Thomas Ray Sanchez

Skull fracture vs. accessory sutures: how can we tell the difference?

Plain film radiography remains the most cost effective method in evaluating skull fractures and can easily differentiate major sutures and common vascular grooves from fractures. However, in children this can be complicated due to the presence of numerous synchondroses and unusual accessory sutures. Plain film evaluation is especially challenging not only because of various artifacts that can degrade the study but also the inability to visualize intracranial processes, such as contusions and hemorrhage, that can substantiate a calvarial finding. Minimal soft tissue swelling can be difficult to see even with oblique views. Superimposition of normal suture lines like the metopic suture can mimic a fracture if one is not careful to obtain additional views [1]. During the past decade, the increasing use of spiral and multidetector CT have lead to the ability of workstations to generate three-dimensional (3D) reconstructions of the skull. Therefore if cranial CT is deemed clinically necessary in trauma patients, questionable fractures can be confidently differentiated from unusual accessory sutures using these additional workstation capabilities.

Retrospective evaluation and dating of non-accidental rib fractures in infants

AIM To describe the sequential appearance of healing rib fractures on initial and follow-up radiographs using published guidelines in approximating the age of rib fractures in infants with the aim of establishing a more objective method of dating rib fractures by measuring the thickness of the callous formation. MATERIALS AND METHODS This was a retrospective analysis of initial and follow-up digital skeletal surveys of infants less than 12 months of age performed between January 2008 and January 2012 at the University of California Davis Childrens Hospital. Six radiological features of rib fractures evaluating the appearance of the callous formation (C stage) and fracture line (F stage) were assessed. Patients with osteogenesis imperfecta, known vitamin D deficiency, and skeletal or metabolic dysplasia were not included in the study. Thereafter, callous thickness was measured and recorded for each stage. RESULTS Sixteen infants (age range 1-11 months, seven males and nine females) with 23 rib fractures were analysed. The thickness of the callous formation follows a predictable pattern advancing one stage after a 2-week follow-up with progressive callous thickening starting from stage 2, peaks at around stage 4, and then tapers and remodels until it almost disappears when the fracture is healed at stage 6. CONCLUSION It appears that rib fractures in infants follow a predictable pattern of healing. Measuring the thickness of the callous formation is a more objective way of guiding the radiologist in estimating the age of the fracture.

An interactive teaching device simulating intussusception reduction

Intussusception is relatively uncommon, occurring in 0.5 to 2.3 cases per 1,000 live births in the USA. Radiology residents, therefore, have few opportunities to participate in intussusception reduction during training, and practicing radiologists encounter it infrequently. Training is essential, as successful reduction avoids surgery. The judgment involved in reducing an intussusception is best gained with experience. We developed a training device that simulates fluoroscopic intussusception reduction with air. The device consists of a doll that contains a cylinder with similar stress and strain characteristics to the human colon. The trainee pumps air into the cylinder through a rectal tube using a standard hand-held air reduction pump. A sensor measures the pressure within the chamber and transmits readings to a computer, which displays images from actual intussusception reductions based on the pressure maintained within the device. A random component in the software gives the user a new experience each time and models uncertainties in the actual reduction process, including perforation. This intussusception reduction simulator can enhance resident education, giving residents the opportunity to practice this technique before employing it on a real patient. The simulator can also help practicing radiologists become more comfortable with intussusception air reduction.

Dynamic sonographic evaluation of posterior shoulder dislocation secondary to brachial plexus birth palsy injury.

onographic evaluation of hip dysplasia has been used since the early 1980s and is now a well-established procedure for the assessment and monitoring of neonatal and infantile hip stability. This same technology can be applied to glenohumeral joint evaluation. Computed tomography (CT) was the first radiographic modality to be used to describe shoulder instability in children with Erb palsy 25 years ago, 1 followed by magnetic resonance imaging

Sonographically Guided Enema for Intussusception Reduction A Safer Alternative to Fluoroscopy

Received June 7, 2012, from the Divisions of Pediatric Radiology (T.R.S.S., A.P., C.V.P.) and Pediatric Surgery (J.L.G., L.P.A.), University of California, Davis Children’s Hospital, Sacramento, California USA. Revision requested June 21, 2012. Revised manuscript accepted for publication July 16, 2012. Address correspondence to Thomas Ray S. Sanchez, MD, DepartmentofRadiology, University of California, Davis, 4860 Y St, Sacramento, CA 95817 USA. E-mail: thomas.sanchez@ucdmc.ucdavis.edu

Nonsurgical Management of Childhood Intussusception Retrospective Comparison Between Sonographic and Fluoroscopic Guidance

The purpose of this study was to compare the effectiveness of sonography and fluoroscopy in guiding intussusception reduction and evaluate possible complications for each procedure.

Sonography of Abdominal Pain in Children Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Fetal Gallbladder Duplication

A 29-year-old woman, gravida 2, para 1001, was seen for a new pregnancy. Her history was notable for a pregnancy 2 years earlier with preeclampsia (high blood pressure and proteinuria) at 38 weeks. She had no other health issues. For the current pregnancy, she underwent a sonographic nuchal translucency study at 12 weeks 5 days as well as full integrated maternal serum screening, both having negative results with a final trisomy 21 risk of 1 per 20,000 and trisomy 18 risk of less than 1 per 100,000. At an estimated menstrual age of 20 weeks, a fetal sonographic anatomic survey was performed, with the only positive finding being parallel double tubular structures with anterior blind endings positioned under the lower aspect of the liver, extending in the anteroposterior plane (Figure 1A). The appearance and location corresponded to the usual fetal gallbladder, but in this case there were 2. The first diagnostic possibility was gallbladder duplication. Other possibilities for an extracystic structure in the right upper quadrant of the abdomen were also considered, such as a choledocal cyst, a mesenteric cyst, and gastrointestinal duplication. Vascular malformations and a persistent right umbilical vein were excluded because of a lack of detectable blood flow. Follow-up sonographic examinations at estimated menstrual ages of 22 and 30 weeks (Figure 1B) revealed similar findings. A healthy male neonate was delivered vaginally at term with weight of 4115 g and Apgar scores of 8 and 8 at 1 and 5 minutes, respectively. On the basis of the obstetric sonographic findings and in the first days of life, the neonate had a sonographic examination (not shown), which again showed 2 tubular structures under the liver. This finding was reported with a differential diagnosis of a choledocal cyst versus a duplicated gallbladder. The first possibility was considered because it is more common and because a separate common bile duct was not identified. Because of these consideraClinical Letters

Characteristics of rib fractures in child abuse-the role of low-dose chest computed tomography

Objectives Our aim is to describe the radiologic characteristics of rib fractures in clinically diagnosed cases of child abuse and suggest a complementary imaging for radiographically occult injuries in highly suspicious cases of child abuse. Methods Retrospective analysis of initial and follow-up skeletal surveys and computed tomography (CT) scans of 16 patients younger than 12 months were reviewed after obtaining approval from our institutional review board. The number, location, displacement, and age of the rib fractures were recorded. Results Out of a total 105 rib fractures, 84% (87/105) were detected on the initial skeletal survey. Seventeen percent (18/105) were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Majority of the fractures were posterior (43%) and anterior (30%) in location. An overwhelming majority (96%) of the fractures are nondisplaced. Conclusions Seventeen percent of rib fractures analyzed in the study were not documented on the initial skeletal survey. Majority of fractures are nondisplaced and located posteriorly or anteriorly, areas that are often difficult to assess especially in the acute stage. The CT scan is more sensitive in evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspicious cases of child abuse when initial radiographic findings are inconclusive.

The role of high-resolution chest CT in the diagnosis of neuroendocrine cell hyperplasia of infancy - A rare form of pediatric interstitial lung disease.

Interstitial lung disease (ILD) is rare in infancy or early childhood. Differentiating between the different types of ILD is important for reasons of treatment, monitoring of clinical course and prognosis. We present a case of a 5-month old female with tachypnea and hypoxemia. The clinical suspicion of neuroendocrine cell hyperplasia of infancy (NEHI) was confirmed by high-resolution chest CT and subsequent lung biopsy. We conclude that high-resolution chest CT has characteristics findings that can be used as a non-invasive test to support the clinical diagnosis of neuroendocrine cell hyperplasia of infancy.