Failed Intussusception Reduction in Children: Correlation Between Radiologic, Surgical, and Pathologic Findings.

OBJECTIVE: The objective of this study was to identify causes of irreducible intussusception after contrast enema and to correlate imaging findings with surgical and histopathologic findings. MATERIALS AND METHODS: Between 2005 and 2013, a total of 543 children underwent reduction of intussusception with the use of an enema technique (hereafter referred to as "enema reduction"). The medical records of 72 children (56 boys [mean age, 24.8 months; range, 3.8 months to 10.9 years] and 16 girls [mean age, 14.2 months; range, 1.5 months to 6.9 years) who underwent unsuccessful reduction and were treated surgically were retrospectively analyzed. The data collected included information on the cause of intussusception, the risk factors noted on ultrasound, operative management, outcome, and the length of the hospital stay. The imaging findings for these patients were compared with findings for statistically similar age-matched control subjects. RESULTS: Ultrasound detected 56 of 57 cases of intussusception, but it failed to detect the lead point in three cases and failed to detect ischemic necrosis in seven cases. Positive predictors of failed enema reduction were the presence of a distal mass and observation of the dissecting sign. Of the 72 patients who underwent surgical treatment of intussusception, 26 (36.1%) underwent laparoscopy, 38 (52.8%) underwent laparotomy, and eight (11.1%) underwent conversion from laparoscopy to laparotomy. Surgical reduction was performed in 61.1% of cases, small bowel resection in 19.4%, ileocecectomy in 12.5%, and self-reduction in 69%. Pathologic lead points (noted in 25% of cases) included lymphoid hyperplasia (n = 7), Meckel diverticulum (n = 3), Burkitt lymphoma (n = 3), enteric duplication cyst (n = 2), juvenile polyp (n = 2), and adenovirus appendicitis (n = 1). The length of the hospital stay was significantly longer after laparotomy. CONCLUSION: The distalmost location of the intussusception mass and presence of the dissecting sign on images obtained during contrast enema have a higher positive predictive value for failed reduction. Screening ultrasound decreases the number of unnecessary contrast enemas performed; however, classic pathologic lead points, such as Burkitt lymphoma and Meckel diverticulum, may be difficult to diagnose with the use of ultrasound. Laparotomy and laparoscopy are equally safe and efficacious in reducing intussusception, with the length of the hospital stay after laparoscopy significantly shorter than that noted after laparotomy. Most failed enema reductions are idiopathic, and pathologic lead points are noted in 25% of cases.

Extra-appendiceal findings in pediatric abdominal CT for suspected appendicitis.

BACKGROUND: Much has been written regarding the incidence, types, importance and management of abdominal CT incidental findings in adults, but there is a paucity of literature on incidental findings in children. OBJECTIVE: We sought to determine the prevalence and characteristics of extra-appendiceal and incidental findings in pediatric abdominal CT performed for suspected appendicitis. MATERIALS AND METHODS: A retrospective review was performed of abdominal CT for suspected appendicitis in a pediatric emergency department from July 2010 to June 2012. Extra-appendiceal findings were recorded. Any subsequent imaging was noted. Extra-appendiceal findings were divided into incidental findings of doubtful clinical significance, alternative diagnostic findings potentially providing a diagnosis other than appendicitis explaining the symptoms, and incidental findings that were abnormalities requiring clinical correlation and sometimes requiring further evaluation but not likely related to the patient symptoms. RESULTS: One hundred sixty-five children had abdominal CT for suspected appendicitis. Seventy-seven extra-appendiceal findings were found in 57 (34.5%) patients. Most findings (64 of 77) were discovered in children who did not have appendicitis. Forty-one of these findings (53%) could potentially help explain the patient's symptoms, while 30 of the findings (39%) were abnormalities that were unlikely to be related to the symptoms but required clinical correlation and sometimes further work-up. Six of the findings (8%) had doubtful or no clinical significance. CONCLUSION: Extra-appendiceal findings are common in children who undergo abdominal CT in the setting of suspected appendicitis. A significant percentage of these patients have findings that help explain their symptoms. Knowledge of the types and prevalence of these findings may help radiologists in the planning and interpretation of CT examinations in this patient population.

Low-dose fetal CT in the prenatal evaluation of skeletal dysplasias and other severe skeletal abnormalities.

OBJECTIVE: Prenatal diagnosis of skeletal dysplasia is often difficult and based on findings with ultrasound, a technique with 40-60% sensitivity. The purpose of this study was to evaluate a preliminary experience in assessing severe prenatal osseous abnormalities with low-dose fetal CT. The hypothesis was that use of CT may improve the prenatal diagnosis of skeletal dysplasia beyond the available capabilities of ultrasound. MATERIALS AND METHODS: Retrospective search of a radiology database (July 2008-February 2011) yielded the records of unenhanced CT examinations of patients referred because of abnormal fetal bones. The original ultrasound and CT reports as interpreted at image acquisition were independently analyzed by two radiologists blinded to the final diagnosis and to the findings of the opposing imaging modality. Blinded review of the images was also performed. Correlation was made with the postmortem and postnatal findings. RESULTS: According to the reports of the studies, 5 of 21 cases were interpreted correctly with CT and incorrectly with ultrasound. In 17 cases, CT revealed additional osseous findings not in the ultrasound report. There were no cases in which ultrasound findings were correct and CT findings were incorrect. Blinded review of the images revealed that CT outperformed ultrasound (p < 0.001). There were a total of four CT errors among 218 total measures recorded and a total of 19 ultrasound errors among 218 total measures. CONCLUSION: Although low-dose fetal CT should never be used as the initial diagnostic modality in cases of suspected skeletal dysplasia, it is a powerful imaging adjunct that depicts the fetal bones in exquisite detail. Use of CT of fetuses at risk of skeletal dysplasia may provide clinicians with more accurate information for counseling of families regarding neonatal morbidity and mortality.

CYP11B1 variants influence skeletal maturation via alternative splicing.

We performed genome-wide association study meta-analysis to identify genetic determinants of skeletal age (SA) deviating in multiple growth disorders. The joint meta-analysis (N = 4557) in two multiethnic cohorts of school-aged children identified one locus, CYP11B1 (expression confined to the adrenal gland), robustly associated with SA (rs6471570-A; ß = 0.14; P = 6.2 × 10-12). rs6410 (a synonymous variant in the first exon of CYP11B1 in high LD with rs6471570), was prioritized for functional follow-up being second most significant and the one closest to the first intron-exon boundary. In 208 adrenal RNA-seq samples from GTEx, C-allele of rs6410 was associated with intron 3 retention (P = 8.11 × 10-40), exon 4 inclusion (P = 4.29 × 10-34), and decreased exon 3 and 5 splicing (P = 7.85 × 10-43), replicated using RT-PCR in 15 adrenal samples. As CYP11B1 encodes 11-ß-hydroxylase, involved in adrenal glucocorticoid and mineralocorticoid biosynthesis, our findings highlight the role of adrenal steroidogenesis in SA in healthy children, suggesting alternative splicing as a likely underlying mechanism.

Normal appendiceal diameter in children: does choice of CT oral contrast (VoLumen versus Gastrografin) make a difference?

Appendicitis is a common pediatric emergency and one of the most common causes for surgical exploration in the pediatric patient. Imaging has become an essential tool in the evaluation of the child with suspected appendicitis, aiming to avoid misdiagnosis and to facilitate early surgery, thus decreasing potential morbidity from ruptured appendicitis. The objective of this paper is to compare the luminal diameter of the normal appendix by computed tomography (CT) when utilizing the traditionally used high-attenuation oral contrast material (OCM), Gastrografin, and the relatively new neutral agent VoLumen, with the goal of establishing normal appendiceal size parameters for this neutral OCM. Twenty-six cases of VoLumen-enhanced CT studies of the abdomen and pelvis were identified, of which 13 met the inclusion criteria. These were randomly matched to age control Gastrografin CT examinations. Appendiceal diameters (from wall to wall) were measured in three orthogonal planes and the average of these was recorded. We show that there is no statistical difference between normal appendiceal diameters in patients with a VoLumen-opacified CT versus a Gastrografin-enhanced CT (p = 0.8) being 5.0 +/- 1.3 and 5.1 +/- 1.5 mm, respectively. Chart review revealed no clinical suspicion of appendicitis prior to imaging or on discharge diagnosis in the patients included in this study. The rate of nonvisualization of the appendix with VoLumen in our study was 31%, which equals previously published estimates in children. In summary, as VoLumen use increases in the evaluation of abdominal pathology in the ailing child, we provide guidelines to identify the normal appendix when utilizing this oral contrast agent.

The bone mineral density in childhood study: bone mineral content and density according to age, sex, and race.

CONTEXT: Low bone mass may increase risk of fracture. Several chronic medical conditions, medications, and lifestyle factors affect bone mineral accrual. Appropriate reference values are essential for identification of children with bone deficits. OBJECTIVE: Our objective was to establish reference curves for bone mineral content (BMC) and density (BMD) in children. DESIGN AND SETTING: The Bone Mineral Density in Childhood Study is an ongoing longitudinal study in which measurements are obtained annually at five clinical centers in the United States. PARTICIPANTS: Participants included 1554 healthy children (761 male, 793 female), ages 6-16 yr, of all ethnicities. MAIN OUTCOME MEASURES: Scans of the whole body, lumbar spine, hip, and forearm were obtained using dual-energy x-ray absorptiometry. Percentile curves based on three annual measurements were generated using the LMS statistical procedure. RESULTS: BMC of the whole body and lumbar spine and BMD of the whole body, lumbar spine, total hip, femoral neck, and forearm are given for specific percentiles by sex, age, and race (Black vs. non-Black). BMC and BMD were higher for Blacks at all skeletal sites (P < 0.0001). BMC and BMD increased with age, and a plateau was not evident by age 16 (girls) or age 17 (boys). The variation in BMC and BMD also increased with age. CONCLUSIONS: Age-, race-, and sex-specific reference curves can be used to help identify children with bone deficits and for monitoring changes in bone in response to chronic diseases or therapies.

Relative Skeletal Maturation and Population Ancestry in Nonobese Children and Adolescents.

More rapid skeletal maturation in African-American (AA) children is recognized and generally attributed to an increased prevalence of obesity. The objective of the present study was to evaluate the effects of population ancestry on relative skeletal maturation in healthy, non-obese children and adolescents, accounting for body composition and sexual maturation. To do this, we leveraged a multiethnic, mixed-longitudinal study with annual assessments for up to 7 years (The Bone Mineral Density in Childhood Study and its ancillary cohort) conducted at five US clinical centers. Participants included 1592 children, skeletally immature (45% females, 19% AA) who were aged 5 to 17 years at study entry. The primary outcome measure was relative skeletal maturation as assessed by hand-wrist radiograph. Additional covariates measured included anthropometrics, body composition by dual-energy X-ray absorptiometry (DXA), and Tanner stage of sexual maturation. Using mixed effects longitudinal models, without covariates, advancement in relative skeletal maturation was noted in self-reported AA girls (∼0.33 years, p < 0.001) and boys (∼0.43 years, p < 0.001). Boys and girls of all ancestry groups showed independent positive associations of height, lean mass, fat mass, and puberty with relative skeletal maturation. The effect of ancestry was attenuated but persistent after accounting for covariates: for girls, 0.19 years (ancestry by self-report, p = 0.02) or 0.29 years (ancestry by admixture, p = 0.004); and for boys, 0.20 years (ancestry by self-report, p = 0.004), or 0.29 years (ancestry by admixture, p = 0.004). In summary, we conclude that advancement in relative skeletal maturation was associated with AA ancestry in healthy, non-obese children, independent of growth, body composition, and puberty. Further research into the mechanisms underlying this observation may provide insights into the regulation of skeletal maturation. © 2016 American Society for Bone and Mineral Research.

Fetal pulmonary malformations: defining histopathology.

Although classification schemes have sought to categorize congenital cystic lung malformations, studies including the pathology of pulmonary malformations occurring specifically during the fetal period are limited. To better characterize such histopathology, we reviewed a total of 23 fetal lung malformations seen at the Children's Hospital of Philadelphia from 1996 to 2004. Twenty-one of the 23 fetal pulmonary malformations could be categorized into 1 of 3 groups based upon the predominant histologic features present within each lesion. Group 1 (9/21) demonstrated tubular airspaces lined by columnar epithelium. Group 2 (6/21) contained airspaces lined by cuboidal epithelium and surrounded by smooth muscle with abundant interstitial mesenchyme. Group 3 (6/21) showed a mixture of relatively mature-appearing airspaces lined by flattened epithelium and scattered dilated bronchiole-like structures. Cysts were of variable size but in all cases showed a respiratory-type lining. Gestational ages ranged from 21 5/7 to 38 2/7 weeks. Patients in groups 1 and 2 were generally younger than those in group 3; however, morphology did not seem to correlate entirely with normal stages of fetal lung development, and group 2 lesions in particular were the least akin to normal fetal lung. In 4 cases a systemic vascular supply to a lobe of lung was identified, providing evidence that such vasculature is embryonic in origin. The histopathology of fetal lung malformations highlights the variability seen in such lesions at all ages, and it is hoped that continued investigations will provide further insight into these enigmatic lesions.

Effect of Low-Magnitude Mechanical Stimuli on Bone Density and Structure in Pediatric Crohn's Disease: A Randomized Placebo-Controlled Trial.

Pediatric Crohn's Disease (CD) is associated with low trabecular bone mineral density (BMD), cortical area, and muscle mass. Low-magnitude mechanical stimulation (LMMS) may be anabolic. We conducted a 12-month randomized double-blind placebo-controlled trial of 10 minutes daily exposure to LMMS (30 Hz frequency, 0.3 g peak-to-peak acceleration). The primary outcomes were tibia trabecular BMD and cortical area by peripheral quantitative CT (pQCT) and vertebral trabecular BMD by QCT; additional outcomes included dual-energy X-ray absorptiometry (DXA) whole body, hip and spine BMD, and leg lean mass. Results were expressed as sex-specific Z-scores relative to age. CD participants, ages 8 to 21 years with tibia trabecular BMD <25th percentile for age, were eligible and received daily cholecalciferol (800 IU) and calcium (1000 mg). In total, 138 enrolled (48% male), and 121 (61 active, 60 placebo) completed the 12-month trial. Median adherence measured with an electronic monitor was 79% and did not differ between arms. By intention-to-treat analysis, LMMS had no significant effect on pQCT or DXA outcomes. The mean change in spine QCT trabecular BMD Z-score was +0.22 in the active arm and -0.02 in the placebo arm (difference in change 0.24 [95% CI 0.04, 0.44]; p = 0.02). Among those with >50% adherence, the effect was 0.38 (95% CI 0.17, 0.58, p < 0.0005). Within the active arm, each 10% greater adherence was associated with a 0.06 (95% CI 0.01, 1.17, p = 0.03) greater increase in spine QCT BMD Z-score. Treatment response did not vary according to baseline body mass index (BMI) Z-score, pubertal status, CD severity, or concurrent glucocorticoid or biologic medications. In all participants combined, height, pQCT trabecular BMD, and cortical area and DXA outcomes improved significantly. In conclusion, LMMS was associated with increases in vertebral trabecular BMD by QCT; however, no effects were observed at DXA or pQCT sites. © 2016 American Society for Bone and Mineral Research.

Mandibular dimensions in children with obstructive sleep apnea syndrome.

OBJECTIVE: We hypothesized that mandibular size may play a role in the etiology of obstructive sleep apnea syndrome (OSAS) in children, since a smaller mandible may reduce airway size. We used magnetic resonance imaging to determine the mandible dimensions of children with OSAS. DESIGN: Case control study. SETTING: Tertiary-care pediatric hospital. PARTICIPANTS: Twenty-four subjects (mean age 4.9 +/- 1.7 years) with mild to moderate OSAS (Apnea Index 3.5 +/- 5.1), and 24 matched controls (mean age 4.9 +/- 1.8 years). INTERVENTION: Magnetic resonance imaging of the upper airway under sedation. MEASUREMENTS: Eight measurements were obtained from a 3-dimensional segmentation of the mandible using 3DVIEWNIX software. Measurements included length, height, width, midsymphysis menti angle, angle of mandible, enclosure area, surface area, and volume. Descriptive comparisons using Student t test and multivariate analyses of variance were performed. RESULTS: Individual measurement comparisons revealed no significant differences between groups. Multivariate analysis showed a lower bound of a 95% confidence interval for an effect size measure for "general mandibular size," including all 6 linear, the area, and the volume measurements, to be -0.25. CONCLUSION: Our study shows that a smaller mandible is not a feature in children with OSAS who do not have apparent craniofacial abnormalities.

Magnetic resonance imaging of soft-tissue tumors in children.

Magnetic resonance imaging (MRI) has become an important diagnostic tool in the detection and characterization and local anatomic staging of soft-tissue tumors in children. This article outlines some of the procedural issues unique to the pediatric population.

Revised reference curves for bone mineral content and areal bone mineral density according to age and sex for black and non-black children: results of the bone mineral density in childhood study.

CONTEXT: Deficits in bone acquisition during growth may increase fracture risk. Assessment of bone health during childhood requires appropriate reference values relative to age, sex, and population ancestry to identify bone deficits. OBJECTIVE: The objective of this study was to provide revised and extended reference curves for bone mineral content (BMC) and areal bone mineral density (aBMD) in children. DESIGN: The Bone Mineral Density in Childhood Study was a multicenter longitudinal study with annual assessments for up to 7 yr. SETTING: The study was conducted at five clinical centers in the United States. PARTICIPANTS: Two thousand fourteen healthy children (992 males, 22% African-Americans) aged 5-23 yr participated in the study. INTERVENTION: There were no interventions. MAIN OUTCOME MEASURES: Reference percentiles for BMC and aBMD of the total body, lumbar spine, hip, and forearm were obtained using dual-energy x-ray absorptiometry for Black and non-Black children. Adjustment factors for height status were also calculated. RESULTS: Extended reference curves for BMC and aBMD of the total body, total body less head, lumbar spine, total hip, femoral neck, and forearm for ages 5-20 yr were constructed relative to sex and age for Black and non-Black children. Curves are similar to those previously published for 7-17 year olds. BMC and aBMD values were greater for Black vs. non-Black children at all measurement sites. CONCLUSIONS: We provide here dual-energy x-ray absorptiometry reference data on a well-characterized cohort of 2012 children and adolescents. These reference curves provide the most robust reference values for the assessment and monitoring of bone health in children and adolescents in the literature to date.

Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children.

CONTEXT: In children, bone mineral content (BMC) and bone mineral density (BMD) measurements by dual-energy x-ray absorptiometry (DXA) are affected by height status. No consensus exists on how to adjust BMC or BMD (BMC/BMD) measurements for short or tall stature. OBJECTIVE: The aim of this study was to compare various methods to adjust BMC/BMD for height in healthy children. DESIGN: Data from the Bone Mineral Density in Childhood Study (BMDCS) were used to develop adjustment methods that were validated using an independent cross-sectional sample of healthy children from the Reference Data Project (RDP). SETTING: We conducted the study in five clinical centers in the United States. PARTICIPANTS: We included 1546 BMDCS and 650 RDP participants (7 to 17 yr of age, 50% female). INTERVENTION: No interventions were used. MAIN OUTCOME MEASURES: We measured spine and whole body (WB) BMC and BMD Z-scores for age (BMC/BMD(age)), height age (BMC/BMD(height age)), height (BMC(height)), bone mineral apparent density (BMAD(age)), and height-for-age Z-score (HAZ) (BMC/BMD(haz)). RESULTS: Spine and WB BMC/BMD(age)Z and BMAD(age)Z were positively (P < 0.005; r = 0.11 to 0.64) associated with HAZ. Spine BMD(haz) and BMC(haz)Z were not associated with HAZ; WB BMC(haz)Z was modestly associated with HAZ (r = 0.14; P = 0.0003). All other adjustment methods were negatively associated with HAZ (P < 0.005; r = -0.20 to -0.34). The deviation between adjusted and BMC/BMD(age) Z-scores was associated with age for most measures (P < 0.005) except for BMC/BMD(haz). CONCLUSIONS: Most methods to adjust BMC/BMD Z-scores for height were biased by age and/or HAZ. Adjustments using HAZ were least biased relative to HAZ and age and can be used to evaluate the effect of short or tall stature on BMC/BMD Z-scores.

Effective radiation dose from radiologic studies in pediatric trauma patients.

Evaluation of the pediatric trauma patient frequently requires radiologic studies. Although low-dose radiation from diagnostic radiology is considered safe, lifetime risks per unit dose of radiation are increased in children compared to adults. The total effective dose of radiation to a typical pediatric trauma patient is unknown. We sought to estimate the total effective dose of radiation related to the radiologic assessment of injured children admitted to a pediatric Level I trauma center. We reviewed the radiology records of all children admitted directly to a trauma center in 2002 and tabulated all plain films, computed tomograms, angiographic/fluoroscopic studies, and nuclear medicine studies. Using age-adjusted effective doses (which incorporate biologic effects of radiation), we computed each patient's total effective dose of radiation. Of 506 admitted patients, 394 (78%) underwent at least one radiologic study. The mean total effective dose per patient was 14.9 mSv (median: 7.2 mSv; interquartile range: 2.2-27.4 mSv). On average, computed tomography accounted for 97.5% of total effective dose. Age and injury severity score did not predict total effective dose. We conclude that in pediatric trauma patients, the estimated total effective dose of radiation varied widely. Computed tomography contributed virtually the entire total effective dose. Regarding radiographic evaluation of pediatric trauma patients, the risks and benefits of current practices should continue to be evaluated critically, because lifetime risks associated with radiation exposure are inversely proportional to age at exposure.

Effect of lateral positioning on upper airway size and morphology in sedated children.

BACKGROUND: Lateral positioning decreases upper airway obstruction in paralyzed, anesthetized adults and in individuals with sleep apnea during sleep. The authors hypothesized that lateral positioning increases upper airway cross-sectional area and total upper airway volume when compared with the supine position in sedated, spontaneously breathing children. METHODS: Children aged 2-12 yr requiring magnetic resonance imaging examination of the head or neck region using deep sedation with propofol were studied. Exclusion criteria included any type of anatomical or neurologic entity that could influence upper airway shape or size. T1 axial scans of the upper airway were obtained in the supine and lateral positions, with the head and neck axes maintained neutral. Using software based on fuzzy connectedness segmentation (3D-VIEWNIX; Medical Imaging Processing Group, University of Pennsylvania, Philadelphia, PA), the magnetic resonance images were processed and segmented to render a three-dimensional reconstruction of the upper airway. Total airway volumes and cross-sectional areas were computed between the nasal vomer and the vocal cords. Two-way paired t tests were used to compare airway sizes between supine and lateral positions. RESULTS: Sixteen of 17 children analyzed had increases in upper airway total volume. The total airway volume (mean +/- SD) was 6.0 +/- 2.9 ml in the supine position and 8.7 +/- 2.5 ml in the lateral position (P < 0.001). All noncartilaginous areas of the upper airway increased in area in the lateral compared with the supine position. The region between the tip of the epiglottis and vocal cords demonstrated the greatest relative percent change. CONCLUSIONS: The upper airway of a sedated, spontaneously breathing child widens in the lateral position. The region between the tip of the epiglottis and the vocal cords demonstrates the greatest relative percent increase in size.

The significance of contrast blush on computed tomography in children with splenic injuries.

PURPOSE: Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The "blush sign" is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the "blush sign" as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the "blush sign" in children with blunt splenic injuries. METHODS: A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a "blush sign." RESULTS: There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A "blush sign" on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a "blush sign" who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury. CONCLUSIONS: Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures.

BACKGROUND: Computed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation. METHODS: A retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings. RESULTS: For the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs). CONCLUSION: The pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.

Terminal ileum intubation in pediatric colonoscopy and diagnostic value of conventional small bowel contrast radiography in pediatric inflammatory bowel disease.

BACKGROUND: Small bowel contrast radiography is often suggested as the first diagnostic tool in evaluating pediatric inflammatory bowel disease. The purpose of this study was to determine the sensitivity and specificity of small bowel radiography compared with terminal ileal biopsies in diagnosing pediatric inflammatory bowel disease, and to determine the success rate and safety of terminal ileum intubation during pediatric colonoscopy. METHODS: We retrospectively reviewed the records of 164 subjects who had colonoscopies with terminal ileal biopsies between 1994 and 1996. Small bowel contrast radiography was performed in 84 subjects within two weeks of the colonoscopy. We also reviewed all the colonoscopy reports from the years 1994 to 1996 and 1999 to 2000 to determine the percentage of terminal ileal intubation. RESULTS: Eighty-four subjects with small bowel contrast radiography and terminal ileal biopsies were reviewed. Using small bowel radiography as a screening test for the diagnosis of terminal ileum inflammatory bowel disease resulted in a sensitivity of 45% (17/37) and a specificity of 96% (17/19). Between the years 1994 and 1996 the percentage of pediatric colonoscopies that resulted in terminal ileal intubation was 21.5%; between the years 1999 and 2000 the percentage increased to 65.6%. CONCLUSIONS: A normal small bowel radiography alone should not be used to rule out pediatric inflammatory bowel disease when the symptoms suggest it. Colonoscopy with terminal ileal intubation is feasible and safe; it should be attempted in all children with symptoms consistent with inflammatory bowel disease.

Pattern of abdominal free fluid following isolated blunt spleen or liver injury in the pediatric patient.

BACKGROUND: This study correlated isolated, blunt liver or spleen injury with the presence, location, and amount of free fluid in the pediatric blunt trauma patient. METHODS: The hospital trauma registry was reviewed for the period 1/89 to 12/99 for pediatric patients (age < or = 17 years) who sustained blunt, isolated spleen or liver injury and had an abdominal CT scan. Patients with other intraabdominal injuries or inadequate scans were excluded. CT scans were reviewed by two radiologists and the isolated liver or spleen injury confirmed and graded. The presence, location, and amount of free fluid were evaluated in the RUQ, LUQ, and pelvis. Free fluid was quantified as 0 = no fluid, 1 = small amount, 2 = moderate, and 3 = large for each area. RESULTS: There were 134 pediatric patients with an isolated spleen (n = 66) or liver (n = 68) injury. Free fluid was noted in 101 patients (75%), more commonly with spleen (82%) than with liver (69%) injuries. As injury grade increased, so did frequency of patients with free fluid (grade 1 = 50% to grade 5 = 100%) and mean total volume (sum of fluid scores from each region) of free fluid (grade 1 = 0.75 to grade 5 = 6.5). The mean total volume of free fluid was greater for splenic injury (3.1) than for liver injury (1.7). The pelvis was the most common location for free fluid (liver 53%, spleen 71%) and had the greatest mean volume of free fluid (liver 0.9, spleen 1.5) of any single region. CONCLUSION: There is a direct correlation between the severity of the isolated injury and the likelihood and volume of associated free fluid. The pelvis was the most common location to detect free fluid and had the greatest estimated fluid volume.

Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries.

The purpose of this study was to determine the role of magnetic resonance imaging (MRI) in the evaluation of children with suspected cervical spine injury (CSI). The authors studied 237 consecutive children, 74 of whom were evaluated by MRI based on a trauma protocol of the authors' institution. The criteria for MRI were: (1) an obtunded or nonverbal child suspected of having CSI, (2) equivocal plain films, (3) neurologic symptoms without radiographic findings, or (4) an inability to clear the cervical spine within 3 days, based on testing. The average age of the evaluated children was 8 years. MRI confirmed the plain radiography diagnosis in 66% of children and altered the diagnosis in 34%. MRI is valuable in the evaluation of potential CSI, especially in obtunded children or children with equivocal plain radiographs.