The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Documenting your career as an educator electronically.

Academic radiologists on the clinician-educator track are required to provide a teaching portfolio as well as a curriculum vitae (CV) for academic promotion. The specific components of a teaching portfolio vary slightly depending on the institution. Traditionally academicians have collected the necessary documentation in paper format, often stuffing them in a binder or a desk drawer. However in the digital age most academic works are readily available in electronic format and can be accessed online. An electronic portfolio is the ideal method to efficiently organize this digital material. In this article, we describe the specific advantages of an online academic portfolio, explain how to set one up and review many options available to build an online electronic portfolio.

Anatomy and injuries of the pediatric wrist: beyond the basics.

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection.

Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy. © RSNA, 2017.

Brachial plexus birth palsy: multimodality imaging of spine and shoulder abnormalities in children.

OBJECTIVE. The purpose of this article is to provide a comprehensive overview of the imaging of brachial plexus palsy, including both pathologic conditions of the spine and shoulder and clinical background and management. CONCLUSION. Brachial plexus birth palsy can result in permanent disability and limb deformity. Identifying the lesion type and associated sequelae is important in clinical management aimed at optimizing outcome. The imaging algorithms used are guided by clinical presentation and are designed to assess the extent of injury to guide possible surgical intervention.

Ultrasound-guided joint injections for MR arthrography in pediatric patients: how we do it.

In children, MR arthrography is typically performed using fluoroscopic guidance. This article explores the role of US-guided joint injections as an alternative for MR arthrography in children, discussing its advantages and disadvantages compared to standard methods. We describe techniques for performing US-guided injection of the shoulder, elbow, hip, knee, ankle and posterior subtalar joints, highlighting pertinent anatomy, routes of access and unique considerations for this modality in children. Written descriptions, images and links to video clips are used to illustrate proper arthrographic technique. We conclude that US provides effective guidance for intra-articular injection prior to MR arthrography, with the advantages of improved visualization of internal structures, reduced radiation exposure, convenience of performing the procedure portably and ease of performance. Although this paper does not address therapeutic steroid injections, these techniques could easily be translated for such purposes. We propose US guidance as a viable alternative to fluoroscopic technique for arthrography in children.

Techniques for creating video content for radiology education.

Video podcasts, or vodcasts, are an innovative tool for teaching and learning that allow the efficient distribution of tutorials, lectures, and other educational content. Certain types of content lend themselves to presentation in a video format. For example, vodcasts are well suited to teaching radiologic procedures. Vodcasts might also be quite useful in demonstrating the use of an audience response system and how one system differs from another, providing background content before an active-learning session, comparing magnetic resonance imaging pulse sequences, and teaching valuable interpersonal skills such as how to deliver bad news to a patient or how to maintain professionalism in the work environment. The authors present a step-by-step text-and-video tutorial on how to create, edit, and export vodcasts using a variety of software tools, describing both the "how" and the "why" of creating vodcasts. Interested readers are encouraged to examine both the print and online versions of this article to gain a more comprehensive knowledge of the ideas presented by the authors. Online supplemental material is available for this article.

Pediatric CT: strategies to lower radiation dose.

OBJECTIVE: The introduction of MDCT has increased the utilization of CT in pediatric radiology along with concerns for radiation sequelae. This article reviews general principles of lowering radiation dose, the basic physics that impact radiation dose, and specific CT integrated dose-reduction tools focused on the pediatric population. CONCLUSION: The goal of this article is to provide a comprehensive review of the recent literature regarding CT dose reduction methods, their limitations, and an outlook on future developments with a focus on the pediatric population. The discussion will initially focus on general considerations that lead to radiation dose reduction, followed by specific technical features that influence the radiation dose.

MR imaging of the paediatric foot and ankle.

Radiography is the mainstay for initial evaluation of paediatric foot and ankle pathology. MRI is the preferred exam for further characterisation of the majority of these conditions. The modality features high sensitivity and specificity for this purpose with few exceptions. Findings on MRI will often dictate patient referral and further management, and are frequently required for surgical planning. This article will provide an overview of a variety of pathologies that afflict the foot and ankle in children. These include tarsal coalition, osteochondral lesions, osteonecrosis, osteochondroses, stress fractures, osteomyelitis, inflammatory arthritis, neoplasms of bone and soft tissue, and foreign bodies. Their respective imaging manifestations on MRI are the focus of the paper. Technical parameters and marrow signal variation are also discussed.

Safety essentials: acute reactions to iodinated contrast media.

The objectives of this article are to review the diagnosis and management of acute nonrenal reactions to iodinated contrast media. We will begin by discussing the types of contrast media and their correlative rates of reaction. The mechanism of contrast reactions, predisposing risk factors, and preventative measures will then be discussed. The remainder of the article will review the assessment of potential reactions, initial management, and treatment algorithms for specific reactions.

Software Aids for radiologists: Part 1, Useful Photoshop skills.

OBJECTIVE: The purpose of this review is to describe the use of several essential techniques and tools in Adobe Photoshop image-editing software. The techniques shown expand on those previously described in the radiologic literature. CONCLUSION: Radiologists, especially those with minimal experience with image-editing software, can quickly apply a few essential Photoshop tools to minimize the frustration that can result from attempting to navigate a complex user interface.

Pediatric bone imaging: imaging elbow trauma in children--a review of acute and chronic injuries.

OBJECTIVE: Pediatric elbow trauma is challenging because of the complex nature of the growing skeleton. The objectives of this article are to review the anatomy and radiographic landmarks and to discuss common acute and chronic injuries sustained. CONCLUSION: Radiographic evaluation of elbow trauma in the acute setting requires a firm understanding of developmental anatomy, radiographic landmarks, and the common injury patterns. Both radiography and MRI are vital tools for diagnosing chronic elbow overuse injuries in adolescent athletes.

Optimizing peer review: A year of experience after instituting a real-time comment-enhanced program at a children's hospital.

OBJECTIVE: Peer review has become an essential component of a comprehensive radiology department quality assurance program. Multiple commercial programs, such as RADPEER, are available to fill this need but may be limited by low radiologist compliance and delayed or limited feedback. Consequently, these peer review programs may not achieve the greater goal of improving diagnostic quality. This article presents data from a peer review system implemented in an academic radiology group at a large urban multidisciplinary children's hospital. The peer review system offered instantaneous feedback with an enhanced comment feature for peer radiologists. MATERIALS AND METHODS: Peer review data were collected on 5278 radiologic studies over a 12-month period including 15 radiologists. The data were analyzed for compliance rate, discrepancy rate, and comment usage. RESULTS: The compliance rate for peer review averaged 52% for the 12-month period. The compliance rate trended upward over the course of the year, with a final month's compliance rate of 76%. The discrepancy rate between original interpretation and peer review was 3.6%. Comments were voluntarily included in 7.3% of nondiscrepant peer review scores. CONCLUSION: Our peer review process was enhanced by real-time comment-enriched feedback on both discrepant and nondiscrepant peer reviews. We show improved radiologist compliance over the course of a year in a peer review program with no incentives or penalties for performing reviews. To our knowledge, no compliance rates exist in current literature for comparison.

MRI of pediatric patients: Part 1, normal and abnormal cartilage.

OBJECTIVE: Cartilage development has a profound impact on musculoskeletal growth. The objective of this article is to offer insights about the maturation of hyaline cartilage through MRI. We begin by briefly describing the molecular make up of hyaline cartilage. We will then follow with a discussion of the basic principles to apply to optimize hyaline cartilage imaging. The remainder of the article will focus on the MR appearances of the distinct histologic types of hyaline cartilage, normal variations in cartilage development, and the sequelae of cartilage injury on normal skeletal development. CONCLUSION: Knowledge of the normal and abnormal appearances of hyaline cartilage on MRI of pediatric patients will allow readers to avoid mistaking the changes associated with skeletal maturation for pathologic findings.

MRI of pediatric patients: Part 2, normal variants and abnormalities of the knee.

OBJECTIVE: The purpose of this article is to discuss MRI of the pediatric knee and familiarize the reader with conditions encountered in the pediatric population. Clinical scenarios are included to convey important concepts and to orient the learner to normal variants and abnormalities of the pediatric knee. The conditions discussed include, but are not limited to, distal femoral metaphysial irregularity, isolated popliteus tendon avulsion, juvenile idiopathic arthritis, and discoid meniscus. CONCLUSION: The knee is the joint that is most commonly imaged by MRI in children. Injury patterns and signs of other pathologic processes seen in skeletally immature patients are different from those seen in adults. Interpreting pediatric knee MRI studies may be a challenge for those unfamiliar with the evolving patterns of normal development and of the signs of conditions that are more prevalent in children. Through case scenarios, this article describes and provides images that depict conditions commonly encountered in the pediatric knee. Most of the described normal findings and abnormalities are more prevalent in the pediatric population than in adults, and a few of the conditions are, in fact, unique to pediatric patients.

Imaging of chronic recurrent multifocal osteomyelitis: self-assessment module.

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of both the imaging and clinical findings of chronic recurrent multifocal osteomyelitis (CRMO).

Imaging bithalamic pathology in the pediatric brain: demystifying a diagnostic conundrum.

OBJECTIVE: The thalami are subject to multiple insults including metabolic and toxic phenomena, acute demyelination, infection, infarction, hemorrhage and neoplastic involvement. The purpose of this article is to review the neuroimaging approach, classification, and imaging of bilateral thalamic lesions with histopathology correlation and application of advanced techniques. CONCLUSION: Neuroimaging of abnormal pediatric thalami uses conventional MRI sequences and advanced techniques to characterize lesions. Although there is considerable imaging overlap, a tailored approach can facilitate diagnosis and management.

MRI of closed spinal dysraphisms.

We present a pictorial review of MRI features of various closed spinal dysraphisms based on previously described clinicoradiological classification of spinal dysraphisms proposed. The defining imaging features of each dysraphism type are highlighted and a diagnostic algorithm for closed spinal dysraphisms is suggested.

Radiographic assessment of pediatric foot alignment: self-assessment module.

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the imaging spectrum of pediatric foot alignment issues.