Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses.

Recognising the skeletal manifestations of inflicted injury (II) in infants and young children is of crucial importance. There are specific fracture patterns which are highly suspicious of II in addition to common differential diagnoses with which radiologists should be familiar. Our objective is to provide a non-exhaustive review of the important factors relevant to the imaging and reporting of II as a platform for further learning. Part 2 encompasses fracture patterns of the axial skeleton and important differential diagnoses.

Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 1: initial considerations and appendicular skeleton.

Recognising the skeletal manifestations of inflicted injury (II) in infants and young children is of crucial importance. There are specific fracture patterns which are highly suspicious of II in addition to common differential diagnoses with which radiologists should be familiar. Our objective is to provide a non-exhaustive review of the important factors relevant to the imaging and reporting of II as a platform for further learning. Part 1 encompasses important initial considerations and fracture patterns of the appendicular skeleton.

Subcapsular haematoma and multifocal necrosis as fatal liver complications following umbilical vein catheterisation in a premature baby.

We describe a case of subcapsular haematoma of the right lobe (SHL) and multifocal necrosis of the left lobe (MNL) of the liver following umbilical vein catheterisation (UVC) in a female at 24 weeks' gestation. SHL and MNL have been described as uncommon complications following umbilical vein catheterisation. To our knowledge this is the first time both complications have developed in the same patient. SHL should be considered in the differential diagnosis of hypovolaemic shock in this group of patients.

Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors.

BACKGROUND: Subdural haematomas are thought to be uncommon in babies born at term. This view is mainly based on findings in symptomatic neonates and babies in whom subdural haemorrhages are detected fortuitously. We aimed to establish the frequency of subdural haemorrhages in asymptomatic term neonates; to study the natural history of such subdural haematomas; and to ascertain which obstetric factors, if any, are associated with presence of subdural haematoma. METHODS: We did a prospective study in babies who were born in the Jessop wing of the Central Sheffield University Hospitals between March, 2001, and November, 2002. We scanned neonates with a 0.2 T magnetic resonance machine. FINDINGS: 111 babies underwent MRI in this study. 49 were born by normal vertex delivery without instrumentation, 25 by caesarean section, four with forceps, 13 ventouse, 18 failed ventouse leading to forceps, one failed ventouse leading to caesarean section, and one failed forceps leading to caesarean section. Nine babies had subdural haemorrhages: three were normal vaginal deliveries (risk 6.1%), five were delivered by forceps after an attempted ventouse delivery (27.8%), and one had a traumatic ventouse delivery (7.7%). All babies with subdural haemorrhage were assessed clinically but no intervention was needed. All were rescanned at 4 weeks and haematomas had completely resolved. INTERPRETATION: Presence of unilateral and bilateral subdural haemorrhage is not necessarily indicative of excessive birth trauma.

A comparative study of routine versus selective fetal anomaly ultrasound scanning.

OBJECTIVES: To evaluate the cost-benefit of changing from selective (high risk) to routine ultrasound screening for fetal anomaly. SETTING: Women booked by general practitioners for primary antenatal care at their local hospital. METHODS: Prospective study of the 12 months before and after introduction of routine second trimester ultrasound for fetal anomaly at our institution. All congenital abnormalities, mode of detection, and outcome were recorded and a cost analysis of the programme attempted. RESULTS: In the 12 months of selective (high risk) ultrasound policy, detailed second trimester scans were performed in 1007 (26%) pregnancies. In the 12 months of routine ultrasound anomaly screening, scans were performed in 3529 (93%) pregnancies. Routine ultrasound was the sole method of detection for 11 major and 18 less severe congenital abnormalities found in low risk pregnancies which would not previously have qualified for high risk ultrasound. In seven of these cases the parents opted for termination of pregnancy, with estimated savings on treatment and long term care of 1,015,546 pounds. The financial cost of providing the ultrasound screening service at our hospital for 12 months was calculated at 57,573 pounds and the resulting financial benefit for the year was estimated at 957,973 pounds. CONCLUSION: Although it is recognised that many of the emotional and psychological costs and benefits of the service are difficult to evaluate, routine fetal anomaly ultrasound would seem to be economically justifiable. The financial savings achieved at our hospital would translate into a potential annual saving for the National Health Service of nearly 170 million pounds if screening were offered in all hospitals in England and Wales.

Low field strength magnetic resonance imaging of the neonatal brain.

BACKGROUND: Magnetic resonance (MR) imaging of the neonate has been restricted by the need to transport the sick baby to the large magnetic resonance scanners and often the need for sedation or anaesthesia in order to obtain good quality images. Ultrasound is the reference standard for neonatal imaging. OBJECTIVE: To establish a dedicated neonatal MR system and compare the clinical usefulness of MR imaging with ultrasound imaging. DESIGN: Prospective double blind trial. SETTING: Neonatal intensive care unit, Sheffield. MAIN OUTCOME MEASURES: Imaging reports. PATIENTS: 134 premature and term babies. RESULTS: In 56% of infants with pathology suspected on clinical grounds, MR provided additional useful clinical information over and above that obtained with ultrasound. CONCLUSION: Infants can be safely imaged by dedicated low field magnetic resonance on the neonatal intensive care unit without the need for sedation at a cost equivalent to ultrasound.

The value of ultrasound in the assessment of bone.

The impenetrability of bone to ultrasound can be turned to advantage and the effects of bony lesions on the adjacent soft tissues can be analysed. Fractures, bone destruction, inflammation, distraction of bone and new bone formation can be diagnosed.

Reduction of radiation doses in leg lengthening procedures by means of audit and computed tomography scanogram techniques.

Children with congenital bone dysplasias may benefit from leg lengthening procedures. Such procedures, by necessity, require frequent and regular imaging. It is necessary to minimize the total radiation dose to these patients, and particularly the dose to the gonads. In the present study the films of 13 patients who had completed leg lengthening procedures were reviewed. The number of films was assessed together with the use of appropriate gonad shielding. In a second part of the study, thermoluminescent dosemeter measurements of radiation doses to a phantom were made for both plain radiographs (with and without gonad protection) and computed tomography (CT) scanograms. The results show that audit plays an important role in assessing radiographic practice with respect to accurate placement of gonad protection and confirm that a significant dose reduction can be accomplished by careful use of this lead shielding. Dose reduction can also be achieved by using alternative radiographic techniques such as CT scanograms. Other techniques such as ultrasound or dual-energy X-ray absorptiometry are briefly discussed. These may play an important additional part in the reduction of total radiation dose to the patients.

Iodixanol in paediatric gastrointestinal imaging: safety and efficacy comparison with iohexol.

Iodixanol (Visipaque) is a dimeric, non-ionic iodinated contrast medium that is isotonic with blood at all clinically relevant concentrations. Iodixanol was compared in a randomized, double blind, parallel group, phase III multicentre trial with a monomeric, non-ionic contrast medium, iohexol (Omnipaque), at two concentrations assessing safety, tolerability and radiographic efficacy during contrast enhanced gastrointestinal radiography examinations of children. 154 children entered the trial; 152 formed the safety population and 147 the efficacy population. All examinations were performed following standard departmental practice. Children were assigned into either a high or low concentration group (iodixanol, 150 mgI ml(-1) and 320 mgI ml(-1) vs iohexol, 140 mgI ml(-1) and 300 mgI ml(-1)). The primary outcome measure for efficacy was the overall quality of visualization, which was assessed using a 100 mm visual analogue scale (VAS). The secondary efficacy variables assessed were quality of contrast opacification, mucosal coating and overall quality of diagnostic information. Safety evaluation involved patient follow-up for at least 48 h. Taste acceptance was also assessed. There was no statistically significant difference between the two contrast media with regard to the primary and secondary efficacy variables assessed, although higher ratings were observed for iodixanol. The 100 mm VAS score overall was 86 mm for iodixanol and 82 mm for iohexol (95% confidence interval -2.56, 10.42). The frequency of adverse events was lower for patients receiving iodixanol. Adverse events, mainly diarrhoea, occurred in 12 patients (16.2%) in the iodixanol group and 28 patients (35.9%) in the iohexol group. This reached statistical significance (p=0.006). Overall, iodixanol is well suited for examinations of the gastrointestinal tract, giving good efficacy results and fewer adverse events than iohexol.

A retrospective study of large ovarian masses in paediatric practice.

A retrospective review of 15 patients presenting over a 15-year period with large ovarian tumours is reported in whom the presenting complaint was gross abdominal swelling. Histological confirmation of all the tumours was obtained. There were three serous cystadenomas, two mucinous cystadenomas, one Brenner tumour, three benign juvenile granulosa cell tumours--two not menstruating, three benign teratomas--one not menstruating, one malignant teratoma--not yet menstruating, one malignant embryonic carcinoma and one hydatid disease. All the patients are currently well. The radiological findings are described and some of the marked differences in the radiological appearances of adult and paediatric ovarian masses are illustrated.

Tibial torsion measured by ultrasound in children with talipes equinovarus.

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot.

Endoscopy-guided balloon dilatation of esophageal strictures and anastomotic strictures after esophageal replacement in children.

This study evaluates the safety, efficacy, and technical problems of the new technique of endoscopy-guided balloon dilation (EGBD) in the treatment of strictures of the esophagus and its replacement. Between 1986 and 1990, the authors treated 33 children (aged 3 weeks to 20 years) with EGBD; 18 had esophageal strictures (primary esophageal atresia repair, 13; reflux esophagitis, 5), 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, 1), and 2 had caustic strictures. The majority (23 of 33) had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). EGBD was performed using flexible endoscopy and flouroscopic screening under general anesthesia. Endoscopy identified and resolved the errors or uncertainties of preoperative contrast studies in 7 patients, 5 of whom had colon interposition. EGBD was achieved in all 31 patients with esophageal or replacement strictures; the mean number of EGDB procedures per patient was 2.1 (range 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7 patients. Both patients with caustic strictures had esophageal perforation from EGBD (excessive inflation, 1; false passage of guide wire, 1). Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and resumed eating sooner. The authors conclude that EGBD is safe and effective for treating esophageal and replacement strictures but not caustic strictures.

A multi-observer study examining the radiographic visibility of fishbone foreign bodies.

The use of plain radiographs to localize a suspected fishbone foreign body is the subject of controversy. Accordingly radiographs of 14 species of fishbone, impacted in a soft tissue phantom, were assessed by a series of observers from the ENT department (consultant surgeons, senior registrars and house officers). The agreement was assessed by graphical description of the data and tested by a Spearman's rank correlation test. The overall results showed that, for the clinician, radiography is very useful to detect the bones of: cod, haddock, lemon sole, cole fish, grey mullet and plaice; useful for red snapper, monk fish, gurnard and salmon; and unhelpful in detecting bones from herring, pike, mackerel and trout. The use of radiographs to locate these impacted fishbones can be rationalized in the light of these findings.

Current imaging of childhood urinary infections: prospective survey.

OBJECTIVES: To assess whether ultrasonography alone is adequate for routine screening of childhood urinary infection, whether clinical features determine the need for further investigations, and which investigations are most appropriate. DESIGN: Prospective survey of children with proved urinary infection and a preinvestigation record of clinical features. Ultrasonography and intravenous urography were routine, with choice of further studies determined by ultrasonographic findings. SETTING: A children's hospital and two district general hospitals in Mersey region. MAIN OUTCOME MEASURES: Sensitivity and specificity of ultrasonography both generally and in relation to clinical features. Accuracy of intravenous urography compared with radioisotope examinations. RESULTS: Specificity of ultrasonography was good (99% (95% confidence interval 96% to 100%)) but sensitivity modest (43% (32% to 55%)), principally with respect to detecting vesicoureteric reflux and renal scarring. Among older children (aged 2-10 years) with positive ultrasound results and fever or vomiting the sensitivity in detecting reflux (with and without renal scarring) was 78% (62% to 89%) and the specificity 69% (60% to 78%); in detecting renal scarring (with and without reflux) the sensitivity was 100% (80% to 100%) and specificity 65% (56% to 74%). Renal scarring and obstructive uropathies were better assessed by radioisotope examinations than by intravenous urography. CONCLUSIONS: Ultrasonography alone is inadequate for routine screening of childhood urinary infection. Though further investigations remain advisable in infants, in older children they can be restricted to a minority who have positive ultrasound examinations or have had fever or vomiting. Radioisotope examinations largely eliminate the need for intravenous urography.

Ultrasonography aids decision-making in children with abdominal pain.

INTRODUCTION: Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution. METHODS: Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other. RESULTS: A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4%, a positive predictive value of 92.1% and a negative predictive value of 94.0%. CONCLUSIONS: Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.

Micturating cystography and "double urethral catheter technique" to define the anatomy of anorectal malformations.

Ano-rectal malformations (ARM) in the male patient may be associated with a fistulous communication between the rectum and urethra. Pre-operative radiological assessment is important to delineate (a) the presence and level of the fistula, (b) the anatomy of the posterior urethra and (c) any anomalies in adjacent structures. Bladder catheterisation can be technically difficult when performing an MCUG and distal loopogram in such patients. This can be due to urethral stricture, tortuous or kinked urethra or preferential passage of catheter into a large fistula and leads to an inadequate study. We describe a "double urethral catheter technique" to enable urethral catheterisation when the fistula is large.

Fetal malformations diagnosed antenatally 1: General principles.

Fetal malformations can be diagnosed antenatally by biochemical screening, karyotype analysis or ultrasound scanning. Good teamwork and communication is necessary between obstetrician, paediatrician, geneticist and ultrasonographer to explain the significance of any abnormality to a pregnant woman.