Congenital cystic dysplasia of the rete testis.

Cystic dysplasia of the rete testis (the network of straight seminiferous tubules within the mediastinum testis leading to the efferent ductules) is a rare congenital anomaly. There are only 15 cases reported in the literature to date and only one report of the US findings [1-5]. This report highlights the characteristic appearance of the lesion on ultrasound examination and its association with renal abnormalities in two patients.

Magnetic resonance imaging of growth plate injuries: the efficacy and indications for surgical procedures.

In 23 patients with growth plate injuries, magnetic resonance imaging (MRI) studies were performed a total of 31 times to evaluate the physis which showed plain radiographic evidence of possible damage. Fourteen patients clinically showed growth arrest, and 10 patients required a Langenskiold operation. In 3 patients who underwent this operation, subsequent premature total fusion of the physis adversely affected the postoperative results. We propose that the merging shape of the arrest line with calcification of the provisional zone of the metaphysis shown by MRI indicates poor viability of the physis. MRI provided useful information on the appearance of the growth plate and changes in the metaphysis, both of which affected the prognosis and the results of the surgical procedures.

Traumatic pancreatitis: long-term review of initial non-operative management in children.

OBJECTIVE: To assess the safety and long-term efficacy of an initial non-operative approach to the management of pancreatic trauma in children. METHODOLOGY: Retrospective case-note review of children admitted to our institution with the diagnosis of pancreatic trauma over a 10-year period from 1985 to 1994 inclusive. RESULTS: Fourteen children were identified with a diagnosis of traumatic pancreatitis. Eleven of the injuries were secondary to motor vehicle accidents or trauma from a bicycle handlebar. In seven patients there were associated intra-abdominal injuries and in eight patients the traumatic pancreatitis was complicated by development of a pseudocyst. Three pseudocysts settled without intervention, two resolved with percutaneous external drainage and the remaining three required open surgery. The mean in-patient stay was 21.2 days. The average length of follow-up was 7.7 years with no observed long-term complications. CONCLUSIONS: Non-operative management of traumatic pancreatitis in the absence of complete duct transection is safe in children and does not appear to be associated with adverse sequelae.

Renal length in Chinese children: sonographic measurement and comparison with western data.

PURPOSE: The purpose of this study was to determine the normal range of renal length in Hong Kong Chinese children and compare it with Western data. METHODS: Two hundred fifty children undergoing routine abdominal sonography were examined prospectively, and the maximum length of 1 kidney per child was recorded. Ages ranged from newborn to 19 years, and there were 109 girls and 141 boys. Similar data from Australian children involved maximum lengths of both kidneys in 554 children ranging in age from newborn to 14 years. There were 361 girls and 193 boys. No children had known renal disease. RESULTS: There was no statistically significant difference between the mean renal lengths of girls and boys. Statistical comparison of the data from Hong Kong and Australia showed no significant difference except in the 8-12 month age group (this difference is unlikely to be clinically significant). Although direct statistical comparison with published data on kidney lengths in 203 U.S. children was not possible, plots of the three sets of data were strikingly congruent. CONCLUSIONS: Despite expectations that smaller body size in Hong Kong children might equate to smaller kidneys, comparison with 2 sets of Western data showed no clinically significant difference in renal length between the 3 groups.

Thyroglossal duct cyst or ectopic thyroid gland?

We report a 16-year-old boy with an anterior midline neck mass clinically diagnosed as a thyroglossal duct cyst. An ultrasound scan performed prior to surgery suggested a normally located thyroid gland. Following surgical excision of the presumed thyroglossal duct cyst the patient became hypothyroid. A radioisotope scan confirmed no active thyroid tissue. A pitfall in the ultrasonographic identification of the thyroid gland is discussed.

High-resolution ultrasonography in the differential diagnosis of cystic diseases of the kidney in infancy and childhood: preliminary experience.

Autosomal recessive polycystic kidney disease, autosomal dominant polycystic disease, and glomerulocystic disease may all appear in the perinatal period as bilaterally enlarged echogenic kidneys. Current ultrasonographic equipment can better demonstrate the underlying pathologic state and assist in the differentiation of these conditions. The primary abnormality in autosomal recessive polycystic kidney disease is at the level of the collecting ducts, which are dilated and saccular. The nephrons remain normal. These dilated ectatic tubules are seen in their usual distribution as a radial array, with major ducts being perpendicular to the renal capsule, in both the renal cortex and the medulla. The peripheral renal cortex does not normally contain collecting ducts and remains unaffected in patients with mild disease. Autosomal dominant polycystic disease is characterized by cystic changes involving both the nephron and the collecting ducts. The nephron may become cystic at any point. Multiple discrete cysts of varying sizes are seen in both the renal cortex and the medulla in the severely affected infant. Subcapsular cysts are seen regularly. Glomerulocystic disease is an unusual sporadic condition characterized by the cystic dilation of the space of Bowman and the proximal convoluted tubule. On ultrasonographic examination tiny, isolated cysts, usually smaller than those occurring in autosomal dominant polycystic kidney disease, are seen in the echogenic renal cortex and may extend to the periphery of the kidney. No cysts are seen in the renal medulla. Correlation between pathologic findings and sonographic images is of value in correctly diagnosing these conditions.

Slipped capital femoral epiphysis. Incidence and clinical assessment of physeal instability.

In an unselected series of 55 cases of slipped capital femoral epiphysis (SCFE) we observed an incidence of 25% of epiphyseal reduction, mostly unintentional. Reduction indicated physeal instability and was associated with an effusion, detected by sonography on admission, and inability to bear weight. The true prevalence of instability may be higher since an effusion was noted in 33 cases (60%) on the initial sonographic assessment. Serial radiographs showed reduction in 12 (22%), with an average change of 15.1 degrees in the head-neck angle. Serial sonography showed reduction in 7 out of 20 cases (35%), with an average change of 3.7 mm in displacement. In two cases reduction was seen on sonography but not on radiography. Of the hips which showed subsequent reduction, 12 had had a bone scan on admission; three showed initial epiphyseal avascularity but only one progressed to symptomatic avascular necrosis. All stable hips had normal epiphyseal vascularity on the initial bone scan. This indicates the importance of injury from the initial displacement in causing avascular necrosis, rather than effusion, vascular compromise or iatrogenic injury from gentle repositioning. Physeal instability in SCFE is common and should be assessed clinically on admission. It is indicated by joint effusion or inability to bear weight. A slip is very unlikely to be unstable in a child able to bear weight and with no sonographic effusion.

Ultrasonic features of acute osteomyelitis in children.

The ultrasonic findings in 38 children with osteomyelitis of the limb bones were analysed in four time-related groups based on the interval between the onset of symptoms and the ultrasonic examination. Deep soft-tissue swelling was the earliest sign of acute osteomyelitis; in the next stage there was periosteal elevation and a thin layer of subperiosteal fluid, and in some cases this progressed to form a subperiosteal abscess. The later stages were characterised by cortical erosion, which was commonly present in those who had had symptoms for more than a week. Concurrent septic arthritis was revealed in 11 patients, most frequently in association with osteomyelitis of the proximal femur or the distal humerus. Four weeks after clinical cure, ultrasonic examination showed no abnormalities. Ultrasonography is therefore a useful additional method for the diagnosis and assessment of osteomyelitis and its complications.

Ultrasonic signs of pelvic osteomyelitis in children.

The ultrasonic findings were reviewed in 13 children in whom pelvic osteomyelitis was diagnosed by a positive 99mtechnetium methylene diphosphonate (MDP) bone scan in conjunction with clinical and laboratory features of osteomyelitis. All patients presented with pain in the region of the hip joint. In six patients the ultrasound study was confined to the hip joint, and all six had normal findings. In seven patients the ultrasound study was extended to include the pelvis. Deep soft tissue swelling was demonstrated in six of these, including a periosseous abscess in one case. Ultrasonography was negative in one patient with a 5-week history, whose pelvic osteomyelitis was resolving at the time of the ultrasound study. Oedema of the obturator internus and externus muscles was observed in osteomyelitis affecting the pubis and ischium, and of the iliacus and/or the gluteus medius muscle in osteomyelitis of the ilium. In children presenting with hip pain who have a normal hip ultrasound study, extension of the ultrasound examination to include these four pelvic muscles may help to identify and document the progression of acute pelvic osteomyelitis.

Ultrasonography in Perthes' disease. Clinical relevance and influence on treatment.

A detailed description of the ultrasonographic findings in the course of Perthes' disease has recently been evolved. Synovitis was a prominent finding in the early stages. Lateral extrusion of the femoral head and signs of healing were found earlier by ultrasonography than by radiography. This has clinical implications. Immobilisation in the acute phase was shown to decrease capsular distension, and treatment using containment can be started earlier. The findings in 25 hips were evaluated in this study and their influence on treatment is discussed.

Classification in slipped capital femoral epiphysis. Sonographic assessment of stability and remodeling.

In a prospective study of 26 hips in 21 patients with slipped capital femoral epiphyses (SCFEs), serial sonography was more sensitive than radiography in showing epiphyseal displacement and reduction. Reductions were associated with grossly visible hip joint effusions. The initial slips were reduced by treatment in seven of 11 hips with effusion. The 15 hips without effusion were unreduced. After stabilization and pinning, the effusion did not recur in any case. Sonography is sensitive and free from projectional errors in the assessment of metaphyseal remodeling. If any remodeling is present, the SCFE is at least three weeks in duration. A new classification into acute, acute-on-chronic, and chronic SCFEs is proposed, based on the objective sonographic data. Joint effusion represents physeal instability or recent progression, and remodeling is a sign of chronicity. An acute SCFE is characterized by effusion, whereas a slip without effusion but with remodeling is designated as chronic. An acute-on-chronic SCFE is associated with both effusion and remodeling. Joint effusion suggests that SCFEs should be operatively fixed and that displacement may diminish with traction or intraoperative positioning of the hip.

Remodeling in slipped capital femoral epiphysis: sonographic assessment after pinning.

Twenty-one children and 26 hips with recent slipped capital femoral epiphysis (SCFE) underwent serial sonographic examination after operative fixation. The initial sonographic step at the anterior outline of physis decreased as a result of metaphyseal resorption. The first signs of resorption were evident 3 weeks after onset of symptoms; thereafter, the rate of resorption was 2 mm for each 3 weeks of follow-up. Finally, the physeal step was smooth and the anterior aspect of the femoral neck was straight. Sonography is accurate and free of projectional errors in assessment and classification of remodeling in SCFE.

Sonographically demonstrated thickening of the renal pelvis in children.

Thickening of the wall of the renal pelvis has been attributed to infection, to rejection in allografts and to non-specific causes by different authors. We reviewed the clinical data, imaging studies and pathology of 35 patients with sonographically demonstrable thickening in 41 renal pelves of native kidneys. Our findings are that less than 50% of the patients had infection. The others had a wide variety of apparent causes for the thickening which include obstruction, surgery, edema induced by chemicals and other processes. Vesicoureteral reflux was demonstrated in 50% of the patients studied by cystography. We concluded that renal pelvic thickening is a non-specific finding.

Ultrasonography in Legg-Calvé-Perthes disease.

Ultrasonography was found to be a valuable investigation in the assessment and management of Legg-Calvé-Perthes disease (LCPD). It was used to assess 23 patients with LCPD in 25 affected hips and was compared with radiographs obtained at the same time. A chronological five-part staging of LCPD is proposed, expressing the degree of flattening and fragmentation as well as reconstitution of the femoral head as seen on ultrasound examination. Thickening of articular cartilage was documented, and associated findings of synovitis and lateral extrusion of the femoral head were evaluated. An intraarticular hip effusion was present in 74% of cases in stages I-II. Lateral extrusion increased from stage II onwards until the healing stage. The phase of reconstitution (stage IV) demonstrated both resorption of the necrotic bone and formation of new immature osteoid tissue. Lateral extrusion and the start of the healing phase can be shown earlier by ultrasonography than by radiography.

Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity.

We used ultrasonography to study 26 hips with slipped capital femoral epiphyses. In recently slipped epiphyses the ultrasound image revealed a step at the anterior physeal outline (mean 6.4 mm), diminished distance between the anterior acetabular rim and the femoral metaphysis (mean 4.3 mm) and an effusion. As metaphyseal remodelling progressed the physeal step decreased. The femoral neck appeared straighter in hips which had been symptomatic for longer than three weeks. It was possible to measure posterior epiphyseal displacement without projectional errors and the method was accurate in diagnosing minimal slip and in staging displacement. The suggested criteria are, less than 7 mm for a mild slip, 7 to 11 mm for a moderate slip and more than 11 mm for a severe slip. We recommend ultrasonography for the diagnosis, staging and follow-up management of slipped upper femoral epiphysis.

The value of a new ultrasound stress test in assessment and treatment of clinically detected hip instability.

Fifty patients with clinical suspicion of hip dislocation were investigated prospectively with a dynamic ultrasound stress test. A posterior force was applied to hips in flexion and any movement between the femoral head and the acetabulum was measured. The results of this test showed that posterior movement ranged from 0 to 13.0 mm. Hips that were clinically normal had a mean movement of 1.4 mm, hips with minor clinical instability had a mean movement of 0.6 mm, hips with moderate instability had a mean movement of 4.5 mm, and those with major instability had a mean movement of 5.1 mm. This was statistically significant to a 1% confidence interval. We propose two groups of ultrasound-detected movement: group A less than 5.0 mm representing physiologic laxity, and group B greater than or equal to 5.0 mm being pathological and requiring treatment.

Urological anomalies detected on antenatal ultrasound: a 9 year review.

One hundred and forty-eight patients (107 male, 41 female), in whom a urological anomaly was detected on antenatal ultrasound examination, are reviewed. Postnatal imaging was done primarily by ultrasonography (US) which was often repeated. Depending upon the ultrasound findings, the patients had a renal nuclide scan (RNS) and/or micturating cysto-urethrogram (MCU), but intravenous urogram (IVU) was not usually considered necessary. A range of urological anomalies was encountered, but renal anomalies were most common. Over half the cases had anomalies which did not require surgery, with non-obstructive pelvicalyceal dilatation being frequent. Almost half the operated cases had features which should have allowed a clinical diagnosis without the knowledge of the antenatal findings. A fifth of the cases were occult in that they would not have been diagnosed early in life but for the antenatal detection. The majority had congenital pelviureteric junction obstruction and results of early reconstructive surgery were satisfactory.

Alexander's disease: cranial ultrasound findings.

This is thought to be the first report of the recognition by cranial ultrasound of the abnormal pattern of cerebral tissues which occurs in Alexander's disease. This finding suggests that cranial ultrasound could be a useful adjunct in the diagnosis of this cerebral leukodystrophy, particularly in those infants presenting with megalencephaly.

Alexander's disease: cranial ultrasound findings.

This is thought to be the first report of the recognition by cranial ultrasound of the abnormal pattern of cerebral tissues which occurs in Alexander's disease. This finding suggests that cranial ultrasound could be a useful adjunct in the diagnosis of this cerebral leukodystrophy, particularly in those infants presenting with megalencephaly.