Pediatric Radiology Fellow – 2023/2024

 Radiation Safety (Image Gently)

 Pediatric pathologies
 Non-accidental Injury (NAI)
 Cases
 Focus on the initial study of choice
 Image gently.org

 ALARA
 As Low as Reasonably
Achievable
 DOTDAM
 Don’t order tests that don’t
affect management
 Minimize ionizing
radiation
 Tailor studies to clinical
question and size of
child
 Ultrasound None
 Magnetic resonance imaging None

 Plain radiography 1d
 Fluoroscopy (Interventional) 10 d – 6 m
 Computed tomography 8m+
 Nuclear medicine 1d+

 Cross country flight 4d

 Chest

 Bones (MSK)

 Brain
Adult w/ OA
 Metaphysis
Physis

Epiphysis

Epiphysis
Physis
Metaphysis
 I II* III IV V

S A* L T R

Best Worst
I

Statdx.com
II

Statdx.com
III

Statdx.com
IV

Statdx.com
V

Statdx.com
 In 2001, approximately 903,000 children were
victims of maltreatment

 Diagnostic , ethical, and legal challenge

 Radiologists may be the 1st clinical staff to

suspect NAI due to particular injury patterns
 Classic metaphyseal
lesion
 “corner fracture”
 “bucket-handle
fracture”
 Rib fractures (posterior)
 Differing stages of
healing
 Subdural > epidural
hematomas
Corner fracture Bucket-handle fracture
Subdural Epidural
*CT Abdomen/Pelvis
Focus on initial imaging studies
 2 yo F with history of recurrent urinary tract
infections

 What is (are) your initial imaging choice(s)?

 Voiding cystourethrogram (VCUG)
▪ Anatomy, dynamic study
 Renal ultrasound
▪ Anatomy
 Nuclear renogram
▪ Function (differential)
 UTI (fever >102.2oF, non-E. coli infection)
 Dysuria
 Dysfunctional voiding
 Hydronephrosis/hydroureter
 Bladder outlet obstruction
 Trauma
 Urinary incontinence
 Neurogenic bladder
 Congenital anomalies
 Postoperative evaluation
 2 mo M with non-bilious, non-bloody
projectile emesis

 What is your initial imaging study of choice?

 Abdominal ultrasound (pylorus)
Liver

Stomach

>3mm
Liver

Stomach
 1 mo F with bilious vomiting.

 What is the initial imaging study of choice?

 Emergent Upper GI study
 Midgut Volvulus
Malrotation
Duodenojejunal junction normally crosses over midline.
 Term neonate with abdominal distension, has
not passed meconium yet

 What is the initial imaging choice?

 KUB
 What next?
 Barium enema (BE)?
 Upper GI (UGI) series?

 Start with the barium enema

 UGI contrast would obscure interpretation of BE
Small rectum, compared to sigmoid colon (R/S < 1)
 Absence of distal enteric ganglion cells
causes a functional bowel obstruction
 Always involves the rectum and extends
proximally

 Aganglionic colon is very small (R/S <1)

 Normal rectosigmoid ratio (R/S) > 1

 Definitive dx = biopsy
 3 yo M presents with colicky abdominal pain
and history of currant jelly stool.

 What is (are) your initial imaging choice(s)?

 KUB
 Ultrasound abdomen (confirmation)
Target Sign
Target/Donut Sign Pseudo-kidney Sign
 Air contrast enema to reduce intussusception

Sudden visualization of multiple loops of SB = success!

 Former 24wk (pre-term) M, now presents
with abdominal distension

 What imaging study should be ordered?

 KUB
Rigler’s sign: free air
outlining both sides of
bowel

Pneumatosis
 Falciform
ligament sign

Football sign:
massive free air
outlines the entire
abdominal cavity
 Preterm >> term infants
 Multifactorial
 Ischemia and/or reperfusion injury
 Infectious
 S/S: abdominal distention, feeding
intolerance, hematochezia, abdominal
discoloration
 13 yo M with acute ,non-traumatic scrotal
pain

 What is your initial imaging study of choice?

 Testicular/Scrotal Ultrasound with Doppler
Right Left
 Most commonly due to Bell Clapper deformity
 Adolescents, young adults
 Can have torsion/detorsion phenomenon
 5 yo M presents with right-sided hip pain.
Denies history of trauma or recent illness.

 What is your initial imaging study of choice?

 Pelvic/Hip X-ray
 Idiopathic avascular necrosis (AVN) of the
femoral head
 Peak presentation: age 5-8 years old
 Male:female is 5:1
 ~13% can be bilateral
 S/S: limp, groin/hip pain
 Tx
 50% conservative treatment, bracing
 Femoral osteotomy, acetabular reconstruction
 Image Gently
 ALARA, DOTDAM

 Normal pediatric anatomy (chest, bones, brain)

 Pediatric pathologies, initial imaging
 Non-accidental injury/trauma
 VUR
 Hypertrophic pyloric stenosis
 Malrotation, midgut volvulus
 Hirschsprung’s disease
 Intussusception
 NEC, pneumoperitoneum
 Testicular torsion
 Legg-Calves-Perthes (AVN)
 Thank You!
Presenter: TCH Ped. Rad. Fellow