Pediatric Imaging

Adynamic ileus, Pneumatosis intestinalis,  Gas in portal vein may be seen transiently,  Pneumoperitoneum
football sign
NeCrotiziNg eNteroColitis (NeC)
Radiographic Features (Fig. 11-30)
• Small bowel dilatation: adynamic ileus (first finding), unchanging configuration over serial radiographs
• Pneumatosis intestinalis, 80% (second most common sign)
• Gas in portal vein may be seen transiently (US more sensitive than plain film); this finding does not imply as bad an outcome as it does in adults.
• Pneumoperitoneum (20%) indicates bowel perforation: football sign (floating air and ascites give the appearance of a large elliptical lucency in supine position).
• Barium is contraindicated; use water-soluble contrast if a bowel obstruction or Hirschsprung disease needs to be ruled out.
Bilateral. C sign in subtalar bony coalition. tarsal CoalitioN (Fig. 11-69)
Fusion of 2 or more tarsal bones. Union may be complete, partial, bony, cartilaginous, or fibrous. Present at birth but usually asymptomatic until early adulthood.
• Calcaneonavicular (most common)
• Talocalcaneal (common)
Commonly results in spastic flatfoot. Bilateral. C sign in subtalar bony coalition.
doublebubble sign CoNgeNital duodeNal atresia, steNosis
Results from failure of recanalization (around 10 weeks).
Incidence: 1:3500 live births. Atresia : stenosis = 2:1.
Common cause of bowel obstruction. Bilious vomiting occurs within 24 hours after birth. Treatment
is with duodenojejunostomy or duodeno duo denostomy.
• 30% have Down syndrome.
• 40% have polyhydramnios and are premature.
• Malrotation, EA, biliary atresia, renal anomalies, imperforate anus with or without sacral anomalies,
Radiographic Features
• Enlarged duodenal bulb and stomach (doublebubble sign)
• Small amount of air in distal small bowel does
not exclude diagnosis of duodenal atresia
(hepatopancreatic duct may bifurcate in “Y”
shape and insert above and below atresia).
drooping lily sign • Diminished number of calyces compared with normal side;
drooping lily sign
fallen fragment sign CommoN pediatriC boNe tumors
• EG
• Ewing sarcoma
• Bone cysts
UBC: single cavity, fallen fragment sign
ABC: eccentric
• Neuroblastoma metastases
• Lymphoma
• Leukemia
Fat pad sign Fat pad sign (posterior pad is normally absent, anterior fat pad is usually present); absence of the posterior fat pad sign virtually excludes a fracture (90% of patients with fat pad sign have a fracture)

elboW iNjuries
hematogeNous osteomyelitis Plain film (Fig. 11-57)
• Soft tissue swelling (earliest sign; often in metaphyseal region), blurring of fat planes, sinus tract formation, soft tissue abscess
• Cortical loss (5 to 7 days after infection), bone destruction

hematogeNous osteomyelitis
Neuhauser's sign Plain film
• Neuhauser's sign: “Soap bubble” appearance (air mixed with meconium)
• Small bowel obstruction
• Calcification due to meconium peritonitis, 15%
Enema with water-soluble contrast medium
• Microcolon is typical: small unused colon
• Distal 10 to 30 cm of ileum is larger than colon.
• Inspissated meconium in terminal ileum
• Hyperosmolar contrast may stimulate passage of meconium.

meCoNium ileus
Ortolani's jerk or click sign          
Barlow's sign
Clinical Findings deVelopmeNtal dysplasia oF the hip (ddh) (CoNgeNital disloCatioN oF the hip)
• Ortolani's jerk or click sign: relocation click while abducting hip with thumb and placing pressure on greater trochanter
• Barlow's sign: dislocation click while adducting hip with pressure on knee
• Limited abduction of flexed hip
• Shortening of one leg
• Waddling gait
shoulder sign
string sign
Upper gastrointestinal (UGI) findings of HPS:
• Indented gastric antrum (shoulder sign)
• Compression of duodenal bulb
• Narrow and elongated pylorus: string sign

hypertrophiC pyloriC steNosis (hps)
Steeple sign:  Radiographic Features (Fig. 11-6)
• Subglottic narrowing (inverted “V” or “steeple sign”)
• Key view: AP view
• Lateral view should be obtained to exclude epiglottitis.
• Steeple sign: loss of subglottic shoulders
Stripe Sign Stripe Sign (Fig. 12-4)
This sign refers to a perfusion abnormality with a zone of preserved peripheral perfusion. Because PE is pleural based, presence of this sign makes PE unlikely.

PE absent
1. Normal perfusion
2. Very low probability
3. Nonsegmental lesion; e.g., prominent hilum, cardiomegaly, elevated diaphragm, linear atelectasis
4. Perfusion defect smaller than radiographic lesion
5. A solitary CXR-Q matched defect in the mid or upper lung confined to a single segment
6. Stripe sign around the perfusion defect
7. Pleural effusion ≥ one third of the pleural cavity with no other perfusion defect in either lung
Target or doughnut sign IntussusCeption
Radiographic Features
Plain film
• Frequently normal (50%)
• Intraluminal convex filling defect in partially air-filled bowel loop (commonly at hepatic flexure)
Ultrasound (US)
• Target or doughnut sign
Widened joint Radiographic Features (Fig. 11-61)
Early phase
• Widened joint: may be due to increased cartilage or joint effusion (earliest sign)
• Subchondral fissure fracture, best seen on frogleg view (tangential view of cartilage)
• Increase in bone density Intermediate phase
• Granular, fragmented appearance of femoral epiphysis due to calcification of avascular cartilage (no fracture of epiphysis)
• Lateralization of ossification center
• Cysts of demineralization (30%)
• Apposition of new bone makes the femoral head appear dense.
Late phase
• Flattened and distorted femoral head
• Osteoarthritis (OA)

legg-CalVé-perthes (lCp) disease

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