondral fracture – fracture
 Metaphyseal fx of the distal portion of the radius in an older child
composed of cartilage and subjacent
bone
 Epiphyseal separation of the radius in an adolescent
 Carpal injury in a young adult
 Colles type fx of the distal portion of the radius in a middle-aged  Each fracture is associated with
person soft tissue injury
 Fx of the surgical neck of the humerus in an elderly person
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Acute Trauma – Fractures Incomplete Fractures
 Fracture types:  In immature skeleton, fractures that do not

1) Elastic deformation (momentary) completely penetrate the entire shaft of bone
2) Bowing (permanent)  Includes:
3) Torus (buckle) fracture  Bowing fracture
4) Greenstick fracture  Greenstick fracture – incomplete transverse fracture
with intact periosteum on the concave side and
5) Complete fracture
rupture periosteum on the convex side; more
common in elementary school age
 Torus fracture – buckling of cortex
 Stress fracture (discussed later)
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Incomplete Fractures
 Bowing fracture 6 yom, fall while running

 Longitudinal compression forces lead to bony forearm deformity, tenderness,
deformation with plastic deformation reduced range of motion at
occurring as a result of greater force following the elbow
an initial elastic deformation; results in
permanent bowing of the bone Findings: volar bowing of both
 Still further increases in stress will lead to the radius and ulna on the
fracture lateral view with no visible
fracture line
 m/c in radius and ulna
 Abnormality may be subtle and necessitate
comparison radiographs of the opposite side
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 44173
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 Greenstick fracture
 aka hickory stick, willow
 Perforates one cortex and ramifies within the
medullary bone
 Due to angular force
 Commonly become converted to complete
fractures because of exaggeration of the
deformity as the bone continues to grow
 m/c locations: proximal metaphysis or 5 yom trauma
diaphysis of tibia, middle third of radius and
ulna bowing with incomplete fracture through middle third of radius
Case courtesy of Dr M ohammad Taghi Niknejad, Radiopaedia.org, rID: 65820
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 Torus fracture
history of trauma; distal
 Results from injury insufficient in force to create
forearm/wrist pain
a complete discontinuity of bone but sufficient
to produce buckling of the cortex
Findings: buckling of the
 Longitudinal compressive force distal metadiaphyseal
 Common in metaphyseal regions of long region of the radius on
bones dorsal aspect, volar cortex is
intact; mild bowing of radius
 Oblique and lateral radiographs may be more
helpful than frontal projections
Case courtesy of Dr M aulik S Patel, Radiopaedia.org, rID: 10733
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Bone Bruise
 Trabecular microfractures or occult intraosseous

fractures
 Altered signal intensity on MR imaging due to

hyperemia, hemorrhage, and edema in the bone
 Usually located close to a joint surface
 Frequent association with other traumatic

abnormalities such as cruciate and collateral
ligament injuries of the knee
Case courtesy of Dr M ohammad A. ElBeialy, Radiopaedia.org, rID: 39780
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Stress Fracture
16 yom with left knee pain

 Can occur in normal or abnormal bone that is
and limitation of movement
subjected to cyclic loading with the load being less
following twisting injury during
than that causing acute fracture of bone
basketball game
Findings: ruptured ACL,  Fatigue fractures – the application of abnormal stress or

buckled but intact PCL, small torque on a bone with normal elastic resistance – are
vertical tear of posterior horn generally seen in young adults
of lateral meniscus, joint
effusion, and moderate  Features:
contusion of the lateral
femoral and tibial condyles  Activity is new or different for the person
 The activity is strenuous
 The activity is repeated with a frequency that ultimately
produces symptoms and signs
Case courtesy of Dr Ahmed Abdrabou, Radiopaedia.org, rID: 24907
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Stress Fracture Stress Fracture
 Radiographic abnormalities depend on the location of

 More children are participating in organized and the fracture and the interval between the time of injury
recreational athletics at a younger age and exam
 Increased athletic specialization and year-round
activities have resulted in higher incidences of overuse  Initially can be radiographically occult
injuries (i.e., stress fractures and stress reactions)  Continued stress on the injured bone or cartilage can lead
 Factors: to progressive radiographic changes
 Weaker osteochondral junctions

 On x-ray may appear as a linear cortical radiolucent
 Thinner cortices area with periosteal and endosteal cortical thickening
 Hormonal changes
 Decreased mineralization  Bone formation can be extreme and obscure the
radiolucent defect within the cortex
 Participation in sports with demanding schedules which
may not allow adequate time for recovery  Can be similar to an osteoid osteoma or abscess
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Stress Fracture
9 yom, hx of renal
 Femur stress fracture transplant on chronic
 Relatively rare in comparison to those of the tibia, fibula, immunosuppressive
and foot therapy presenting with
 m/c in endurance runners, jumpers, and dancers
thigh pain
 Result from repetitive loading, leading to subperiosteal Findings: linear band of

bone resorption and microfractures which are not given
sclerosis through the
sufficient time to heal
distal femoral metaphysis
 Can present with pain at the groin, hip, or knee and are and periosteal reaction
typically aggravated by activity consistent with healing
 m/c site is femoral neck, but can occur anywhere along stress fracture
the femoral diaphysis
 X-rays can show linear sclerosis, periosteal elevation, and
cortical thickening
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146.
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Stress Fracture
 Diaphyseal stress fracture

 Common site for stress fractures in adolescents 3 yof with a limp
is the tibia, followed by the fibula
 Commonly found in children participating in Findings: periosteal reaction
football, soccer, tennis, and running along the posteromedial left
tibia at the middle third,
 X-rays demonstrate cortical irregularity and consistent with stress fracture
periosteal reaction, typically along the
posteromedial proximal third of the tibial shaft
 MRI can be used in equivocal cases
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Stress Fracture
 Ankle and foot

 In children, m/c sites of stress fracture in the
foot are the metatarsals and calcaneus,
followed by cuboid, talus, and navicular
 More susceptible following immobilization for
other fractures, injuries, or surgeries
two different 12 yof who been immobilized
Findings: stress fractures of the calcaneus (left)

and 2nd metatarsal (right)
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Stress Fracture
 MRI has high sensitivity and specificity with

14 yom involved in multiple sports
changes seen earlier than with x-ray
Findings: linear signal abnormality
in the distal tibia consistent with
 Appear m/c as a linear zone of low signal
stress fracture (white arrow);
intensity surrounded by a broader, poorly multiple additional areas of signal
defined area of surrounding bone marrow abnormality (red arrows) also
edema consistent with stress reaction
 In a tubular bone, however, when there is

marrow edema without a visible fracture line,
can simulate the appearance of osteomyelitis
or a neoplasm
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Stress Fracture
 Sacral stress fractures

 Known to have a higher incidence in female athletes,
particularly in runners
 Female athlete triad describes the relationship between
caloric imbalance, hormonal dysregulation, and impaired
bone health
8 yof with foot pain and limp  Injury has components of both a fatigue and insufficiency
fracture
Findings x-ray: subtle sclerosis in cuboid
 Radiographs are often normal
Findings MRI: linear low T1 signal intensity focus through lateral  MRI demonstrates linear low signal intensity on T1-W
images with corresponding edema
aspect of cuboid with corresponding edema on T2
 In endurance athletes, similar findings of a stress fracture
can be seen in the inferior pubic rami
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Stress Fracture
 Not limited to cortical defects and fractures of

tubular bones
 Stress at the physis and apophysis may result in

18 yof cross country runner with gradually worsening low disruption of endochondral ossification and
back pain resulting in physeal widening
Findings: stress fracture of the left sacral ala extending to

the sacral foramen
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Stress Fracture
 Gymnast’s wrist
 Repetitive stress on the upper extremities can lead to
physeal injury
 Mechanical forces of dorsiflexion and compression triggers
physeal injury at the distal radius 11 yo gymnast with ongoing wrist pain
 Similar forces can lead to the same injury in weightlifters
 X-rays can demonstrate widening and fraying or Findings x-ray: unremarkable (no physeal widening,
irregularity of the physis, while MRI demonstrates edema irregularity, or fraying)
through the metaphysis
Findings MRI: marrow edema through distal metaphyses of
 Severe or chronic injury can lead to premature fusion and
positive ulnar variance, TFCC injury, and scapholunate or radius and ulna (white arrows), and to a lesser extent, the
lunotriquetral ligament disruption radial and ulnar styloids (red arrows)
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Stress Fracture
R L
 Little leaguer’s shoulder 13 yo baseball pitcher

 Injury to the proximal humeral physis typically caused
by repetitive overhead throwing Findings: diffuse widening
of the right proximal
 Often observed in male baseball pitchers between humeral physis (arrow);
ages 11-16 in whom the excessive rotational forces
comparison left shoulder
of overhead throwing lead to physeal injury
demonstrates normal
 Tend to present with focal pain over the width of the physis
anterolateral shoulder that is worse with overhead
throwing
 X-rays demonstrate widening and irregularity
 MRI reveals similar findings or widening of the physis
with marrow edema
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Stress Fracture
14 yo baseball pitcher
with medial elbow pain
for 1 month
 Little leaguer’s elbow
 Injury to the medial epicondylar apophysis Findings x-ray:
asymmetric widening of
 Usually young adolescent pitchers or catchers with medial the right medial
elbow pain either with direct palpation or valgus stress to epicondyle physis
the elbow (arrow), A; left elbow is
 Can present with mild flexion contracture at the elbow unremarkable, B
secondary to pain
Findings MRI: edema
 Radiographs demonstrate widening or fragmentation of within the medial
the apophysis (contralateral asymptomatic elbow can be condyle epiphysis (arrow)
used for reference in determining physeal widening or and the adjacent
normal apophyseal development) metaphysis of the
 MRI demonstrates marrow edema and aids in determining humerus
the integrity of the common flexor tendon and ulnar
collateral ligament
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Stress Fracture
collegiate football player

with shoulder pain and
 Acromial apophysiolysis/os acromiale known lesser tuberosity
 Failure of fusion of the acromion ossification centers (1-4) avulsion
in the background of chronic repetitive traction forces
from the deltoid = acromial apophysiolysis Findings x-ray: unfused
 Without healing, this may progress to an os acromiale, apophysis (arrow) at the
which can in turn lead to impingement symptoms in the acromion
shoulder
 Typically present with chronic shoulder pain of insidious Findings MRI: edema at the
onset apophysis, consistent with
 In younger patients, differentiating from the normal
acromial apophysiolysis
apophyseal development can be challenging as the age
range of acromial fusion can vary from 18-25
 Irregular cortical margins and abnormal marrow signal
with adjacent bony edema favors the dx
91 92
Spondylolysis Spondylolysis
 Spondylolysis = stress fracture of the neural arch of the  More commonly from a fatigue fracture
vertebra in the pars interarticularis (stress fracture) after repeated trauma
 May or may not be associated with slippage of one
vertebral body onto the adjacent one =  An increase in lumbar lordosis, as well as
spondylolisthesis more vertical orientation of the top of the
sacrum, may accentuate the stress placed
 m/c at L5 (90%), unilateral or bilateral on the neural arch
 Greater frequency in adolescent athletes, particularly:
 ~65% of patients with spondylolysis will
 Gymnastics progress to spondylolisthesis occurring before
 Diving the age of 16
 Weight-lifting
 The defect commonly persists
 Pole-vaulting
 Football  Fibrous union and pseudoarthrosis can occur
93 94
Spondylolysis Spondylolysis
 Clinical presentation is variable and does not  Wiltse classification of lumbar spondylolisthesis:
correlate with degree of displacement  Type I: dysplastic
 Type II: isthmic with a defect in the pars
interarticularis
 Spondylolysis can be asymptomatic  II-a: fatigue fracture
 II-b: an elongated but intact pars (d/t repeated, minor
trabecular stress fractures of the pars with subsequent
 Back pain with activity may be present with healing)
developing spondylolysis  II-c: an acute fracture
 Development of spondylolysis in a teenage athlete  Type III: degenerative

or young adult is usually painful  Type IV: traumatic
 Pain with lumbar extension and/or rotation  Type V: pathologic
95 96
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Spondylolysis
 Radiologic features:
 Weight-bearing AP and lateral views
 Lateral view most useful for visualizing the pars and assessment of
George’s line
 However, superimposition of the transverse processes over the
pars region may simulate pars defects
 Limited sensitivity compared to advanced imaging
 AP angulated (tilt-up) lumbosacral spot projection also helpful

 The pars region of L5 projects immediately inferior and slightly
medial to the pedicle and is particularly difficult at L5 because of
the projectional distortion produced by the lumbosacral lordosis
 Tube angled 25-30o cephalad with the CR passing through the
lumbosacral disc midway between the pubic symphysis and level
of the ASIS
97 98
AP lumbar view (cropped) AP lumbosacral spot projection
99 100
Spondylolysis: Spondylolysis:
Assessment Assessment
Ullmann’s line
George’s line
*helpful for evaluation of
subtle spondylolisthesis at
L5-S1
101 102
17
4/15/2021
Back Pain in Children and Adolescents. M icah Lamb and Joel S. Brenner. Pediatrics in Review November 2020, 41 (11) 557-569; DOI: Haidar, Rachid & Saad, Sara & Khoury, Nabil & M usharrafieh, Umayya. (2011). Practical approach to the child presenting with back pain. European journal of
https://doi.org/10.1542/pir.2019-0051 pediatrics. 170. 149-56. 10.1007/s00431-010-1220-9.
103 104
18 yof athlete
22 yof former gymnast
National University of Health Sciences National University of Health Sciences
105 106
pseudospondylolysis
results from
superimposition of the
transverse process due to
slight rotation at the time
of imaging
15 yof athlete
compare to radiograph
of a true break in the pars
interarticularis with
cortical offset and
vertebral translation
LSM Chiropractic
107 108
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4/15/2021
Spondylolysis
 Radiologic features:
 Oblique lumbar projections
 Difficulty in positioning
 Anterior oblique preferred
 Often the pars defect is not tangential to the
beam at 45o and defects at L5 may not be
identified
 Increased radiation exposure
** If a pars interarticularis defect is visible on routine

2-3 view lumbar spine radiographs, then bilateral
oblique projections are not indicated
https://learningradiology.com/notes/bonenotes/spondylolysis.htm
109 110
https://www.physio-pedia.com/Spondylolysis_in_Young_Athletes National University of Health Sciences
111 112
Spondylolysis
13 yo basketball player
 Radiologic features → MRI complaining of low back
 Stress reaction: marrow edema with intact cortical pain
margins
Findings: transversely
 Incomplete stress fracture: marrow edema with
oriented low signal through
incomplete cortical fracture or fissure
the L5 pedicle and pars
 Acute complete stress fracture: marrow edema with with corresponding edema;
complete cortical fracture extending through the pars findings consistent with
interarticularis
unilateral stress fracture
 Chronic stress fracture: no marrow edema, fractures through the left pars
extending completely through pars interarticularis interarticularis
 Sclerosis of the contralateral pedicle if unilateral defect,

which could also be seen on x-ray
113 114
19
4/15/2021
16 yo baseball pitcher with recent onset low back pain
Findings: bone marrow edema in the left L3 pedicle,

consistent with non-displaced stress fracture
Shelat NH, El-Khoury GY. Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 2016;36:138-146. https://www.physio-pedia.com/Spondylolysis_in_Young_Athletes
115 116
Salter-Harris Fractures
 Epiphyseal plate fractures are analogous to ligamentous

injuries in the adult
 Represent 35% of all skeletal injuries in children
 Age: 10-15 yoa 75%
 Physis is injured so permanent deformities may occur; early
diagnosis and treatment can prevent significant growth
disturbance and deformity
 Increasing grade of Salter-Harris fracture correlates with
increasing risk of deformity
 Occur acutely as a result of a single episode of trauma or
chronically as a consequence of prolonged stress,
15 yom particularly athletics (e.g., gymnastics)
 Subtle clinical findings may follow the acute traumatic
insult: pain, swelling, tenderness, limitation of motion
Case courtesy of Dr Bruno Di M uzio, Radiopaedia.org, rID: 39863
117 118
Salter-Harris Fractures Salter-Harris Fractures
 m/c location:  Classification

 m/c in wrist (50%) and ankle (30%)  Mnemonic: “SALTR”
 Phalanges  Slipped (type 1)

 Distal tibial, fibular, ulnar, and radial growth plates  Above (type 2)
 Proximal humerus  Lower (type 3)
 Together (type 4)
 Ruined (type 5)
119 120
20
4/15/2021
 Type 1 (6%)
 Pure epiphyseal separation with the fracture
isolated to the growth plate itself
 A shearing or avulsion force
 m/c location: proximal portions of humerus and

femur, and distal portion of humerus
121 122
12 yom fall onto 15 yom little finger

shoulder while playing struck by football
football
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 22229 Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 30373
123 124
 Type 2 (75%)
 m/c type
 Shearing or avulsion force that splits the growth
plate for a variable distance before entering the
metaphyseal bone and separating a small fall, tender ankle
fragment of the bone (Thurston Holland fragment
or corner sign)
 Periosteum on opposite side of the metaphyseal
fracture is disrupted
 m/c location: distal ends of the radius, tibia,
fibula, femur, and ulna
 Generally good prognosis, easily reduced
Case courtesy of Dr Hani M akky Al Salam, Radiopaedia.org, rID: 9687
125 126
21
4/15/2021
 Type 3 (8%)
 Fracture line extends vertically through the
epiphysis and growth plate and then horizontally
across the growth plate
11 yom fell during a
soccer game
 m/c location: medial or lateral portion of the
distal tibia, proximal tibia, distal femur
 Displacement generally minimal and growth

arrest deformity is rare if care is exercised during
reduction
Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 43162
127 128
 Type 4 (10%)
 Vertically oriented splitting force that fractures across
the epiphysis, the growth plate, and the metaphysis
 m/c location: distal portions of the humerus and tibia
16 yom fall from bike  In younger children where the epiphysis is unossified
or only partially ossified, the injury may be mistaken for
a type II fx
 Type IV may require open reduction and careful
realignment so that growth arrest and joint deformity are
not encountered later
 Arthrography and MR imaging may be needed to
further define a possible type IV injury
Case courtesy of Dr Aneta Kecler-Pietrzyk, Radiopaedia.org, rID: 53308
129 130
ankle pain after 14 yom rugby tackle

tackled while playing injury
rugby
Case courtesy of Dr Stefan Lazic, Radiopaedia.org, rID: 51225 Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 84964
131 132
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Salter-Harris Fractures Salter-Harris Fractures – Hip
 Type 5 (1%)  Slipped capital femoral epiphysis (SCFE)

 A crushing or compressive injury to the end of a  m/c 10-17 yoa in boys and 8-15 yoa in girls
tubular bone
 Injury to the vascular supply or the germinal cells of
the plate occurs without any immediate  Some reports that boys > girls, greater in black
radiographic signs; no irregularity or widening of the patients than whites, and especially high in
growth plate is seen overweight children
 Subsequent radiographic examination may
indicate focal areas of diminished or absent bony
growth, which in the presence of adjacent normal  Left side 2x m/c than right in male patients
development, can lead to angular deformity
 m/c location: distal femur and tibia and proximal
 20-35% B/L involvement (girls > boys)
tibia
133 134
Salter-Harris Fractures – Hip Salter-Harris Fractures – Hip
 SCFE – contributing factors:  Slipped capital femoral epiphysis (SCFE)

 Trauma  Radiographic analysis remains essential to the dx
 Adolescent growth spurt  AP and frog-leg projections are mandatory
 A minimal amount of shearing stress is needed to displace  Comparison radiographs of the opposite side can be
the epiphysis when the growth plate is relatively wide as is very useful, particularly frog-leg view
during periods of rapid growth
 Further accentuated by its change in configuration from  CT, scintigraphy, MR imaging, and ultrasonography have
a horizontal to an oblique plane which increases shearing also been used
stresses  CT and MRI more sensitive to early diagnosis when x-
 Hormonal influence rays are normal
 Weight and activity  MRI – subtle physeal widening, synovitis, and marrow
edema
 Obesity increases shearing stress on growth plate
135 136
Salter-Harris Fractures – Hip
 SCFE – radiographic signs:

 Osteoporosis of the femoral head and neck
 Margin of the metaphysis may appear blurred or
indistinct
 Growth plate may appear increased in width
 Epiphyseal height reduced
 Abnormal Klein line – a tangential line drawn along the
lateral border of the femoral neck may fail to intersect
any part of the epiphysis or may cross only a small
portion of it 10 yom left sided hip
 Metaphysis may appear displaced from the acetabulum
pain,
no trauma
 Displacement of the epiphysis
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7688
137 138
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4/15/2021
15 yof
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10357 Case courtesy of Dr Hani M akky Al Salam, Radiopaedia.org, rID: 9298
139 140
Salter-Harris Fractures – Hip Salter-Harris Fractures – Hip
 Chronic SCFE – radiographic signs:  SCFE sequelae

 Reactive bone formation along the medial and  Varus deformity
posterior portions of the femoral neck (buttressing)
 Shortening and broadening of the
femoral neck
 Premature fusion of the growth plate may result in  Osteonecrosis (6-15%)
femoral shortening
 Chondrolysis (40%)
 DJD
age 27 with FAI deformity;
ORIF age 13 for SCFE,
removed 1.5 yrs later
E. Nectoux, J. Décaudain, F. Accadbled, A. Hamel, N. Bonin, P. Gicquel. Evolution of slipped capital femoral epiphysis after in situ screw fixation at a mean
11years’ follow-up: A 222 case series. Orthopaedics & Traumatology: Surgery & Research, Volume 101, Issue 1, 2015, Pages 51-54. ISSN 1877-0568.
141 142
Salter-Harris Fractures – Knee Salter-Harris Fractures – Knee
 Birth, athletic, or automobile injuries  At proximal tibial metaphysis, mechanism is

 Type II and III especially common usually hyperextension
 Includes wagon-wheel fracture resulting when children
catch their legs between the spokes of wagon or  Partial or complete arrest of growth 20% resulting
bicycle wheels in limb length discrepancies and angular
 Also includes clipping injury of adolescent football deformities
players
 Prognosis guarded because of possible sequelae of
shortening and angulation  Associated with anterior compartment syndrome,
ligamentous and meniscal abnormalities, and
 In hyperextension injury may damage popliteal artery,
peroneal nerve palsy
and with varus angulation there may be peroneal nerve
damage; ACL may be disrupted in some cases
143 144
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Salter-Harris Fractures – Ankle Salter-Harris Fractures – Ankle
 Distal tibial growth plate injuries common  Triplane fracture

 Represent approximately 5-10% of all injuries in the ankle
 Adolescents
 m/c type II
 MOI – external rotation of foot
 Several variations to the resulting injury:
 10-12% growth disturbance  Two plane fx (Tillaux or Kleiger fx) which involves only the
epiphysis
 Three plane fx with additional metaphyseal fx
 Presents as appearance of two different types of
Salter-Harris injury (type III on AP and type II on
lateral) but is actually a variation of a type IV injury
 Complex fracture – CT best evaluation
145 146
Salter-Harris Fractures – Shoulder
 Disruption of proximal humeral epiphysis and physis

relatively uncommon
 m/c in boys 11-16 yoa
 Variable mechanism
 Occurrence in adolescent baseball pitchers as an
epiphysiolysis = little league shoulder syndrome
 Residual shortening of the extremity in 10%
14 yom football injury
Case courtesy of Dr Hisham Alwakkaa, Radiopaedia.org, rID: 55779
147 148
Salter-Harris Fractures – Shoulder Salter-Harris Fractures – Elbow
 Epiphysis at medial end of clavicle  Accurate diagnosis of elbow injury in an

 Last one in the body to merge with the adjacent shaft
immature skeleton is complicated by multiple
of the bone ossification centers
 Epiphysis ossifies at approximately 18-20 yoa
 At birth, entire distal portion of the humerus is
 Merges with closure of growth plate at approximately
cartilaginous and no centers of ossification are
25 yoa
present
 Injury to the medial end of clavicle (type I or II) can
produce an epiphyseal separation that may be  First secondary ossification center to appear is
misdiagnosed as a sternoclavicular joint dislocation capitulum which begins to ossify during the first
year of life
 CRITOE
149 150
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4/15/2021
Salter-Harris Fractures – Elbow
 Capitulum → 1
 Radial head → 3-6
 Internal (medial) epicondyle → 4-7
 Trochlea → 8-10
 Olecranon → 8-10
 External (lateral) epicondyle → 10-13
 Fuse with the shaft between ages 14-16 except for

medial epicondyle which may not fuse until 18-19 yoa
Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 80555
151 152
Salter-Harris Fractures – Elbow
 Many types of epiphyseal injuries in the pediatric elbow

 Lateral condyle of humerus (Salter-Harris type IV)
 Fracture-separation of the distal humeral epiphysis

 From FOOSH or from lifting an infant by grasping the forearm
 Separation of medial epicondyle ossification center as a result of

stress placed on the flexor pronator tendon that leads to a
transverse fracture or inferior displacement of the epicondyle
(10% of all elbow injuries)
 In some cases, the epicondyle may become entrapped within the
joint which can simulate a normal trochlear center and the dx may be
missed
 The appearance of a “trochlear” center without a medial epicondylar
center is inconsistent with the normal sequence of ossification
https://epomedicine.com/medical-students/mnemonic-approach-to-elbow-xray-fool/
153 154
Chondral and Osteochondral Fractures
 Shearing, rotational, or tangentially aligned

impaction forces generated by abnormal joint
motion may produce fractures of one or both of
the two apposing joint surfaces
 Can produce fragments of cartilage alone

(chondral fracture) or cartilage and underlying
bone (osteochondral fracture)
 After injury, the detached portion of the articular

surface can remain in situ, be slightly displaced,
or become loose/free within the joint cavity
12 yom dislocated elbow while playing baseball  May be visible with x-ray but MR imaging is the
preferred examination
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9450
155 156
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4/15/2021
15 yof twisting injury, pain and intermittent locking
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8442 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8442
157 158
Chondral and Osteochondral Fractures Chondral and Osteochondral Fractures
 Osteochondritis dissecans  Osteochondritis dissecans – femoral condyle

 Fragmentation and possible separation of a portion of  Presence and degree of displacement of the
the articular surface with gradual fragmentation chondral or osteochondral fragment can vary
 Onset in adolescence is most common  Purely chondral lesions require arthrography, MRI, or
arthroscopy
 Asymptomatic or symptomatic (pain aggravated by
movement, limitation of motion, clicking, locking, and  The osseous component is detectable with x-ray or CT
swelling)  May also see a femoral defect
 Femoral condyles – one of the m/c locations
 Male > female
 Age 15-20 yo
 Significant history of trauma in about 50% of cases
159 160
16 yom
Case courtesy of Dr Hani M akky Al Salam, Radiopaedia.org, rID: 9246 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8299
161 162
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Chondral and Osteochondral Fractures
 Osteochondritis dissecans – capitulum of humerus

 Adolescents, especially those involved in throwing activities
(e.g., baseball pitchers)
 d/t valgus force and immature articular surface
 Pain, swelling, and limitation of elbow motion
 Radiographic appearance:
 Flattening, cystic, and sclerotic changes
 Fragmentation of the capitulum
normal developmental OCD with marrow edema,
variation thinning of cartilage, and  Bone fragments may remain at their site or become
extension to intercondylar notch partially or completely detached
https://radsource.us/developmental-variants/
163 164
Avulsion Fractures
 Abnormal tensile stresses on ligaments and tendons

caused by a single violent injury or repetitive injuries may
lead to avulsions at sites of attachment to bone
 In children or adolescents, and entire apophysis may

undergo avulsion
 Degree of displacement is variable
 Most frequently encountered in the pelvis and hips

 Particularly in young athletes
Uchida, Soshi & Utsunomiya, Hajime & Taketa, Tomonori & Sakoda, Shinsuke & Hatakeyama, Akihisa & Nakamura, Toshitaka & Sakai, Akinori. (2015). Arthroscopic Fragment Fixation Using
Hydroxyapatite/Poly-L-Lactate Acid Thread Pins for Treating Elbow Osteochondritis Dissecans. The American journal of sports medicine. 43. 10.1177/0363546515570871.
165 166
Avulsion Fractures – Pelvis
ASIS sprinters at origin of the tensor fasciae

femoris or sartorius muscle
AIIS straight and reflected heads of the rectus
femoris muscle
lesser trochanter apophysis psoas major muscle during strenuous hip
flexion
ischial tuberosity apophysis violent contraction of hamstring muscles
(soccer players and hurdlers)
greater trochanter gluteal muscle contraction
iliac crest apophysis severe contraction of abdominal muscles
assoc. with abrupt directional change
during running
symphysis pubis adductor muscle
https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children
167 168
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Avulsion Fractures – Pelvis
 Clinically: local pain, tenderness, and swelling

 Radiographs may appear normal or reveal irregularity at
the site of avulsion
 Displaced pieces of bone of variable size
 MR is more sensitive method; however, associated

changes in periosseous soft tissue may simulate the
appearance of a tumor or infection
 Follow-up radiographs may show new bone formation or

healing with incorporation of the fragment into the
parent bone, which in some cases is associated with
bizarre skeletal overgrowth or deformity simulating
neoplasm
169 170
15 yom acute football trauma 16 yom soccer injury
Case courtesy of Dr M ark Holland, Radiopaedia.org, rID: 16820 Case courtesy of Dr M ark Holland, Radiopaedia.org, rID: 19164
171 172
13 yom, hamstring injury?
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 30012 Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 47175
173 174
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Spinal Trauma Spinal Trauma
 Spinal column trauma in children is variable depending on  Lumbosacral injuries are more common than cervical in
age, frequency of injury, causes of injury, vertebral level, pediatric patients
and the specific pattern of injury
 However, injuries of the upper and lower cervical spine
 Decreasing trend in annual incidences of both spinal more frequently result in spinal cord injury
column and spinal cord injury among pediatric patients
 In general, the net effect of the anatomical and
 MVCs account for 50% of spinal column injuries in physiological differences from the mature adult spine is
adolescents and 32% in children that the pediatric spine is much more flexible to external
 Falls 10% of spinal column injuries in adolescents and 18.3% forces but is far more susceptible to damage to the
underlying spinal cord
in children
 Developing pediatric spine, particularly the cervical spine,
 Also includes penetrating injuries, pedestrian injuries, and reaches adult biomechanical maturity between ages 8-10
non-accidental trauma
175 176
Spinal Trauma Spinal Trauma
 Craniovertebral junction (O-C2) is the most  Four patterns of injury:

susceptible zone of the pediatric spine to injury 1) Fracture with subluxation
2) Fracture without subluxation
 Thoracolumbar spine also has more likelihood of 3) Subluxation without fracture (purely ligamentous injury)
fracture and dislocations vs. ligamentous injury 4) Spinal cord injury without CT evidence of trauma
due to increased ligamentous laxity, incomplete
ossification, and more horizontally oriented facet
joints in children (less stability and more mobility)
177 178
Spinal Trauma Cervical Spine Trauma

 During initial evaluation, immobilization is critical to prevent  Jefferson (C1) fractures with minimal ligamentous disruption
further injury
and an intact transverse ligament
 Younger children and infants have larger heads in proportion  Acute and subacute atlantoaxial rotary
to their torsos, resulting in cervical flexion when placed supine subluxation/fixation
on a flat surface
 Minimally displaced or angulated odontoid fractures and
 Specific MOIs are associated with underlying spinal cord hangman (C2) pedicle fractures
injuries:
 Minor ligamentous injuries without instability
 Diving injuries
 “clothes-line” injuries  Fracture dislocation
 High-risk motor vehicle injuries  Burst fracture
 Seat-belt-type injuries
 Compression fractures with deformity
 Falls
 Suspected non-accidental trauma
 Atlanto-occipital dislocation
179 180
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4/15/2021
4 yom s/p MVC with head strike

presenting with diffuse upper
and lower extremity weakness
Findings: C3 burst fracture with

kyphotic deformity
14 yom with neck pain and transient paresthesias after

snowboarding accident
Findings: C5 fracture with kyphosis and ligamentous injury
Pediatric Spine Trauma: A Brief Review, Neurosurgery Pediatric Spine Trauma: A Brief Review, Neurosurgery
181 182
Cervical Spine Trauma Cervical Spine Trauma
 Atlantoaxial rotary fixation (AARF)  Atlantoaxial rotary fixation (AARF)

 Rotational subluxation or dislocation of C1 on C2  Type I: atlas rotated on the odontoid with no anterior
 Resulting from osseous or ligamentous abnormalities – displacement
congenital or acquired
 Type II: atlas rotated on one lateral articular process with
 As a result of instability, excessive motion and spinal cord 3-5 mm of anterior displacement
compression may occur at the atlantoaxial joint
 Type III: comprises rotation of the atlas on both lateral
articular processes with anterior displacement greater
 Etiology
than 5 mm
 Grisel syndrome (retropharyngeal irritation secondary to URI) m/c
 Type IV: rotation and posterior displacement of the atlas
 Trauma
 Postoperative (e.g., tonsillectomy)
 Down syndrome, RA, AS, Klippel-Feil syndrome, odontoid
congenital anomalies
183 184
https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS) https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS)
185 186
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Cervical Spine Trauma Cervical Spine Trauma
 Atlantoaxial rotary fixation (AARF) clinical  Atlantoaxial rotary fixation (AARF) x-ray:
findings:  APLC and APOM views
 Cock-robin head position (rotation and contralateral  Asymmetric distance between the lateral mass and dens
tilt of the head in relation to the lateral mass of C1)
 Anteriorly displaced lateral mass will appear wider and
 Neck pain (increased with attempted passive closer to midline
correction in acute cases)  Lateral view
 Headache  Lateral facet translated anteriorly and appears wedged
 SCM spasticity on the side to which the chin is rotated instead of oval shaped
 Decreased cervical ROM  Flexion-extension views

 Can be used to measure ADI and prove instability
 May not be useful acutely in the presence of pain and
muscle spasm
187 188
Cervical Spine Trauma
 Atlantoaxial rotary fixation (AARF) CT and MRI:

 CT
 Will clearly demonstrate rotatory subluxation and
remains gold standard
 MRI
 Possible spinal cord compression, disruption of
• APOM → asymmetry between lateral masses and dens,
transverse atlantal ligament, bone or soft tissue
head tilt to right
infection
• CT confirms rotation of atlas with continued asymmetry in
paraodontoid space
• MRI shows hemorrhage at the alar ligament
189 190
8 yof with chronic

AARF secondary to
retropharyngeal
abscess
Sferopoulos NK. Atlantoaxial rotatory subluxation in children: A review. J Radiol M ed Imaging. 2018; 2: 1009. https://posna.org/Physician-Education/Study-Guide/Acute-Atlantoaxial-Rotary-Subluxation(AARS)
191 192
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Cervical Spine Trauma Thoracolumbar Spine Trauma
 Atlantoaxial rotary fixation (AARF)  Compression, burst, and chance fractures

 Treatment is non-operative  Vertebral apophysis fractures
 Soft collar, therapy, NSAIDs, stretching exercise  Traumatic spondylolisthesis
program, traction, muscle relaxants, soft collar, halo
traction
 May necessitate open reduction with posterior spinal
instrumentation and fusion if chronic with neuro
deficits or failure of previous management
193 194
Osteochondroses
 Osteochondrosis = describes a group of disorders that

share a predilection for:
16 yof jumped out of a 3-story
window  The immature skeleton
 Involvement of an epiphysis, apophysis, or epiphysioid bone
 A radiographic picture that is dominated by fragmentation,
L2 burst fracture with 3-column collapse, sclerosis (“mixed sclerosis, lucency, fragmentation, and
injury without significant canal collapse”** is hallmark of AVN of bone, but can be seen in all
osteochondroses)
compromise
 Frequently, reossification with reconstitution of the osseous contour
 It represents a heterogenous group of unrelated lesions

 Some of the osteochondroses are not disorders at all but
represent variations in normal ossification
Pediatric Spine Trauma: A Brief Review, Neurosurgery ** Jeff Rich, DC, DACBR
195 196
Osteochondroses Osteochondroses
Age
Disorder Site
(Years)
Probable Mechanism  Articular osteochondroses are characterized by initial
Legg-Calve-Perthes disease femoral head 4-8 osteonecrosis, perhaps from trauma deformity of the developing epiphysis with the
Freiberg infraction metatarsal head 13-18 osteonecrosis from trauma potential for subsequent alteration in the joint itself
Kienbock disease carpal lunate 20-40 osteonecrosis from trauma
osteonecrosis or altered sequence of
Kohler disease tarsal navicular 3-7
ossification
Panner disease
capitulum of
5-10 osteonecrosis from trauma
 Nonarticular osteochondroses involve tendinous and
humerus
ligamentous attachments to apophyses, or in
Thiemann disease phalanges of hand 11-19 osteonecrosis, perhaps from trauma
Osgood-Schlatter disease tibial tuberosity 11-15 trauma
response to abnormal pressure or chronic stress
proximal tibial
Blount disease 1-3 or 8-15 trauma
epiphysis
discovertebral
Scheuermann disease
junction
13-17 trauma  Both alter normal chondrogenesis and osteogenesis
Sinding-Larsen-Johansson
patella 10-14 trauma
disease
Sever’s phenomenon calcaneus 9-11 normal variation in ossification
ischiopubic
Van Neck’s phenomenon 4-11 normal variation in ossification
synchondrosis
197 198
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Osteochondroses – Trauma Osgood-Schlatter Disease
 Many become apparent in the first decade of life  Occurs in adolescents, usually 11-15
yoa
 Usually a history of participation in
 Almost always more frequent in boys than girls sports, particularly those that involve
kicking, jumping, and squatting
 In epiphyseal disorders, the ossifying portion of  May also include a rapid growth spurt
before the onset of symptoms and
bone within the cartilage is especially vulnerable signs
to mechanical pressure superimposed on  Local pain and tenderness
hormonal or nutritional changes  Pain may be aggravated with activity,
relieved with rest
 Some occur during the adolescent growth spurt  Soft tissue swelling and palpable firm
masses
(e.g., Osgood-Schlatter disease or Scheuermann
disease)  Generally unilateral
199 200
Osgood-Schlatter Disease
 Tibial tuberosity lies slightly lateral to the midline, so a

lateral projection with the knee in slight rotation should
be used
 Careful to not overpenetrate the image so soft tissue
alterations are not missed
 May include two lateral radiographs with bone
technique and soft tissue technique
 Diagnosis requires knowledge of the normal pattern of
ossification of the tibial tuberosity
 Several ossific nodules anterior to the tibial metaphysis is
normal and should not be misinterpreted as fragmentation 11 yom 13 yom 15 yom
of bone
 Bony fusion of the tuberosity to the tibial metaphysis not
before age 15 in girls and 17 in boys
https://bonexray.com/
https://bonepit.com/
201 202
 Radiographic features:
 Soft tissue swelling in front of the tuberosity
 Margins of patellar tendon may be indistinct
10 yom  Increased radiodensity of the infrapatellar fat pad
 Avulsed fragments of cartilage and bone
 May include fragmentation of the inferior pole of the
patella
 After acute stage, displaced pieces of bone may

increase in size or may reunite; eventually
appearance may result to normal or may have
persistent ossific fragment(s)
https://bonepit.com/
203 204
34
4/15/2021
R L
18 yom with pain and

swelling over tibial
tuberosity, exacerbated
with exercise
adolescent male with pain and swelling of anterior right knee

and infrapatellar region
Case courtesy of Dr M aulik S Patel, Radiopaedia.org, rID: 10135 Case courtesy of Dr M ohammad Taghi Niknejad, Radiopaedia.org, rID: 20861
205 206
 Musculoskeletal ultrasound
 Development and structure of the ossification center
 Integrity of the nonossified cartilage and superficial soft
tissues
 MRI
 Evidence of patellar tendinosis
 Infrapatellar bursitis
two different patients demonstrating Osgood-Schlatter disease
Case courtesy of Dr Nasir Siddiqui, Radiopaedia.org, rID: 12417

Case courtesy of Dr M axime St-Amant, Radiopaedia.org, rID: 18930
207 208
Scheuermann Disease Scheuermann Disease
 aka juvenile kyphosis, juvenile discogenic  Etiology

disease, or vertebral epiphysitis  Cartilaginous node formation through the
 Results in kyphosis of the thoracic or cartilaginous endplates which are thinner than
thoracolumbar spine normal
 Dx usually made on x-ray  The congenital weakness of the endplates

predisposes to intraosseous disc displacement
during periods of excessive physical stress
 5% of general population  Traumatically induced growth arrest with
secondary nuclear degeneration →
 Typical age presentation 12-17 years
adolescent endplate injury
 Slight male predominance
 Nodes, as well as vertebral body irregularity
and wedging identified with increased
frequency in athletic adolescents
209 210
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Scheuermann Disease Scheuermann Disease
 Clinical  Radiographic features

 Highly variable  Irregularity in vertebral contour – undulant superior
and inferior surface
 Some totally asymptomatic to
prominent signs and symptoms  Schmorl nodes
 Middle and lower thoracic spine m/c  Can be accompanied by loss of intervertebral disc
height
 Fatigue, defective posture, aching
 Wedging or reduction in height of the anterior portion
pain aggravated by physical
of the vertebral bodies can be seen
exertion, tenderness to palpation
 Small or moderately-sized osteophytes with narrowed
 Kyphotic deformity, may be intervertebral discs
associated with mild scoliosis
 Increased kyphosis
 Neurologic complaints not common
 Limbus vertebrae
211 212
22 yof with mild

changes
18 yom with back pain
Case courtesy of Dr Dalia Ibrahim, Radiopaedia.org, rID: 58862 LSM Chiropractic
213 214
19 yom
15 yof post-MVC
LSM Chiropractic Case courtesy of Dr Andrew Van, Radiopaedia.org, rID: 45407
215 216
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4/15/2021
Scheuermann Disease
 Treatment
 Management largely dependent
on degree of kyphosis
teenager
 <50o: conservative, stretching,
postural changes
15 yof post-MVC  50-75o: brace
 >75o: surgery
217 218
Juvenile Lumbar Osteochondrosis Juvenile Lumbar Osteochondrosis
 Shares some features of Scheuermann disease  Radiographs show prominent depression of the
but localized to the lower thoracic and lumbar vertebral endplates with wedging and increased
spine AP dimension of affected vertebral bodies
 Pain, often severe, appearing during  Decreased height of lumbar intervertebral discs
adolescence  Retrolisthesis of lumbar vertebrae
 Boys > girls  Spinal stenosis – CT or MRI can confirm presence
 Thoracic deformity absent  May also reveal posterior disc extension into the spinal
 Occurs with higher frequency in persons canal
involved in competitive athletics
219 220
@article{Palazzo2014ScheuermannsDA, title={Scheuermann's disease: an update.}, author={C. Palazzo and F. Sailhan and M . Revel}, journal={Joint, bone, spine :
revue du rhumatisme}, year={2014}, volume={81 3}, pages={ 209-14 } } West, E.Y., Jaramillo, D. Imaging of osteochondrosis. Pediatr Radiol 49, 1610–1616 (2019). https://doi.org/10.1007/s00247-019-04556-5
221 222
37
4/15/2021
Osteochondroses – Other
 Legg-Calve-Perthes disease
 Osteonecrosis, perhaps from trauma
 Kohler disease
 Osteonecrosis or altered sequence of ossification
 Sever phenomenon
 Normal variation in ossification
 Van Neck’s phenomenon

 Normal variation in ossification
LSM Chiropractic
223 224
idiopathic avascular
necrosis of the left femoral
epiphysis: small, mixed
sclerosis and lucency,
fragmented, blurring of
physeal plate
5 yom with foot pain, painful gait
Findings: sclerosis, fragmentation, collapse of navicular

consistent with Kohler disease, a childhood-onset AVN
Case courtesy of Dr M uhanad Jaff, Radiopaedia.org, rID: 21954 Case courtesy of Dr M aulik S Patel, Radiopaedia.org, rID: 13686
225 226
8 yof with posterior heel

pain for one month
duration
true calcaneal apophysitis

demonstrating bone
8-13 yom all normal
marrow edema of the
calcaneal apophysis,
extending into the
adjacent calcaneal
tuberosity
x-rays are usually normal
https://bonepit.com/ Case courtesy of Dr Paulo A Noronha, Radiopaedia.org, rID: 63302
227 228
38
4/15/2021
12 yom with left-sided hip

pain
Findings: asymmetry of the

ischiopubic synchondrosis
with marked prominence
on the left
consistent with van Neck

phenomenon, an anatomic
variant
normal,
3 mos.
Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 24279 https://epos.myesr.org/
229 230
14 yof, normal development at the

ischiopubic junction Non-accidental Trauma
normal, not asymmetry or variant
 Child abuse
 Radiographic abnormalities can be

detected in 50-75% of cases
LSM Chiropractic
231 232
Non-accidental Trauma
 Elevation of periosteal membrane, which is loosely attached to the diaphysis
of tubular bones
 Periostitis is a delayed radiographic finding
 Firm attachment of the periosteal membrane to the metaphyses of the
tubular bones can lead to immediate visualization of single or multiple
metaphyseal bone fragments (corner fx)
 Physeal injuries
 Radiolucent zones appearing in the metaphyses with healing
 Single or multiple fractures in different stages of healing, particularly the ribs,
or bilateral acute fractures
 Skull fractures that are multiple or that cross sutures
1 yo
 Transverse diaphyseal or metaphyseal fractures
 Unusual fractures – sternum, lateral clavicle, scapula, vertebral bodies
 Fractures in the lower extremities in infants or young children who are not
walking
 Rib fractures that are bilateral and paravertebral
Case courtesy of Rad_doc, Radiopaedia.org, rID: 47998
233 234
39
4/15/2021
Non-accidental Trauma
 Radiographic survey of all the long bones, the pelvis, the

spine, the ribs, and the skull is recommended in the proper
workup of a child suspected of having been physically
abused
 Bone scintigraphy may be a useful addition
4 mos.  In Wisconsin, chiropractors are mandated reporters

 Both suspected abuse or neglect of a child, or that abuse
or neglect will occur
 Reports should be made to the county where the child
resides or where the possible abuse and/or neglect
occurred
 https://dcf.wisconsin.gov/reportabuse
Case courtesy of Dr Augusto César Vieira Teixeira, Radiopaedia.org, rID: 23537
235 236
Scoliosis
6-week female brough to hospital after
noticed her to be irritable after
inadvertent forceful twisting of the thigh
when changing diaper; spiral midshaft
femur fx seen
follow-up skeletal survey negative,

but bone scan showed focal
increased uptake in posterior 4th-7th
ribs consistent with fxs
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 10321
237 238
Scoliosis Scoliosis
 Abnormal lateral curvature of the spine  Terminology

 >10o  Dextroscoliosis – curve convex to the right
 Levoscoliosis – curve convex to the left
 Kyphoscoliosis – scoliosis with a component of kyphosis
 Signs/symptoms
 Visible physical deformities
 C-curve – a single curve (may be long or short in
 Adam’s test span)
 Generally asymptomatic – but may progress rapidly  S-curve – two adjacent curves, one to the right and
during growth spurts one to the left
 If painful, the scoliosis is assumed to be secondary  Primary curve – the curve with the greatest angulation
to a different issue and, therefore, requires
advanced imaging  Secondary or compensatory curve – the smaller curve
which balances the primary curve
239 240
40
4/15/2021

241 242
Scoliosis: Classification Scoliosis: Classification
 Classification based on location of apex:  Classification based on etiology:

 Cervical → C1-C6  Structural
 Cervicothoracic → C7 or T1  A lateral curvature that is fixed
 Thoracic → between T2-T11  Fails to correct with side-bending radiographic studies

 Rib humping will be seen on the convex side
 Thoracolumbar → T12 or L1
 Lumbar → L1-L4
 Non-structural
 Lumbosacral → L5 or below
 aka functional
 A scoliosis with no structural alteration
 Will lessen or disappear (correct) with lateral bending
radiographic studies
 Rib humping will disappear with forward flexion
243 244
Scoliosis: Classification
 Structural  Non-structural (functional)
 Idiopathic  Postural
 Neuromuscular (e.g., CP, syrinx,  Nerve root irritation (e.g., HNP,
poliomyelitis, muscular dystrophy) tumors)
 Congenital  Inflammatory (e.g., appendicitis)
 Neurofibromatosis  Leg length discrepancy
 Mesenchymal disorders (e.g.,  Hip contractures
Marfan, Ehlers-Danlos)
 Rheumatoid disease
 Trauma
 Infection of bone
 Vertebral or spinal cord tumor
 Metabolic disorders (e.g., rickets,
OI)
 Osteochondrodystrophies (e.g.,
dwarfisms and dysplasias)
C. Hirsch, B. Ilharreborde, K. M azda. Flexibility analysis in adolescent idiopathic scoliosis on side-bending images using the EOS imaging system, Orthopaedics &
Traumatology: Surgery & Research, Volume 102, Issue 4, 2016, Pages 495-500. ISSN 1877-0568. https://doi.org/10.1016/j.otsr.2016.01.021.
245 246
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Idiopathic Scoliosis Scoliosis

Undetermined etiology without underlying bony or neuromuscular

disease  Imaging
 X-ray is still the gold standard in evaluating an
 Onset abnormal curvature
 Infantile (<3) – m/c in males, usually left convex thoracic
 For an initial evaluation, should include AP and lateral
 Childhood (3-10) – aka juvenile, m/c in females, dextroscoliosis m/c
projections of either 1, 2, or all 3 sections of the spine
 Adolescent (>10) – m/c type, m/c in females
 Lateral views should be convex side towards the IR
 Common; m/c in females (F:M 7:1)  Follow-up evaluations can be just frontal projections
 m/c pattern is thoracic dextroscoliosis with a compensatory
lumbar levoscoliosis  Cobb angle has a margin of error +/- 3-7o
 A thoracic levoscoliosis has a higher incidence of underlying syrinx
and spinal cord tumors
 Also, any idiopathic scoliosis of 15o or more that occurs before the
 Advanced imaging will play a role in the evaluation of
age of 11 years should be viewed with a high index of suspicion secondary causes or associations to the scoliosis
as evidence of the presence of a significant intraspinal
pathology, particularly left-sided thoracic curves
247 248
incorrect correct
B B
U U
C C
K K
Y tube Y tube
249 250
10 yof
12o right thoracic with apex

at T8 using T4 and T11
21o left thoracolumbar with

apex at L1, measured using
T11 and L3
Case courtesy of Dr Sachintha Hapugoda, Radiopaedia.org, rID: 64183 LSM Chiropractic
251 252
42
4/15/2021
14 yof
49o right thoracic with apex at

T7 using T4 and T11
15 yof
91o right thoracic and 85o left

thoracolumbar
LSM Chiropractic LSM Chiropractic
253 254
child with asymmetric

abdominal reflexes
a pronounced C-shaped
levoscoliosis present centered
in the thoracic spine
follow-up MRI performed

MRI demonstrates a Chiari I malformation with associated
extensive syrinx
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10358 Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 10358
255 256
Juvenile Idiopathic Arthritis (JIA)
 aka juvenile rheumatoid arthritis
 The m/c chronic arthritic disease of childhood

Arthritis
 Must start before 16 yoa, females m/c (F:M 2:1)
257 258
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4/15/2021
Juvenile Idiopathic Arthritis (JIA) Juvenile Idiopathic Arthritis (JIA)
 Clinical presentation  Subtypes:

 Oligoarticular or polyarticular arthritis with a duration of  Oligoarticular JIA
6 weeks or longer
 <4 joints in first 6 months of illness
 Peak age 1-6 years
 Acute onset of symptoms or more gradual
 Mainly affects medium and large joints
 Symptoms often worse in the morning but typically
persist to some extent throughout the day  Polyarticular JIA
 >5 joints affected
 Systemic onset (Still disease) – intermittent spiking fevers,  Peak age 1-4 years, 7-10 years
rash involving trunk and/or extremities,  Mainly affects small and medium joints
hepatosplenomegaly
 Systemic onset JIA (Still disease)
 A proportion have serum RF  Arthritis may present weeks to months after onset of systemic
symptoms
259 260
Juvenile Idiopathic Arthritis (JIA) Juvenile Idiopathic Arthritis (JIA)
 Imaging shows a varied spectrum of involvement  X-ray cervical spine

based on the severity and duration of the
 Atlantoaxial subluxation
disease
 Odontoid erosions
 Predilection for large joints rather than small
 Ankylosis, especially of the facet joints
 X-ray
 Soft tissue swelling
 Osteopenia
 Loss of joint space
 Erosions
 Growth disturbances (epiphyseal overgrowth or “ballooning”)
 Joint subluxation
261 262
11 yof with stiffness and pain in

both wrists, limitation in
movement of bilateral wrist
joints, right > left
14 yo with long-standing
polyarticular JIA demonstrating
Findings: severe erosions in B/L
ankylosis of the posterior
MCP and PIP joints, soft tissue
elements of the cervical spine
swelling, periarticular
with narrowed vertebral bodies
osteoporosis, subluxation of 1st
and disc space narrowing
MCP joint, ulnar deviation of
right fifth finger, severe
destruction and fusion of right
sided carpal bones, destruction
of distal epiphysis of right radius
and ulna
Imaging of Juvenile Idiopathic Arthritis: A M ultimodality Approach Elizabeth F. Sheybani, Geetika Khanna, Andrew J. White, and Jennifer L. Demertzis
Case courtesy of Dr Prashant M udgal, Radiopaedia.org, rID: 30383 RadioGraphics 2013 33:5, 1253-1273
263 264
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child with late-stage JIA

child with JIA showing soft demonstrating growth arrest due to
tissue swelling, displacement premature closure of most physes in
of periarticular fat planes, the elbows, marked periarticular
and osteoporosis osteoporosis, and increased size of
the humeral epiphyses
https://radiologykey.com/juvenile-idiopathic-arthritis-2/ https://radiologykey.com/juvenile-idiopathic-arthritis-2/
265 266
Infection
15 yom
Findings: erosions and joint space reduction of bilateral

glenohumeral and hip joints with protrusion acetabuli
Case courtesy of Dr Wael Nemattalla, Radiopaedia.org, rID: 7416
267 268
Pediatric MSK Infection Pediatric MSK Infection
 A diagnostic challenge  Staphylococcus aureus continues to be the

 Difficult to recognize in the early stages leading cause of musculoskeletal infection in
 Can be confused with other osseous pathology (e.g., children
tumors, trauma)  MRSA associated with a higher rate of complications
 Incidence higher in infants and young children

 Tuberculosis
 Risk factors:  Fungal
 Premature birth
 UTI
 Immunodeficiency
 Other preexisting disease
269 270
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4/15/2021
Pediatric MSK Infection Osteomyelitis
 Earlier diagnosis and treatment help to reduce

 Osteomyelitis = inflammation of bone due to
complications
infection, typically bacterial
 Even when successfully treated, there may be

 m/c between the ages of 2-12 years, m/c in
significant long-term effects on growth
males (M:F of 3:1)
 Imaging studies play a critical role in the

diagnosis and management
271 272
Osteomyelitis Pediatric MSK Infection
 Imaging
 Location of osteomyelitis within a bone varies
 X-ray usually the first study performed
with age:
 Other imaging modalities used, as needed
 Neonates – metaphysis and/or epiphysis
 Ultrasound is helpful in detecting joint effusions and fluid
 Children – metaphysis collections in the soft tissue and subperiosteal regions
 CT can demonstrate osseous and soft tissue abnormalities
and is ideal for detecting gas in soft tissues
 Nuclear scintigraphy and MR imaging are valuable because
of high sensitivity
 Scintigraphy for multifocal involvement
 MRI provides accurate information on both the soft tissues and
bones and is the imaging study of choice for evaluating the local
extent of musculoskeletal infections
273 274
Osteomyelitis Osteomyelitis
 X-ray  Ddx:
 Earliest changes in soft tissues with swelling and loss/blurring of normal
fat planes, effusion may be seen in adjacent joint  Metastases
 In general, must extend at least 1 cm and compromise 30-50% of  Primary bone neoplasm – Ewing sarcoma,
bone to produce noticeable changes on x-ray
osteosarcoma, lymphoma
 Early findings are subtle and changes may not be obvious until 5-7
days from onset in children (10-14 days in adults); after this time:  Langerhans cell histiocytosis
 Regional osteopenia
 Periosteal reaction/thickening (periostitis); may be aggressive
 Focal bony lysis or cortical loss
 Endosteal scalloping
 Loss of trabecular bone architecture
 Eventual peripheral sclerosis
 In chronic/untreated cases, eventual formation of a sequestrum,
involucrum, and/or cloaca may be seen
275 276
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4/15/2021
12 yo with osteomyelitis of distal radius

osteomyelitis of the first distal phalanx due to chronic thumb sucking
https://blog.cincinnatichildrens.org/radiology Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7526
277 278
pain and swelling in the calf

15 yof +fever
diffuse soft • diffuse intramedullary

tissue swelling altered signal with
with suspicious periosteal reaction in tibia
erosion of distal • interosseous and
fibular cortex circumferential soft tissue
abscess
• diffuse circumferential
myositis
Case courtesy of Dr M aulik S Patel, Radiopaedia.org, rID: 10046 Case courtesy of Dr Ashutosh Gandhi, Radiopaedia.org, rID: 19684
279 280
Brodie Abscess
 Brodie abscess = an intraosseous abscess

related to a focus of subacute or chronic
pyogenic osteomyelitis
 Typically present in children with unfused

epiphyseal plates, m/c in boys
12 yo with calf
swelling for 2 mos.
after traumatic  Predilection for metaphysis of tubular bones
football injury  Proximal/distal tibial metaphysis m/c
demonstrating
chronic osteomyelitis  Femur
 Carpal and tarsal bones
Case courtesy of Dr Fabien Ho, Radiopaedia.org, rID: 61327
281 282
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4/15/2021
Brodie Abscess Brodie Abscess
 X-ray  Ddx:
 Lytic lesion, oval, oriented along the long axis of the  Osteoid osteoma
bone
 Eosinophilic granuloma
 Surrounded by a thick dense rim of reactive sclerosis that
 Sarcoma
fades imperceptibly into surrounding bone
 Skeletal metastasis
 Lucent channel extending toward growth plate
(pathognomonic)
 Periosteal new bone formation +/- adjacent soft tissue
swelling
 May persist for months
283 284
12 yom with pain and swelling of the ankle with limp and fever
Cossio, A., Graci, J., Lombardo, A.S. et al. Bilateral tibial Brodie’s abscess in a young patient treated with BAG-S53P4: case report. Ital J Pediatr 45, 91 (2019). T. M oser, M. Ehlinger, M . Chelli Bouaziz, M . Fethi Ladeb, J. Durckel, J.-C. Dosch, Pitfalls in osteoarticular imaging: How to distinguish bone infection from tumour?,
https://doi.org/10.1186/s13052-019-0685-z Diagnostic and Interventional Imaging, Volume 93, Issue 5, 2012, Pages 351-359.
285 286
Septic Arthritis
 Septic arthritis = infection in a joint

 Destructive arthropathy
 Severe symptoms such as pain, decreased range of
motion, and fever
 May occur in isolation or as a secondary

process related to underlying osteomyelitis
https://radiologyassistant.nl/pediatrics/hip/hip-pathology-in-children
287 288
48
4/15/2021
Septic Arthritis
 Radiography may be normal in the acute setting

 Joint effusion may be seen
 Juxta-articular osteoporosis due to hyperemia
 Narrowing of joint space due to cartilage
destruction followed by destruction of
subchondral bone on both sides of a joint
 If left untreated or a severe case, ankylosis will
develop
https://www.orthobullets.com/spine/2028/disk-space-infection--pediatric
289 290
10 yom evaluated for kidney stone shows narrowing and irregularity of L2-L3
disc space on x-ray; CT shows subtle hypoattenuation at superior endplate of
Transient Synovitis of the Hip
L3; MRI demonstrates loss of disc space at L2-L3 with high T2 signal and
contrast enhancement of L3 superior endplate
 A self-limiting acute inflammatory condition
affecting the synovial lining of the hip
 Usually has no residual sequelae
 Typically affects young children (3-8 yoa); male
predilection
 Exact pathogenesis is not well known but a viral
etiology has been suggested
 Clinical presentation: hip pain for 1-3 days,

associated with limping or the refusal to bear
weight
291 292
Transient Synovitis of the Hip
 X-ray
 Non-specific but there may be an increase in medial joint
space
 US
6 yom with one-week history of
 Useful to demonstrate joint effusion right groin pain
 MRI
 Hip joint effusion with synovial enhancement (+C), synovial
thickening, and signal alterations in surrounding soft tissue
 ddx septic arthritis

another patient, 6 yom, left hip pain
 Septic arthritis will often demonstrate signal abnormality in
marrow and “affects children younger than 4 yoa with a
hx of fever”
https://radsource.us/pediatric-hip-disorders/
293 294
49
4/15/2021
5 yof with 2-week history of

limping and suspicion for
osteomyelitis
Other MSK Disorders

Findings: large left hip joint
effusion and medial joint
space widening; no
additional findings
https://radsource.us/pediatric-hip-disorders/
295 296
Langerhans Cell Histiocytosis
 A rare multisystem disease with a wide and

heterogenous clinical spectrum and variable
Findings: amorphous area of sclerosis
in the proximal humeral diaphysis
extent of involvement
ddx?
 m/c in the pediatric population, peak
incidence 1-3 yoa; male predilection (M:F 1.5:1)
 Due to uncontrolled monoclonal proliferation of

Langerhans cells (monocyte-macrophage
radiograph one year earlier
shows a non-ossifying fibroma lineage)
 Considered a malignancy
https://blog.cincinnatichildrens.org/radiology
297 298
Langerhans Cell Histiocytosis Langerhans Cell Histiocytosis
 Any part of the body can be affected so clinical  Three forms:

presentation will depend on specific involvement  Letterer-Siwe disease
 Skeletal  Hand-Schuller-Christian disease
 CNS  Eosinophilic granuloma (EG)
 Hepatobiliary  70% affect bone
 Pulmonary  Best prognosis
 Salivary gland
 GI
299 300
50
4/15/2021
Langerhans Cell Histiocytosis Langerhans Cell Histiocytosis
 The skeleton is the most common involved organ  Skeletal location:

system in LCH and is by far the most common  Skull ~50%
location for single-lesion LCH (often referred to as
EG)  Pelvis 23%
 Femur 17%
 Skeletal lesions may be asymptomatic and  Ribs 8%

discovered as an incidental radiographic finding  Humerus 7%
 Mandible 7%
 When symptomatic: pain, swelling, and  Spine
tenderness around the lesion; systemic symptoms
may also be present
301 302
Langerhans Cell Histiocytosis
 Radiographic appearance:
 Skull – solitary or multiple punched out lytic lesions
without a sclerotic rim, beveled edge appearance
 Mandible – irregular radiolucent areas, floating tooth
 Spine – vertebra plana (m/c cause of vertebra plana in
children, more often in thoracic spine)
 Long bones – permeative and aggressive appearing
lesion, mainly diaphysis or metadiaphysis and respects
growth plates, endosteal scalloping, periosteal reaction
5 yof with painful swelling of the skull
Case courtesy of Dr M ohammad Taghi Niknejad, Radiopaedia.org, rID: 61259
303 304
9 yof
4 yof with limp
305 306
51
4/15/2021
References
 ACR Appropriateness Criteria

 American Journal of Roentgenology
 http://www.bonepit.com
 Diagnosis of Bone and Joint Disorders. Resnick. 2002
 Essentials of Skeletal Radiology. Tochum, Rowe.
 Musculoskeletal MRI. Kaplan, et al. 2001
 http://www.radiopaedia.org
 Alexiades N., et al. Pediatric Spine Trauma: A Brief Review, Neurosurgery,
Volume 87, Issue 1, July 2020, Pages E1-E9.
 Nguyen J., et al. Imaging of Pediatric Growth Plate Disturbances,
Musculoskeletal Imaging, October 11, 2017.
 Shelat NH, et al. Pediatric stress fractures: a pictorial essay. Iowa Orthop
J. 2016;36:138-146.
307
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4/15/2021

Common Conditions  Trauma

 Other musculoskeletal disorders

 Bones take many years to grow and mature

 Primary ossification center

 Growth of a long bone at the epiphyseal plates

Case courtesy of Dr M att Skalski, Radiopaedia.org, rID: 29729

Case courtesy of Dr M att Skalski, Radiopaedia.org, rID: 27354

* Epiphysis initially partially or  MSK x-ray

Imaging Guidelines Bone Marrow – MRI

 MSKUS  Red marrow

Bone Marrow – MRI

 Amount and distribution of red and yellow marrow change

Case courtesy of Dr M att Skalski, Radiopaedia.org, rID: 21541

Bone Marrow – MRI

 Rate of conversion from red to yellow marrow

Age Group Marrow Findings

Congenital Disorders of Bone Congenital – Skull

 Can be divided into:  Parietal foramina

 Craniocervical junction (e.g., atlantooccipital assimilation, third

Case courtesy of Benjamin Pereira Zimmermann, Radiopaedia.org, rID: 72098

 Typically asymptomatic but symptoms from nerve or

 Complete (C1 not identifiable) to incomplete (C1 partially

 Classic triad (50%)

Congenital – Spine Congenital – Spine

 Klippel-Feil syndrome  Klippel-Feil syndrome

 CT: may additionally demonstrate canal stenosis

 MRI: indicated in patients with neurologic deficits;

Case courtesy of Dr M ostafa El-Feky, Radiopaedia.org, rID: 52725

 Developmental dysplasia of the hip

Congenital – Hip/Pelvis Congenital – Hip/Pelvis

 Developmental dysplasia of the hip (DDH)  Developmental dysplasia of the hip

 Developmental dysplasia of the hip (DDH)

Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 78984

30 months female years after acetabular osteotomy

Congenital – Knee & Ankle/Foot Congenital – Upper Extremity

 Tarsal coalition  Supracondylar process

Trauma: X-Ray Trauma: X-Ray

 Conventional radiography (x-ray) is well suited  Stress radiography

Trauma: CT/MRI Trauma: CT

Trauma: MRI Trauma: MRI

 Bone is visible on MR imaging  Provides diagnostic information related to integrity of:

Acute Trauma – Fractures Acute Trauma – Fractures

Acute Trauma – Fractures Fracture Terminology

Acute Trauma – Fractures Incomplete Fractures

 Fracture types:  In immature skeleton, fractures that do not

 Bowing fracture 6 yom, fall while running

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 44173

Case courtesy of Dr M ohammad Taghi Niknejad, Radiopaedia.org, rID: 65820

Case courtesy of Dr M aulik S Patel, Radiopaedia.org, rID: 10733

 Trabecular microfractures or occult intraosseous

 Altered signal intensity on MR imaging due to

 Usually located close to a joint surface

 Frequent association with other traumatic

16 yom with left knee pain

Findings: ruptured ACL,  Fatigue fractures – the application of abnormal stress or

Case courtesy of Dr Ahmed Abdrabou, Radiopaedia.org, rID: 24907

Stress Fracture Stress Fracture

 Radiographic abnormalities depend on the location of

 Weaker osteochondral junctions

 Result from repetitive loading, leading to subperiosteal Findings: linear band of

 Diaphyseal stress fracture

 Ankle and foot