Radiographic skeletal survey for non-accidental injury: systematic review and development of a national New Zealand protocol.

INTRODUCTION: Clinically occult fractures from non-accidental injury (NAI) are best detected on radiographic skeletal survey. However, there are regional variations regarding the views included in such surveys. We undertook a systematic review of the evidence supporting skeletal survey protocols to design a protocol that could be implemented across New Zealand. METHODS: In June 2013, we searched Medline, Google Scholar, the Cochrane database, UpToDate and relevant reference lists for English-language publications on skeletal survey in NAI from 1946. We included publications that contained a protocol or reported evidence supporting including, or excluding, specific views in a skeletal survey. All included publications were critically appraised. Based on this systematic review, a draft protocol was developed and presented to an Australian and New Zealand Society for Paediatric Radiology NAI symposium in October 2013. Feedback from the symposium and later discussions was incorporated into the final protocol. RESULTS: We identified 2 guidelines for skeletal survey, 13 other protocols and 15 articles providing evidence for inclusion of specific images in a skeletal survey. The guidelines scored poorly on critical appraisal of several aspects of their methods. We found no studies that validate any of the protocols or compare their performance. Evidence supporting inclusion in a skeletal survey is limited to ribs, spine, pelvis, hands and feet, and long bone views. Our final protocol is a standardised, two-tiered protocol consisting of between 17 and 22 views. CONCLUSION: A standardised protocol for radiographic skeletal survey protocol has been developed in New Zealand. We present it here for consideration by others.

Ossification of sacral vertebral bodies in neonates born 24 to 38 weeks' gestational age and its relevance to spinal ultrasonography.

OBJECTIVE: Determination of gestational age and/or birth weight at which sacral ossification centers appear. STUDY DESIGN: Radiographs were reviewed of newborns admitted to Auckland City Hospital between January 2008 and December 2010. Infants were divided into weight clusters increasing in 100-g increments from 400 g to 3000 g and 500-g increments thereafter, for a total of 29 weight clusters. Adequate images were available for at least five newborns per cluster. RESULTS: Images of 163 newborns were reviewed. All but six newborns had five sacral ossification centers by 32 weeks' gestation and a birth weight of 1800 g. Five of the six infants had a congenital anomaly and associated growth restriction. CONCLUSIONS: Infants can be expected to have all five sacral ossification centers present by the time they reach a gestational age of 32 weeks and/or a birth weight of 1800 g. Variation from this can be associated with congenital anomalies and growth restriction.

Demonstration of fourth ventricular choroid plexus on neonatal cranial ultrasonography.

The choroid plexus of the fourth ventricle can be identified on neonatal cranial US via the mastoid fontanelle, particularly when transducers of high frequency are used. Its presence as a normal, echogenic structure might not be appreciated by all sonographers. It should not be mistaken for vermian hemorrhage or clotted blood within the fourth ventricle or cisterna magna.

Syringocoele of the bulbourethral duct with additional lower genito-urinary anomalies.

The ultrasonographic (US) appearance of a syringocoele of the bulbourethral (Cowper) duct, with correlative urethrocystoscopic images, is demonstrated. An infant boy, 5 weeks of age, who presented with E. coli infection of the urinary tract also had bilateral hydroureteronephrosis, small bilateral simple ureterocoeles, and posterior urethral valve leaflets.

John C. P. Williams of Williams-Beuren syndrome.

John C.P. Williams of New Zealand, whose name is associated with Williams-Beuren syndrome, spent his known professional career primarily in cardiovascular research. His disappearance in the mid-1970s and his later life remain a mystery.

Williams-Beuren syndrome: historical aspects.

Williams syndrome, also known as Williams-Beuren syndrome (OMIM database entry 194050), is now known to be commonly associated with a hemizygous chromosomal deletion at 7.q11.23. The way in which the condition came to be recognized historically is reviewed along with some biographical details of the people involved.

Ultrasonographic detection of intracranial melanocytosis in an infant.

An infant who had an extensive cutaneous melanotic nevus with satellite lesions had cranial US for an unrelated problem. Small spherical echogenic foci in the cerebral and cerebellar parenchyma were identified. Subsequent MRI confirmed these as characteristic of melanotic deposits, thereby identifying this infant as having neurocutaneous melanosis.

Catheters, wires, tubes and drains on postoperative radiographs of pediatric cardiac patients: the whys and wherefores.

Surgical treatment of congenital heart disease has advanced dramatically since the first intracardiac repairs in the mid-20th century. Previously inoperable lesions have become the focus of routine surgery and patients are managed successfully in intensive care units around the world. As a result, increasing numbers of postoperative images are processed by departments of radiology in children's hospitals. It is important that the radiologist accurately documents and describes the catheters, wires, tubes and drains that are present on the chest radiograph. This article reviews the reasons for the placement and positioning of perioperative equipment in children who have surgical repair of atrial septal defect, ventricular septal defect or transposition of the great arteries. Also included are a brief synopsis of each cardiac anomaly, the surgical procedure for its correction, and an in-depth discussion of the postoperative chest radiograph including illustrations of catheters, wires, tubes and drains.

Greater trochanteric stippling in trisomy 7p.

Trisomy 7p is a rare condition involving partial or complete duplication of the short arm of chromosome 7. Radiological features include large fontanelles, widened sutures, dolicocephaly and asymmetrical skull. We report a new radiological finding of punctate calcifications in the region of femoral trochanters. This finding has not previously been reported with chromosome 7p duplication.

A guide to the recognition of skeletal disorders in the fetus.

The discovery of fetal skeletal abnormality on prenatal US mandates an extended study of the fetus. This extended examination includes specific views and measurements of the fetal skeleton. Lethality can be predicted if severe pulmonary hypoplasia is present. Specific diagnosis of a fetal osteochondrodysplasia is difficult; a collaborative approach among obstetric, neonatal and genetic services is necessary to provide the parents with all available information regarding the pregnancy. Pediatric radiologists who have experience in radiologic assessment of osteochondrodystrophies of infants and children can provide expertise in this area.

Perinatal assessment of hereditary cystic renal diseases: the contribution of sonography.

The aims of this review article were to clarify the steps that may lead to a proper diagnosis of fetal and neonatal renal cystic diseases. All the hereditary cystic diseases are reviewed and a classification is proposed. The various sonographic patterns that can be used to ascertain the diagnosis are also reviewed. Finally, tables with differential diagnoses are presented to help the reader in the work-up of such pathologies.

High incidence of nephrocalcinosis in extremely preterm infants treated with dexamethasone.

BACKGROUND: The use of postnatal corticosteroids to treat or prevent chronic lung disease is common in very preterm infants. Medullary nephrocalcinosis has been noted as a possible side effect. OBJECTIVE: This prospective study was designed to assess the incidence of nephrocalcinosis in extremely preterm infants exposed to dexamethasone. PATIENTS AND METHODS: A prospective study of extremely preterm infants, recruited to a randomized trial of dexamethasone treatment for chronic lung disease, was initiated. Infants had US of the renal tract scheduled on entry into the study, at day 28 and at discharge or at the corrected gestational age of 36 weeks. RESULTS: Thirty-three infants were enrolled in the study. Birth weight ranged between 440 and 990 g and gestation between 24 and 28 weeks. Nine infants died and six had incomplete data. Because there was no difference in incidence of calcification between those on the short course and those on the long course of dexamethasone, analysis was made on the entire cohort. One infant had nephrocalcinosis at the time of the initial US examination on day 26 of life. By day 28, nephrocalcinosis was present in 31% of those with complete data. By discharge, or corrected gestational age of 36 weeks, US evidence of nephrocalcinosis was present in 15 (83%) of 18 infants. All infants had at least one course of an aminoglycoside antibiotic during the study. All infants had parenteral nutrition. Only four infants received furosemide more regularly than single doses. The longest course was 10 days, received by an infant who did not develop nephrocalcinosis. CONCLUSION: The incidence of nephrocalcinosis is high in this group of sick, extremely preterm infants. Dexamethasone may be a factor in the development of nephrocalcinosis. Future research should focus on the natural history of nephrocalcinosis in extremely preterm infants.

Abnormal sagittal sinus blood flow in term infants following a perinatal hypoxic ischaemic insult.

Ultrasound is a useful tool for the study of the superior sagittal sinus in neonates. The normal patterns of blood flow have been established, and the technique has been used to diagnose sagittal sinus thrombosis. This report describes the sonographic diagnosis of abnormally sluggish or absent sagittal sinus flow in two term infants. The first was a 2,320-g female infant with postnatal hypoxia. The second was a 5,000-g male infant who developed hypoxic ischaemic encephalopathy after delivery complicated by shoulder dystocia. In both cases the normal pattern of blood flow in the superior sagittal sinus was re-established on follow-up ultrasonography.