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Hello and welcome to Noon Conference hosted by Modality.

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Noon Conference connects the global radiology community through free live

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educational webinars that are accessible for all and is an opportunity to learn

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alongside top radiologists from around the world.

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Today, we are honored to welcome Dr.

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Grace Mitchell for a lecture entitled Pediatric MSK

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Trauma. Dr. Mitchell is a pediatric radiologist at Children's Mercy

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Hospital and an associate professor of radiology at the University of

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Missouri, Kansas City. She earned her MD/MBA

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from Tufts University, completed an internal medicine internship at Carney

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Hospital, and a diagnostic radiology residency at

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Baystate Medical Center. She further specialized with a fellowship in

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pediatric radiology at Cincinnati Children's Hospital Medical Center in twenty

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fifteen. Passionate about radiology education, Dr.

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Mitchell serves as the associate program director for the UMKC Diagnostic

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Radiology Residency and the site director for all diagnostic

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radiology residency rotations at Children's Mercy Hospital.

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At the end of the lecture, please join Dr.

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Mitchell in a Q&A session where she will address questions you may have on today's

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topic. Please remember to use the Q&A feature to submit your questions, so

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we can get to as many as we can before our time's up.

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With that said, we're ready to begin today's lecture. Dr.

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Mitchell, please take it from here.

1:20

Hi. Thanks very much. Thanks for having me.

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I have no financial disclosures. I am a volunteer with the American Board

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of Radiology. And also, with regards to this set

1:33

of cases that we'll be reviewing today, be aware that some may be normal.

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So although we're talking about pediatric MSK trauma, not all the

1:41

cases necessarily will have something abnormal about it, just like in real

1:44

life. We're gonna start with just a series of unknown

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cases. So I will show these cases for several seconds, and in your own

1:52

mind, you can try and figure out what you think is going on, and then

1:56

we'll review all of the cases with explanations and

1:59

comparisons. Here is case number

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one, a frontal view of a shoulder in a pediatric

2:06

patient.

2:14

Case number two, this is an

2:16

elbow.

2:26

Case number three, an elbow in a different patient.

2:30

We have an oblique and a lateral view.

2:39

Case number four, another elbow in

2:42

another

2:43

patient.

2:53

Case number five, forearm frontal and

2:57

ra-- lateral

2:58

radiographs.

3:08

Case six, frontal view of a pe-

3:12

pediatric young child's

3:14

wrist.

3:24

Case seven,

3:26

focused on the fourth and fifth digits.

3:29

We have frontal and oblique radiographs and then individual lateral

3:33

radiographs of the fourth and fifth digits.

3:37

With this particular case, I will say that there is or are

3:40

fractures. There is a fracture or there are fractures.

3:44

My question to you is how many fractures do you

3:46

see?

3:50

Give you a little extra time on this one.

4:02

Case eight, chest radiograph. This is an infant

4:06

who came in to the emergency department with

4:09

fussiness.

4:21

Case nine, we have a young child,

4:24

six-year-old, that comes in with

4:27

left hip or pubic region

4:30

pain.

4:44

Case ten, an older child with

4:46

pain.

4:52

This is the same child. The image on the left is the same image I just showed you,

4:56

and the image on the right is an additional

4:58

view.

5:09

Case eleven, we have bilateral knee radiographs of a

5:12

four-week-old.

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Case twelve, we have a toddler,

5:28

four-year-old, knee

5:30

pain.

5:43

Case thirteen, we have a toddler, an almost

5:46

three-year-old, that is unable to bear weight

5:50

after jumping on a

5:51

trampoline.Case

6:06

14, we have a two-year-old who f- comes in

6:10

after a

6:10

fall.

6:20

Here we

6:20

have...

6:24

Sorry about that. Here we have case 15, a

6:28

teenager

6:30

who had some sort of sports

6:31

injury.

6:44

And our final case, we have three views of the foot

6:48

in an older child with pain.

7:00

All right. And I know in some of these cases, I didn't give you very much

7:03

information, maybe just pain. I didn't give you a location, and that

7:07

was on purpose. All right. So we're gonna move on to discuss each of these

7:11

cases, starting from the first one.

7:12

This was case number one, frontal radiograph of the shoulder.

7:16

What we are seeing here is, a seven-year-old

7:20

who was a pitcher for his Little League team,

7:23

and what we see here is widening of the physis of the

7:27

proximal humerus. So although we are used to seeing open physis in

7:31

children, this is too wide. It's separated, and the metaphysis

7:35

is quite irregular and fragmented-looking.

7:38

Little bit of sclerosis along that metaphysis.

7:40

If we compare this to a child of a similar age with a normal physis,

7:44

you can see the distinction. You can see the open physis that's not as

7:48

wide. We have, clear margins along the

7:51

physis on the m- both epiphyseal and metaphyseal side,

7:55

whereas here we can see that indistinctness.

7:57

So this is, frequently called Little Leaguer shoulder.

8:00

This is a chronic repetitive stress injury through the physis.

8:04

It's a Salter-Harris I type injury that involves the

8:07

physis, and this is a more extreme case.

8:10

Sometimes they're not as obvious.

8:12

When you have more subtle cases in particular, you wanna pay attention to the

8:15

lateral side of the physis. That's where sometimes it can be more evident.

8:19

Although sometimes you have to be careful.

8:21

That also can be a kind of m- slightly wider looking,

8:25

normally. You don't wanna misinterpret this apparent widening here.

8:29

That's probably more projectional than it is a true widening.

8:34

So Little Leaguer shoulder.

8:39

Case number two. This is a frontal view of

8:43

the elbow, and what we're looking at here in particular is

8:46

this bone right here. So this

8:50

is kind of an interesting case because we probably have a combination of an

8:54

acute on chronic injury, certainly at least a chronic component.

8:57

So this is also sometimes called a Little Leaguer injury

9:01

related to, pitching, except in the elbow as opposed to

9:05

the shoulder. So this is a chronic, again, a chronic,

9:09

repetitive injury causing, the,

9:14

sorry, the medial epicondyle to

9:17

fr- to separate from the parent bone.

9:20

And so when you have this chronic type injury, again, you get

9:23

widening between the epicondyle and the parent

9:27

bone. In this particular case, we also had a little bit of a displaced fragment,

9:30

and that perhaps may be an acute component.

9:33

It's hard to tell 'cause it does look like it's a bit well corticated, along

9:36

most of it, so it's hard to know from this one image alone, but there might be an

9:40

acute on chronic aspect to this. Um, with the

9:44

chronic, you can get both. You can have, patients with an acute

9:48

injury from pitching, and you might see something similar in terms of displacement

9:52

of the epicondyle. But what tells us that this is more of a chronic injury in

9:56

this patient, is you can get, this

9:59

irregular, thickened kind of look, of the

10:02

fragmented aspect. So you can get this traction apothecitis,

10:07

you can get epicondylitis. And so I also have a

10:10

comparison here of a similar age child with a normal elbow where you

10:14

can still see that the epicondyle ossification center is not yet fused to the

10:18

underlying bone. Uh, however, it is not as separated as

10:22

this one, and we don't have that same irregularity and sclerosis, and we certainly

10:26

don't have that fragment hanging out that we do on this

10:28

case. So this right side is a normal

10:32

medial epicondyle, and this is an abnormal

10:34

one.

10:38

This is a companion case showing the bilateral elbows in

10:42

oblique views of the same patient right and left, and this one is challenging.

10:46

And this can be challenging in kids in the elbow in particular because we have so

10:49

many ossification centers that are, showing up

10:53

with different appearances that are all within normal limits.

10:57

We can see little ossification centers in multiple places.

11:01

However, in this kid in particular, if they have focal medial

11:04

pain, and in this case they did on the right side, notice that on the normal left

11:08

side, we have that normal-looking epicondyle, normal distance from the parent

11:12

bone, normal-looking ossification center, whereas on the

11:16

contralateral side, we've got fragmentation along the inferior aspect.

11:19

There's some slightly subtle but increased sclerosis and probably

11:23

some separation here. It's a little challenging 'cause these two angles of the

11:26

elbows are not exactly identical to each other, so we've got a little bit of

11:30

overlap artifact happening here on the left, but this is just a bit separated, a

11:34

little bit more than we're used to seeing, and certainly these look asymmetric to

11:38

each other. If you only had this image of the right side

11:41

alone, this could be challenging.

11:43

It could be feasible that this is within normal developmental variation.

11:47

It's just an irregular ossification center.

11:49

So in those sorts of cases, especially if you have focal pain where the pain

11:53

is right at this area, it can be helpful to subsequently

11:57

request a contralateral view to compare the other

12:00

side. They aren't always necessarily gonna be perfectly symmetric, but they, it

12:04

might give you an idea if there's a likelihood of a chronic injury, which we

12:08

have here. So this was another Little Leaguer elbow with

12:11

chronic, repetitive stress

12:13

injury.Case

12:17

three, different patient. A sort of oblique

12:20

and lateral radiograph of the elbow.

12:23

And what I want you to notice here is that although we don't see, like we saw in

12:27

the last case, a separated, epicondyle

12:30

adjacent to the parent bone, instead we see a fracture frag- or we

12:34

see a bone fragment somewhere it should not be, namely right

12:38

here. If you had this frontal or this oblique view alone,

12:42

you might be tempted to say, "Oh, that little bit of bone is likely

12:45

the, trochlear ossification center, and that's probably

12:49

normal." However, if you look at the lateral view, you'll see that corresponding

12:54

fragment is intra-articular. That, that...

12:57

The trochlear ossification center should not be there in the joint.

13:00

This is not normal. So this is also a medial,

13:04

epicondyle or medial condyle fracture that has actually

13:07

displaced, and it is now intra-articular, and this

13:11

absolutely is going to need surgical treatment.

13:14

Here are fluoroscopic images from the surgical reduction.

13:18

So we can see again an oblique image here.

13:21

There's that little fragment that's in the joint, and then we can see that it's now

13:25

been reduced to a more normal location here, and then ultimately we see

13:29

those fixation screws fixating it in place.

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So even though in this kid most of the ossification centers have

13:35

largely started to fuse to the parent bone and there aren't as many open

13:39

physis, the radial, proximal radial physis is still open, but a lot of these

13:43

are fusing, this, fractured and completely displaced

13:47

into the joint and had to be surgically

13:49

fixed. As a

13:52

reminder, these are sort of fuzzy images that I borrowed from the Radiology

13:55

Assistant website. When we think about the pediatric

13:59

elbow and its ossification centers, we want to remember the CRITO

14:03

mnemonic. Each of... Oops, sorry.

14:05

Each of these stand for one of the, ossification

14:08

centers, and in particular, you want to remember the I-T, the

14:12

IT, and this is relative, this is related to the cases that I just

14:16

showed. The internal, or sometimes called the medial

14:20

epicondyle, should start showing up, meaning the ossification

14:23

center should start ossifying earlier than the trochlear

14:27

ossification center. This mnemonic, the order of these

14:31

letters is the order in which these ossification centers should start

14:35

showing up in a kid, and they, they show up in a fairly,

14:38

reproducible way every couple of years starting in childhood.

14:41

And so, the thing that can be most tricky is the case I

14:45

just showed you. If you see what looks like an ossification center

14:49

in the region of the trochlea

14:51

but you do not see an internal or a medial epicondyle

14:55

ossification center, you need to be very

14:59

careful to evaluate whether that apparent trochlear ossification center is, in

15:03

fact, instead a displaced internal epicondyle,

15:07

avulsion fracture, because the I comes before the

15:10

T in the mnemonic, and so that means the I should show

15:14

up before the T. So if you see a T but no I, then perhaps that T is

15:18

actually the I, and it's displaced.

15:20

And so that's very similar to the case I just showed.

15:25

Case number four, different elbow.

15:27

Clearly there's a fracture in the distal humerus.

15:30

This is what we call a supracondylar fracture.

15:33

Obviously displaced quite a bit, angulated, lots of soft tissue

15:37

swelling. You can see all the fat straining.

15:39

You can also see the elevated, fat pad, both anteriorly and

15:42

posteriorly. It's clearly a fracture, not a diagnostic dilemma.

15:46

There is a classification or a grading system for these supracondylar fractures.

15:50

It's not something I'm going to go through in detail, but you can always look it

15:53

up, or if you're not sure of it, you can just give measurements in your report how

15:57

much it's displaced,

16:00

and that will help guide surgical management.

16:03

While this is a very obvious case, however, a lot of the times we

16:07

don't have the most obvious cases.

16:09

So here's a companion case of a younger child, and we

16:13

can see probably what stands out the most to me initially is on

16:17

the lateral radiograph, we see that this anterior fat pad is

16:21

uplifted. It can be normal to see an anterior

16:25

fat pad in a normal elbow. However, it should have a

16:29

relatively parallel appearance to the anterior humerus.

16:32

Here, it's got more of a triangular appearance because it's getting uplifted.

16:36

If you see a posterior fat pad, which is a little more subtle over here,

16:40

but we saw in our previous case, the presence of that is pretty much

16:44

always abnormal. So if you see the posterior fat pad, and it's usually

16:47

uplifted, that should indicate to you that there's a fracture somewhere.

16:51

Again, with the anterior fat pad, it needs to be kind of uplifted and

16:54

displaced-looking and make you think of a fracture.

16:56

So if you notice that and you don't first, at first see a fracture, you should

17:00

really start scrutinizing for any subtle additional finds, findings of a

17:04

fracture. Sometimes we cannot find them.

17:06

Uh, in fact, on radiographs, up to about a quarter of cases that have supracondylar

17:10

fractures, we don't see them on the radiographs. We just see the effusion.

17:14

So they can hide. Uh, and in my own reports, if I see

17:18

the effusion with the elevation of the fat pads, I will

17:22

put in my impression, elbow joint effusion, highly

17:25

suspicious for an occult fracture.

17:27

In this case, however, we do see the fracture.

17:30

It is subtle, but we see this really subtle little buckling along the

17:33

distal humerus that we can see both, on the lateral side and

17:37

posteriorly that's just a little bit too angulated for normal.

17:41

So this is a non-displaced supracondylar fracture

17:45

with the corresponding effusion.

17:48

Uh, the most common elbow fracture in young children is this type, the

17:51

supracondylar fracture. As kids get older, the radial head becomes more

17:55

common.

18:00

And the, orange arrow just pointing out that fat pad

18:02

again. Here's a companion case. The

18:06

v- this is a kid, who has a frontolateral radiograph,

18:10

and you might s- notice here again that we see the fat pad, so...

18:13

Oops, sorry. So we see subtly a little elevation of that anterior fat

18:17

pad, but then we also see the presence of that posterior fat pad that's a little

18:21

bit elevated. That is abnormal. There is a fracture here.

18:24

Again, just like our previous case, you can see that little bit of buckling along

18:28

the posterior distal humerus. So you might say to yourself, "Ah, here's another

18:31

case of a subtle non-displaced supracondylar fracture."

18:35

Howev-However, in this case, if you look at the frontal, you can actually see the

18:39

fracture line right here, the lucent fracture line, and that is not

18:42

supracondylar. Supracondylar would go across the width of

18:46

the distal humerus above the condyles.

18:49

Here, you can see it goes through,

18:53

the, external, the, the lateral margin through

18:57

the external condyle, to this articular margin, so...

19:00

Or sorry, the physeal margin. So this is actually a lateral condylar

19:04

fracture. Not a supracondylar fracture, but a lateral condyl- condylar

19:07

fracture. And it just so happens that on the lateral view, the little bit of

19:11

buckling that we get shows up and looks similar but is, in fact, only

19:15

lateral. So again, it's really important to look at all the views that you have,

19:18

all the views that you're given to try and distinguish between the

19:21

two. Sometimes all you get is this, in which

19:25

case you might not be able to tell. Uh, again, supracondylar is gonna be more

19:29

common in the young age group, but still, this is the, the sort of thing that you

19:32

wanna scrutinize for, to be able to try and be as

19:36

specific as possible. There's our fat pad sign

19:39

again.

19:43

Moving on to the wrist. We have a frontal view of the wrist.

19:47

Now, this is, actually a case of a normal wrist, and the reason I wanted to

19:51

point this one out is that depending on the age of the kid and which body

19:55

part,

19:56

sometimes there can be prominence of we- what we call the metaphyseal

20:00

collar, which is normal. This is the normal metaphysis, and it can sometimes have

20:04

this kind of irregular look, and it's important to be able to distinguish this

20:07

from, in particular, metaphyseal corner fractures, which

20:11

are highly suspicious for child abuse.

20:14

And oftentimes, these prominent metaphyseal collars can happen in a similar

20:18

age group as those that are at high risk for child abuse or this type of...

20:22

or the, metaphyseal corner fractures of child abuse.

20:25

So notice here that you do have this little bit of apparent irregularity

20:28

along the metaphysis of the distal radius, but notice that the

20:33

direction of it is away from the physis or away from the

20:36

joint. It's heading more proximally, and that can be a clue that you're dealing

20:40

with a normal metaphyseal collar, also sometimes called bone

20:43

bark. The peak of it is pointing away from the

20:47

physis. Now, this can be a little bit challenging, sometimes just depending

20:51

on the angle, that the, that the patient was

20:55

positioned. It can be challenging sometimes where I think if you look at

20:59

the ulna, you might say, "Hey, well, what about that ulnar margin of the distal

21:02

ulna? That sort of looks like it's getting pointed in the opposite direction.

21:05

Is that abnormal?" And in this case, I think we have a combination of probably just

21:09

some soft tissue artifact, just some densities related to the soft tissue that's

21:12

superimposed, and also, again, just the positioning of the patient can make it

21:15

challenging. And even we, the pediatric radiologists who look at this all day,

21:19

every day, we can find it challenging, and sometimes we're,

21:23

we are stumped as to whether or not we're looking at a normal variant or

21:26

not. Uh, in

21:30

distinction to the one I just showed you, here's a case that has a lot of

21:33

similarities, and in fact, was initially called normal when this was interpreted.

21:37

Again, you can kinda see what seems like prominence of the metaphyseal co-

21:41

collar of the distal radius. In retrospect, though, there

21:45

are some extremely subtle findings that no one would fault you for not

21:49

noticing initially, but notice how

21:52

there is a little bit of that pulled, kind of pinched look towards

21:56

the physis. Um, we don't even have epiphyseal ossification centers yet,

22:00

so that li- that's over here somewhere.

22:02

But that's going towards the physis or towards the wrist joints.

22:05

It's a little bit funny looking, and s- kinda

22:09

happening at the ulna as well. Does it look very similar to the last image I showed

22:12

you? It does a little bit, but now we see it in a couple places.

22:16

It's making us kind of scratch our heads.

22:17

And the other finding that's super subtle here is that you have just a little bit

22:21

of lucent undercutting, along those metaphyses just below

22:25

the surface, which is not usually normal.

22:27

Whereas on our other case, there wasn't this lucency of the distal radius, so it

22:31

was more contiguous, and we didn't have that lucency there at the distal ulna

22:34

that's present here. Again, these are extremely subtle

22:37

findings, understandable that they wouldn't be picked up, but I point them out

22:41

because there was continued clinical concern for this particular

22:45

patient who wasn't moving this extremity, so we got more dedicated

22:48

views, within the same day or within 24

22:51

hours. And we can see now that distal

22:55

radius has an assoc- sorry. Well, there's the ulna first, and it's

22:58

still, i- again, it's looking a little bit more conspicuous.

23:01

That's got that pinched look with a little lucent undercutting, and then same with

23:05

the distal radius. Now we have a clear lucency along that metaphysis.

23:09

And when we got the additional views, we can clearly see along the metaphysis that

23:13

there is a metaphyseal corner fracture.

23:15

There is definite lucency and separation.

23:18

Again, that's becoming more obvious along the distal ulna as well, not really

23:21

obvious on the initial radiograph.

23:23

And on the lateral here, absolutely, definitely, without a question, there is

23:27

now a fracture of the metaphysis. That fracture was always there.

23:31

It was just on the initial view is more hidden and difficult to see, showing us

23:35

the importance of multel- multiple views.

23:41

Okay, so this is important because this,

23:45

fracture pattern, this metaphyseal fracture pattern

23:48

is, very suspicious for child abuse.

23:50

So

23:51

especially if you have a child that, is young,

23:55

non-weightbearing, not walking, not able to talk because they're too

23:58

young, there are not usually great,

24:02

reasons for a, an accidental trauma that could lead

24:06

to this particular

24:07

pattern.

24:13

Next case, we have a child with forearm radiographs,

24:17

frontal and lateral, and it's not so subtle

24:21

that we've got a, an ulnar diaphyseal fracture.

24:24

We can see a little bit of angulation here, a little bit of separation.

24:27

That's pretty obvious. What you don't wanna miss is that there is also a radial

24:31

head dislocation. Uh, it might be easy to miss on this

24:34

view. However, you can see that radial head is not qui-Quite lined up with

24:38

the capitellum, so that radial capitellar line is not quite right here,

24:42

and then certainly the radial capitellar line is disrupted here.

24:45

It's completely, dislocated, anteriorly, and

24:49

so we have radial capitellar dislocation in addition to our ulnar

24:53

fracture.

24:54

In adults, we frequently think about how when we have a

24:58

ring-like structure such as the forearm, if you have one fracture somewhere, you

25:02

need to scrutinize for another fracture or dislocation.

25:05

In kids, this doesn't always happen.

25:07

It's not uncommon that we'll get distal radial fractures from a FOOSH or a fall on

25:11

outstretched hand injury, and that's the only fracture, and we don't

25:15

necessarily have another fracture or a dislocation.

25:18

However, it of course can still happen, and in this case it has, and you don't want

25:22

to miss that. Um, I don't know if the eponyms are being used as

25:26

frequently, but the Galeazzi fracture,

25:31

dislocation pattern, I used to remember the mnemonic

25:34

GFR. Uh, Galeazzi fractures the radius and

25:38

dislocates the ulna, and then this is the opposite.

25:40

This is where the ulna is fractured and we've got, radial head dislocation.

25:44

This is the Monteggia fracture dislocation,

25:47

pattern. All right.

25:51

Next case. This is the one of the fourth and fifth fingers where I asked you to

25:54

count up as many fractures that you can find, and this one is

25:58

challenging because there are a-- there are multiple. There are three.

26:01

So the first one I'll point out is this fifth proximal

26:05

phalangial fracture. So here

26:08

it's subtle, but there is too much angulation, sort of inward

26:12

angulation of that, metaphysis, particularly on the oblique view.

26:16

It looks kind of like a boot. Or for anyone who skis or snowboards, the way I

26:20

like to describe it is these bones should usually look like a very

26:24

steep, non-moguly black diamond.

26:26

It should be pretty steep all the way down to the end.

26:28

At the very end, there might be a little bit of flaring as it reaches the physis,

26:32

but this is too much. We go from a black diamond to all of a sudden we've got

26:35

pretty fairly flat green, green slope here.

26:39

Um, and so that's abnormal. And you can also notice the adjacent proximal

26:43

phalanges simil-- do not have that similar kind

26:46

of, abrupt change from a black diamond to a

26:50

green. So this one is the abnormal one.

26:52

So that's one of the fractures. And when you have a fracture that looks like this,

26:56

even though it's very difficult to identify a lucent fracture line, when

27:00

it's this close to the physis, you can assume it is extending to the physis.

27:04

And I would call this a Salter-Harris II fracture, where the

27:07

metaphyseal fracture extends to the fracture li- to the physeal line.

27:11

And if you really look carefully, you can probably see the lucency coming out right

27:15

over here. And, on the

27:18

lateral, it's challenging because of overlap from the other images.

27:22

But if you look really carefully, there's a little bit of separation along that

27:25

dorsal side of the metaphysis. So even when you've got artifacts like

27:29

overlapping structures, it's still incumbent upon you to s- to

27:33

scrutinize them to see if you can find the fracture.

27:36

In the hands and feet, I-- particularly the fingers, I always tell my residents and

27:40

fellows, "If you see focal soft tissue swelling, like really obvious focal soft

27:43

tissue swelling, or they have very, focal pain," like I had a

27:47

basketball injury and my-- the middle of my middle finger really hurts,

27:51

then really pay attention. The vast majority of the time

27:55

you will find a fract- or there is a fracture.

27:57

It just might be really subtle and hard to find.

27:59

But if you know where to look and you know what type of pattern to look for, you

28:02

can find it. And there's correspondingly a

28:05

tiny bit of a little buckling. So there's a baby mogul, on this ski

28:09

slope that shouldn't be there. Again, compared to the other sides, it's a smooth

28:13

black diamond. It should not be a moguly type of slope.

28:18

Okay, next fracture. So if we look at the lateral on the

28:21

fourth proximal phalanx, you can see very similar to the fifth, just a

28:25

little bit easier to see, that there is a lucency, a little bit of cortical offset

28:29

of the metaphysis on the dorsal side.

28:31

So actually, on the fourth proximal phalanx, there's also a fracture that's

28:35

basically invisible on the other two views.

28:37

So we've got a Salter-Harris II fracture of the fourth phalanx, the fourth

28:41

proximal phalanx. And then the third fracture is in the fifth middle

28:45

phalanx. If we look at this lateral view, again, we've got that kind of tr- abrupt

28:49

transition from a black

28:51

diamond,

28:55

steep ski slope all of a sudden to more of a green where it's flattened out, and it

28:58

shouldn't look like that. And then if we scrutinize the original frontal view as

29:02

well, you can actually see the lucent fracture line going throughout the majority

29:06

of the length of that phalanx extending to the physis.

29:09

So this is also a Salter-Harris II fracture that extends more

29:12

distally. So we have three fractures

29:16

here. Um,

29:18

just because you find one fracture, don't, you know, have that satisfaction of

29:21

search where you stop looking elsewhere. They can have more than one.

29:25

So make sure that you look at every bone for the same pattern.

29:29

Look for those steep, smooth black diamond ski slopes without

29:32

moguls and without abrupt transition to green.

29:36

And if those analogies didn't make sense to you because you don't ski, just

29:40

remember, you should have a pretty smooth appearance to these

29:44

bones with gentle flaring out towards the

29:47

metaphysis.

29:51

Here's a companion case of another fracture just to show a little bit further up

29:54

close. This is the thumb of a patient who's got a metaphyseal fracture of the

29:58

proximal phalanx or Salter-Harris II fracture. Again, same idea.

30:01

Notice we've got, our normal kind of the vol- volar

30:05

side of the, middle... sorry, proximal phalanx that's pretty smooth.

30:09

But then on the dorsal side, we see that there's a hump

30:13

right here at the metaphysis that should not be there.

30:16

Similarly, on the other views, more normal appearance,

30:19

abrupt hump right there. We don't like that.

30:23

And then very subtle on the lateral, but you've got a little bit of indentation

30:26

there that corresponds to the fracture.The reason I'm showing you all these cases

30:30

in these different views is that you never know what you're gonna get.

30:33

Sometimes you'll get a fracture that you can see on all three views.

30:36

Sometimes you get a fracture that you only see on one or two views, and it can look

30:39

like any of these things. And so it's, but just careful, it's important

30:43

to be careful and know about these so that you can find some of these subtle

30:47

fractures. It's not uncommon in the pediatric population that they look as

30:51

subtle as these, and they're, we see them all the time.

30:54

So the more you can familiarize yourself with these margins and these

30:58

borders that you need to be looking out for, the more easily you'll be able to

31:01

identify these.

31:05

Moving on to the next case, case number eight, this is a chest

31:09

radiograph. This baby came in with just fussiness, and so they wanted to see

31:13

if maybe they had some sort of viral respiratory thing going on, and so they got

31:16

the chest X-ray. And what we saw was, unfortunately, multiple healing

31:20

rib fractures. So what we're looking at here is, callus

31:24

formation along multiple lateral ribs on the right.

31:28

You can see periosteal reaction along the ribs, and you can see some exuberant

31:31

callus over here.

31:34

Same sort of thing happening on the left.

31:35

We see this pretty obvious bulbous, round

31:39

callus surrounding the healing fractures.

31:42

We have another one here, more posteriorly on the left

31:45

side. And so whenever we see rib

31:48

fractures, we get very concerned about child abuse.

31:51

So I know I showed a child abuse case earlier, but this is another location.

31:55

And this is one of those things that you just never, ever wanna miss.

31:57

And occasionally, we do diagnose cases on patients without,

32:01

the corresponding known history. They come in with fussiness.

32:04

They come in with lethargy. Um, they can't tell us that their,

32:08

their chest hurts or that any of their body parts hurt, right?

32:10

So, we need to be really fastidious about looking at the bones, even on

32:14

chest X-rays.

32:17

And this same patient had a dedicated skeletal survey where we got

32:21

more, specific views of all the entire

32:25

skeleton. So these are oblique views of the ribs where you can sometimes see rib

32:28

fractures more obviously. And we can see those same fractures

32:33

that I showed earlier, just from different views.

32:35

Again, we see callus formation, but we can also see the lucent fracture lines in

32:38

several of them, both on the left and

32:40

right. And then this patient actually did in fact

32:45

have radiographs two weeks prior. I just didn't tell you that at the beginning.

32:48

They also had had a preceding CAT scan, which is why you can see, IV

32:52

contrast excreted into the renal collecting systems here.

32:55

But I wanna show you what, fractures can look at

32:59

at different time points in their stages of healing.

33:01

So at that time, the, left rib fractures were

33:05

more acute, so there isn't that callus that we saw on the

33:09

images I showed earlier. You can actually see the lucent fracture lines, but

33:12

they're subtle, right? If you're not looking carefully, you might wi- walk right by

33:16

them. They might be overlying other structures.

33:18

Here we have a monitor lead that happens to be going across one of the fractures,

33:22

so you're, it could be easy to just ignore that.

33:26

If that were the only fracture and you ignored it because that line was in the way

33:29

and you thought it was due to Mach effect, you would miss it.

33:32

And here, the next level is a little bit more obvious c- because there's a

33:36

little bit of displacement, a little bit of offset.

33:41

We also have some, some of those fractures that showed up more obviously on the,

33:44

the initial im- or the earlier images I showed you that were taken two weeks

33:48

later. Um, very, very subtly, I don't know if it's showing up on your screen, but

33:52

there are very subtle lucent fractures of those same

33:54

ribs. That posterior left rib

33:58

fracture was actually more exuberantly heal, had healing,

34:02

changes at this time. So what this tells us is at the time of these original

34:06

radiographs, we had a healing fracture here, and we had more acute

34:10

fractures over here. So we had both acute and healing fractures at the

34:13

time, which is very, very suspicious, highly specific

34:17

for child abuse, when you have, fractures of different

34:21

ages. The other clue here, if you hadn't noticed all these

34:25

fractures on, the initial radiographs if you were reading this on

34:29

call, is that this patient also has pleural thickening

34:33

or pleural effusion, which is not normal.

34:36

They shouldn't have a pleural effusion, really.

34:39

So, especially if they don't have respiratory sys- symptoms

34:43

and a pneumonia or something like that that could be causing an effusion.

34:46

So in this case, this was because the patient had rib fractures that were very

34:50

subtle over here, and this was, blood, pleural,

34:53

pleural blood or, hemothorax.

34:56

So something to just kinda tip you off that something else is going

34:59

on. Here's a companion case of a different

35:03

patient. We've got oblique views of the ribs.

35:05

If you, again, were just looking at it cursorily, you might not notice anything.

35:08

There are fractures of the ribs, however.

35:11

They're very subtle, and so I will zoom in further on that left side, and you can

35:15

just barely make out a little bit of buckling and angulation of this rib.

35:19

And you can actually see slight displacement of a lucent fracture line of this

35:23

lower rib. However, you can also see another monitor lead going right

35:27

across it and makes it very difficult to, see that.

35:30

So when possible, try to, help train your

35:34

techs or encourage your techs, and any other support staff to get the

35:38

leads out of the way or any other external material out of the way.

35:41

Even sheets and clothes and towels can cause artifact.

35:45

And so we try to minimize that as much as possible so we don't have something like

35:48

this happen, where, the lead could obscure your visualization of a

35:52

fracture. Um,

35:56

and so this is that same kid two weeks later, and then we can see the more

36:00

obvious healing changes about those ribs that we pointed out

36:04

earlier. Additionally, there are more fractures on the right side that were not

36:07

identified originally. Again, this sort of indicates, or not

36:11

sort of, this does indicate the importance of getting follow-up films.

36:15

So in a lot of our patients for whom we have positive findings or

36:20

potential findings or c- very concerning

36:23

clinical, clinical exam findings or clinical stories,

36:28

we are, we have a fairly low threshold to get follow-up imaging in usually ten to

36:32

14 days, specifically for this reason, is sometimes they'll have acute fractures

36:36

that are s- subtle or occult. And if we wait a couple of weeks to start to see

36:39

the healing changes, then they become much more obvious, and we can be more certain

36:44

of the diagnosis.This particular child on

36:48

their bone survey had additional fractures, healing fractures in other bones as

36:51

well. So this was

36:53

a pretty definite case of child

36:54

abuse. Okay.

36:59

Next case, pelvic radiographs. So these are pretty standard views where we

37:02

get frontal and frog leg lateral radiographs of the pelvis.

37:06

I gave you that he, he or she, he had,

37:11

left pubic region pain, and so

37:14

what I wanted you to notice was this ischiopubic

37:17

junction. And the reason this is important is because in the vast ma-

37:21

majority of kids who have a prominent-looking,

37:24

bulbous ischiopubic junction that's

37:27

asymmetric, or even if it's symmetric, it can happen on both sides, most kids

37:31

actually that have this are normal and asymm-

37:34

asymptomatic. These can look like

37:38

this and just be part of the normal fusion process of that

37:41

synchondrosis. And so sometimes we'll have kids who are getting full

37:45

abdominal radiographs for upper abdominal pain, let's say, and, but their pelvis

37:49

looks like this.

37:51

It's so common that I don't even mention it in my report unless they

37:54

have focal corresponding pain. And so this exact

37:58

image could also be seen with patients who

38:02

do have, pathology there, and it's important

38:06

to know this because knowing whether this is abnormal or not really

38:10

is gonna depend on their symptoms and the foc- focality of their symptoms.

38:13

So, a different patient who had very similar radiographs went on to have an

38:17

MRI. These are axial T2 fat satu- fat

38:20

saturated wi- images of the, same region.

38:24

And so we have the normal-looking right ischiopubic

38:28

junction where that's actually fused or mostly fused.

38:31

And then on the left side, these are just contiguous images, slightly different

38:34

levels. We can see that synchondrosis is not fused, and in fact,

38:37

the marrow surrounding it in the bones in the ischium and the

38:41

pubis, are hyperintense. There's marrow

38:44

edema, maybe a little bit of cystic change.

38:46

And so when you see that, that is, not just

38:50

normal, ischiopubic synchondrosis that's fusing.

38:53

Uh, this is often ca- called Van Neck-Odelberg disease, and

38:57

this is thought to be due, to stress injury

39:02

and can, be caused by weight-bearing

39:06

changes and changes in mechanics.

39:07

And so you can end up with, with a picture that looks like this.

39:10

So again, the radiographs can be identical and won't necessarily distinguish

39:14

between the two, but if you were to get an MRI for focal or persistent symptoms,

39:18

you might find this. And in this case, this would be abnormal.

39:20

If you took that same radiograph of a patient who is asymptomatic, you would expect

39:24

that although there might be, the presence still of the

39:28

junction there, you wouldn't expect the edema.

39:34

Uh, it is important to understand the difference between that, the

39:37

ischiopubic, synchondrosis or, or alternatively

39:41

Van Neck-Odelberg disease, from what this patient has.

39:44

This patient also had left-sided groin region pain, but this patient has

39:48

fused synchondrosis. Those are over here more medially.

39:51

What this patient has is a hamstring avulsion

39:55

injury. So you can see this asymmetric, thin, curvilinear

39:59

fracture, avulsion fracture fragment just pulled off,

40:03

of the ischium, asymmetric to the other side.

40:06

And although you can have apophyses in similar regions, they should

40:10

be more symmetric looking, and they shouldn't have focal pain there.

40:13

So in this case, we had a hamstring injury, and, this was

40:17

the, the same patient a couple weeks later showing that there's healing changes.

40:21

It's much more obvious. There's, call formation as it's trying to heal

40:24

itself. So this is not just a normal apophysis.

40:29

This is an image from Radiology Assistant, which,

40:34

commonly is used for residents and trainees who are studying for board

40:37

exams. They like to test you on which muscles attach to

40:41

which part of the pelvic bone so that if you see an avulsion fracture, you know

40:45

what muscle has, avulsed. And so in our

40:49

case, that again was the hamstring's tendon,

40:53

that should be, attached to the ischial tuberosity.

40:56

So that's what avulsed in our case.

41:02

Case number 10. Again, we've got frontal and lateral, frog

41:06

re- frog leg lateral radiographs of the pelvis.

41:10

And in this case, what we're looking at is something different.

41:13

We're looking at the femurs here. So if you think of

41:17

the proximal femur as an ice cream cone, where the femoral head is

41:21

the scoop of ice cream and then the femoral neck is like the

41:24

cone, that scoop of ice cream should sit squarely on

41:28

top of the cone. Should be a nice, evenly distributed ice cream

41:31

scoop. And in this case, you can see much more obviously on the frog leg lateral

41:36

that here's the cone and the scoop is slipping off.

41:39

The kid has tipped the, the cone in their hand, and

41:42

now the ice cream scoop is gonna fall off to the floor.

41:45

And this is a case of SCFE, or slipped capital femoral

41:48

epiphysis. This is a Salter I

41:52

stress, chronic stress injury, another type.

41:55

And what happens here is you get a fracture through the

41:58

physis, with... And it is a

42:02

chronic injury, so it doesn't heal itself, and eventually that ice cream

42:05

scoop or the femoral head can slip off of the metaphysis or the

42:09

cone. And

42:14

here we have a different patient who has the same diagnosis.

42:17

It's much more subtle. Sometimes they're more obvious, but here again, in this

42:21

particular patient, you see the slippage more obviously on the frog leg

42:25

lateral, but even here, it's quite subtle.

42:28

That slippage is very minimal. However, what is telling on this case is

42:32

that we can see

42:33

there is a cystic change along the

42:37

metaphysis with surrounding sclerosis.

42:40

Uh, and so this is our indicator that something funny is happening.

42:43

So this is a case of SCFE, that Salter I

42:45

injury.But, where- whereas we don't see the

42:49

slippage as well, we do see the secondary,

42:53

effects on the metaphysis here.

42:56

These are treated surgically. They will be,

43:00

fixated with, fixation screws.

43:04

A large percentage of patients who have unilateral SCFE will go

43:08

on to develop bilateral SCFE, if they don't already have it, within the next year

43:12

or two. But whether or not surgeons will do prophylactic

43:16

contralateral pinning is a little bit controversial.

43:19

Some do, some don't. So I've seen both happening.

43:24

That can also sometimes depend on where they are in their,

43:28

their physeal maturation. So as I've seen cases of SCFE,

43:32

unilateral SCFE, where the normal contralateral side already

43:36

has a fusing or completely fused physis, and so there's no need to fix that,

43:40

fixate that, because it's already fused.

43:44

Case number 11, we have bilateral knee radiographs.

43:48

And so what I'm showing here, I'm gonna explain using a graphic first.

43:51

So this is another case of abuse. So this is my third case

43:55

of abuse because it's so important to not miss.

43:59

Even for people who are not pediatric radiologists, they may see pediatric

44:03

cases coming in on call, and so it's just something you don't wanna miss.

44:07

And so I wanted to show you several cases of different body parts.

44:10

This is, however, a really similar kind of finding to that, distal radial and

44:14

ulnar case that I showed you. Now, what happens usually in these young patients,

44:18

usually, they're quite young, they're babies, they're not usually walking or

44:21

crawling, it's thought to be due to,

44:25

a traction injury. So if you look at the blue

44:28

arrows, imagine that this lower part of the leg is getting pulled,

44:32

an adult or an older person is pulling down on that leg, and then there's an, a

44:35

rotational or twisting injury of the upper part here.

44:39

And so the force of the injury goes through the physis and comes out the

44:43

metaphysis. And so that metaphagus- metaphysis gets

44:47

pulled off, and depending on, the position of the

44:50

patient and the X-ray beam and the, the fracture itself, it can sometimes

44:54

look like a little triangle of that metaphysis getting pulled off.

44:58

Sometimes it looks more like a curvilinear.

45:00

You can see the whole metaphysis sheared off.

45:02

And so there are several names for this same type of injury.

45:06

Classic metaphyseal lesion is one of them.

45:09

Corner fracture, because of that corner look, that, that pulled look of the

45:12

corner of the metaphysis. Or a bucket handle fracture when it has more of that

45:16

curvilinear look. And so in this particular patient, we actually see that in

45:20

both of the distal tibi- sorry, both of the distal femurs.

45:23

That exact kind of pulled corner look is happening right

45:27

here. You can actually see it just separated a little bit.

45:31

And then questionably, the proximal left tibia as well.

45:34

Is there a little corner fracture with a little lucid undercutting?

45:38

This one is less obvious. We're less sure about this.

45:41

But then this patient went on to get, follow-up imaging in a couple of weeks,

45:44

and we can see healing of all of these fractures, including that

45:48

proximal tibia. You can see now more of that buckle handle ki- bucket handle

45:52

kind of appearance. All of these now with surrounding callus and periosteal

45:56

reaction indicative of healing. So all of these were classic

45:59

metaphyseal lesions, due to child

46:02

abuse.

46:07

Um, here's that same case I showed their initial radiographs of one

46:10

side, just to compare it to a normal patient.

46:13

Now, this is a little bit of an older patient.

46:15

You can see there's more ossification of their epiphyses.

46:17

But just to compare, note that in a normal young

46:21

child, they could have a very, irregular,

46:25

fluffy, fragmented appearance of their epiphyses, and

46:29

that is normal, and that doesn't mean that, there's a, a avulsion or

46:33

an acute fracture. Similarly, notice that, like I showed

46:37

you with the radial case, these corner fractures get pulled

46:41

towards the physis, pulled towards the joint, whereas a normal collar

46:46

should not. It should go more kind of away, flare out, flounce

46:50

out. This is a normal metaphysis. It does have a little bit of a flounce, a little

46:54

irregularity, but it's not in the same direction.

46:57

Uh, there's no loose and undercutting. So these are normal. The...

46:59

And then more subtly, we can kinda see similar things on the other side of the

47:02

femur and then the proximal tibia and the proximal fibula. These are normal.

47:06

And so, yes, these can be quite subtle. These can be challenging.

47:10

Again, if you're ever not sure, especially if you're worried about child abuse for

47:13

some clinical reason or for, because you see other findings in other body

47:17

parts, you can get bilateral images.

47:19

You can talk to your child abuse colleagues.

47:22

Um, we, again, sometimes it's a challenge for us as well.

47:25

But again, just to be aware of that when you see a little flounce like this, those

47:29

are normal.

47:32

Okay. Case number 12. So this is another knee.

47:36

This is another normal knee. So this is a four-year-old.

47:38

Again, we see that fluffy, irregular, sort of

47:42

fuzzy appearance to the epiphysis.

47:44

That is normal and quite common in the knee.

47:46

The other thing I wanted to point out here is that we have just the beginnings of

47:50

ossification of the patella on the lateral view.

47:53

And so in babies, patellas are not ossified yet, so it doesn't happen until a

47:57

little bit later on in childhood. And so don't confuse this early

48:01

ossification of the patella with some sort of avulsion,

48:05

like, severely displaced avulsion fracture.

48:08

Another thing to be aware of, where I see sometimes people get tripped up, is when

48:12

you have open physis and you have these ossification centers that are not fully

48:16

ossified yet, there is cartilage around these,

48:19

ossification centers, that, that cartilage will eventually become ossified.

48:23

Do not mistake the soft tissue density of that cartilage for a joint

48:26

effusion. On the lateral here, this patient does not have a joint

48:30

effusion. If you see this soft tissue density over

48:34

here, that is the unossified cartilage of

48:38

the distal, fem- femoral epiphysis.

48:41

Similarly, this is the unossified cartilage of the

48:45

patella. And then here is our pata- our quadriceps and our patellar

48:48

tendons, attaching to it. So if you had an

48:52

effusion, that would be up in here somewhere with soft tissue density.

48:55

These arecartilaginous. A little harder to

48:59

appreciate around the, proximal tibia.

49:02

It is there, but just not showing up as well here.

49:04

Keep this in mind when you're looking at joints, including the ankles, including,

49:08

the knees, the wrists, other joints.

49:10

There's cartilage that hasn't ossified yet.

49:11

So think about that before you call a soft tissue injury or a

49:15

joint effusion.

49:18

Case number 13.

49:21

We have a toddler who was on a trampoline.

49:24

Whenever you get that history, trampoline injury, bounce house

49:27

injury, if you have imaging of the proximal tibia, the first thing you should think

49:31

about is what's called the trampoline pattern injury.

49:34

That has to do with the double bounce phenomenon.

49:36

If you have a lo- a young child that is, in

49:40

their jump, they're up, they're in the air, and as they're coming down, if a much

49:44

larger person starts their jump, the recoil from the

49:48

trampoline or the bounce house is gonna be

49:50

faster and higher from that heavier person.

49:53

So when the ch- young child comes down, their feet will meet the

49:57

surface of the trampoline sooner than their body is ready, and so they end up

50:00

having this axial load injury, and that can cause this very classic

50:04

appearance of the proximal tibia.

50:06

We have a fracture through the proximal metaphysis here, more

50:09

obvious on this oblique view with buckling on this other side, subtly

50:13

over here anteriorly. I'll zoom in for you to show it more obviously.

50:17

There's the lucent fracture line, lucent fracture line, buckling,

50:21

lucent fracture line with some buckling.

50:25

This is, pretty classic. Now, sometimes it can be

50:29

very subtle. Again, maybe you'll only see it on one view.

50:32

Um, sometimes you don't see it at all, but they've got soft tissue swelling

50:35

overlying this region, in which case you can raise the concern,

50:39

especially with that history. There's that buckling

50:41

again. Okay. Case

50:45

fourteen, toddler that fell. This is a pretty classic, what we call toddler

50:49

fracture. You just see a spiral fracture of the distal tibia.

50:52

That's it. But the reason I show you this is because although that's very common

50:55

for people to think of this as the toddler fracture, pretty much any

50:59

fracture in a toddler is a toddler fracture.

51:02

So as they're learning to walk and run, and they take a lot of falls, and they're

51:05

putting a lot of stress on their, their bones as they're putting more weight on it,

51:09

they can get fractures in other places, too, and I'll show you that in a moment.

51:12

I do want to, however, highlight not to confuse the toddler fracture with

51:16

other things. So here's a more subtle case of a toddler fracture that you see more

51:19

obviously on the frontal. Sometimes all you get is the frontal.

51:22

Sometimes all you get is the lateral. So scrutinize all your views.

51:26

It is very subtle h- here on the lateral.

51:29

Uh, this is a different case of a patient who had an extremely subtle

51:33

fracture that you can only see on the lateral, and sometimes that's the case.

51:36

Just driving the point home. The reason I, want to

51:40

push this is because, there are other lucencies that you can

51:44

see, particularly in the tibia, that can be confusing.

51:46

So, don't confuse a fracture such as this one

51:50

with a normal nutrient foramen. This is-- where the yellow

51:54

arrow is, that's a very common place to see a more vertically

51:58

oriented, usually more proximal,

52:01

foramen, and we see it on all three of these cases.

52:04

And so just remember that that can happen there, and that's a very typical place.

52:08

That's not the fracture. The fractures are the red lines in these three different

52:11

patients. The nutrient foramens are the yellow lines.

52:14

And then on this middle image, also notice that there's a lucency going in a

52:18

different direction. This is not either of those things.

52:21

This is a fat plane. This is in the soft tissues either be- or

52:24

behind the bone itself. And so if you really squint, you might be able

52:28

to see how that fat plane continues into the soft tissues.

52:31

So don't mistake that either. That's quite common as well.

52:35

Okay. Um, as a companion cl- case, I mentioned that a toddler

52:39

fracture is really any fracture in a toddler.

52:41

Here's a case of a young toddler that's just learning how to walk and run, and so

52:45

is putting stress on his or her feet.

52:47

And so what we end up with is sclerosis that persists on all three

52:51

views. Um, this is the cuboid, but it can happen in other tarsals as

52:55

well. And so this is like a chronic stress injury, basically, from running a lot

52:59

because they're trying to learn how to run and walk.

53:02

This can also be classified as a toddler fracture. Just be aware.

53:04

And so if you have a patient who's coming in with pain or not weight-bearing, and

53:07

this is your finding, this could very well be the reason.

53:09

It's not an acute fracture, but could be causing their symptoms.

53:12

Case number fifteen. Uh, this is a patient who has an epiphyseal fracture that

53:16

goes out the physis. This one is a little bit unique in the sense that this is in

53:20

a patient who has a partially fused physis.

53:23

So some of their ph- physis is fused, but some isn't.

53:26

And the physis in the distal tibia, closes in a pretty

53:30

pred- predictable fashion from medial to lateral.

53:33

So if you end up with a Salter-Harris injury, it's gonna preferentially go out the

53:37

lateral side because it's still open.

53:39

And so in this case, it's a little bit more obvious on the frontal view.

53:43

It's less obvious on the oblique view, but I show it again because sometimes all

53:46

you get is one, and you'll see the fracture obviously on one and not the other.

53:50

So this is, a Salter-Harris three fracture, and this is called a juvenile Tollo

53:54

fracture when you've got that partial fusion of the physis,

53:58

but you still have a partially open physis.

54:01

And then our last case here, these are three views of the foot, and I didn't give

54:05

you really any history except pain, so I didn't give you a, a

54:08

location. What I wanted you to notice here is the base of the

54:12

fifth metatarsal. There is a normal apophysis that lives here, and in

54:16

this particular case, it's almost ready to fuse to the parent bone, but it's

54:20

quite irregular and sort of lumpy, bumpy looking.

54:24

Um, in the earlier stages, it might just look like a thin little curvilinear piece

54:27

of bone. What's important here is that the plane of the,

54:31

of the lucent portion, the unossified portion, is vertically

54:35

oriented, kind of more parallel to the metatarsal itself.

54:38

When you see that, that is typically normal.

54:42

And so, that is just an unfused

54:45

apophysis. This is an interesting case where you have an unfused

54:49

apophysis. You've got that vertical orientation of the lucency, but in

54:53

addition, you actually have a horizontal lucency, and that is a

54:56

fracture. So typically, fractures of the base of the fifth metatarsal are gonna

55:00

be horizontally oriented. So this patient, in fact, has

55:03

both.And that is to distinguish it from this patient who no longer

55:07

has an apophysis. It has fused, and they just have a fracture

55:11

through the base of the apophysis.

55:13

I'm sorry, through the base of the meta- the

55:16

metatarsal. Uh, there is no apophysis. All right.

55:19

So I rushed through those last few cases, but those are all of my

55:23

cases. Thank you so much. We do still have a little bit of time for

55:26

questions. Can I answer anything?

55:30

Uh, we have one question that just popped up.

55:32

When do you perform follow-up MRI to confirm or uncover subtle fractures rather

55:36

than follow-up radiographs? That's a great question.

55:38

It will depend on a number of things.

55:41

If the thought is that it's accidental trauma, in a

55:44

child or teenager who's had a sports injury or something like that, much of the

55:48

time they will go with their clinical symptoms.

55:50

Even if we don't see an obvious fracture, if they're clinically

55:54

concerned, they have high clinical suspicion, often they will immobilize and then

55:58

re-image in a couple of weeks. They will treat them as if they have a

56:01

fracture because they're acting like they have a fracture.

56:04

Um, it depends, however. So if they have...

56:08

Uh, if it's a young baby who should not be having any kind of trauma, and we're

56:12

worried about abuse, then what, what might, what might happen next actually would

56:15

be a full skeletal sur- survey to do the whole body to see if there are

56:19

any other fractures anywhere else that,

56:23

could be hiding in there that we don't know

56:25

about. Uh, if we have patients

56:29

who have a sports injury that, has

56:33

persisted despite conservative treatment, then they might go on to MRI.

56:37

So it depends a lot on the clinical scenario, but a lot of the times they'll treat

56:40

first clinically and then decide from there, depending on how they're

56:44

doing. Next question, how to confidently diagnose Sever

56:48

disease based on an X-ray? So Sever disease is when you have, like, an

56:51

apophysitis of the posterior calcaneus when it's, it's got its own

56:55

apophysis. Um, and generally, I say you can't, not on

56:59

radiographs. Very commonly, on a lateral radiograph of

57:02

the, of the hindfoot, that apophysis can look quite

57:06

sclerotic relative to the other tarsals, and that's can be normal.

57:10

Just like I was talking about with the ischiopubic synchondrosis looking exuberant

57:14

and that can be normal, same thing can happen with the apophysis looking sclerotic.

57:17

So that's really more of a clinical diagnosis as well.

57:19

You could, I suppose, get bilateral images, and if it looks quite asymmetric, that

57:23

could point you in that direction.

57:25

But again, if they're clinically a- acting like it, a lot of the times these

57:29

radiographs will help exclude something else, like an acute fracture or

57:33

something else going on. And if you can exclude those, then they'll treat

57:36

clinically. Perhaps they'll just, they'll clinically treat for Sever's

57:38

disease. Case number seven, is there a fracture of the

57:42

fourth proximal phalanx at the head? What?

57:46

Let's find out. Let's go back. Um, case

57:51

seven. Case seven, case seven. Oh, there

57:54

was one thing I did wanna say, actually, with regards to those fingers that I

57:57

forgot to say. Um, so we'll see if that answers it. Case seven.

58:01

Is there

58:02

fourth proximal

58:04

phalanx at the head?

58:07

Oops, sorry. I am wondering if you're perhaps

58:11

pointing to these little divots in here. Great question.

58:14

So, no. So there is normal developmental clefting that

58:18

can happen in the hands and the feet, and I think this is one of

58:22

them.

58:23

I will also point out... Let's see if I have a good hand radiograph, to show

58:27

you. Da, da, da. So if you

58:31

look at the, proximal metacarpals of the hand on this particular

58:35

patient, I think actually I can zoom in, talking about

58:39

clefting, something to be aware of.

58:41

The physis of the first metacarpal, also

58:44

metatarsal, the physis are, is proximal on

58:48

those. Whereas you can't really see the full thing here, but the physis of

58:52

the second through the fifth are distal.

58:54

And so if you see anything that looks like a physis at the

58:58

bases of the second through the fifth, those are not physis.

59:01

Those are not partially fused physis. Those are developmental clefts.

59:04

Same with the distal aspect of the first metacarpal and metatarsal.

59:08

Anything along here is clefting, or a fracture I suppose is possible,

59:12

but there is normal clefting. So very important to know.

59:14

Don't call a Salter-Harris, two fracture of the base of the second.

59:18

Even if there's a fracture, don't call it a Salter-Harris fracture 'cause there's

59:20

no physis there. You can't classify it as such.

59:23

So first has a physis proximally, second through fifth, physis are

59:27

distal. The other thing I wanted to...

59:30

Whoops, that's my

59:32

zoom. Um, the other thing I

59:35

wanted to mention on these finger radiographs is sometimes if they're in pain, it's

59:39

really hard for them to straighten out their fingers, and so you get kind of flexed

59:42

fingers on your radiographs. That can sometimes artificially make

59:46

that metaphysis look like it's flaring out as if there was some kind of buckling

59:50

or indentation or something, and that's artifactual.

59:52

So be very careful also to evaluate whether you have a good quality,

59:56

good positioning of the fingers to, confidently

60:00

call a fracture.

60:03

Um, why is there contrast in the kidneys of the rib fracture child?

60:06

That was because they happen to have had, a CT scan with IV contrast

60:10

before those images were taken, so they had excreted contrast in their

60:13

system. When do we perform bone scan

60:17

rather than radiography? We generally don't do bone scan.

60:20

So bone scan is a nuclear study, and we don't do

60:23

that. Um, radiography is much more, sensitive and

60:27

specific because open physis in a bone

60:30

scan, are gonna show hot. And so

60:34

if you have a fracture very close to the physis, or

60:38

physis, which is where many of those fractures can happen, it's gonna be very easy

60:42

to miss. So that is not a standard, imaging choice for

60:45

us. Was the knee joint case normal with the fragmented

60:49

patella? Let's go back to

60:52

patellaKnee

60:57

joint, knee joint, knee joint. Um, this

61:00

one. Um,

61:04

normal. I, I assume you're talking about this case. This was a normal case.

61:07

Everything about this is normal. So the fragmented look is simply incomplete

61:11

ossification. That can happen when you have a bone.

61:15

It'll have, like, multiple little ossification centers that eventually will

61:18

fuse, and the whole thing will get ossified.

61:21

That can happen frequently in the tarsals as well.

61:24

A lot of time, those tarsal bones will have little, tiny, well-corticated,

61:28

rounded, or lobular

61:30

mini ossification centers that will eventually join together.

61:32

So yes, this is a totally normal knee.

61:38

Let's see. I think that is

61:43

all of the questions. Oh, someone is clarifying

61:47

case number seven, not the companion case. So I was showing you the wrong one.

61:53

The original case and the original question

61:56

was fourth finger. Oh, yeah, fourth finger,

62:00

not the, not the thumb. Proximal phalanx at the head.

62:04

S- oh, I see wh- I see what you're saying. You're talking about right there.

62:08

Right there.

62:10

Hmm. That is an excellent

62:13

question.

62:16

Huh. I think you very well

62:20

could be correct. We may have all missed this. Let's see.

62:24

Can I... Does this let me... Where's

62:26

the...

62:31

Yeah. You know what?

62:34

I think you might be right.

62:38

Well, I think you might be right. I think this patient may have four fractures that

62:42

we did not diagnose at the time of interpretation.

62:45

Great pickup. I'm gonna have to amend this. Thank you.

62:49

I think you're right, 'cause I think it comes out this side.

62:51

I don't think that's a cleft. I think it looks too abrupt.

62:56

Thank you. Look at that. I'm learning

63:00

something. I learn something every day.

63:03

Awesome. Looks like you got all the questions, and you learned something along the

63:06

way. Isn't that great?

63:08

I love it.

63:09

Well, thanks everyone for sharing those great questions, and thank

63:13

you for sharing your lecture with us, Dr. Mitchell.

63:17

Thank you. Thanks for having me. Thanks for everyone who attended, and

63:21

also, thanks for the great questions.

63:24

You can access the recording of today's conference and all our previous noon

63:27

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63:29

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63:32

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63:36

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63:40

Anatomy and Pathology of the Nasopharynx.

63:43

You can register for that at modality.com and follow us on social media for updates

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63:50

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