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.

Imaging of the Pediatric Knee.

During normal development, imaging findings in the immature knee joint may mimic pathology or indicate transient sites of weakness, prone to injury. This article reviews the development of the knee joint, age- and maturation-dependent imaging considerations, and various developmental variants that can be encountered, subdivided into those that involve the tibiofemoral and patellofemoral compartments, soft tissues, and osseous components. The tibiofemoral compartment section reviews the focal periphyseal edema zone (FOPE), ossification variants of the femoral condyles, distal femoral metaphyseal cortical irregularity from periosteal traction, and the metaphyseal subperiosteal stripe, which should be distinguished from pathologic mimickers such as endochondral ossification dysfunction, osteochondritis dissecans (OCD), fibroosseous lesion, periosteal and subcortical pathologies. The patellofemoral compartment section includes a review of partite patella, dorsolateral defect, variant trochlear morphology, and maturation-dependent sites of transient weakness that are prone to injury from repetitive overuse (Sinding-Larsen-Johansson syndrome and Osgood-Schlatter disease) and avulsion fractures (patellar sleeve and tibial tubercle avulsions). Finally, soft tissue (discoid lateral meniscus, meniscal flounce, anterior cruciate ligament variants) and osseous components (meniscal ossicle, fabella, and cyamella) are reviewed.

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 incidence of fractures in children under two years of age: a systematic review.

BACKGROUND: Epidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma. OBJECTIVE: This systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics. METHODS: A systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0-2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies. RESULTS: Twelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0-2 years of age; with commonest sites being the radius/ulna (25.2-40.0%), followed by tibia/fibula (17.3-27.6%) and the clavicle (14.6-14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50-60% of fractures. CONCLUSIONS: There is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

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.

Mechanical Ventilation during Bronchiolitis: The Macklin Effect.

This is a case of barotrauma imaging (Macklin effect) after invasive mechanical ventilation in a 14-week-old newborn with complicated bronchiolitis. Teaching point: Imaging could help us improve defining the anatomical boundaries of the Macklin effect, an incompletely known anatomo-physiological entity.

Fibromatosis Colli: A Thorough Description of Its MRI Characteristics and a Review of the Literature.

Introduction: Fibromatosis colli (FC) is a rare pseudotumor of the sternocleidomastoid muscle with an incidence of 0.4%, generally diagnosed using ultrasound between 2 and 4 weeks of age. This is an important entity considering the clinical concerns it causes due to its appearance as a cervical mass with torticollis. Few magnetic resonance imaging (MRI) descriptions of its appearance have been made, with the existing reported cases being sporadic. We aim to provide a thorough description of this paediatric entity. Materials and Methods: We conducted a retrospective study by searching our hospital's database for previous cases of FC where an MRI had been performed. We found six cases of FC where an MRI had been performed. Of these cases, five out of six were contrast-enhanced. We examined the MRIs to be able to discern and describe the MRI characteristics of FC. Results: We found that FC presents a T1 signal isointense to the muscle, a T2 signal hyperintense to the muscle, a variable diffusion signal and a thick enhancing peripheral ring after contrast administration. Discussion: Our results match what has been reported in the literature to date regarding the MRI signal of FC, confirming previous reports. However, we provide new data regarding the characteristic appearance post-enhancement, which was previously unreported. Conclusion: The MRI characteristics of FC have rarely been described, with only a few isolated case reports in the medical literature. We review the current literature, describe the key MRI characteristics of the pathology, and provide the most thorough description to date.

Should the Radiologist Always Request a Blood Test Before an Emergency CT Scan in Children.

Renal failure is relatively common in children presenting to the emergency department, suggesting that the assumption of normal renal function is not always valid. Although some computed tomography (CT) scans necessitate the use of intravenous contrast, one should probably consider whether a blood test is necessary to assess the patient's renal function and possibly consider other imaging modalities before proceeding. With no pediatric-specific guidelines and no validated pediatric prevention strategies, further research is needed to establish clear recommendations for contrast-enhanced exams in stable and unstable pediatric patients with unknown renal function.

The beauty of pediatric musculoskeletal ultrasound.

Ultrasound is a powerful technique in pediatric imaging and musculoskeletal (MSK) imaging in many specific clinical scenarios. This article will feature some common and less common spot diagnoses in pediatric musculoskeletal ultrasound.Cases were collected by members of the Educational Committee of the ESSR (European Society of musculoSkeletal Radiology) and the Pediatric Subcommittee of the ESSR with expertise in musculoskeletal ultrasound.Fifteen clinical entities are discussed based on the features that allow diagnosis by ultrasound.Clinical history, location, and ultrasound appearance are the keys to spot diagnoses when performing pediatric musculoskeletal ultrasound. · Ultrasound in pediatric musculoskeletal imaging can achieve a diagnosis in specific clinical settings.. · Clinical history, location, and ultrasound appearance are keys to spot diagnoses.. · Knowledge of spot diagnoses in pediatric musculoskeletal ultrasound facilitates daily clinical practice..

The impact of radiomics in the management of soft tissue sarcoma.

INTRODUCTION: Soft tissue sarcomas (STSs) are rare malignancies. Pre-therapeutic tumour grading and assessment are crucial in making treatment decisions. Radiomics is a high-throughput method for analysing imaging data, providing quantitative information beyond expert assessment. This review highlights the role of radiomic texture analysis in STSs evaluation. MATERIALS AND METHODS: We conducted a systematic review according to the Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in PubMed/MEDLINE and Scopus using the search terms: 'radiomics [All Fields] AND ("soft tissue sarcoma" [All Fields] OR "soft tissue sarcomas" [All Fields])'. Only original articles, referring to humans, were included. RESULTS: A preliminary search conducted on PubMed/MEDLINE and Scopus provided 74 and 93 studies respectively. Based on the previously described criteria, 49 papers were selected, with a publication range from July 2015 to June 2023. The main domains of interest were risk stratification, histological grading prediction, technical feasibility/reproductive aspects, treatment response. CONCLUSIONS: With an increasing interest over the last years, the use of radiomics appears to have potential for assessing STSs from initial diagnosis to predicting treatment response. However, additional and extensive research is necessary to validate the effectiveness of radiomics parameters and to integrate them into a comprehensive decision support system.

How to Approach the Imaging Differential Diagnosis of Rheumatic Diseases by Anatomic Location.

The purpose of this review is to present an approach to differential diagnosis based on the particular features of involvement of the most common rheumatological conditions focused on anatomic location (by joint). The most common radiological signs and how they are demonstrated in different modalities, as well as the typical patterns of involvement are analyzed, with the aim to facilitate the differential diagnosis. Early and adequate adjustment of treatment has an effect on outcome, and on this basis, early diagnosis and characterization are paramount to appropiately manage patients.

Idiopathic parietal bone thinning mimicking a bone lesion.

Idiopathic focal unilateral skull thinning is a rare finding. An explanation, such as trauma or disease, can often be found. However, in some cases, no explanation is forthcoming, and thus, we must look further into their history for a possible cause. The case of a nine-year-old boy with a crescent-shaped unilateral parietal bone thinning and a history of ventouse-assisted birth is presented. The lesion matches a ventouse's typical location, shape, and size. Thus, with the support of one other reported similar case, we hypothesise this may be the origin. We present the case of a crescent-shaped lesion matching the imprint of a ventouse in a child with a concordant history. This finding is put in the context of similar reports in the literature, and we believe that this report provides further evidence of this obscure phenomenon. Funding: None declared.