Conventional Radiography Assessment of the Pediatric Knee: Pearls and Pitfalls.

Knee pain is one of the most common indications for radiography in the evaluation of musculoskeletal disorders in children and adolescents. According to international guidelines, knee radiographs should be obtained when there is the suspicion of an effusion, limited motion, pain to palpation, inability to bear weight, mechanical symptoms (such as "locking"), and persistent knee pain after therapy. When indicated, radiographs can provide crucial information for the clinical decision-making process. Because of the developmental changes occurring in the knee during growth, the assessment of knee radiographs can be challenging in children and adolescents. Radiologists unfamiliar with the appearance of the knee on radiographs during skeletal maturation risk overcalling or overlooking bone lesions. Image acquisition techniques and parameters should be adapted to children. This article describes the most common challenges in distinguishing pathology from the normal appearance of knee radiographs in the pediatric population, offering some pearls and pitfalls that can be useful in clinical practice.

The sternoclavicular ganglion cyst, a rare pediatric diagnosis.

We briefly describe the case of a 4-year-old girl, referred for imaging of a small, firm, round, skin-colored, subcutaneous nodule that suddenly appeared at her right sternoclavicular junction. A plain radiograph was non-contributory, but ultrasonography revealed a small cystic structure, leading to the diagnosis of a sternoclavicular ganglion cyst. Sternoclavicular ganglion cysts are a rare diagnosis, with only seven reported pediatric cases. A watchful waiting approach can be adopted so long as they remain asymptomatic.

Does ethnicity influence bone health index in children? A pilot study.

BACKGROUND: Several pathological conditions can lead to variations in bone mineral content during growth. When assessing bone age, bone mineral content can be estimated without supplementary cost and irradiation. Manual assessment of bone quality using the Exton-Smith index (ESI) and automated assessment of the bone health index (BHI) provided by the BoneXpert® software are available but still not validated in different ethnic groups. OBJECTIVE: Our aim is to provide normative values of the ESI and BHI for healthy European Caucasian and first-generation children of North Africans living in Europe. MATERIALS AND METHODS: A sex- and aged-match population of 214 girls (107 European-Caucasian and 107 North African) and 220 boys (111 European-Caucasian and 109 North African) were retrospectively and consecutively included in the study. Normal radiographs of the left hand and wrist from healthy children were retrieved from those performed in a single institution from 2008 to 2017 to rule out a left-hand fracture. Radiographs were processed by BoneXpert® to obtain the BHI and BHI standard deviation score (SDS). One radiologist, blinded to BHI values, manually calculated ESI for each patient. The variability for both methods was assessed and compared using the standard deviation (SD) of the median (%) for each class of age and sex, and ESI and BHI trends were compared by sex and ethnic group. RESULTS: The final population comprised 434 children ages 3 to 15 years (214 girls). Overall, BHI was lower in North African children (mean = 4.23 for girls and 4.17 in boys) than in European Caucasians (mean = 4.50 for girls and 4.68 in boys) (P < 0.001). Regardless of ethnicity, 29 girls (13.6%) and 34 boys (15.5%) had BHI more than 2 SD from the mean. While correlated to BHI, ESI has a higher variability than BHI and is more pronounced from 8-12 years for both sexes (mean ESI in European Caucasian girls and boys 17.47 and 20.87, respectively) (P < 0.001). ESI showed more than 15% variability in European girls from 8-12 years and a plateau in North African boys from 12 years to 16 years. However, the BHI has less than 15% variability regardless of age and ethnic group. CONCLUSION: BHI may be a reliable tool to detect children with abnormal bone mineral content, with lower variability compared to ESI and with specific trends depending on sex and ethnicity.

The use of shear-wave elastography for the assessment of muscle spasticity in patients with cerebral palsy, a systematic review.

We explore the use of shear wave elastography (SWE) for assessing muscle stiffness and treatment response in cerebral palsy (CP) children by way of a systematic review. SWE offers real-time muscle stiffness measurements, showing significant differences between CP patients and controls. Studies suggest that SWE can be used to follow muscle stiffness post-botulinum toxin treatment, correlating with clinical improvement. However, methodological variations and small sample sizes prevent comparison between different studies. Standardized protocols could enhance SWE's clinical utility. In conclusion, SWE holds promise for CP management, though standardized methodologies and larger studies are needed to validate its efficacy and integration into clinical practice.

Virtual reality simulations to alleviate fear and anxiety in children awaiting MRI: a small-scale randomized controlled trial.

Up to 75% of paediatric patients experience anxiety and distress before undergoing new medical procedures. Virtual reality is an interesting avenue for alleviating the stress and fear of paediatric patients due to its ability to completely immerse the child in the virtual world and thus expose them to the sights and sounds of an MRI before undergoing the exam. We aimed to explore the impact of virtual reality exposure on reducing fear and anxiety in paediatric patients scheduled to undergo an MRI. We hypothesised that patient who had undergone VR exposure before the MRI would experience lower levels of fear and anxiety and subsequently have a higher MRI success rate. We conducted a prospective randomized control trial in a tertiary paediatric hospital over three weeks. Inclusion criteria comprised children aged 4 to 14 undergoing MRI without medical contraindications for VR use. Thirty patients (16 in VR, 14 in control) were included in the study. The VR room, created in-house by a researcher, that the VR group experienced, simulated MRI room with typical sounds for up to 5 min before their actual MRI. Fear and anxiety were measured using the FACES scale before and after MRI for the control group as well as after VR exposure for the VR group. The VR group exhibited a significant reduction in anxiety post-VR exposure regarding the upcoming MRI (p = 0.009). There was no significant difference with regards to fear and anxiety between the VR and control groups before or after the MRI exam. There was no significant difference between the MRI exam success rates. VR exposure effectively reduces pre-MRI anxiety in paediatric patients who are about to undergo the exam, this is important as it alleviates the psychological burden on the child. This research is in line with previous findings, showing the validity of VR as a method of reducing pre-procedural paediatric anxiety and suggesting that complex VR experiences may not be necessary to have a significant impact. There is, however, a need for further investigation in this field using larger and MRI-naïve groups of patients.

Current Role of Conventional Radiography of Sacroiliac Joints in Adults and Juveniles with Suspected Axial Spondyloarthritis: Opinion from the ESSR Arthritis and Pediatric Subcommittees.

This opinion article by the European Society of Musculoskeletal Radiology Arthritis and Pediatric Subcommittees discusses the current use of conventional radiography (CR) of the sacroiliac joints in adults and juveniles with suspected axial spondyloarthritis (axSpA). The strengths and limitations of CR compared with magnetic resonance imaging (MRI) and computed tomography (CT) are presented.Based on the current literature and expert opinions, the subcommittees recognize the superior sensitivity of MRI to detect early sacroiliitis. In adults, supplementary pelvic radiography, low-dose CT, or synthetic CT may be needed to evaluate differential diagnoses. CR remains the method of choice to detect structural changes in patients with suspected late-stage axSpA or established disease and in patients with suspected concomitant hip or pubic symphysis involvement. In children, MRI is the imaging modality of choice because it can detect active as well as structural changes and is radiation free.

Online software Boneureka assessing bone age based on metacarpal length in healthy children: proof-of-concept study.

BACKGROUND: Bone age in children is mainly assessed using the Greulich and Pyle (GP) atlas, a validated method with limited interobserver accuracy. While automated methods increase interobserver accuracy, they represent considerable costs and technical requirements. OBJECTIVE: A proof-of-concept study to create and evaluate an online software program, Boneureka©, based on linear metacarpal length measurements, to assess bone age in healthy children. MATERIALS AND METHODS: The study retrospectively included 434 consecutive children (215 girls) who underwent a left-hand radiograph to rule out trauma between March 2008 and December 2017. Two reviewers measured the second to fourth metacarpal lengths on each radiograph and the distance between the centre of the epiphyses of the second and fifth metacarpals. A single reviewer estimated the bone age using the GP atlas. The automated software assessed the bone age for all radiographs. A mathematical model was developed based on linear regressions to provide the mean bone age and standard deviation based on the estimates. Pearson and intraclass correlation coefficient (ICC) were used to evaluate the correlation and agreement between the estimated bone ages using Boneureka©, the GP atlas and BoneXpert® compared to chronological age. RESULTS: The measure that showed the highest correlation (r2=0.877 for girls and r2=0.834 for boys; P<.001) and the highest ICC (ICC=0.937 for girls and ICC=0.926 for boys; P<0.001) with chronological age was length of the second metacarpal. The GP atlas and the automated software evaluation had excellent ICC with chronological age (ICC>0.95 for both methods and sexes). Using this data, we created an online software program based on the second metacarpal length to obtain bone age estimates, means and standard deviations. CONCLUSION: The newly created online software Boneureka,© based on the second metacarpal length, is a reliable and user-friendly tool to assess bone age in healthy children. Further studies on a larger population should be performed to validate the developed reference values.

The effect of selective ultrasound screening on the incidence of late presentation of developmental hip dysplasia-a meta-analysis.

Different screening strategies for developmental dysplasia of the hip (DDH) exist. Despite screening efforts, cases of late presentation continue to occur, often necessitating surgery. This systematic review and meta-analysis assess the effect of newborn selective ultrasound screening for DDH on the incidence of late presentation in infants and children, compared to a universal ultrasound strategy. A systematic search across Medline and EMBASE databases was performed between January 1950 and February 2021. A consensus-based evaluation of abstracts led to retrieval of relevant full text, original articles or systematic reviews in English only. These were assessed according to agreed eligibility criteria, and their reference lists were reviewed to identify additional eligible publications. Following final consensus on included publications, data was extracted, analysed and reported as per PRISMA and Prospero (CRD42021241957) guidelines. The 16 eligible studies consisted of 2 randomised controlled trials and 14 cohort studies, published between 1989 and 2014, with a total of 511,403 participants. In total, 121,470 (23.8%) received a neonatal hip ultrasound, of whom 58,086 and 63,384 were part of a selective or a universal ultrasound screening strategy, respectively. The difference in the proportion of late presentation between the universal and selective strategies was 0.0904 per 1,000 (P = 0.047). The time effect, i.e. the difference between early and late presentation defined respectively, as less than and more than 3 months of age, regardless of screening strategy, was not significant (P = 0.272). Although there was variability in study design and reporting, the quality of the evidence, based on the critical appraisal skills programme appraisal tools, was generally good. Compared to universal ultrasound screening for DDH, selective screening resulted in a slightly higher rate of late presentation. Uniformity in design and reporting of DDH studies and a cost-effectiveness analysis are needed.

Widespread kidney anomalies in children with Down syndrome.

BACKGROUND: Rare autopsy studies have described smaller kidneys as well as urinary tract anomalies in Down syndrome. This observation has never been investigated in vivo and little is known about the possible consequences upon kidney function. Here we wish to confirm whether children with Down syndrome have smaller kidneys and to evaluate their kidney function in vivo. METHODS: This retrospective cohort study enrolled 49 children with Down syndrome, as well as 49 age- and sex-matched controls at the Queen Fabiola Children's University Hospital in Brussels, Belgium. Doppler and kidney ultrasonography, spot urine albumin to creatinine ratio, estimated glomerular filtration rate (eGFR), and anthropometric data were recorded. RESULTS: Kidney size in children with Down syndrome was smaller than age- and sex-matched controls in terms of length (p < 0.001) and volume (p < 0.001). Kidney function based on eGFR was also decreased in Down syndrome compared to historical normal. Twenty-one of the children with Down syndrome (42%) had eGFR < 90 mL/min/1.73 m2, with 5 of these (10%) having an eGFR < 75 mL/min/1.73 m2. In addition, 7 of the children with Down syndrome (14%) had anomalies of the kidney and/or urinary tract that had previously been undiagnosed. CONCLUSIONS: Children with Down syndrome have significantly smaller kidneys than age-matched controls as well as evidence of decreased kidney function. These findings, in addition to well-noted increased kidney and urologic anomalies, highlight the need for universal anatomical and functional assessment of all individuals with Down syndrome. A higher resolution version of the Graphical abstract is available as Supplementary information.

Postsurgical Evaluation of the Pediatric Foot and Ankle.

This article reviews situations in which surgical treatment is required in the context of different types of pathology in the foot and ankle of children, focusing on the role of imaging in surgical planning and postsurgical assessment. The types of pathology analyzed from this perspective are congenital pathology, neuromuscular disorders, osteochondral lesions, fractures and infection, ligament injuries, and tumors.We address the most common pitfalls of postsurgical imaging of the ankle and foot in children. With some exceptions, postsurgical follow-up focuses on clinical assessment, with imaging follow-up only needed in patients where complications are suspected or symptoms recur. Postoperative assessment of the foot and ankle in children and adolescents requires knowing the indications for surgery and the most common types of interventions, along with their imaging characteristics. The radiologist needs to be aware of the normal sequence of development of structures and how to select adequate imaging techniques to assess anatomy at various stages or in different postsurgical scenarios.

The Adolescent Spine.

Adolescent idiopathic scoliosis (AIS) is the most characteristic disorder of the adolescent spine. It is a three-dimensional (3D) disorder that occurs from 10 years of age and comprises 90% of all idiopathic scolioses. Imaging plays a central role in the diagnosis and follow-up of patients with AIS. Modern imaging offers 3D assessment of scoliosis with less radiation exposure. Imaging helps rule out occult conditions that cause spinal deformity. Various imaging methods are also used to assess skeletal maturity in patients with AIS, thus determining the growth spurt and risk of progression of scoliosis. This article provides a brief overview of the pathophysiology, biomechanics, clinical features, and modern imaging of AIS relevant to radiologists in clinical settings.

Imaging of Bone Marrow: From Science to Practice.

The study of the bone marrow may pose important challenges, due to its changing features over the life span, metabolic stress, and in cases of disease or treatment. Bone marrow adipocytes serve as storage tissue, but they also have endocrine and paracrine functions, contributing to local and systemic metabolism.Among different techniques, magnetic resonance (MR) has the benefit of imaging bone marrow directly. The use of advanced MR techniques for bone marrow study has rapidly found clinical applications. Beyond the clinical uses, it has opened up pathways to assess and quantify bone marrow components, establishing the groundwork for further study of its implications in physiologic and pathologic conditions.We summarize the features of the bone marrow as an organ, address the different modalities available for its study, with a special focus on MR advanced techniques and their addition to analysis in recent years, and review some of the challenges in interpreting the appearance of bone marrow.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies.

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Congenital and Developmental Abnormalities of the Hand and Wrist.

Identification of congenital skeletal abnormalities is complex because of the large variety of individual syndromes and dysplasias that are often difficult to remember. Although a correct diagnosis relies on a combination of clinical, radiologic, and genetic tests, imaging plays an important role in selecting those patients who should be referred for further genetic counseling and expensive genetic tests. In addition to information derived from radiologic analysis of other skeletal elements, radiographs of the hand and wrist may provide particular useful information. In the first part of this article, we provide a guide for a systematic radiologic analysis of the hand and wrist bones that may help characterize congenital and developmental diseases. Special attention is given to the use of correct terminology. In the second part, we discuss typical examples of congenital and developmental diseases involving the hand and wrist, with an emphasis on skeletal dysplasias.

Anatomical Considerations of Embryology and Development of the Musculoskeletal System: Basic Notions for Musculoskeletal Radiologists.

The musculoskeletal (MSK) system begins to form in the third week of intrauterine development. Multiple genes are involved in the complex different processes to form the skeleton, muscles and joints. The embryonic period, from the third to the eighth week of development, is critical for normal development and therefore the time when most structural defects are induced. Many of these defects have a genetic origin, but environmental factors may also play a very important role. This review summarizes the embryology of the different components of the MSK system and their configuration as an organ-system, analyzes the clinical implications resulting from failures in the process of organogenesis, and describes the first approach to diagnosis of skeletal abnormalities using prenatal ultrasound.

Conventional Radiography and Ultrasound Imaging of Rheumatic Diseases Affecting the Pediatric Population.

Juvenile idiopathic arthritis is the most frequent rheumatic disease in the pediatric population, followed by systemic lupus erythematosus, juvenile scleroderma syndromes, juvenile dermatomyositis, chronic recurrent multifocal osteomyelitis, and juvenile vasculopathies. The imaging approach to inflammatory connective tissue diseases in childhood has not changed dramatically over the last decade, with radiographs still the leading method for bony pathology assessment, disease monitoring, and evaluation of growth disturbances. Ultrasonography is commonly used for early detection of alterations within the intra- and periarticular soft tissues, assessing their advancement and also disease monitoring. It offers several advantages in young patients including nonionizing radiation exposure, short examination time, and high resolution, allowing a detailed evaluation of the musculoskeletal system for the features of arthritis, tenosynovitis, enthesitis, bursitis, myositis, as well as pathologies of the skin, subdermis, vessels, and fasciae. In this pictorial essay we discuss radiographic and ultrasound inflammatory features of autoimmune pediatric inflammatory arthropathies: juvenile idiopathic arthritis, lupus erythematosus, juvenile scleroderma, juvenile dermatomyositis and polymyositis.

Preoperative and Postoperative Imaging in Idiopathic Scoliosis: What the Surgeon Wants to Know.

The term idiopathic scoliosis covers a broad spectrum of spinal deformities in the pediatric population without an underlying congenital anomaly of the spine. Depending on the age of presentation, it has both characteristic clinical and imaging features and a different prognosis. The radiologist should provide the surgeon with critical information to assess the degree of deformity and eventually plan surgery. Thoracic deformities and lung volume must also be part of the preoperative assessment. Imaging has a critical role in postsurgical follow-up and in surgical complications. This review highlights the importance of common terminology and measurement methods to avoid incongruences. The different imaging modalities are discussed with their indications and limitations. We pay special attention to imaging modalities that can help the surgeon assess skeletal maturation reliably and thus predict the prognosis of scoliosis. Radiation protection and the risk of cumulative radiation exposure in these patients is emphasized.

Imaging assessment of children presenting with suspected or known juvenile idiopathic arthritis: ESSR-ESPR points to consider.

Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatic disease. It represents a group of heterogenous inflammatory disorders with unknown origin and is a diagnosis of exclusion in which imaging plays an important role. JIA is defined as arthritis of one or more joints that begins before the age of 16 years, persists for more than 6 weeks and is of unknown aetiology and pathophysiology. The clinical goal is early suppression of inflammation to prevent irreversible joint damage which has shifted the emphasis from detecting established joint damage to proactively detecting inflammatory change. This drives the need for imaging techniques that are more sensitive than conventional radiography in the evaluation of inflammatory processes as well as early osteochondral change. Physical examination has limited reliability, even if performed by an experienced clinician, emphasising the importance of imaging to aid in clinical decision-making. On behalf of the European Society of Musculoskeletal Radiology (ESSR) arthritis subcommittee and the European Society of Paediatric Radiology (ESPR) musculoskeletal imaging taskforce, based on literature review and/or expert opinion, we discuss paediatric-specific imaging characteristics of the most commonly involved, in literature best documented and clinically important joints in JIA, namely the temporomandibular joints (TMJs), spine, sacroiliac (SI) joints, wrists, hips and knees, followed by a clinically applicable point to consider for each joint. We will also touch upon controversies in the current literature that remain to be resolved with ongoing research. KEY POINTS: • Juvenile idiopathic arthritis (JIA) is the most common chronic paediatric rheumatic disease and, in JIA imaging, is increasingly important to aid in clinical decision-making. • Conventional radiographs have a lower sensitivity and specificity for detection of disease activity and early destructive change, as compared to MRI or ultrasound. Nonetheless, radiography remains important, particularly in narrowing the differential diagnosis and evaluating growth disturbances. • Mainly in peripheral joints, ultrasound can be helpful for assessment of inflammation and guiding joint injections. In JIA, MRI is the most validated technique. MRI should be considered as the modality of choice to assess the axial skeleton or where the clinical presentation overlaps with JIA.

Dual-tracer PET/CT scan after injection of combined [18 F]NaF and [18 F]FDG outperforms MRI in the detection of myeloma lesions.

The detection rates of whole-body combined [18 F]NaF/[18 F]FDG positron emission tomography combined with computed tomography (PET/CT), CT alone, whole-body magnetic resonance imaging (WB-MRI), and X-ray were prospectively studied in patients with treatment-requiring plasma cell disorders The detection rates of imaging techniques were compared, and focal lesions were classified according to their anatomic location. Twenty-six out of 30 initially included patients were assessable. The number of focal lesions detected in newly diagnosed patients (n = 13) and in relapsed patients (n = 13) were 296 and 234, respectively. The detection rate of PET/CT was significantly higher than those of WB-MRI (P < 0.05) and CT (P < 0.0001) both in patients with newly diagnosed and in those with relapsed multiple myeloma (MM). The X-ray detection rate was significantly lower than those of all other techniques, while CT detected more lesions compared with WB-MRI at diagnosis (P = 0.025). With regard to the infiltration patters, relapsed patients presented more diffuse patterns, and more focal lesions located in the limbs compared with newly diagnosed patients. In conclusion, the detection rate of [18 F]NaF/[18 F]FDG PET/CT was significantly higher than those of CT, MRI, and X-ray, while the detection rate of X-rays was significantly lower than those of all other imaging techniques except for focal lesions located in the skull.