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To compare the diagnostic accuracy and interpretation time for detection of pediatric fractures on hand radiographs with and without localization cues.Consecutive children, who underwent radiographic examinations after injury, over 2 years (2019-2021) and with 2 weeks of follow-up to confirm the presence or absence of a fracture, were included. Four readers, blinded to history and diagnosis, retrospectively reviewed all images twice, without and with cue, at least 1 week apart and after randomization, to determine the presence or absence of a fracture, and if present, anatomic location and diagnostic confidence were recorded. Interpretation time for each study was also recorded and averaged across readers. Inter-reader agreement was calculated using Fleiss' kappa. Diagnostic accuracy and interpretation time were compared between examinations using sensitivity, specificity, and Mann-Whitney U correlation.Study group included 92 children (61 boys, 31 girls; 10.8 ± 3.4 years) with and 40 (31 boys, 9 girls; 10.9 ± 3.7 years) without fractures. Cue improved inter-reader agreement (κ = 0.47 to 0.62). While the specificity decreased (63 to 62%), sensitivity (75 to 78%), diagnostic accuracy (71 to 73%), and confidence improved (78 to 87%, p 0.01), and interpretation time (median: 40 to 22 s, p 0.001) reduced with examinations with localization cue. Specifically, examinations with fracture and cue had the shortest interpretation time (median: 16 s), whereas examinations without fracture and without cue had the longest interpretation time (median: 48 s).Localization cues increased inter-reader agreement and diagnostic confidence, reduced interpretation time in the detection of fractures on pediatric hand radiographs, while maintaining diagnostic accuracy.

PURPOSE OF REVIEW: The purpose of this review is to highlight the radiographic assessments of utility in the evaluation of a pediatric patient with patellofemoral instability to facilitate a thorough work-up. Understanding of these measures is useful in understanding evolving research in this field, providing accurate patient risk assessment, and appropriately directing surgical decision-making. RECENT FINDINGS: Recent literature has broadened the radiographic characterization of the pediatric patellar instability and its anatomic risk factors. Knee MRI can inform the assessment of skeletal maturity and novel axial alignment measurements may enhance our identification of patients at increased risk of recurrent instability. Additional improvements have been made in the objective measurement and classification of trochlear dysplasia. SUMMARY: Knee MRI-based skeletal age assessments may obviate the need for hand bone age assessments in growing children with patellofemoral instability. Novel objective measures exist in the evaluation of pediatric patellar instability both in the assessment of axial alignment and trochlear dysplasia. Future work should focus on how these measures can aid in guiding surgical decision-making.

Magnetic resonance imaging (MRI) sagittal alignment is a measure that has been described and validated in the adult population as a means of distinguishing normal knees from those with anterior cruciate ligament (ACL) injury, but this measure has not been formally assessed among pediatric patients. The purpose of this study was to (1) assess the reliability of this MRI-based measure in a pediatric cohort, and (2) validate its ability to distinguish between ACL and non-ACL-injured knees in this population.A consecutive series of knee MRI examinations performed at our center were reviewed to identify studies of pediatric patients (1) with ACL injury, and (2) without significant pathology. Patient age, sex, physeal status (open, closing, or closed), knee laterality, and magnet strength (1.5 or 3-Tesla) were collected. The sagittal alignment was measured in both medial and lateral tibiofemoral compartments using a previously described method. Mean anterior tibial translation was then calculated for each study. Inter-rater and intrarater reliability testing was performed on a subset of randomly-selected patients from each cohort by three raters by calculating intraclass correlation coefficients. Sagittal alignment measurements of all patients were then completed by a single author after reliability was confirmed. The medial and lateral compartment translation and mean anterior tibial translation measurements of normal and ACL-injured knees were compared.Inclusion criteria were met by 131 studies: 86 from uninjured knees (normal cohort) and 45 knees with ACL injury (ACL cohort). Studies were performed at a mean age of 13.4 with a near equivalent sex distribution. Inter-rater and intrarater reliability were good to excellent for all measures for patients in both normal and ACL cohorts. Normal and ACL-injured knees demonstrated a significant difference in anterior tibial translation in all measured regions. The mean anterior tibia translation for ACL-injured knees was 2.01 mm (95% confidence interval: 1.03-2.98) versus -0.44 mm (95% confidence interval: -0.89-0.014).This study identified good to excellent inter-rater and intrarater reliability of knee sagittal alignment measurements among pediatric patients. It also demonstrated a significant difference in medial compartment, lateral compartment, and mean tibial translation in patients with and without ACL injury, validating previous findings demonstrated in adult cohorts. These findings may be useful in assisting providers in the confirmation of suspected ACL injury and insufficiency and guide operative management in cases of clinical uncertainty.Level III-retrospective comparative study.

Following open or closed reduction for children with developmental dysplasia of the hip, there remains a significant risk of residual acetabular dysplasia which can compromise the long-term health of the hip joint. The purpose of this study was to use postoperative in-spica magnetic resonance imaging (MRI) data to determine factors predictive of residual acetabular dysplasia at short-term follow-up.We retrospectively reviewed 63 hips in 48 patients which underwent closed or open reduction and spica casting for developmental dysplasia of the hip. MRI performed in-spica at ∼3-week follow-up were used to assess 11 validated metrics and 2 subjective factors. Acetabular index (AI) was measured on anteroposterior pelvic radiographs at 2-year postoperative follow-up. Binary logistic regression was then used to identify variables predictive of residual dysplasia, defined as an AI greater than the 90th percentile for age based on historic normative data.Average age at surgical reduction was 9.3±3.2 months. 58.7% (37/63) of reductions were open. A total of 43 (68.3%) hips demonstrated residual acetabular dysplasia at 2 years postoperatively based on normative values. In those with persistent dysplasia, patients were on average older at the time of reduction (10.0 mo±3.2 vs. 8.0 mo±2.8, P=0.010) and more likely female (88.4% vs. 60.0%, P=0.010). Patients with residual dysplasia were more likely to have mild subluxation on postoperative MRI (40.0% vs. 10.5%, P=0.022). Hips with a cartilaginous acetabular index (CAI) of23 degrees were 7.6 times more likely to develop residual dysplasia. Type of reduction (ie, closed vs. open) did not appear to influence the rate of residual dysplasia (P=0.682).In this series, the rate of residual dysplasia after surgical reduction was higher than most previous reports, with no appreciable difference between closed and open reductions. Older age, female sex, and a higher CAI were associated with a greater risk of persistent radiographic dysplasia. In particular, hips with a CAI23 degrees were 7.6 times more likely to be dysplastic at 2-year follow-up.Level III.

Leg length discrepancy studies are labor intensive. They are procedurally simple and represent inefficient use of the radiologists' time and expertise. We hypothesized that radiology technologists could be trained to measure leg length discrepancies, and that their performance would be statistically equivalent to that of board-certified, fellowship-trained pediatric radiologists.Four radiology technologists were selected to participate in a supervised practice session. They independently measured and calculated leg length discrepancies on 10 randomly selected cases. Their performance was compared to measurements obtained by an experienced pediatric radiologist (reference standard). After 1 week, the technologists repeated their measurements on the same cases, which were resorted to simulate new cases. Intraclass correlation coefficients (ICC) determined interobserver agreement between the technologists and radiologist and intra-observer reliability among the technologists.Among the four technologists, similarity in measurements between session 1 and the reference standard was very high, with ICC values ranging from 0.93 to 0.98 (p0.001). The ICC between session 2 and the reference standard was also high, ranging from 0.93 to 0.98 (p0.001). Finally, among the four technologists, ICC values between session 1 and session 2 were ≥ 0.96 (p0.001).Radiology technologists can be rapidly trained to calculate leg length discrepancies as accurately as a board-certified pediatric radiologist. Delegation of this time-consuming task to technologists or radiology assistants will permit radiologists to spend time on more demanding studies, such as studies that require subspecialty training.

OBJECTIVE To define the clinical importance of various pediatric musculoskeletal diagnoses, determine preferred communication methods based on the acuity level of findings, and investigate differences between specialties utilizing the Delphi methodology. METHODS Radiologists, orthopedic surgeons, and sports-medicine pediatricians at a tertiary children's hospital were surveyed (n = 79) twice using REDCap (Research Electronic Data Capture). Surveys were conducted anonymously and at least 1 year apart, first eliciting all potentially non-routine findings and various communication methods (round 1), and later categorizing the acuity (emergent, urgent, or non-urgent) of different diagnosis categories and selecting the preferred communication method (verbal, written electronic messages, and report) and timeframe (round 2). Chi-square, Fisher's exact, and Kruskal-Wallis H tests were used to compare variables between specialties. RESULTS Round 1 produced 267 entries for non-routine findings (grouped into 19 diagnoses) and 71 for communication methods (grouped into 3 categories). Round 2 found no significant difference in the acuity assignments for the 19 predetermined diagnoses (p = 0.66) between the 3 specialties; however, there was reduced agreement for the top urgent diagnoses within and between specialties. Most pediatricians preferred written electronic messages. The preferred communication timeframe for urgent diagnoses was significantly different (

To investigate MRI findings in children with physeal fractures of the knee with respect to age, location, and articular involvement.Children with physeal fractures who underwent knee MRI between 2008 and 2021 were included. Two radiologists retrospectively reviewed all examinations to determine articular involvement, findings of physeal instability (perichondral disruption, periosteal entrapment), and internal derangement (cruciate ligament injury, meniscal tear, chondromalacia). Independent samples t, Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests were used to compare findings.Fifty-six patients (37 boys, 19 girls; mean age: 12.2 ± 2.5 years; 32 distal femur, 24 proximal tibial fractures) included 24(43%) intraarticular fractures. Fractures were more common in the tibia than the femur (67% versus 25%, p = 0.004) and intraarticular fractures were more common in older than younger children (13.1 ± 2.0 versus 11.5 ± 2.7 years, p = 0.01), to associate with chondromalacia (46% versus 12%, p = 0.02) and undergo surgery (33% versus 10%, p = 0.04) when compared to extraarticular fractures. Perichondral disruption (n = 44, 79%) and periosteal entrapment (n = 13, 23%) did not significantly differ based on location or articular involvement (p 0.05). At a median follow-up of 17.5 months (interquartile range: 1.25-34), 3 patients (2 intraarticular, 1 extraarticular fractures) developed osteoarthritis, osteochondral lesion, and leg-length discrepancy from growth arrest, which required additional surgery.Intraarticular physeal fractures were more common with older children, associate with chondromalacia, and underdo surgical intervention when compared to extraarticular fractures of the knee. While MRI findings of physeal instability were common, no significant differences were found between fractures based on anatomic location or fracture pattern.

Overuse injuries are common in sporting children and adolescents. These injuries are a particular concern when they involve the epiphyseal–physeal–metaphyseal (EPM) complex given their potential to disturb skeletal growth. Specifically, the limits of mechanical tolerance of the EPM complex to repetitive stress may be exceeded by the intense and continuous training characteristic of many youth sports today. This article describes the present status of knowledge on the occurrence and outcome of primary periphyseal stress injuries (PPSIs) affecting the EPM complex in the extremities of children and adolescents involved in youth sports. A comprehensive review of the sports medicine literature was conducted to determine the nature and extent of PPSIs affecting the EPM complex of the extremities among youth sports participants and the potential for consequent skeletal growth disturbance and resultant limb deformity associated with these injuries. Our initial search uncovered 128 original published scientific articles reporting relevant data on PPSIs. There were 101 case reports/series, 19 cross-sectional, 1 case–control, and 7 cohort studies with relevant data. The case reports/series studies reported 448 patients with PPSIs involving the extremities. Children and adolescents representing a variety of high impact repetitive youth sports activities—including baseball, badminton, climbing, cricket, dance, gymnastics, rugby, soccer, swimming, tennis, and volleyball—may sustain PPSIs involving the shoulder, elbow, hand and wrist, knee, and ankle and foot. Although incidence data from prospective cohort studies are lacking, data arising from cross-sectional studies suggest that PPSIs may be common in select groups of youth athletes—including the shoulder in baseball players (0–36.6%), wrist in gymnasts (10–83%) and platform divers (52.6%), and fingers in rock climbers (5–58%). Notably, not all stress-related skeletal changes detected on imaging were symptomatic in these studies. When diagnosed and treated with an appropriate period of rest and rehabilitation, most patients studied were able to return to their sport activities. However, our data also show that 57/448 PPSIs (12.7%) produced growth disturbance, and that 28/448 patients (6.2%) underwent surgery for their injuries. Absence of treatment, delayed presentation and diagnosis, and non-compliance with a rest regimen were common in cases that produced growth disturbance. PPSIs may affect the extremities of children and adolescents engaged in a variety of youth sports, especially at advanced levels of training and competition. Most skeletally immature patients with PPSIs respond well to timely treatment; however, in extreme cases, PPSIs can progress to produce skeletal growth disruption which may necessitate surgical intervention. Clearly, establishing the early diagnosis of PPSIs and providing timely treatment of these injuries are needed to ensure the skeletal health of youth sports participants. Rigorous prospective longitudinal epidemiological and imaging studies designed to provide incidence rates of PPSIs and to determine the effect of PPSIs on long-term skeletal health are also necessary.

While overall survival for children is greater than that for adults, synovial sarcoma remains an aggressive neoplasm with a potentially poor prognosis, and its magnetic resonance imaging (MRI) findings in children are not well described. We aimed to characterize the spectrum of MRI findings of synovial sarcoma in children with respect to anatomical location and outcome. Children with histologically confirmed synovial sarcoma and preoperative MRI performed within the past 11 years (2009–2020) were included. Two radiologists retrospectively reviewed each MRI to categorize location, signal characteristics and associated findings. Chi-square and Fisher exact tests were used to assess associations with locations and outcomes. This study included 23 children (13 girls, 10 boys; mean age: 12.7±4.2 years) with 7 axial, 8 proximal and 8 distal appendicular lesions. Kappa ranged from 0.53 to 1. MRI findings differed significantly between locations with axial lesions measuring larger (P=0.01) and more likely to contain fluid levels (P=0.02), triple sign (P=0.02), inhomogeneous signal (T1-weighted images, P=0.003; T2-weighted images, P=0.02, contrast-enhanced images, P=0.03) with all lesions containing partially solid composition (P=0.03). At a median follow-up of 14 months (interquartile range: 7–33 months), 39% relapsed. Predictors of relapse (P

Delayed diagnosis of scaphoid fractures can lead to long-term morbidity. While radiography is the preferred screening examination, there is a relative paucity of literature that examines fracture visibility in younger children, who have smaller ossification centers, an abundance of unossified cartilage and fractures that preferentially involve the distal scaphoid. To characterize acute scaphoid fractures in younger children on radiographs with observer agreement and with respect to fracture location. This institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant cross-sectional study included children (≤10 years of age) with acute scaphoid fractures (≤7 days), who underwent radiographic examinations at a tertiary children’s hospital between December 2008 and June 2019. Three readers (two pediatric radiologists and one orthopedic surgeon) reviewed each examination to determine fracture visibility on each radiographic view and fracture location. Kruskal-Wallis, Fisher exact and Cochran-Armitage tests were used to compare fracture visibility and location, and Kappa tests were used to calculate observer agreement. Twenty-eight children (15 boys, 13 girls; mean age: 9.5±0.6 years) with 10 (36%) distal corner, 11 (39%) distal body and 7 (25%) mid-body fractures, underwent 7 (25%) 4-view, 18 (64%) 3-view and 3 (11%) 2-view examinations. Twenty-six (93%) fractures were visible on at least one view with six (21%) fractures visible on all available views. No significant association was found between fracture visibility and fracture location (P=0.32). Observer agreement was substantial to almost perfect. Only 7% of these acute scaphoid fractures in younger children are inconspicuous on the initial radiographic examination.

The purpose of this study was to systematically investigate the performance of different radiographic views in the identification of scaphoid fractures in children. This case-control study compared 4-view radiographic examinations of the wrist between children with scaphoid fracture and age- and sex-matched children without fractures performed between January 2008 and July 2019. After randomization, each examination was reviewed 3 times, at least 1 week apart, first using each view separately and later using multiple views without (3-view) and with the posteroanterior (PA) scaphoid view (4-view), to determine the presence or absence of a scaphoid fracture. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with inter-rater agreement. The study group of 58 children (48 boys and 10 girls; mean age 13.1 ± 2.1 years) included 29 with scaphoid fractures (8 corner, 9 distal pole, 10 waist, and 2 proximal pole) and 29 without fractures. Multiple views had higher sensitivity (3-view, 93.0%; 4-view, 96.5%) for fracture identification when compared to individual views (41.0–89.6%). The oblique view was 100% specific for the identification of a scaphoid fracture, but it lacked sensitivity. The PA scaphoid view had the highest sensitivity (89.6%) and NPV (90%) when compared to other individual views and its inclusion in the 4-view examinations produced the highest inter-rater agreement (93%, κ = 0.86). Multiple radiographic views of the wrist with the inclusion of a PA scaphoid view (4-view) produced the highest sensitivity, NPV, and inter-rater agreement for the identification of a scaphoid fracture in children.

Magnetic resonance imaging (MRI) plays a critical role in disease characterization of intra-articular tenosynovial giant cell tumor. To characterize the MRI features of intra-articular tenosynovial giant cell tumor in children with respect to disease subtype and anatomical location. This retrospective study included children with tenosynovial giant cell tumor who underwent preoperative MRI between January 2006 and May 2020. Two radiologists reviewed each examination to determine disease subtype, signal intensities and the presence of an effusion, osseous changes, chondromalacia, juxtacapsular disease and concomitant joint involvement. Fisher exact, Mann-Whitney U, and Kruskal-Wallis H tests were used to compare findings between subtypes and locations. Twenty-four children (16 girls, 8 boys; mean age: 13.1±3.8 years) with 19 knee and 5 ankle-hindfoot tenosynovial giant cell tumor had either diffuse (n=15) or localized (n=9) disease. An effusion (P=0.004) was significantly more common with diffuse than localized disease. There was no significant difference in MRI signal (P-range: 0.09–1) or other imaging findings (P-range: 0.12–0.67) between subtypes. Children with knee involvement were significantly more likely to present with diffuse disease while those with ankle-hindfoot involvement all presented with focal disease (P=0.004). Juxtacapsular (n=4) and concomitant proximal tibiofibular joint involvement (n=5) were observed with diffuse disease in the knee. Erosions (P=0.01) were significantly more common in the ankle than in the knee. In our study, diffuse tenosynovial giant cell tumor was more common than localized disease, particularly in the knee where juxtacapsular and concomitant proximal tibiofibular joint disease can occur.

Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Antenatal hydronephrosis is the most frequent urinary tract anomaly detected on prenatal ultrasonography. It occurs approximately twice as often in males as in females. Most antenatal hydronephrosis is transient with little long-term significance, and few children with antenatal hydronephrosis will have significant obstruction, develop symptoms or complications, and require surgery. Some children will be diagnosed with more serious conditions, such as posterior urethral valves. Early detection of obstructive uropathy is necessary to mitigate the potential morbidity from loss of renal function. Imaging is an integral part of screening, diagnosis, and monitoring of children with antenatal hydronephrosis. Optimal timing and appropriate use of imaging can reduce the incidence of late diagnoses and prevent renal scarring and other complications. In general, follow-up neonatal ultrasound is recommended for all cases of antenatal hydronephrosis, while further imaging, including voiding cystourethrography and nuclear scintigraphy, is recommended for moderate or severe cases, or when renal parenchymal or bladder wall abnormalities are suspected. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

To investigate the performance of contrast-enhanced MRI for predicting avascular necrosis (AVN) of the treated femoral head after surgical reduction for developmental dysplasia of the hip (DDH) using qualitative and quantitative methods. This IRB-approved, HIPAA compliant retrospective study included 47 children who underwent same-day contrast-enhanced MRI following unilateral surgical hip reduction between April 2009 and June 2018. Blinded to the clinical outcome, 3 reviewers (2 pediatric radiologists and 1 pediatric orthopedist) independently categorized the enhancement pattern of the treated femoral head. Signal intensities, measured using regions of interest (ROI), were compared between treated and untreated hips and percent enhancements were compared between hips that developed and did not develop AVN. Post-reduction radiographs were evaluated using Salter’s criteria for AVN and Kalmachi and MacEwen’s classification for growth disturbance. Non-parametric tests and Fisher exact test were used to compare enhancement values between AVN and non-AVN hips. Bonferroni correction was used for multiple comparisons. Ten (21%) out of the 47 children (7 boys and 40 girls; mean age 9.0 ± 4.7 months) developed AVN. Age at surgical reduction was significantly higher (p = 0.03) for hips that developed AVN. No significant differences were found in gender (p = 0.61), laterality (p = 0.46), surgical approach (p = 0.08), history of pre-operative bracing (p = 0.72), abduction angle (p = 0.18–0.44), enhancement pattern (p = 0.66–0.76), or percent enhancement (p = 0.41–0.88) between AVN and non-AVN groups. Neither enhancement pattern nor percent enhancement predicted AVN, suggesting that post-reduction conventional MRI does not accurately distinguish between reversible and permanent vascular injury.

To systematically investigate age-dependent changes in scaphoid fracture prevalence and fracture patterns on radiographs in children under 15 years of age. This retrospective study included children with scaphoid fractures, who underwent radiographic examinations between May 1, 2009, and August 31, 2019. Blinded to outcome, all radiographs were reviewed to determine fracture visibility on initial radiographs; to characterize fracture location (distal corner, distal, mid, and proximal body) and orientation (horizontal oblique, transverse, and vertical oblique); and to identify the presence or absence of gap, displacement, and concomitant fractures. Demographic information and information on weight and height were collected. Mann-Whitney U, Kruskal-Wallis rank sum, chi-square, and post hoc tests were used to investigate associations between age, fracture characteristics, and BMI percentile. The study included 180 children (134 boys and 46 girls; 12.3 ± 1.4 years) with 59 (33%) distal corner, 42 (23%) distal, 76 (42%) mid, and 3 (2%) proximal body fractures. Younger children were more likely to present with distal corner and distal body fractures while older children with mid and proximal body fractures (p = 0.035). No association was found between age and fracture visibility (p = 0.246), fracture orientation (p = 0.752), presence of gap (p = 0.130), displacement (p = 0.403), or concomitant fractures (p = 0.588). Younger children with scaphoid fractures were more likely to be obese (n = 117; p = 0.038). Scaphoid fractures of the distal corner and distal body were significantly more common in younger children, who are more likely to be obese.

Pneumonia is one of the most common acute infections and the single greatest infectious cause of death in children worldwide. In uncomplicated, community-acquired pneumonia in immunocompetent patients, the diagnosis is clinical and imaging has no role. The first role of imaging is to identify complications associated with pneumonia such as pleural effusion, pulmonary abscess, and bronchopleural fistula. Radiographs are recommended for screening for these complications and ultrasound and CT are recommended for confirmation. The second role of imaging is to identify underlying anatomic conditions that may predispose patients to recurrent pneumonia. CT with intravenously administered contrast is recommended for this evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The purpose of our study was to investigate the performance of MRI findings to predict instability of osteochondral lesion of the talus (OLT) in children and the association between skeletal maturity and lesion stability. This retrospective IRB-approved and HIPPA-compliant study included children with OLT, who underwent an ankle MRI examination between March 1, 2011, and May 31, 2018. Blinded to the clinical outcome, 2 radiologists retrospectively assessed each MRI study for the presence or absence of various features on the articular side, along the interface, and on the subchondral side of each lesion. Regional skeletal maturity was recorded. Lesion stability was classified using clinical and surgical findings. Mann-Whitney U, Chi-square, Fisher’s exact, and Cochran-Armitage tests were used to compare demographic and MRI findings between children with stable and unstable lesions. Of the 48 ankles identified, 36 were stable (12.7 + 3.9 years) and 12 were unstable (14.2 + 1.6 years) lesions. None of the lesions presented as a detached fragment. Skeletal immaturity (p = 0.01) was significantly more common in stable than unstable lesions. No other MRI features were found to be significantly different between stable and unstable lesions, which included the presence of an effusion (p = 0.27), intra-articular body (p = 0.25), cartilage changes (p = 0.19), subchondral disruption (p = 0.51), T2-weighted signal intensity rim (p = 0.16), cysts (p = 0.48), marginal sclerosis (p = 0.70), and perilesional marrow edema (p = 0.17). Results from our study suggest that previously published OCD criteria using conventional MRI are not sufficient for predicting stability of OLT in children. Regional skeletal maturity and older age were more predictive of unstable lesions.

Osteosarcoma is the most common primary bone sarcoma in children. Imaging plays a pivotal role in diagnostic workup, surgical planning, and follow-up monitoring for possible disease relapse. Survival depends on multiple factors, including presence or absence of metastatic disease, chemotherapy response, and surgical margins. At diagnosis, radiography and anatomic MRI are used to characterize the primary site of disease, whereas chest CT and whole-body bone scintigraphy and/or PET are used to identify additional sites of disease. Treatment starts with neoadjuvant chemotherapy, followed by en bloc tumor resection and limb reconstruction, and finally, adjuvant chemotherapy. Preoperative planning requires precise tumor delineation, which traditionally has been based on high-spatial-resolution anatomic MRI to identify tumor margins (medullary and extraosseous), skip lesions, neurovascular involvement, and joint invasion. These findings direct the surgical approach and affect the options for reconstruction. For skeletally immature children, the risk of cumulative limb-length discrepancy and need for superior longevity of the reconstruction have led to the advent and preferential use of several pediatric-specific surgical techniques, including rotationplasty, joint preservation surgery, autograft or allograft reconstruction, and extendible endoprostheses. A better understanding of the clinically impactful imaging features can directly and positively influence patient care.

BACKGROUND: Accurate and precise methods to predict growth remain lacking. Diffusion tensor imaging (DTI) depicts the columnar structure of the physis and metaphyseal spongiosa and provides measures of tract volume and length that may help predict growth. PURPOSE: To validate physeal DTI metrics as predictors of height velocity (1-year height gain from time of MRI examination) and total height gain (height gain from time of MRI examination until growth stops) and compare the prediction accuracy with bone age–based models. MATERIALS AND METHODS: Femoral DTI studies (b values = 0 and 600 sec/mm(2); directions = 20) of healthy children who underwent MRI of the knee between February 2012 and December 2016 were retrospectively analyzed. Children with height measured at MRI and either 1 year later (height velocity) or after growth cessation (total height gain, mean = 34 months from MRI) were included. Physeal DTI tract volume and length were correlated with height velocity and total height gain. Multilinear regression was used to assess the potential of DTI metrics in the prediction of both parameters. Bland-Altman plots were used to compare root mean square error (RMSE) and bias in height prediction using DTI versus bone age methods. RESULTS: Eighty-nine children (mean age, 13 years ± 3 [SD]; 47 boys) had height velocity measured, and 70 (mean age, 14 years ± 1; 36 girls) had total height gain measured. Tract volumes correlated with height velocity (r(2) = 0.49) and total height gain (r(2) = 0.46) (P < .001 for both) after controlling for age and sex. Tract volume was the strongest predictor for height velocity and total height gain. An optimal multilinear model including tract volume improved prediction of height velocity (R(2) = 0.63, RMSE = 1.7 cm) and total height gain (R(2) = 0.59, RMSE = 1.8 cm) compared with bone age–based methods (height velocity: R(2) = 0.32, RMSE = 2.9 cm; total height gain: R(2) = 0.42, RMSE = 5.0 cm). CONCLUSION: Models using tract volume derived from diffusion tensor imaging may perform better than bone age–based models in children for the prediction of height velocity and total height gain. © RSNA, 2022

UTE MRI offers a radiation-free alternative to CT for bone depiction, but data on children is lacking. The purpose of this study was to determine whether UTE images improve detection and characterization of pediatric tibial eminence fractures.Fifteen MRIs with UTE from 12 children (10 boys, 2 girls; mean age: 12.6 ± 3.3 years) with tibial eminence fractures (2018-2020) and 15 age-matched MRIs without fractures were included. After randomization, 5 readers reviewed images without and with UTE, at least 1 month apart, and recorded the presence of fracture and preferred images. If fracture is present, radiologists also recorded fragment size, number, and displacement; surgeons assigned Meyers-McKeever grade and management. Disagreements on management were resolved through consensus review. Kappa and intra-class correlation (ICC), sensitivity, and specificity were used to compare agreement between readers and fracture detection between images without and with UTE.For fracture detection, inter-reader agreement was almost perfect (κ-range: 0.91-0.93); sensitivity and specificity were equivalent between images without and with UTE (range: 95-100%). For fracture characterization, UTE improved agreement on size (ICC = 0.88 to 0.93), number (ICC = 0.52 to 0.94), displacement (ICC = 0.74 to 0.86), and grade (ICC = 0.92 to 0.93) but reduced agreement on management (κ = 0.68 to 0.61), leading to a change in consensus management in 20% (3/15). Radiologists were more likely to prefer UTE for fracture and conventional images for non-fracture cases (77% and 77%, respectively, p 0.001).While UTE did not improve diagnosis, it improved agreement on characterization of pediatric tibial eminence fractures, ultimately changing the preferred treatment in 20%.

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

OBJECTIVE To assess the feasibility of T2 mapping for evaluating pediatric SIJ cartilage at 3 Tesla (T) magnetic resonance imaging (MRI). METHODS Healthy control subjects and adolescents with sacroiliitis underwent a 3T MRI dedicated pelvic protocol that included a T2 mapping sequence consisting of multislice, multiecho acquisition. Healthy control subjects were prospectively recruited from our primary care practices as part of a larger imaging study, whereas adolescents with sacroiliitis were recruited specifically for this study. Regions of interest (ROIs) were hand-drawn by a senior pediatric radiologist twice and a radiology fellow twice to calibrate and test reliability using the intraclass correlation coefficient (ICC). T2 relaxation time between control subjects and cases was compared using univariate linear regression. We tested the association of T2 relaxation time in adolescents with sacroiliitis with patient-reported outcomes and the Spondyloarthritis Research Consortium of Canada sacroiliac joint (SIJ) inflammation and structural scores using Pearson correlation coefficients. RESULTS Fourteen subjects were evaluable (six control subjects: median age 13.7 years [interquartile range (IQR): 12.2-15.5], 67% male patients; eight cases: median age 17.4 years [IQR: 12.5-20], 88% male patients]. Acquisition time for T2 mapping sequences was approximately 6 minutes, and segmenting the ROI for each SIJ took approximately 3 minutes. The intrarater and inter-rater ICCs were 0.67 and 0.46, respectively, indicating good to fair reliability. There was a trend, albeit statistically insignificant, in longer median T2 relaxation time in cases (43.04 ms; IQR: 41.25-49.76 ms) versus healthy control subjects (40.0 ms; IQR: 38.9-48.6 ms). Although not statistically significant, cases with longer T2 relaxation time tended to occur with poorer patient-reported outcomes. Correlations with the SIJ inflammation and structural lesion scores were weak. CONCLUSION T2 mapping of the SIJ cartilage in children was feasible and reliable. Larger controlled and longitudinal assessments are needed to assess the validity and utility of these measurements for routine clinical practice and trials.

Developmental dysplasia of the hip (DDH) describes a broad spectrum of developmental abnormalities of the hip joint that are traditionally diagnosed during infancy. Because the development of the hip joint is a dynamic process, optimal treatment depends not only on the severity of the dysplasia, but also on the age of the child. Various imaging modalities are routinely used to confirm suspected diagnosis, to assess severity, and to monitor treatment response. For infants younger than 4 months, screening hip ultrasound (US) is recommended only for those with risk factors, equivocal or positive exam findings, whereas for infants older than 4-6 months, pelvis radiography is preferred. Following surgical hip reduction, magnetic resonance (MR) imaging is preferred over computed tomography (CT) because MR can not only confirm concentric hip joint reduction, but also identify the presence of soft-tissue barriers to reduction and any unexpected postoperative complications. The routine use of contrast-enhanced MR remains controversial because of the relative paucity of well-powered and validated literature. The main objectives of this article are to review the normal and abnormal developmental anatomy of the hip joint, to discuss the rationale behind the current recommendations on the most appropriate selection of imaging modalities for screening and diagnosis, and to review routine and uncommon findings that can be identified on post-reduction MR, using an evidence-based approach. A basic understanding of the physiology and the pathophysiology can help ensure the selection of optimal imaging modality and reduce equivocal diagnoses that can lead to unnecessary treatment.

BACKGROUND Ultrasound (US) is the preferred imaging modality for the diagnosis and treatment of infantile developmental dysplasia of the hip (DDH). Currently accepted indices that distinguish normal from dysplastic hips in the coronal plane include percent femoral head coverage (FHC), α angle, and β angle. Recent data suggests that significant user and interscan variability may exist for these metrics. Less studied, however, is potential variability because of patient positioning, specifically coronal flexion versus coronal neutral views. The purpose of this study was to compare standard DDH indices between coronal US views with hips in flexion versus neutral positions, for hips of varying DDH severity. METHODS This retrospective study included normal infants and those treated for different severities of DDH. Coronal flexion and coronal neutral US images from the same study were evaluated at diagnosis, early treatment, start of weaning, and treatment resolution. FHC, α, and β angles were measured on both views at each time point and compared. Inter-rater and intra-rater reliability assessments were performed for all metrics. RESULTS Among the 168 hips in this study (45 normals, 45 Ortolani positive, 17 Barlow positive, and 61 stable dysplasia), median FHC was significantly lower in coronal flexion compared with coronal neutral for normals and all 3 severities of DDH at each time point (mean decrease 8.4%; range 5.5% to 10.9%; P

To use magnetic resonance imaging (MRI) to investigate the knee joint of children following arthroscopic fixation of osteochondral lesions using bioabsorbable nails and to correlate these imaging findings with time from arthroscopic treatment and with risk factors at the time of imaging. Our study included postarthroscopic MRI studies from 58 children (mean age at arthroscopy, 13.8 + 2.1 years) who have undergone bioabsorbable nail fixation of unstable osteochondral lesions between February 1, 2011 and September 30, 2017. All studies were retrospectively reviewed for broken nails, intra-articular debris, and internal knee derangement. Demographic information and information pertaining to active symptoms was obtained from both MRI questionnaire that was completed at the time of the study and clinical note that preceded the study. Marginal logistic regression models estimated using generalized estimating equations (GEE) were used to identify factors associated with a broken nail and joint effusion. A total of 104 postoperative studies were reviewed, which included 60 with symptoms and 44 without symptoms. Nail breakage was present in 38 (36.6%) studies and associated with presence of symptoms (OR 2.43, p = 0.036) and effusion (OR 2.76, p = 0.025). An effusion was present in 40 (38.5%) studies which decreased with increasing time from treatment (OR 0.89, p = 0.007) and increased with symptoms (OR 10.87, p

Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This study was conducted in order to evaluate whether an MRI protocol with only fluid-sensitive sequences can be used to evaluate for musculoskeletal (MSK) infection of the pelvis and limbs in children. This retrospective study analyzed 90 contrast-enhanced (CE) MRI studies from 88 consecutive patients (52 boys and 36 girls; mean age 9 ± 4.3 years; range 2–17) that were performed for the clinical suspicion of MSK infection. Two radiologists reviewed each study twice. The initial study review included only the fluid-sensitive sequences (fluid-sensitive study); the second review, performed at least 1 month later, included all sequences of the contrast-enhanced study (CE study). At each review, anatomic sites of abnormal signal and overall suspicion for infection were recorded. Cohen’s kappa and percent agreement were performed to compare agreement between readers, types of studies, and clinical diagnoses. Interreader agreement for both types of studies had kappa values between 0.86 and 1. For the assessment of MSK infection, the fluid-sensitive study had 100% sensitivity and 61.3% specificity, with 84.8% interreader agreement; and the CE study had 100% sensitivity and 71.0% specificity, with 88.6% interreader agreement. All cases of septic arthritis (13 cases) and osteomyelitis (25 cases) were identified as possible infection or infection until proven otherwise (negative predictive value 100%) with 100% interreader agreement on fluid-sensitive sequences. An abbreviated MRI study using only fluid-sensitive sequences has the same high degree of sensitivity as a CE study to identify MSK infection in children and could be used to exclude septic arthritis and osteomyelitis. • MRI with only fluid-sensitive sequences can be used to evaluate for musculoskeletal infection in children.

To define the clinical importance of various pediatric musculoskeletal diagnoses, determine preferred communication methods based on the acuity level of findings, and investigate differences between specialties utilizing the Delphi methodology.Radiologists, orthopedic surgeons, and sports-medicine pediatricians at a tertiary children's hospital were surveyed (n = 79) twice using REDCap (Research Electronic Data Capture). Surveys were conducted anonymously and at least 1 year apart, first eliciting all potentially non-routine findings and various communication methods (round 1), and later categorizing the acuity (emergent, urgent, or non-urgent) of different diagnosis categories and selecting the preferred communication method (verbal, written electronic messages, and report) and timeframe (round 2). Chi-square, Fisher's exact, and Kruskal-Wallis H tests were used to compare variables between specialties.Round 1 produced 267 entries for non-routine findings (grouped into 19 diagnoses) and 71 for communication methods (grouped into 3 categories). Round 2 found no significant difference in the acuity assignments for the 19 predetermined diagnoses (p = 0.66) between the 3 specialties; however, there was reduced agreement for the top urgent diagnoses within and between specialties. Most pediatricians preferred written electronic messages. The preferred communication timeframe for urgent diagnoses was significantly different ( 2 h for pediatricians, 4 h for radiologists, and 8 h for surgeons; p = 0.003) between specialties whereas no difference was found for emergent (p = 1) and non-urgent diagnoses (p = 0.80).Acuity assignment for the 19 pediatric-specific musculoskeletal diagnoses was not significantly different between specialties, but the preferred communication timeframe for urgent diagnoses was significantly different, ranging between 2 and 8 h.

BACKGROUND Nonossifying fibroma (NOF) is a common benign lesion in children and adolescents. This study investigated the risk of pathologic fracture in NOF lesions of the distal tibial based on anatomic location, clinical symptomatology, and imaging features, in order to propose an algorithm for the management of such lesions. METHODS In an IRB-approved retrospective case-control study, all patients diagnosed with NOF between 2010 and 2017 were extracted from our database. Patients below 18 years of age at the time of diagnosis and with lesions involving the distal tibia were included. Demographic data, the reason for visit, and the mechanism of injury were recorded. Radiographs were reviewed to record the size (absolute and relative to bone width) and location of each lesion. Computed tomography and magnetic resonance imaging examinations were also reviewed when available. Two authors graded all lesions using the Ritschl classification and determined the presence of 2 novel signs: the syndesmosis sign and the Pac-Man sign. RESULTS A total of 84 patients were included in the final analysis, of which 25 were in the fracture group and 59 in the nonfracture group. None of the patients in the fracture group was previously diagnosed with NOF, but nine (36%) patients had symptoms for >6 months preceding the fracture. Ankle sprain was the most common reason for visit in the nonfracture group. The lateral location of the lesion in the distal tibia (P=0.001), size (P

While overall survival for children is greater than that for adults, synovial sarcoma remains an aggressive neoplasm with a potentially poor prognosis, and its magnetic resonance imaging (MRI) findings in children are not well described.We aimed to characterize the spectrum of MRI findings of synovial sarcoma in children with respect to anatomical location and outcome.Children with histologically confirmed synovial sarcoma and preoperative MRI performed within the past 11 years (2009-2020) were included. Two radiologists retrospectively reviewed each MRI to categorize location, signal characteristics and associated findings. Chi-square and Fisher exact tests were used to assess associations with locations and outcomes.This study included 23 children (13 girls, 10 boys; mean age: 12.7±4.2 years) with 7 axial, 8 proximal and 8 distal appendicular lesions. Kappa ranged from 0.53 to 1. MRI findings differed significantly between locations with axial lesions measuring larger (P=0.01) and more likely to contain fluid levels (P=0.02), triple sign (P=0.02), inhomogeneous signal (T1-weighted images, P=0.003; T2-weighted images, P=0.02, contrast-enhanced images, P=0.03) with all lesions containing partially solid composition (P=0.03). At a median follow-up of 14 months (interquartile range: 7-33 months), 39% relapsed. Predictors of relapse (P0.05) included metastasis at presentation, larger lesions, axial lesions and MRI findings of fluid level, T1-weighted hyperintensity, inhomogeneous signal (T1- and T2-weighted images) and poorly circumscribed margins.A significant association was found between location and MRI findings in our cohort of children with synovial sarcoma. Axial lesions were more likely to be larger, appear heterogeneous and be associated with a worse outcome.

Please see the Editorial Comment by Diego Jaramillo discussing this article. BACKGROUND. Undiagnosed and unrepaired root tears are increasingly recognized as a preventable cause of accelerated oste...

Antalgic gait is a common clinical presentation among pediatric patients and can have many different etiologies, with rare life-threatening etiologies including primary bone malignancies. Osteosarcoma is the most common primary malignancy of bone in pediatric and adolescent patients. The incidence rate of osteosarcoma has been reported as high as 5 to 7 per million among patients 19 years old or younger with males slightly more affected than females and African-Americans more than other racial groups. This report describes the case of a five-year-old African-American female who presented with an antalgic gait secondary to osteosarcoma in the left distal femur and follows her through treatment. In this case, the age is atypical as the peak incidence for osteosarcoma is around 16 years of age and is postulated to coincide with growth spurts. Osteosarcoma can have a range of presentations making it difficult to diagnose, which can cause delays in treatment and potential poor patient outcomes. Due to this, such a diagnosis must be included in the differential for patients presenting with antalgic gait. Because primary-care physicians and pediatricians may be the first medical providers to encounter patients with osteosarcoma, it is imperative that such clinicians are familiar with the signs and symptoms associated with osteosarcomas in order to reduce the risk of metastasis and disease progression and prevent treatment delays. Additionally, we believe these clinicians should have a low threshold to refer patients to orthopedists or oncologic specialists in the cases of persistent pain or inconsistencies with history, physical exam, and diagnostic studies. Finally, direct communication and discussion between radiologists and referring clinicians helps decrease delays in diagnosing of osteosarcoma and other life-threatening conditions.

BACKGROUND In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. METHODS Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. RESULTS From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. CONCLUSIONS Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

BACKGROUND Determination and longitudinal monitoring of progressive skeletal maturity are essential in the management of children with scoliosis. Although different methods for determining skeletal maturity exists, the most widely practiced method relies on the ossification pattern of the bones of the hand and wrist, which is traditionally acquired using conventional techniques and after the acquisition of the spine using the low-dose slot-scanning technique. Whereas the existing published literature has published promising results on the use of the slot-scanning technique to acquire these hand and wrist radiographs, image quality and radiation dose have not been systematically compared between these techniques. Thus, the objective of our study is to compare image quality, interpretation reliability, and radiation dose of hand bone age radiographs between slot-scanning and conventional techniques using age- and sex-matched children. METHODS This retrospective study included children who underwent hand radiographs using slot-scanning between October 1, 2019 and December 31, 2019; and matched children who underwent conventional radiography. Blinded to technique, 5 readers reviewed all radiographs after randomization to rate image quality and to determine bone age using the Greulich and Pyle classification. Dose area product was recorded. Mann-Whitney and t tests were used to compare variables between techniques and intraclass correlation (ICC) to determine observer agreement. RESULTS Our study cohort of 194 children (128 girls, 66 boys; mean age: 13.7±2.3 y) included 97 slot-scanning and 97 conventional radiographs. One (1%) slot-scanning and no conventional radiograph was rated poor in image quality. There was almost perfect interpretation reliability with slot-scanning with high interobserver (ICC=0.948) and intraobserver (ICC=0.996) agreements, comparable with conventional radiographs (ICCs=0.919 and 0.996, respectively). Dose area product (n=158) was lower (P

The purpose of this study was to systematically investigate the performance of different radiographic views in the identification of scaphoid fractures in children.This case-control study compared 4-view radiographic examinations of the wrist between children with scaphoid fracture and age- and sex-matched children without fractures performed between January 2008 and July 2019. After randomization, each examination was reviewed 3 times, at least 1 week apart, first using each view separately and later using multiple views without (3-view) and with the posteroanterior (PA) scaphoid view (4-view), to determine the presence or absence of a scaphoid fracture. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with inter-rater agreement.The study group of 58 children (48 boys and 10 girls; mean age 13.1 ± 2.1 years) included 29 with scaphoid fractures (8 corner, 9 distal pole, 10 waist, and 2 proximal pole) and 29 without fractures. Multiple views had higher sensitivity (3-view, 93.0%; 4-view, 96.5%) for fracture identification when compared to individual views (41.0-89.6%). The oblique view was 100% specific for the identification of a scaphoid fracture, but it lacked sensitivity. The PA scaphoid view had the highest sensitivity (89.6%) and NPV (90%) when compared to other individual views and its inclusion in the 4-view examinations produced the highest inter-rater agreement (93%, κ = 0.86).Multiple radiographic views of the wrist with the inclusion of a PA scaphoid view (4-view) produced the highest sensitivity, NPV, and inter-rater agreement for the identification of a scaphoid fracture in children.

Delayed diagnosis of scaphoid fractures can lead to long-term morbidity. While radiography is the preferred screening examination, there is a relative paucity of literature that examines fracture visibility in younger children, who have smaller ossification centers, an abundance of unossified cartilage and fractures that preferentially involve the distal scaphoid.To characterize acute scaphoid fractures in younger children on radiographs with observer agreement and with respect to fracture location.This institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant cross-sectional study included children (≤10 years of age) with acute scaphoid fractures (≤7 days), who underwent radiographic examinations at a tertiary children's hospital between December 2008 and June 2019. Three readers (two pediatric radiologists and one orthopedic surgeon) reviewed each examination to determine fracture visibility on each radiographic view and fracture location. Kruskal-Wallis, Fisher exact and Cochran-Armitage tests were used to compare fracture visibility and location, and Kappa tests were used to calculate observer agreement.Twenty-eight children (15 boys, 13 girls; mean age: 9.5±0.6 years) with 10 (36%) distal corner, 11 (39%) distal body and 7 (25%) mid-body fractures, underwent 7 (25%) 4-view, 18 (64%) 3-view and 3 (11%) 2-view examinations. Twenty-six (93%) fractures were visible on at least one view with six (21%) fractures visible on all available views. No significant association was found between fracture visibility and fracture location (P=0.32). Observer agreement was substantial to almost perfect.Only 7% of these acute scaphoid fractures in younger children are inconspicuous on the initial radiographic examination.

OBJECTIVE. The purpose of this study was to investigate the performance of MRI criteria for identifying meniscal ramp lesions in children with concomitant anterior cruciate ligament (ACL) tear, with arthroscopy used as the reference standard. MATERIALS AND METHODS. This retrospective study included 85 children who underwent a preoperative MRI examination and arthroscopically guided primary ACL reconstruction between June 1, 2017, and December 31, 2019. Blinded to arthroscopic findings, two radiologists reviewed all MRI examinations and reached consensus on the presence or absence of an effusion and various findings within the medial and lateral tibiofemoral joints. Chi-square, Fisher exact, independent t, and Mann-Whitney U tests were used to compare MRI findings between patients with and without arthroscopically confirmed meniscal ramp lesions. RESULTS. At arthroscopy, 35 children (23 boys and 12 girls; mean [± SD] age, 15.7 ± 2.0 years) had ramp lesions and 50 children (22 boys and 28 girls; mean age, 15.1 ± 2.4 years) had intact meniscocapsular junctions. Knees in which a ramp lesion was observed were significantly more likely to have MRI findings of a medial meniscus tear (p = .005), peripheral meniscal irregularity (p = .001), junctional T2-weighted signal (p < .001), and a meniscocapsular ligament tear (p < .001). No significant difference was found between children with and without ramp lesions with regard to the presence of an effusion (p = .65) or a lateral meniscus tear (p = .08) or the extent of medial and lateral tibial plateau marrow edema (p = .67 and p = .83, respectively). CONCLUSION. MRI findings associated with an arthroscopic diagnosis of meniscal ramp lesion include medial meniscus tear, peripheral meniscal irregularity, junctional fluidlike signal, and capsular ligament tear.

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.