Association of Time Since Diagnosis of Pediatric Ileocolic Intussusception With Success of Attempted Reduction: Analysis in 1065 Patients.

BACKGROUND: Radiologists generally treat pediatric ileocolic intussusceptions emergently given potential worse outcomes from delayed reduction attempts. However, relevant literature is conflicting. OBJECTIVE: To identify factors associated with successful image-guided ileocolic intussusception reduction in children, with attention to the time interval since diagnosis. METHODS: This retrospective study included patients <6 years old who underwent attempted image-guided enema reduction of ileocolic intussusception between May 2009 and July 2023. Patients were separated into two groups: those presenting directly to the institution (nontransferred patients, who all underwent attempted reduction <8 hours after ultrasound diagnosis), and those transferred from outside facilities. EHR data were extracted. Each patient's first image-guided reduction attempt was classified as successful or unsuccessful. Univariable and multivariable analyses were performed. RESULTS: The study included 1065 patients (649 male, 416 female; mean age, 18.1 months; age range, 2.2-71.0 months; 793 nontransferred and 272 transferred patients). In nontransferred patients, the mean interval between ultrasound diagnosis and reduction attempt was 150.8 minutes; in transferred patients, the mean interval between outside facility advanced imaging and reduction attempt was 460.1 minutes (p<.001). Successful reduction occurred in 84.6% and 81.6% of nontransferred and transferred patients, respectively (p=.25). In nontransferred patients, success occurred in 85.6% of attempts <2 hours after diagnosis versus 84.0% of attempts 2-<8 hours after diagnosis (p=.54); the mean interval from diagnosis to attempted reduction was 149.7 minutes and 156.8 minutes for successful and unsuccessful attempts, respectively (p=.53). In multivariable analysis, factors showing independent associations with success were proximal intussusception location (OR=3.63, p<.001) and absence of high-risk ultrasound findings (OR=2.57, p<.001); success was not independently associated with age, sex, bloody stools, reduction method, or time since diagnosis <2 hours (p>.05). In transferred patients, the mean interval from outside advanced imaging to attempted reduction was 463.1 minutes and 440.2 minutes for successful and unsuccessful attempts, respectively (p=.74). CONCLUSION: Intussusception reduction may not require completion emergently (within 2 hours after diagnosis), but potentially may be safely performed on an urgent basis (within 8 hours). CLINICAL IMPACT: The findings have implications for determining the standard of care, including criteria for oncall activation of radiologic resources, in pediatric intussusception management.

Congenital and Traumatic Conditions of the Pediatric Hand: Overview for the Radiologist.

Alignment, longitudinal growth, and function of the musculoskeletal unit of the pediatric hand is complex due to the combination of open growth plates, ossification variations, and their relationship with finger tendinous and ligamentous attachments. This review presents the basics of normal development, acquired and congenital variations, and traumatic conditions of the pediatric hand from the perspective of the pediatric musculoskeletal radiologist and hand surgeon. This multimodality imaging article focuses on non-oncologic and non-rheumatologic conditions of the pediatric hand, inclusive of fingers, thumb, and metacarpal bones.

MR imaging spectrum of adolescent pubic symphyseal injuries/athletic pubalgia.

BACKGROUND: Magnetic resonance imaging (MRI) findings associated with athletic pubalgia are well documented in the adult literature. OBJECTIVE: To describe the spectrum of MRI findings in adolescents with pubic symphyseal injuries/athletic pubalgia. MATERIALS AND METHODS: This is an institutional review board approved, retrospective study of all patients < 18 years who were referred for MRI, over the last 10 years. Two pediatric musculoskeletal radiologists evaluated the MRI in consensus for the following findings: Chronic Salter-Harris (SH)-I equivalent fracture or asymmetric parasymphyseal ossific fraying, non-retractile muscular tear or retraction, and edema of the aponeurosis and arcuate ligament. Radiographs were also reviewed for Risser stage. RESULTS: Fifteen patients were identified (100% male, median age 17 years, IQR 16-17.6). Most patients (14/15, 93%) had either asymmetric parasymphyseal ossific fraying (4/15, 27%) or chronic SH-1 equivalent fracture (10/15, 67%) of the pubic symphysis, and all patients (15/15, 100%) had aponeurotic and arcuate ligament edema. Few patients had rectus abdominis muscular retraction (2/15, 13%), non-retractile muscular tear of the rectus abdominis (2/15, 13%), and/or adductor muscle (4/15, 27%). Risser stage was as follows: stages 0 (13%), 3 (7%), 4 (47%), and 5 (33%). The injuries in our limited data set were independent of skeletal maturity with no statistically significant association between any of the MRI findings and Risser stage. CONCLUSION: The MR imaging spectrum of adolescent athletic pubalgia differs from the described findings in adults due to skeletal immaturity. The cleft sign described in adults manifests in adolescents as asymmetric parasymphyseal ossific fraying and chronic SH-1 equivalent fractures.

Musculoskeletal injections for palliative treatment of neuromuscular hip dysplasia patients: how I do it.

This review describes our institution's standardized technique as well as potential pitfalls for therapeutic steroid injections in children with symptomatic neuromuscular hip dysplasia. Symptomatic, painful neuromuscular hip dysplasia can dramatically affect quality of life. Steroid injections are used to identify the source of perceived pain, temporarily treat pain while awaiting surgical intervention, or for therapeutic management for nonoperative hip joints.

Gartland classification concordance of supracondylar fractures among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

BACKGROUND: The modified Gartland classification is the most widely accepted grading method of supracondylar humeral fractures among orthopedic surgeons and is relevant to identifying fractures that may require surgery. OBJECTIVE: To assess the interobserver reliability of the modified Gartland classification among pediatric radiologists, pediatric orthopedic surgeons, and pediatric emergency medicine physicians. MATERIALS AND METHODS: Elbow radiographs for 100 children with supracondylar humeral fractures were retrospectively independently graded by two pediatric radiologists, two pediatric orthopedic surgeons, and two pediatric emergency medicine physicians using the modified Gartland classification. A third grader of the same subspecialty served as a tie-breaker as needed to reach consensus. Readers were blinded to one another and to the medical record. The modified Gartland grade documented in the medical record by the treating orthopedic provider was used as the reference standard. Interobserver agreement was assessed using kappa statistics. RESULTS: There was substantial interobserver agreement (kappa = 0.77 [95% CI, 0.69-0.85]) on consensus fracture grade between the three subspecialties. Similarly, when discriminating between Gartland type I and higher fracture grades, there was substantial interobserver agreement between specialties (kappa = 0.77 [95% CI, 0.66-0.89]). The grade assigned by pediatric radiologists differed from the reference standard on 15 occasions, pediatric emergency medicine differed on 19 occasions, and pediatric orthopedics differed on 9 occasions. CONCLUSION: The modified Gartland classification for supracondylar humeral fractures is reproducible among pediatric emergency medicine physicians, radiologists, and orthopedic surgeons.

Clinical impact of diagnostic image-guided injections for musculoskeletal pain work-up in adolescent and adult patients at a children's hospital: initial results.

OBJECTIVE: To assess the clinical impact of diagnostic musculoskeletal (MSK) injections on treatment decision-making in adolescent and adult patients at a children's hospital. MATERIALS AND METHODS: Retrospective study in patients who underwent diagnostic MSK injections by fluoroscopy or ultrasound (US) between 8/2020 and 3/2023 at a children's hospital. Patients received ropivacaine and triamcinolone acetonide at pain site, reporting quantitative FACES pain score prior to, immediately following, and 2-3 days following injection. Impact on patient care was subsequently assessed. RESULTS: A total of 109 diagnostic fluoroscopic or US MSK injection referrals (mean: 17.6 years old) were included, most commonly hip (76.2%), ankle (9.2%), and iliopsoas tendon sheath (8.3%). Pain improvement occurred in 89.0% immediately and 67.9% 2-3 days after MSK injection, with net 84.4% exhibiting improvement based on pain scores and clinical exams. When there was pain improvement at the site of injection, there was a statistically higher incidence of operative intervention or additional therapeutic injections compared with the cohort that did not have symptom improvement (88% versus 35.3%, P < 0.0001). For the 15.6% (N = 17) of referrals that did not have pain improvement, 17.6% (n = 3) ultimately had an operative intervention at a separate site from the diagnostic injection, as an alternative etiology for the pain was found. CONCLUSION: Image-guided MSK injections play an important role in the management of musculoskeletal disorders. 84.4% of referrals experienced symptom relief, improving confidence for treatment decision-making. Importantly, 15.6% of patients were found to have an alternative etiology for symptoms, altering management altogether.

Percent Final Height Is a Novel Method That Identifies Differences Between the Rate of Development in American Children of Different Races.

INTRODUCTION: The Greulich & Pyle (G&P) Radiographic Atlas of Skeletal Development uses hand x-rays obtained between 1926 and 1942 on children of Caucasian ancestry. Our study uses modern Caucasian, Black, Hispanic, and Asian children to investigate patterns of development as a function of percent final height (PFH). METHODS: A retrospective review, at a single institution, was conducted using children who received a hand x-ray, a height measurement taken within 60 days of that x-ray, and a final height. BA and CA were compared between races. PFH was calculated by dividing height at the time of the x-ray by their final height. To further evaluate differences between races in CA or BA, PFH was then modeled as a function of CA or BA using a fifth-degree polynomial regression, and mean ages at the 85th PFH were compared. Patients were then divided into Sanders stages 1, 2-4, and 5-8 and the mean PFH, CA, and BA of the Asian, Black, and Hispanic children were compared with the White children using Student t test. P values less than 0.05 were considered significant. RESULTS: We studied 498 patients, including 53 Asian, 83 Black, 190 Hispanic, and 172 White patients. Mean BA was significantly greater than CA in Black males (1.27 y) and females (1.36 y), Hispanic males (1.12 y) and females (1.29 y), and White females (0.74 y). Hispanic and Black patients were significantly more advanced in BA than White patients ( P <0.001). At the 85th PFH, White and Hispanic males were older than Black males by at least 7 months ( P <0.001), and White females were significantly older than Hispanic females by 6.4 months ( P <0.001). At 85th PFH for males, Hispanic and Black males had greater BA than White males by at least 5 months ( P <0.001), and Asian females had a greater BA than Black females by at least 5 months ( P <0.001). Compared with White children, Hispanic children were significantly younger at Sanders 2-4 than White children, and Black children were skeletally older at Sanders 5-8. CONCLUSIONS: BA was greater than CA by ≥1 year in Black and Hispanic children, and that these children had a significantly greater BA than their White counterparts. Black males and Hispanic females reached their 85th PFH at younger ages, and Hispanic males and Asian females were the most skeletally mature at their 85th PFH. Our results suggest that BA and CA may vary as a function of race, and further studies evaluating growth via the 85th PFH may be necessary. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

How Reliable Is the Measurement of the Lateral Center Edge Angle on Scoliosis Radiographs for Detecting Acetabular Dysplasia?

PURPOSE: Hip dysplasia reportedly occurs in up to 12% of the general population and may be higher in patients with adolescent idiopathic scoliosis (AIS). When using lateral center edge angle (LCEA) measurements to help identify hip dysplasia, it is uncertain if this measurement can be performed reliably on scoliosis radiographs due to parallax. The purpose of this study is to evaluate the reliability of measuring LCEA on scoliosis radiographs compared with standard pelvis radiographs. METHODS: This study evaluated 40 hips on 20 patients (mean age 12.5 years ± 3.1; 50% Female) who received PA scoliosis radiographs and AP pelvis radiographs within 1 year of each other. Review was performed by 4 pediatric radiologists (2 general, 2 MSK), 2 pediatric orthopaedic surgeons, and 1 research fellow. Radiographic measurement of the LCEA for each hip was first performed on the scoliosis radiograph. After a minimum of 3 days, the LCEA was measured on a pelvis radiograph of the same individual obtained within 1 year of the scoliosis radiograph. Pearson coefficient was used to measure agreement between scoliosis and pelvis radiograph measurements. Intraclass correlation coefficient (ICC) was used to evaluate intraobserver and interobserver agreement. ICC values <0.5 were classified as poor reliability, 0.5 to 0.75 were classified moderate, 0.75 to 0.90 were classified good, and >0.9 indicated excellent reliability. RESULTS: The mean difference between scoliosis and pelvis radiographs was 54 ± 79 days. There was good-to-excellent interobserver agreement on LCEA measurements made between readers on scoliosis radiographs (ICC: 0.94, 95% CI: 0.90-0.96, P <0.001) and pelvis radiographs (ICC: 0.91, 95% CI: 0.83-0.95, P <0.001), and moderate-to-excellent intraobserver agreement for scoliosis radiographs (ICC range: 0.68 to 0.98; P <0.001) and pelvis radiographs (ICC range: 0.62 to 0.96; P <0.001). There was a strong correlation between LCEA measurements made on scoliosis and pelvis radiographs ( r2 =0.66, P <0.001), and the intermodality agreement between scoliosis and pelvis radiograph LCEA measurements were moderate to good (ICC range: 0.68 to 0.89, P <0.001). CONCLUSIONS: Overall, there was good-to-excellent agreement between readers on scoliosis and pelvis radiographs, respectively, and moderate-to-excellent intraobserver agreement between LCEA measurements made on scoliosis radiographs and pelvis radiographs, respectively. LCEA measurements made on scoliosis radiographs strongly correlated to the measurements made on pelvis radiographs, and the intermodality ICC was also considered moderate to good. Dedicated pelvis radiographs may not be necessary during scoliosis workup and follow-up surveillance, thereby decreasing radiation exposure, cost, and improving patient care workflow. LEVEL OF EVIDENCE: Level IV-diagnostic study.

MRI diagnostic performance and strategies for identifying retears in treated pediatric discoid and non-discoid lateral meniscal repairs.

Magnetic resonance imaging (MRI) plays a role in assessing retears of previously treated lateral menisci (LM). We aim to characterize the rate and pattern of arthroscopically confirmed LM retears in children with and without discoid morphology. 288 patients (312 knees) who underwent arthroscopic repair of isolated LM tears between 2018 and 2023 were identified. 20 patients (21 knees) had arthroscopically confirmed isolated LM retear. This included 11 retears of discoid lateral meniscus (DLM) and 10 retears of non-DLM. MRI correctly identified retear in 81.8% of DLM cases (n = 9) and 100% of non-DLM cases (overall 90.5%, P = 0.476). 78% of DLM cases (n = 7) had residual discoid elements. MRI is highly accurate in diagnosing retears in isolated LM injuries (90.5%). We suggest that the radiological approach to assessing meniscal retears can be similarly applied to treated discoid and non-discoid menisci. However, special attention to residual discoid elements is crucial in previously treated DLMs.

Medial meniscal posterior horn tears and ramp lesions in pediatric patients: lessons learned.

Meniscal injuries are increasingly reported in pediatric patients due to early sports participation and are commonly encountered during anterior cruciate ligament reconstruction. Preoperative identification of meniscal tears is crucial, particularly when involving the posteromedial meniscocapsular junction (ramp lesion). MRI plays an important role in detecting this particular type of meniscal injury. Consequently, pediatric radiologists should be aware of particular MRI findings related to ramp lesions including the presence of a medial meniscal tear, peripheral meniscal irregularity, meniscocapsular junctional fluid-like signal intensity, and capsular ligament tears. Thus, we illustrate the lessons we have learned from our institutional multidisciplinary arthroscopic-MR correlation conference for retrospectively identified posterior horn medial meniscal tears and ramp lesions.

How Often Do Patients Presenting With Severe Adolescent Idiopathic Scoliosis Have Underlying Hip Dysplasia?

INTRODUCTION: Adolescent idiopathic scoliosis radiographic screening will often include the hips. The purpose of this study is to evaluate the prevalence of hip dysplasia by lateral center edge angle (LCEA) on scoliosis radiographs in patients presenting with severe range (>45 deg) idiopathic curves. METHODS: We reviewed 200 consecutive patients (400 hips) with idiopathic scoliosis with major coronal curves ≥45 degrees between October 2009 and October 2022. The presenting scoliosis radiograph PA were reviewed for the following variables: major coronal curve direction, coronal balance, and lateral center edge angles. An LCEA value ≤18 was considered dysplastic. To assess potential measurement variability related to parallax of the scoliosis radiographs, the intermodality intraclass correlation coefficient (ICC) was measured from a subset of 20 hip LCEA values from patients with both scoliosis and pelvis radiographs. RESULTS: A total of 200 patients [mean age: 13.6 (1.8) years; Female: 79%] were reviewed. The mean major curve (SD) was 58.6 degrees (11.4 deg). Overall 19% (37/200) patients or 11% (43/400) of hips had hip dysplasia. Of the dysplastic hips, 16% (6/43, P <0.001) were bilateral and 57% (21/43, P =0.04) were right sided. There was no association between dysplastic hip laterality and ipsilateral or contralateral coronal balance ( P =0.26) or curve direction ( P =0.49). The interobserver ICC for assessment of LCEA on scoliosis radiographs was 0.85, and the intermodality ICC between pelvic and scoliosis radiographs was 0.78. CONCLUSION: Hip dysplasia was present in 19% of patients presenting with large major curves, and many of these patients had right sided hip dysplasia. There was no association between hip dysplasia laterality and the patient's major curve direction or coronal balance. There was good intermodality reliability (ICC=0.78) between LCEA values in patients who had both scoliosis and pelvis radiographs, and good inter-rater reliability between raters. Radiographic interpretation of adolescent idiopathic scoliosis should focus not only on the description of the curve and ruling out underlying segmentation anomalies but should also include critical assessment of the hips to exclude co-existing hip dysplasia. LEVEL OF EVIDENCE: Therapeutic study-level IV.

Providing second-opinion interpretations of pediatric imaging: embracing the call for value-added medicine.

The value of obtaining second-opinion interpretations by specialty radiologists has been established. In pediatric radiology, this has primarily been explored in general terms, comparing tertiary pediatric radiologists' interpretations to referral reads. In adults, second reads by subspecialty radiologists have been shown to yield changes in patient management, including in neuroradiology, musculoskeletal radiology and oncological radiology. Here, we examine second-opinion reads by pediatric radiologists by reviewing the pediatric and adult subspecialty literature. We also present our experience in providing subspecialty outside reads, summarizing lessons learned in implementing a system for outside interpretations into a pediatric radiology practice.

Pediatric Bassett's ligament: pathology or normal anatomy?

BACKGROUND: Bassett's ligament is an accessory fascicle of the anterior inferior tibiofibular ligament. The prevalence, normal thickness and clinical implications of a thickened ligament have not been described in the pediatric radiology literature. OBJECTIVE: The purpose of this study was to determine the prevalence and thickness of Bassett's ligament in pediatric patients with magnetic resonance imaging (MRI) findings of lateral talar osteochondral lesions, medial talar osteochondral lesions and posterior ankle impingement, to compare these measurements with normal MRIs, and to compare the reproducibility of these measurements. MATERIALS AND METHODS: This is a retrospective study of pediatric ankle MRIs with four cohorts containing 21 patients each. All MRIs were retrospectively reviewed by a pediatric musculoskeletal radiologist and a pediatric radiology fellow. The prevalence of Bassett's ligament and its axial thickness were obtained for each cohort with repeat measurements for intra-observer and interobserver variability. Average thickness and standard deviation of Bassett's ligament were calculated. RESULTS: The prevalence of Bassett's ligament and its thickness in each cohort were (mean±standard deviation): lateral osteochondral lesions, 71% (15/21), 1.9±0.5 mm; medial osteochondral lesions, 52% (11/21), 1.4±0.2 mm; posterior impingement, 52% (11/21), 1.3±0.2 mm; and normal ankle examinations, 71% (15/21), 1.5±0.4 mm. The thickness of Bassett's ligament was increased in the lateral talar osteochondral lesion group when compared to normal (P=0.02), while thickness in the medial osteochondral lesion and posterior impingement groups was not significant when compared to normal. The repeat measurements showed no significant difference in intra-observer and interobserver variability. CONCLUSION: Bassett's ligament is a normal structure in children. Thickening of Bassett's ligament is seen with lateral osteochondral lesions and may be an indirect sign of anterolateral tibiotalar capsule injury.

Percutaneous ultrasound-guided ganglion fenestration in children: initial results.

OBJECTIVE: To evaluate our pediatric experience with percutaneous ultrasound-guided fenestration of ganglia (PUGG). MATERIALS AND METHODS: Retrospective study of pediatric patients who underwent PUGG from June 2016 to October 2018 at a free-standing tertiary referral academic children's hospital with a minimum of 6 months follow-up. Electronic medical records, picture archiving system, and post-procedural calls were utilized for patient demographics, lesion characteristics, procedure details, and recurrence. The procedure itself consisted of assessment by Child Life, application of topical anesthetic cream, sterile preparation and draping, and intra-procedural ultrasound guidance for local anesthetic instillation, ganglion aspiration, fenestration, and intra-remnant steroid instillation. Post-procedure care included an ice pack, compression dressing for 48 h, and 4 weeks of brace wear and activity restriction. RESULTS: Forty-five patients met the inclusion criteria, ages 3-18 years, mean 13.5 years, and female to male ratio of 2:1. Ganglion locations consisted of 80% (36/45) in the wrist and 20% (9/45) in other locations (elbow, ankle, and foot). Ninety-eight percent (44/45) of procedures were performed non-sedated, including 20% (9/44) between ages 7 and 11 years. 28.9% (13/45) of ganglia recurred, the earliest at 3 weeks, the latest at 10 months, and an average of 3 months' time. No complication occurred and no patients required post-procedural narcotics or Emergency Department visitation for pain control. CONCLUSION: Percutaneous ultrasound-guided fenestration of ganglia (PUGG) is a safe, minimally invasive alternative to surgical excision in the pediatric population, which can be performed without sedation and does not leave a scar.

Bone age determination using only the index finger: a novel approach using a convolutional neural network compared with human radiologists.

BACKGROUND: Recently developed convolutional neural network (CNN) models determine bone age more accurately than radiologists. OBJECTIVE: The purpose of this study was to determine whether a CNN and radiologists can accurately predict bone age from radiographs using only the index finger rather than the whole hand. MATERIALS AND METHODS: We used a public anonymized dataset provided by the Radiological Society of North America (RSNA) pediatric bone age challenge. The dataset contains 12,611 hand radiographs for training and 200 radiographs for testing. The index finger was cropped from these images to create a second dataset. Separate CNN models were trained using the whole-hand radiographs and the cropped second-digit dataset using the consensus ground truth provided by the RSNA bone age challenge. Bone age determination using both models was compared with ground truth as provided by the RSNA dataset. Separately, three pediatric radiologists determined bone age from the whole-hand and index-finger radiographs, and the consensus was compared to the ground truth and CNN-model-determined bone ages. RESULTS: The mean absolute difference between the ground truth and CNN bone age for whole-hand and index-finger was similar (4.7 months vs. 5.1 months, P=0.14), and both values were significantly smaller than that for radiologist bone age determination from the single-finger radiographs (8.0 months, P<0.0001). CONCLUSION: CNN-model-determined bone ages from index-finger radiographs are similar to whole-hand bone age interpreted by radiologists in the dataset, as well as a model trained on the whole-hand radiograph. In addition, the index-finger model performed better than the ground truth compared to subspecialty trained pediatric radiologists also using only the index finger to determine bone age. The radiologist interpreting bone age can use the second digit as a reliable starting point in their search pattern.

Community-acquired pneumonia requiring hospitalization among U.S. children.

BACKGROUND: Incidence estimates of hospitalizations for community-acquired pneumonia among children in the United States that are based on prospective data collection are limited. Updated estimates of pneumonia that has been confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS: We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among children younger than 18 years of age in three hospitals in Memphis, Nashville, and Salt Lake City. We excluded children with recent hospitalization or severe immunosuppression. Blood and respiratory specimens were systematically collected for pathogen detection with the use of multiple methods. Chest radiographs were reviewed independently by study radiologists. RESULTS: From January 2010 through June 2012, we enrolled 2638 of 3803 eligible children (69%), 2358 of whom (89%) had radiographic evidence of pneumonia. The median age of the children was 2 years (interquartile range, 1 to 6); 497 of 2358 children (21%) required intensive care, and 3 (<1%) died. Among 2222 children with radiographic evidence of pneumonia and with specimens available for bacterial and viral testing, a viral or bacterial pathogen was detected in 1802 (81%), one or more viruses in 1472 (66%), bacteria in 175 (8%), and both bacterial and viral pathogens in 155 (7%). The annual incidence of pneumonia was 15.7 cases per 10,000 children (95% confidence interval [CI], 14.9 to 16.5), with the highest rate among children younger than 2 years of age (62.2 cases per 10,000 children; 95% CI, 57.6 to 67.1). Respiratory syncytial virus was more common among children younger than 5 years of age than among older children (37% vs. 8%), as were adenovirus (15% vs. 3%) and human metapneumovirus (15% vs. 8%). Mycoplasma pneumoniae was more common among children 5 years of age or older than among younger children (19% vs. 3%). CONCLUSIONS: The burden of hospitalization for children with community-acquired pneumonia was highest among the very young, with respiratory viruses the most commonly detected causes of pneumonia. (Funded by the Influenza Division of the National Center for Immunization and Respiratory Diseases.).

Utility of immediate postoperative hip MRI in developmental hip dysplasia: closed vs. open reduction.

BACKGROUND: Magnetic resonance imaging (MRI) of the hips is being increasingly used to confirm hip reduction after surgery and spica cast placement for developmental dysplasia of the hip (DDH). OBJECTIVE: To review a single institutional experience with post-spica MRI in children undergoing closed or open hip reduction and describe the utility of MRI in directing the need for re-intervention. MATERIALS AND METHODS: Seventy-four patients (52 female, 22 male) who underwent post-spica hip MRI over a 6-year period were retrospectively reviewed. One hundred and seven hips were included. Data reviewed included age at intervention, gender, type of intervention performed, MRI findings, the need for re-intervention and the interval between interventions. Gender was compared between the closed and open reduction groups via the Fisher exact test. Age at the first procedure was compared via the Wilcoxon rank test. Rates of re-intervention after closed and open reduction were calculated and the reasons for re-intervention were reviewed. RESULTS: The mean age at the time of the first intervention was 16.4 months (range: 4 to 63 months). Mean age for the closed reduction group was 10.5 months (range: 4-24 months) and for the open reduction group was 23.7 months (range: 5-63 months), which was significant (P-value <0.0001). Of the 52 hips that underwent closed reduction, 16 (31%) needed re-intervention. Of the 55 hips that underwent open reduction, MRI was useful in deciding re-intervention in only 1 (2%). This patient had prior multiple failed closed and open reductions at an outside institute. CONCLUSION: Post intervention hip spica MRI is useful in determining the need for re-intervention after closed hip reduction, but its role after open reduction is questionable.

Radiographic appearance and clinical significance of fidget spinner ingestions.

BACKGROUND: According to anecdotal press reports, there have been medically significant ingestions of fidget spinner toys, including ingestions that required endoscopic intervention. Fidget spinners have been marketed to improve attention and have been suggested as a therapeutic alternative to medications in children with attention deficit hyperactivity disorder (ADHD). OBJECTIVE: To describe the radiographic appearance and features of ingested fidget spinner components. To evaluate clinical significance via rates of endoscopic intervention, incidence in patients on ADHD medications, and mean age compared to other accidental foreign body ingestions. MATERIALS AND METHODS: A nested retrospective case control study analyzed pediatric accidental foreign body ingestions identified via electronic medical record search between March 1, 2017, and Feb. 28, 2018. Radiographic identifiability, component type and maximum diameter of ingested fidget spinner components were described. A nested cohort of non-fidget spinner ingestions between May 1 and Aug. 31, 2017, was compared with the fidget spinner ingestions for rates of endoscopic intervention (a), concomitant use of ADHD medication (b) and mean age (c) using the Fisher exact test (a and b) and independent samples t-test (c). RESULTS: There were 1,095 unintentional foreign body ingestions. Ten were ingested fidget spinner component ingestions. Eight of the 10 ingested components were radiographically identifiable. Compared with the nested cohort of non-fidget spinner ingestions, fidget spinner ingestions were more likely to undergo endoscopic intervention (P=0.009, 5/10 fidget spinner ingestions vs. 54/383 other ingestions). Fidget spinner patients were more likely to be on ADHD medication (P=0.011, 2/10 fidget spinners vs. 5/383 other). Fidget spinner mean patient age was significantly older than other ingestions (P=0.015, mean: 7.1 years fidget spinner ingestions vs. 4.0 years for other ingestions). CONCLUSION: Compared with other foreign body ingestions, patients who ingested fidget spinner components were more likely to undergo endoscopic intervention, had a higher rate of ADHD medication use and were older. Familiarity with the radiographic appearance of ingested fidget spinner components is important for patient management.

Modified Friedman technique: a new proposed method of measuring glenoid version in the setting of glenohumeral dysplasia.

BACKGROUND: Glenoid version angles are measured to objectively follow changes related to glenohumeral dysplasia in the setting of brachial plexus birth palsy. Measuring glenoid version on cross-sectional imaging was initially described by Friedman et al. in 1992. Recent literature for non-dysplastic shoulders advocates time-consuming reconstructions and reformations for an accurate assessment of glenoid version. OBJECTIVE: To compare Friedman's original method for measuring glenoid version to a novel technique we developed ("modified Friedman") with the reference standard of true axial reformations. MATERIALS AND METHODS: With institutional review board approval, we retrospectively examined 30 normal and dysplastic shoulders obtained from magnetic resonance imaging examinations of 30 patients with an established diagnosis of brachial plexus birth palsy between January 2012 and September 2017. Four pediatric radiologists performed glenoid version measurements using Friedman's method, the modified Friedman method and a previously described true axial reformation method. The modified Friedman technique better accounts for scapular positioning by selecting a reference point related to the acromion-scapular body interface. Inter-rater reliability and inter-method agreement were assessed using intraclass correlation, paired t-tests and mixed linear model analysis. Equivalence tests between methods were performed per reader. RESULTS: Glenoid version measurements were significantly different when comparing Friedman's method to true axial reformations in normal (-10.8±5.7° [mean±standard deviation] vs. -8.8±5.3°; P≤0.001) and dysplastic shoulders (-34.6±17.7° vs. -28.1±17.5°; P≤0.001). Glenoid version measurements were not significantly different when comparing the modified Friedman's method to true axial reformations in normal (-6.3±5.8° vs. -8.8±5.3°; P=0.06) and dysplastic shoulders (-29.0±18.3° vs. -28.1±17.5°; P=0.06). Friedman's method was not equivalent to true axial reformations for measurements in dysplastic shoulders for all readers (P=0.68, 0.81, 0.86, 0.99); the modified Friedman method was equivalent to of true axial reformations for measurements in dysplastic shoulders for 3 of 4 readers (P≤0.001, P≤0.001, P≤0.001, P=0.10). CONCLUSION: In glenohumeral dysplasia, the modified Friedman method and post-processed true axial reformations provide statistically similar and reproducible values. We propose that our modified Friedman technique can be performed in lieu of post-processed true axial reformations to generate glenoid version measurements.

Pre-authorization processes have no effect on patients undergoing knee MRI in a pediatric setting when evaluated by specialists.

OBJECTIVE: Pre-authorization processes are often used by medical insurance companies to reduce costs by managing the utilization of advanced diagnostic imaging, and their impact on patient care is unclear. The purpose of our study is to determine if a pre-authorization process increases the rate of surgically significant abnormal knee MRI and surgical referrals compared with patients referred from pediatric orthopedic specialists who do not undergo a pre-authorization process. MATERIALS AND METHODS: A retrospective study was performed; 124 patients were identified who were referred for knee MRI by a pediatric orthopedist. The study population included patients who underwent an insurance pre-authorization process and the control group consisted of those who did not. The results of the MRI and whether they were deemed surgically significant, in addition to surgical referral, were recorded and compared. RESULTS: The study and control groups showed no statistically significant difference in outcome with regard to surgically significant findings on MRI (p = 0.92) or whether the patient required surgery (p = 0.6). CONCLUSIONS: In this population, there is no difference in the likelihood of an abnormal knee MRI demonstrating surgically significant findings or referral to surgery in patients who did and those who did not undergo an insurance pre-authorization process when patients are referred from a pediatric orthopedic specialist. The insurance pre-authorization process does not appear to have an impact on patient diagnosis and treatment and may unnecessarily add bureaucracy and costs.