Natalia Simanovsky

CT Features of Adnexal Torsion

OBJECTIVE Adnexal torsion is most commonly a clinical diagnosis, often aided by sonographic findings. At times, the clinical presentation can mimic nongynecologic causes of acute lower abdominal pain. In these cases, CT may be the initial imaging study. The purpose of this study was to define the CT features associated with adnexal torsion. CONCLUSION On CT, a well-defined adnexal mass abnormally located in the pelvis with ipsilateral deviation of the uterus in a woman or girl with lower abdominal pain should raise the suspicion of adnexal torsion. Inflammatory signs on CT suggest the presence of necrosis.

Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries.

Background: In some pediatric ankle and wrist injuries, the clinical picture is suggestive of a fracture despite negative standard radiographs. Objective: The goal of this prospective study was to determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains. Methods: During a period of 3 years children aged 2 to 16 years, who sustained an acute ankle and wrist injury suggestive of being a fracture on clinical examination, but with negative radiograph, were referred for high-resolution US. Follow-up radiographs were obtained at 2 to 3 weeks. Results: Fifty-eight children (41 children with ankle injury and 17 children with wrist injury) were examined. In 41 patients, US did not reveal fractures, and in 15, small fractures were detected. All patients with negative US studies had negative follow-up x-rays. In 13 patients with positive US, the follow-up radiographs demonstrated a periosteal reaction. In 2 children (1 in each group) in whom a fracture line identified by US was in the depth of the metaphyseal bone, the follow-up radiogram demonstrated an area of increased bone density. In 2 children, 1 in each group, US diagnosed fractures that were not confirmed by follow-up radiograms. Conclusion: Ultrasound is effective in the detecting radiographically silent fractures of the pediatric ankle and wrist. Ultrasound may be used as an adjunct to radiography in clinically suspicious but radiographically negative ankle and wrist injuries. Level of evidence: 1

Pleural Effusion: Characterization with CT Attenuation Values and CT Appearance

OBJECTIVE The purpose of this study was to assess the utility of CT in characterizing pleural effusions on the basis of attenuation values and CT appearance. MATERIALS AND METHODS We retrospectively analyzed 100 pleural effusions in patients who underwent chest CT and diagnostic thoracentesis within 48 hours of each other. On the basis of Lights criteria, effusions were classified as exudates or transudates using laboratory biochemistry markers. The mean value in Hounsfield units of an effusion was determined using a region of interest on the three slices with the greatest quantity of fluid. All CT scans also were reviewed for the presence of additional pleural features such as fluid loculation, pleural thickening, and pleural nodules. RESULTS Twenty-two of the 100 pleural effusions were transudates and 78 were exudates. The mean attenuation of the exudates (7.2 HU; [SD] 9.4 HU; range, 21-28 HU) was not significantly lower than the mean attenuation of the transudates (10.1 HU; 6.9 HU; range, 0.3-32 HU), (p = 0.24). None of the additional CT features accurately differentiated exudates from transudates (p > 0.1). Fluid loculation was found in 58% of exudates and in 36% of transudates. Pleural thickening was found in 59% of exudates and in 36% of transudates. CONCLUSION The clinical use of CT attenuation values to characterize pleural fluid is not accurate. Although fluid loculation, pleural thickness, and pleural nodules were more commonly found in patients with exudative effusions, the presence of these features does not accurately differentiate between exudates and transudates.

Underreduced supracondylar fracture of the humerus in children : Clinical significance at skeletal maturity

Background: Although supracondylar fractures of the humerus in children are common, the literature is sparse regarding acceptable limits of reduction of these fractures in the sagittal plane. Methods: We retrospectively reviewed 223 pediatric cases of supracondylar fractures of the elbow treated in our hospital between the years 1996 and 2000. Results: In 30 patients, we found some degree of underreduction of the extension component of the fracture. Twenty-two of them were followed and evaluated at or close to skeletal maturity. The mean age at the time of fracture was 5.4 years, the mean follow-up was 8.2 years. Radiographic remodeling, range of elbow motion, and awareness of the patients to the functional limitation were evaluated. At final follow-up, 17 (77%) of the patients had radiographic abnormality of the humerocondylar angle (a difference of 5 degrees or more compared with the uninjured side). Eleven patients (50%) had limited elbow flexion, and 7 (31%) were aware of this deficit. Most of the underreductions occurred when reduction was attempted in the emergency department, when the angulation was not appreciated, and when the cast was applied without any reduction attempt. Patients who were left to heal with some degree of extension developed limited end-elbow flexion and were aware of it. Although only 3 patients felt minor subjective functional disability at the last follow-up, 10 patients had unsatisfactory results according to Flynn criteria for motion restriction. Conclusions: The treating surgeon must be aware of this possible outcome and be more demanding in the reduction of the extension component of the fracture. Otherwise, clinically significant limitation in elbow flexion may occur. Although the reduction of moderately displaced fractures may seem simple, it should be performed under general anesthesia and with radiographic control of reduction and pin placement.

The measurements and standardization of humerocondylar angle in children.

Background: Supracondylar fractures of the humerus in children are very common. However, the literature regarding measurements of normal anatomical relationships of the distal humerus in sagittal plane is sparse. Method: We reviewed the radiographs of normal elbow joints in 142 children treated in our hospital over 2 years. No history of previous trauma of distal humerus was found. The children were separated into 3 age groups (<5, 5-10, and 10-15 years old), and measurement of the humerocondylar angle (HCA) in sagittal plane was performed. Results: The mean age of children in group 1 was 3 years 1 month; in group 2, 7 years 8 months; and in group 3, 12 years. There were 99 boys and 43 girls. The mean HCA was 41.6 degrees (range, 30-70 degrees). No statistically significant influence on HCA by age, sex, or side was found. We found a small number of extreme variants in HCA (down to 30 degrees and up to 70 degrees) in children without any history of previous trauma and having a normal range of elbow motion. Conclusions: We found that HCA is close to the well-accepted figure of 40 degrees. Interestingly, this value remains the same in all age groups. That means that the geometry of the distal humerus in sagittal plane is established very early during the growth and remains constant. Due to significant individual variations of HCA, it alone cannot be sufficient for final decisions in evaluation and treatment of supracondylar fractures.

The infant with chronic vomiting: the value of the upper GI series

AbstractBackground. Vomiting is very common in infants. It is usually attributed to gastroesophageal reflux and no radiological evaluation is performed. Pediatric radiologists, however, still perform many upper GI series in these infants to exclude an underlying anatomic abnormality as a cause for vomiting. Objective. To evaluate the yield of upper GI series in the evaluation of otherwise healthy infants 1 month to 1 year of age with vomiting for more than 30 consecutive days. Materials and methods. Clinical records and upper GI reports of 344 otherwise healthy infants that were referred for UGI by pediatric gastroenterologists because of chronic vomiting were analyzed. Patients with hematemesis, bilious vomiting, dysphagia, respiratory symptoms and patients that required hospitalization were excluded. Results. Findings other than gastroesophageal reflux were seen in only 2 patients out of 344 (0.6%). In one patient duodenal stenosis was diagnosed. In another patient a small hiatal hernia was seen. Conclusions. The yield of upper GI in otherwise healthy infants 1 month to 1 year of age with chronic vomiting is extremely low, and the performance of the UGI in this specific group of patients may not be justified.

Ileocolic versus Small-Bowel Intussusception in Children: Can US Enable Reliable Differentiation?

PURPOSE To assess clinical and ultrasonographic (US) criteria that can be used to confidently differentiate ileocolic from small-bowel intussusception. MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective study, and the need to obtain informed consent was waived. US and clinical data for children given a diagnosis of intussusception in the years 2007 through 2011 were evaluated. The diameters of the intussusception and the inner fat core, the outer bowel wall thickness, and the presence or absence of lymph nodes inside the intussusception and mesentery were noted. The Student t test, the Mann-Whitney test, and the Levene test were used for comparison of parametric variables, while the χ(2) and Fisher exact tests were used for comparison of categoric data. RESULTS There were 200 cases of intussusception in 174 patients (126 boys, 48 girls; mean age, 17.2 months (range, 0 years to 7 years 1 month); 57 (28.5%) were small-bowel and 143 (71.5%) were ileocolic intussusceptions. Mean lesion diameter was 2.63 cm (range, 1.3-4.0 cm) for ileocolic versus 1.42 cm (range, 0.8-3.0 cm) for small-bowel intussusception (P < .0001). Mean fat core diameter was 1.32 cm (range, 0.6-2.2 cm) for ileocolic versus 0.1 cm (range, 0-0.75 cm) for small-bowel intussusception (P < .0001). The ratio of inner fat core diameter to outer wall thickness was greater than 1.0 in all ileocolic intussusceptions and was less than 1.0 in all small-bowel intussusceptions (P < .0001). Lymph nodes inside the lesion were seen in 128 (89.5%) of the 143 ileocolic intussusceptions versus in eight (14.0%) of the 57 small-bowel intussusceptions (P < .0001). Children with ileocolic intussusception had more severe clinical symptoms and signs, with more vomiting (P = .003), leukocytosis (P = .003), and blood in the stool (P = .00005). CONCLUSION The presence of an inner fatty core in the intussusception, lesion diameter, wall thickness, the ratio of fatty core thickness to outer wall thickness, and the presence of lymph nodes in the lesion may enable reliable differentiation between ileocolic and small-bowel intussusceptions.

Sonography of brain tumors in infants and young children.

Abstract The sonographic features of five brain tumors are presented to emphasize the variability of imaging findings and the role that sonography may play in the initial diagnosis, determination of tumor vascularity, and biopsy guidance.

Correlation between computed tomography expression of pulmonary hypertension and severity of lung disease in cystic fibrosis patients.

Purpose: Pulmonary hypertension (PHTN) is a significant cause of morbidity and mortality in patients with cystic fibrosis (CF), but a routine noninvasive test for evaluating PHTN is lacking. We aimed to determine whether there is a correlation between computed tomography (CT) signs for PHTN and lung disease severity in CF. Materials and Methods: We retrospectively evaluated high-resolution CT studies of 91 consecutive CF patients. The ratios of the widest diameters of the main pulmonary artery (MPA), right pulmonary artery, and left pulmonary artery to the ascending aorta (Ao) were calculated. MPA/Ao>1 was considered indicative for PHTN. Lung severity was assessed with modified Brody scores for the left lung (LL), right lung (RL), and overall [Total Brody Score (TBS)]. The nonparametric Pearson &khgr;2 test was performed for determining the correlation between Brody score and objective CT signs for PHTN. Results: This study included 54 male and 37 female patients aged between 3 and 67 years (mean 17.6 y). Mean RL, LL, and TBS were 23.71, 23.31, and 47.15, respectively. Of the 91 patients, 28 (30.8%) had MPA/Ao>1, indicating a high probability for PHTN. Among these patients, the mean TBS was 38.8, as compared to mean of 50.8 in 63 patients with MPA/Ao⩽1. No correlation was found for the RL and LL separately. Conclusion: There was no correlation between parenchymal lung disease severity assessed by the modified Brody score and CT signs of PHTN in CF patients.

Partial duplication of the scapula

We report an extremely rare case of partial scapular duplication. Mild shoulder area deformity in a newborn prompted further evaluation that included radiography, ultrasonography and spiral CT. These revealed an additional bone in the area of the left shoulder, above the humerus and lateral to the scapula. The accessory bone articulated with the upper part of the glenoid and caused caudal displacement of the humeral head. However, it did not restrict the normal range of motion in the shoulder joint.