Case 1: Chest
This is a 6-week old male infant. His
parents brought him to the E.D. because of coughing and congestion. He had a 20 minute episode of frequent coughing, but now seems to be better. He is feeding well. There is no history of fever or cyanosis. His vital signs are normal. Oxygen saturation is 100% in room air. Auscultation is clear.
The upper mediastinum shows the usual prominent thymus for this age.
Case 2: Chest
15-month old male with fever, coughing,
and tachypnea
Bilateral central pulmonary infiltrates, but most marked in the right middle and left lower lobes.
Case 3: Chest
3 year old female whose parents do not
speak English well. Her chief complaint is coughing and difficulty breathing. There is mild bilateral stridor on exam. Her cough sounds slightly bronchospastic, but not barking in nature.
No infiltrates are noted. The right side is more lucent (darker)compared to the left. The right hemidiaphragm is slightly higher than the left, however it should be higher than this.
indicated that she was jumping on a bed while eating some food (thought to be meat), when she began choking. Since that time, she has experienced respiratory difficulty. Further radiographs revealed bilateral air trapping. Bronchoscopy revealed bilateral bronchial peanut fragment foreign bodies
Case 4: Chest
A 3-month old female with fever and
coughing.
There is a faintly visible infiltrate in the right upper lobe. Subtle findings may be more difficult to appreciate on dark films.
Case 5: Chest
This is an 11-year old female with a
history of fever and coughing for 5 days. VS T39.1 (oral), P122, R 20, BP 107/76. Oxygen saturation 99% in room air. Auscultation is significant for moist rhonchi in the left base.
There is a patchy infiltrate at the left lung base. This is seen on the lateral view obliquely over the heart and on the PA view as haziness in the left lower lung.
The prominence of the right perihilar region is probably due to rotation. Note the asymmetry of the spinal column and the ribs. This rotation exposes more of the right hilum in the radiograph, making it appear more prominent.
Case 6: Chest
This is a 9-year old male with a history
of fever, headache, nausea, and coughing.
There is a circular density in the right lung. This is the superior segment of the right lower lobe. Although this has the appearance of a mass, it is most likely an infectious process.
Case 7: Ortho
This is a large 10-year old male who
presents to the acute care clinic with a two week history of right thigh and knee pain. He states that the pain is mainly in his thigh (points to his upper thigh) but radiates down to his knee. He was playing basketball when he collided with another player and fell.
Physical Exam
Right lower extremity: Moderate
tenderness in the upper anterior thigh. Severely tender in the hip. Pubic symphysis non tender. Mid thigh and knee non-tender. Tibia/fibula and foot non-tender. No joint swelling noted. Range of motion about the hip is not done. Range of motion of the right knee is good.
A common pitfall is to focus on the patient's chief complaint. In this case, focusing on the thigh may lead one to focus on the mid thigh and ignore the hip. His exam clearly points to his hip as the source of his pain.
The history of his collision and fall suggests an acute injury such as a non-displaced fracture.
Impression: His hip radiographs show a slipped capita femoral epiphysis on the right
SCFE
Most SCFE patients prefer to keep their hip externally rotated A major clinical finding in SCFE is their inability to fully internally rotate their hip In subtle cases, the epiphyseal plate (physis) may be widened or irregular compared to the normal side In other subtle cases, the physis may appear to be thinner than the normal side Treatment is largely the responsibility of the orthopedic surgeon
Case 8: elbow
3 yr male with complaints of right elbow
pain after falling off bed while jumping. Now guarding elbow. Refusing range of motion
C-R-I-T-O-E
The mnemonic of the order of
appearance of the individual ossification centers is C-R-I-T-O-E: Capitellum, Radial head, Internal (medial) epicondyle, Trochlea, Olecranon, External (lateral) epicondyle. The ages at which these ossification centers appear are highly variable, but as a general guide, remember 1-3-5-7-
CRIT0-E 1 3 5 7 9 - 11
Knowing the C-R-I-T-O-E mnemonic is helpful in determining whether a small piece of bone about the elbow joint represents an avulsion fragment or an ossification center.
c
c r r
Both anterior fad pad (with sail sign) and posterior fat pads are present.
Case 9: Ortho
14-year old male with an ankle injury.
AP, mortise, and lateral views are displayed. There is a vertical lucency through the distal tibial epiphysis extending from the physis to the mortise joint space.
Impression: Salter Harris Type III fracture of the distal tib Tillaux Fracture
mostly over the fibular physis rather than the tip of the fibula. Because of this, she is suspected as having a Salter Harris Type I fracture through the fibular physis or the fracture of the fibular metaphysis. She is placed in a splint and is followed clinically.
Although there is an obvious deformity of her forearm on exam, no fracture is evident here. Her elbow does not demonstrate a joint effusion and her radial head is of normal contour and is well aligned with the capitellum
Note the curvature of the ulna which is excessive. This represent a "bowing fracture" of the ulna.
Bone is visible within the mass which has elevated the periosteum of both anterior and posterior cortices of the distal femur
(Normal knee)
Impression: Osteosarcoma
Impression: There is a buckle fracture of both the distal radius and ulna. The fractures are not displaced.
The right hip (left on the image) shows widening of the joint space. The femoral epiphysis is fragmented and flattened The physis appears narrow. The femoral neck is short and wide (Coxa magna). There is flattening of the femoral capitellum (Coxa plana).
Impression: Avascular necrosis (AVN) of the femoral head may be idiopathic (Legg-Calve-Perthe's Disease) or due some insult to the vascular supply of the femur.
Keys to Remember
Evaluate quality of film, if poor, repeat Always think 3D Look for clues (fat pads, comparison views) When clinically you think fracture, splint and refer to ortho