Vernon M. Chapman

Facial fractures in children: unique patterns of injury observed by computed tomography.

To determine the patterns of facial fractures observed in pediatric patients after acute trauma. Materials and Methods: The computed tomography studies of 338 patients (63% male, 37% female; 7 months to 18 years of age) performed after acute nonpenetrating facial trauma were retrospectively reviewed to evaluate for facial fractures and associated orbital hematomas or contiguous skull fractures. Fracture patterns were characterized as orbital roof, orbital floor, medial orbital wall, nasal bone, naso-orbital-ethmoid, zygomatic complex, isolated zygomatic arch, Le Fort type (I, II, or III), maxillary sagittal, alveolar ridge, or mandibular. The frequency of the various fracture types was determined. The correlation between fracture type and orbital hematomas or contiguous skull fractures was assessed (Kendall tau rank correlation). Results: Computed tomography demonstrated facial fractures in 188 (54%) patients. The number and frequency of the fractures observed were as follows: orbital roof, 67 (36%); zygomatic complex, 38 (20%); naso-orbital-ethmoid, 30 (16%); orbital floor, 28 (15%); nasal bone, 25 (13%); mandibular, 24 (13%); medial orbital wall, 16 (9%); maxillary sagittal, 11 (6%); alveolar ridge, 8 (4%); isolated zygomatic arch, 3 (2%); Le Fort type I, 4 (2%); Le Fort type II, 4 (2%); and Le Fort type III, 0 (0%). Fifty children (27%) had multiple fractures. Orbital hematomas were seen in 28 patients (15%), and contiguous skull fractures were seen in 54 patients (29%). There was strong correlation between orbital hematomas and orbital roof fractures (0.62, P < 0.0001), orbital hematomas and naso-orbital-ethmoid fractures (0.18, P = 0.001), contiguous skull and orbital roof fractures (0.57, P < 0.0001), and contiguous skull and naso-orbital-ethmoid fractures (0.39, P < 0.0001). Conclusions: Fractures of the orbital roof are the most common facial fractures observed in pediatric patients after acute nonpenetrating trauma. Orbital roof and naso-orbital-ethmoid fractures are frequently associated with orbital hematomas and contiguous skull fractures.

Multidetector computed tomography of pediatric lateral condylar fractures.

The objective of this study was to compare lateral condylar fracture characterization using radiographs and multidetector computed tomography (MDCT) of the elbow and to evaluate outcomes in a group of children managed based on MDCT findings. Methods: Unenhanced MDCT of the elbow with sagittal and coronal reformations was prospectively performed without sedation in 10 children between 1 and 16 years of age with lateral condylar fractures identified on frontal and lateral radiographs of the elbow. Two blinded readers reviewed all radiographs and MDCT images independently and in consensus. For the radiographs and MDCT images, readers graded the displacement of the lateral condyle fracture fragment and classified the fractures according to the Milch classification. Articular and epiphyseal cartilage integrity was assessed on MDCT. Patients were managed based on the consensus interpretation of the MDCT study. The frequency of interobserver agreement, discordant grading of fracture displacement and fracture classification between radiographs and MDCT images, and altered management based on the MDCT findings were determined. Results: Individual readers agreed on fracture displacement in 9 patients (90%) on radiographs and in all 10 patients (100%) on MDCT. Individual readers agreed on fracture classification in 4 patients (40%) on radiographs and in 9 patients (90%) on MDCT. In 4 patients (40%), grading of fracture displacement differed between the consensus interpretation of the radiographs and MDCT images. In 6 patients (60%), fracture classification differed between the consensus interpretation of the radiographs and MDCT images. All 3 patients with fracture displacement greater than 5 mm and 1 patient with fracture displacement between 2 and 5 mm demonstrated disruption of the articular and epiphyseal cartilage on MDCT. Two patients (20%) with fracture displacement near the surgical threshold of 2 mm had altered management based on the MDCT findings. All patients progressed to complete fracture healing, with no delayed displacement or other complications. Conclusions: Multidetector computed tomography is a highly reproducible means of characterizing pediatric lateral condylar fractures and frequently demonstrates disruption of the epiphyseal and articular cartilage in patients with fracture displacement greater than 2 mm. The findings of MDCT may lead to altered treatment in patients with fracture displacement near the surgical threshold of 2 mm.

Internal hernia through a defect in the broad ligament: a rare cause of intestinal obstruction.

Internal hernias through the broad ligament are an extremely rare cause of intestinal obstruction. Clinical symptoms and imaging are often nonspecific, making preoperative diagnosis difficult. The authors report a case in which multidetector computed tomography proved useful in the preoperative diagnosis.

MDCT of the Elbow in Pediatric Patients with Posttraumatic Elbow Effusions

OBJECTIVE The purpose of this study was to determine the performance characteristics of MDCT in the detection of fractures in children with posttraumatic elbow effusions and to assess the effect of MDCT findings on clinical management. SUBJECTS AND METHODS Unenhanced MDCT of the elbow was prospectively performed without sedation on 31 children 20 months to 16 years old who had posttraumatic elbow effusions. Two blinded reviewers independently and in consensus characterized all MDCT scans as positive or negative for the presence of fracture. Level of interobserver agreement was determined with the kappa statistic. Sensitivity, specificity, positive predictive value, and negative predictive value of MDCT for fracture detection were determined for the consensus MDCT interpretations with follow-up radiographs as the reference standard. Patients were treated with casts and instructed to return in 2-3 weeks for clinical and radiographic follow-up unless a change in management was indicated on the basis of MDCT findings. The frequency of alteration of management was determined. RESULTS Both reviewers detected fractures in 15 (48%) of the patients individually and in 16 (52%) of the patients by consensus. Interobserver agreement for fracture detection with MDCT was excellent (kappa = 0.85). The sensitivity, specificity, positive predictive value, and negative predictive value of MDCT in the detection of fractures were 92%, 79%, 79%, and 92%, respectively. Four (13%) of the children had changes in management based on the MDCT findings. CONCLUSION MDCT is a sensitive means of evaluating for radiographically occult fractures in children with posttraumatic elbow effusions. It has a high negative predictive value and a high level of interobserver agreement. MDCT findings may lead to alteration of treatment of children with nondisplaced lateral condylar and radial head fractures.

The pre-ossification center: normal CT and MRI findings in the trochlea

The pre-ossification center represents the initial structural change in the development of the secondary ossification center. We report CT and MRI findings of a focus in the cartilaginous trochlea of an appropriately aged child compatible with the pre-ossification center.