David C. Moe

Posterior Subtalar Facet Coalition with Calcaneal Stress Fracture

2Present address: Hawkes Bay Hospital New Zealand, Private Bag 9014, Hastings, New Zealand. Address correspondence to D. C. Moe. arsal coalition is an abnormal union (fibrous, cartilaginous, or osseous) between two tarsal bones, with a reported incidence of 1–2%. Most (90%) occur at the calcaneonavicular and talocalcaneal joints [1]. Talocalcaneal coalition usually involves the middle subtalar facet. It rarely occurs at the anterior or posterior facet [2]. Diagnosis of talocalcaneal coalition can be made by radiographs, CT, or MRI. CT classically is held as the gold standard for imaging this entity [3]. However, MRI has been reported to be equally efficacious and often is the choice when other diagnoses are considerations [3]. In this article, we present a novel case of MRI-proven partial posterior subtalar facet coalition with associated medial and lateral calcaneal stress fractures. To our knowledge, this has never been reported. Case Report A 48-year-old woman presented to the Sports Medicine Clinic with 3 months of worsening left heel pain, without preceding accident or injury. Initially she had tenderness at the origin of the plantar fascia. Stretching and arch supports were prescribed for the treatment of presumed plantar fasciitis. However, over several months she continued to suffer from chronic medial calcaneal pain, at times severe. Initial hindfoot radiographs, consisting of lateral and Harris (axial) views, were interpreted as normal. In retrospect, the lateral radiograph of the foot shows a subtle osseous protuberance at the superior margin of the calcaneal tuberosity, creating an abnormal “humpback” appearance (Fig. 1A), which is readily apparent when compared with a lateral radiograph of a normal foot (Fig. 1B). The Harris view of the T

HIDA, percutaneous transhepatic cholecysto-cholangiography and liver biopsy in infants with persistent jaundice: can a combination of PTCC and liver biopsy reduce unnecessary laparotomy?

BackgroundHistorically, HIDA is the initial diagnostic test in the evaluation of biliary atresia (BA). Non-excreting HIDA scans can yield false-positive results leading to negative laparotomy.ObjectiveCholestatic infants must be evaluated promptly to exclude biliary atresia (BA) and other treatable hepatic conditions. Intraoperative cholangiogram (IOC) is the gold standard for diagnosing BA, but requires surgical intervention. Percutaneous transhepatic cholecysto-cholangiography (PTCC) and liver biopsy are less invasive and have been described in small case series. We hypothesized that PTCC and liver biopsy effectively exclude BA, thus avoiding unnecessary IOC.Materials and methodsRetrospective review of cholestatic infants who underwent PTCC, biopsy or cholescintigraphy at a tertiary children’s hospital from August 1998 to January 2009. Group differences were evaluated and the receiver operator curve and safety of PTCC determined.ResultsOne-hundred twenty-eight cholestatic infants were reviewed. Forty-six (36%) underwent PTCC. Forty-one out of 46 (89%) had simultaneous PTCC and liver biopsy. PTCC was completed successfully in 19/23 (83%) children despite a small or absent GB on initial US. Negative laparotomy rate was 1/6 (17%) for simultaneous PTCC/liver biopsy. Complications occurred in 4/46 including bleeding (n = 2), fever with elevated transaminases (n = 1) and oxygen desaturations (n = 1).ConclusionPTCC, particularly when performed in combination with simultaneous liver biopsy, effectively excludes BA in cholestatic infants with acceptable morbidity. PTCC can frequently be performed when a contracted gallbladder is seen on initial US exam. Negative laparotomy rate is lowest when PTCC is coupled with simultaneous liver biopsy.

Ultrasound-guided Tunneled Lower Extremity Peripherally Inserted Central Catheter Placement in Infants

Tunneled lower extremity peripherally inserted central catheters (PICCs) are placed in infants under combined ultrasound and fluoroscopic guidance in the interventional radiology suite. In infants requiring a bedside procedure, image guidance is limited, often using portable radiographs during the procedure. This report demonstrates feasibility of placing tunneled lower extremity PICCs using ultrasound as the sole imaging modality for vascular access, intravascular length measurement, and final confirmation of catheter tip position in a case series of 15 critically ill infants. The technique negates the need for added imaging confirmation methods that use ionizing radiation and can be performed at the bedside.

Pediatric Gastrojejunostomy Tube Replacement: Effects of Communication on the Need for After-Hours Procedures.

Objectives: The aim of the study was to determine whether embedding into the radiology report a patient-specific plan in the event of gastrojejunostomy (GJ) tube dysfunction reduces the need for after-hours utilization of pediatric interventional radiology resources for the replacement of GJ tubes. Materials and Methods: This is a Health Insurance Portability and Accountability Act compliant, institutional review board–approved retrospective repeated cross-sectional study of patients requiring after-hours (5 PM–7 AM) or weekend (Saturday and Sunday) GJ tube replacement at a dedicated childrens hospital, before and after the inclusion of a patient-specific plan in the radiology report as part of the electronic medical record. Results: During a 6-month period before the inclusion of a patient-specific plan, there were 242 total GJ tube changes performed by the pediatric interventional radiology service under image guidance. Twenty-six (10.7%) of these procedures were performed outside of standard operating hours at the request of the emergency department (ED) (6/26), inpatient service (8/26), or patient/caregiver (12/26). Of the 8 inpatients, 3 were admitted from the ED for the sole purpose of tube replacement. Data were again collected for 6 months following inclusion of a patient-specific plan during the same seasonal period of the following year. During this period, 240 total image-guided changes were performed. Fifteen (6.2%) were performed outside of standard operating hours at the request of the ED (2/15), inpatient service (4/15), or patient/caregiver (9/15). No patients were admitted for GJ tube replacement procedures following implementation of the enhanced reporting policy. These data indicate a trend toward reduced after-hours resource utilization for GJ tube replacement requests by the ED (23.1%–13.3%), inpatient service (30.8%–26.7%), and all patients (14.7%–11%). Fewer after-hours GJ tube changes reduced cost by proportionately reducing hourly compensation for interventional radiology nurses and technicians. Conclusions: Our single-center data suggest that the inclusion of patient-specific recommendations at the end of each radiology GJ tube procedure note, generated in collaboration with the feeding service or primary medical provider, reduces off-hour resource utilization in patients who could otherwise have their tubes replaced during standard operating hours with image guidance. Avoidance of tube-related admissions is likely the greatest source of cost savings, followed by lower radiology technical support costs. Cost savings related to improved ED workflow and reduced patient/family anxiety are difficult to quantify, but likely significant. Future studies should be designed to quantify these savings and to assess the effect of this intervention on patient/caregiver satisfaction.

Agenesis of the venous duct: two cases of extrahepatic drainage of the umbilical vein and extrahepatic portosystemic shunt with a review of the literature.

Agenesis of the venous duct is a rare congenital anomaly resulting in abnormal drainage of the umbilical vein into the foetal venous circulation. The clinical presentation and prognosis is variable, and may depend on the specific drainage pathways of the umbilical vein. We present two foetuses with agenesis of the venous duct, both associated with a postnatal portosystemic shunt, but with markedly different postnatal clinical courses. We also review all previously reported cases to better characterise this foetal disorder and the prognosis.

Imaging submandibular pathology in the paediatric patient

A wide range of pathologies may arise from the submandibular space (SMS) or submandibular gland (SMG) in children. We review herein the normal anatomy of the SMS and describe the role of imaging in the evaluation of SMS lesions. A schematic approach for the categorisation of SMS pathology based on imaging characteristics is provided.

Inguinal bladder herniation: an unexpected finding on Tc-99m MAG-3 renogram.

Herniation of bladder into the inguinal canal is a rare occurrence. The diagnosis is rarely made preoperatively as patients typically lack symptoms referable to the urinary tract. Unfortunately, 10% to15% of all bladder hernias are first recognized as postoperative complications after injury to the bladder that occurs during herniorrhaphy or other pelvic surgery. Consequently, recognizing this entity on preoperative imaging is imperative. We present the imaging findings of inguinal bladder herniation incidentally discovered in a 1-month-old infant (born prematurely at 24-week gestation) who underwent a technetium-99m MAG-3 renogram for evaluation of in utero hydronephrosis.

The value of interventional radiology in re-establishment of lost access to catheterizable channels to the bladder and bowel

OBJECTIVE The efficacy of interventional radiology (IR) procedures in regaining lost access to continent catheterizable channels in pediatric urology patients is uninvestigated. This paper assesses this efficacy, as well as prevention of surgical revision of these channels as a result of IR intervention. METHODS A retrospective chart analysis was performed over 8 years for children presenting with lost access to the bladder or bowel that could not be regained by a pediatric urologist. Rates of successful re-establishment of access in IR and the need for future surgical revision were calculated. RESULTS Twenty pediatric patients underwent 32 attempts to re-establish lost access in IR. IR was successful in 78.1% (25/32) of episodes for 15/20 patients. No intervention required general anesthesia. Thirty percent (6/20) were able to avoid surgical revision. Another 45% (9/20) had access re-established in IR but later had surgery related to their channel (endoscopic, percutaneous, or open). Only three patients required open revision. The five patients in whom IR access failed, did require surgery. CONCLUSION Image-guided re-establishment of access to continent catheterizable channels in children is efficacious. It can diffuse an emergency situation and delay or obviate the need for surgical correction. Additionally, a general anesthetic is not necessary.