Greg J. Irwin

MRI in Juvenile Idiopathic Arthritis and Juvenile Dermatomyositis

The use of MRI in the assessment of the musculoskeletal system in children has important differences from its use in adults. Growth in children has significant impact on the epiphysis and growth plate, which are important structures in the growing child, and there are radiological features that differ from those in adults: disease may alter structures during a period of growth; the pathologies themselves are a distinct group of diseases at variance with adult arthritis and myositis, with a different spectrum of differential diagnoses; and many technical issues are different when imaging a child. These are important considerations in choosing the appropriate imaging. MRI is a powerful and valuable imaging technique in pediatric musculoskeletal pathologies, with considerable potential for future developments to enhance its role in diagnosis, management, and therapeutic intervention for these children.

Hypertrophic osteoarthropathy in primary liver rhabdomyosarcoma

Hypertrophic osteoarthropathy is a well-documented paraneoplastic phenomenon in adults. It is a rare, but important finding in children with malignant disease as it can indicate prognosis. We present a case of hypertrophic osteoarthropathy associated with primary liver rhabdomyosarcoma in a 14-year-old boy.

Growth arrest lines and intra-epiphyseal silhouettes: a case series

BackgroundGrowth arrest lines can develop within the skeleton after physiological stress or trauma. They are usually evident on radiographs as transverse lines in the metaphyses and have been used in fields from palaeontology to orthopaedics. This report consists of three cases, two of which describe growth arrest lines in an intra-epiphyseal site hitherto rarely documented, and a third demonstrating their clinical application.Case presentationCase 1 describes a 9-year-old who suffered a knee hyperflexion injury requiring anterior cruciate ligament and posterior cruciate ligament reattachments. She subsequently developed a marked distal femoral intra-epiphyseal arrest silhouette, as well as metaphyseal arrest lines in the femur, tibia and fibula. Case 2 describes an 8-year-old who sustained a tibial spine fracture and underwent open reduction and internal fixation. Subsequent imaging shows a further example of femoral intra-epiphyseal arrest silhouette as well as tibia and fibula metaphyseal arrest lines. Case 3 describes a 10-year-old who sustained a distal tibia fracture which was managed with open reduction and internal fixation. Subsequently the metaphyseal growth arrest line was parallel to the physis, suggesting no growth arrest (a danger with such a fracture).ConclusionThis case series describes two examples of rarely described intra-epiphyseal growth arrest silhouettes and demonstrates the usefulness of arrest lines when assessing for growth plate damage.

Standardising reporting of cervical lymphadenopathy in paediatric neck ultrasound: A pilot study using an evidence-based reporting protocol

OBJECTIVES Cervical lymphadenopathy is common in children and can arise from a wide range of aetiologies. Ultrasound can be a useful imaging tool for initial investigation but is known to be operator dependent. We aimed to compare the content of ultrasound reporting in this clinical scenario before and after the introduction of an evidence-based reporting protocol. METHODS We performed a prospective 8-month pilot study assessing the content of ultrasound reports generated from scans to investigate suspected cervical lymphadenopathy in children referred to our tertiary referral otolaryngology service. We found wide variation in report content and inconsistent reporting of certain radiological features. In response to this we performed a literature search to identify key, clinically relevant ultrasonographic features for cervical lymphadenopathy and then in consultation with our radiology colleagues, devised a protocol to facilitate the reporting of these key features. Content of reports was then prospectively re-audited over a further 8-month period. RESULTS 23 reports were assessed before and 26 after introduction of the reporting protocol. Fishers exact test was used to analyse the data. We found a statistically significant (p < 0.05) improvement in the frequency of reporting of various key features such as nodal distribution, shape, echogenicity, calcification, necrosis and vascular pattern. CONCLUSIONS The introduction of a standardised protocol has helped to streamline the reporting of ultrasounds to investigate cervical lymphadenopathy within our department. In the absence of any national guidelines on the reporting of paediatric neck ultrasound in this scenario, we propose that our protocol could be used by other departments to improve standardisation and as a teaching aid.

Swelling around a child's knee.

Swellings around the paediatric knee have a large differential diagnosis, although the majority can be diagnosed clinically. Some swellings merit further investigation by Magnetic Resonance Imaging (MRI). Clin. Anat. 24:914–917, 2011.

Classification of first branchial cleft anomalies: is it clinically relevant?

Background There are three classification systems for first branchial cleft anomalies currently in use. The Arnot, Work and Olsen classifications describe these lesions on the basis of morphology, tissue of origin and clinical appearance. However, the clinical relevance of these classifications is debated, as they may not be readily applicable in all cases and may provide no additional information on how the lesion should be managed. Objective We seek to investigate this issue by applying these classification systems to cases from our centre and evaluating the information gained. Patients and methods A retrospective case note review of all first branchial cleft anomalies excised at our institution between 2004 and 2014 was carried out, recording patient demographics, information on the anomalies and how they were investigated and managed. Results This search identified eight unilateral cases and one bilateral case of first branchial cleft anomalies. These were a heterogenous group of lesions, which were variably investigated and managed. Categorization of these cases into Arnot, Work and Olsen subtypes did not correlate with the lesion’s relation with the facial nerve or the outcome of excision. Conclusion The current classification systems used for first branchial cleft anomalies have little clinical relevance apart from providing extensive descriptions to aid in diagnosis. We advise instead that clinicians use imaging techniques to gain as much information as possible about these lesions before excision and be aware of the risk to the facial nerve at the time of excision. A description of the lesion’s relation with the facial nerve at the time of excision may provide more information on the likely outcomes compared with the classifications currently in use.

Congenital and Developmental Abnormalities

Congenital hand differences (CHD) have been estimated to occur in 10% of children born with congenital abnormalities. CHD can be classified according to their pre-dominant abnormality using the Swanson classification. Failure of differentiation represents the most common group. Associated (nonlimb) abnormalities are common and it is important to identify those CHD requiring systemic evaluation. Radiology is important in the diagnosis and management of CHD with plain films providing the mainstay of imaging postnatally. The management of CHD should be within a multi-disciplinary environment.

Foot anomalies and proximal symphalangism

We report the case of a 2‐week‐old girl born at term (by vaginal delivery and without antenatal or perinatal events) who was referred as having “bilateral talipes and bilateral proximal symphalangism of little and ring fingers.” The “talipes” was atypical with marked equinus and varus, but no cavus or adductus of the midfoot. Her mother had both symphalangism (absence of proximal interphalangeal joints) of middle, ring, and little fingers bilaterally and fixed pes planus with a rigid fixed hindfoot—and these deformities had also been present from birth. The maternal grandmother was similarly affected. However, the neonatal subject has an unaffected older sibling; maternal siblings are also unaffected. The three affected people did not have other obvious musculoskeletal abnormalities. Because of the coalitions, the childs atypical talipes was managed by a modified Kites procedure. Symphalangism‐coalition syndromes may be associated with conductive deafness because of fusion of the auditory ossicles. Clin. Anat. 25:781–784, 2012.

The Hand and Wrist

The hand and wrist are the most common sites of skeletal injury in children (Hastings and Simmons 1984), with fractures of the distal end of the radius being the most common (Landin 1997). Wrist fractures are usually the result of falls, the ubiquitous ‘FOOSH’ (fall on out-stretched hand) on the X-ray request, or sports related injuries. Again these are common injuries of childhood, with 42% of all fractures of the radius and ulna occurring in children up to the age of 14 (Chung and Spilson 2001).