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Rational and Objectives Ultrasound investigation of peripheral nerves, long used in the adult population, has been shown to be of value in diagnosing a variety of peripheral nerve abnormalities. More recently, nerve sonography has also been shown to be of use in pediatrics. However, normative values for nerve size in children have been lacking. As such, the goal of this research was to establish normative data for cross sectional area (CSA) measurements of the median and ulnar nerves in children. Materials and methods The median and ulnar nerves of 48 children ranging in age from 2 years to 17 years were imaged by ultrasound. CSA measurements were made at 2 separate sites for each nerve and measured independently by 6 pediatric radiologists. Reliability of ultrasound measurements between the radiologists was assessed by calculating intraclass correlation coefficients. Linear mixed-effects modeling was performed to develop prediction models for nerve cross sectional area for each nerve segment; 95% prediction values were generated from these models to approximate normal ranges. Results Agreement in nerve cross-sectional area measurements among the 6 radiologists for all nerve segments was good (ICC 0.82, 95% CI 0.78 to 0.85). CSA for both the median and ulnar nerves is larger in older children. However, statistical models to predict CSA using height perform better rather than those using a child's age. The range of normal nerve segment CSA using these prediction models based on child height are reported. Conclusion Median and ulnar nerve CSA can be reliably measured with ultrasound. Normal reference values for ulnar and median nerve CSA correlate with patient age but may be more optimally determined based on a child's height.

Background: An anteroposterior (AP) radiograph of the elbow in 45° of flexion has been suggested to increase the diagnostic accuracy of capitellum osteochondritis dissecans (OCD). Purpose: To assess the diagnostic performance, inter- and intraobserver reliability, and confidence level for identifying capitellum OCD using plain radiographs (AP, lateral, and 45° flexion AP). Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: This was a retrospective study of pediatric and adolescent patients with capitellum OCD and a control group. Six independent clinicians who were blinded to the official radiologists’ reports reviewed images on 2 separate occasions, 1 week apart. A 5-point Likert scale was used to assess the clinicians’ level of confidence. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for individual and combinations of radiographic views. Inter- and intraobserver reliability was determined using Cohen kappa (κ) coefficients. Results: A total of 28 elbows (mean age, 12.5 ± 2 years) were included. There were no differences in age ( P = .18), sex ( P = .62), or laterality ( P > .999) between groups. There were marked variations in the diagnostic accuracy between views: sensitivity (AP, 85.1; lateral, 73.2; 45° flexion AP, 91.7), specificity (AP, 89.3; lateral, 91.7; 45° flexion AP, 91.1), PPV (AP, 88.8; lateral, 89.8; 45° flexion AP, 91.1), NPV (AP, 85.7; lateral, 77.4; 45° flexion AP, 91.6), and accuracy (AP, 87.2; lateral, 82.4; 45° flexion AP, 91.4). Standard radiographs (AP and lateral views) failed to diagnose capitellum OCD in 4.8% of cases. The sensitivity of the 3 combined views was 100%. Confidence intervals in the clinicians’ diagnostic assessments were similar for each view (AP, 4.0; lateral, 4.0; and 45° flexion AP, 4.1). Interobserver reliability was substantial for AP and lateral views (κ = 0.65 and κ = 0.60, respectively) but highest for the 45° flexion AP radiographs (κ = 0.72). Intraobserver reliability for the 45° flexion AP view was moderate to almost perfect (κ = 0.45 to 0.93). Conclusion: The 45° flexion AP view can detect capitellum OCD with excellent accuracy, a high level of confidence, and substantial interobserver agreement. When added to standard AP and lateral radiographs, the 45° flexion AP view aids in the identification of capitellum OCD.

The expanded use of Magnetic Resonance Imaging (MRI) for evaluation of musculoskeletal pathology in infants has resulted in increased sensitivity and specificity of diagnostic evaluation. The unique anatomic, physiologic and behavioral attributes of the infant however, present challenges in MR imaging. Adjustments to MRI hardware, scan technique and protocols can help circumvent several of these challenges. While sedation and anesthesia can ensure immobilization, they have some inherent side effects. Accelerated and abbreviated MRI protocols with judicious use of gadolinium-based contrast can limit the need for sedation/anesthesia. In this article, we overview musculoskeletal MRI in infants, emphasizing technical optimization and safety.

ObjectiveTo standardize and improve the accuracy of detection of arthritis by thermal imaging.MethodsChildren with clinically active arthritis in the knee or ankle, as well as healthy controls, were enrolled to the development cohort; another group of children with knee symptoms was enrolled to the validation cohort. Ultrasound was performed in the arthritis subgroup for the development cohort. Joint exam by certified rheumatologists was used as a reference for the validation cohort. Infrared thermal data were analyzed using custom software. Temperature after within-limb calibration (TAWiC) was defined as the temperature differences between joint and ipsilateral mid-tibia. TAWiC of knees and ankles was evaluated using ANOVA across subgroups. Optimal thresholds were determined by receiver-operating characteristic analysis using Youden index.ResultsThere were significant differences in mean and 95th TAWiC of knee in anterior, medial, lateral views, and of ankles in anterior view, between inflamed and uninflamed counterparts (P < 0.05). The area under the curve was higher by 30% when using TAWiCknee than that when using absolute temperature. Within the validation cohort, the sensitivity of accurate detection of arthritis in the knees using both mean and 95th TAWiC from individual views or all 3 views combined ranged from 0.60 to 0.70, and the specificity was > 0.90 in all views.ConclusionChildren with active arthritis or tenosynovitis in knees or ankles exhibited higher TAWiC than healthy joints. Our validation cohort study showed promise for the clinical utility of infrared thermal imaging for arthritis detection.

In skeletally immature patients, the presence of growth plates and articular cartilage of the shoulder can create a predisposition for unique injuries not observed in adults. Furthermore, increasing participation in sports by children and adolescents appears to be leading to a corresponding increase in the number of sports-related injuries. The importance of radiologists being familiar with pediatric shoulder imaging and its associated injuries is therefore growing. In this article, we review the normal development and maturation pattern of ossification centers of the shoulder from the early gestational period through adolescence. Brachial plexus birth palsy, physeal injuries, shoulder dislocation, and internal impingement are discussed within the context of the child's age and the mechanism of injury to guide radiologists to a correct diagnosis.

OBJECTIVE. Any combination of abnormal positioning of the ankle, hindfoot, midfoot, and forefoot is possible in the context of cerebral palsy, but some patterns are more common than others. The purpose of this article is to discuss the radiographic manifestations and surgical management of the following common conditions: equinus, equinoplanovalgus, equinocavovarus, vertical talus, oblique talus, hallux valgus, and ankle valgus. CONCLUSION. CP is defined by abnormalities of the developing fetal or infant brain that result in permanent central motor dysfunction. Foot and ankle deformities are very common in the patients with CP, occurring in up to 93% of such patients as a result of underlying abnormal muscle tone, impaired motor control, and dynamic muscle imbalance. Radiologists must develop knowledge of the most common changes in alignment and basic techniques for correction to better recognize abnormalities and improve communication with orthopedic colleagues.

Cerebral palsy is a neurologic condition with myriad musculoskeletal and articular manifestations. While every patient is unique with innumerable variations in presentation, symptoms and treatments, there are broad themes and recognizable patterns of development. Many of these findings spill over to other neurodevelopmental disorders, and lessons learned from children with cerebral palsy translate well to multiple neurologic conditions. This review focuses on the more common manifestations involving the spine, knee, foot and ankle, with an emphasis on collecting and describing imaging features, along with clinical and radiologic pearls and pitfalls.

Background: The initial diagnosis of capitellum osteochondritis dissecans (OCD) is typically confirmed using standard anteroposterior (AP) and lateral elbow radiographs, despite low sensitivity, which is approximately 44-47%. An AP image of the elbow in 45° of flexion has been suggested to increase diagnostic accuracy. Purpose: To assess the diagnostic performance, inter- and intra-observer reliability, and confidence level for identifying capitellum OCD using plain radiographs (AP, lateral, and 45° flexion AP) in pediatric and adolescent patients. Methods: This was a retrospective study including pediatric and adolescent patients with capitellum OCD and a healthy control group. Independent clinicians were blinded to the official radiologists’ reports and reviewed images on a picture archiving and communication system on two separate occasions 1 week apart. A 5-point Likert scale was used to assess the clinicians’ level of confidence (1-not at all confident; 5-very confident). Inter- and intraobserver reliability was determined using kappa statistics. Results: The study included 28 elbows (24 patients) with a mean age of 12.5 ± 2.0 years. 64.3% were female. There were no differences in age ( P = 0.18), sex ( P = 0.62), or laterality ( P = 1.0) between the two groups. There were marked variations in the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each of the following views: AP: Sensitivity 85.1; Specificity 89.3; PPV 88.8; NPV 85.7; accuracy 87.2. Lateral: Sensitivity 73.2; Specificity 91.7; PPV 89.8; NPV 77.4; accuracy 82.4. 45° flexion AP: Sensitivity 91.7; Specificity 91.1; PPV 91.1; NPV 91.6; accuracy 91.4. Standard radiographs (AP and lateral views) failed to diagnose capitellum OCD in 4.8% of cases. The sensitivity of the three combined views was 100%. Confidence levels in the clinicians’ diagnostic assessments were similar for each view (AP, 4.0; lateral, 4.0; and 45° flexion AP, 4.1). Interobserver reliability was substantial for AP and lateral views (k=0.65 and k=0.60, respectively) but highest for the 45° flexion AP radiographs (k=0.72). Intraobserver reliability for all views was moderate to perfect (k=0.52 to 0.93). Conclusion: The 45° flexion AP view can detect capitellum OCD with excellent accuracy, a high level of confidence, and substantial interobserver agreement. When added to standard AP and lateral radiographs, capitellum OCD can be diagnosed in 100% of cases.

The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation and fishtail deformity of the distal humerus.

Chronic recurrent multifocal osteomyelitis (CRMO) is a distinct disease entity of unknown etiology primarily affecting children and adolescents. It is an autoinflammatory process that typically affects multiple bones with a waxing and waning course. About one third of the patients diagnosed with CRMO have spinal involvement which can lead to long term morbidity. The clinical presentation and imaging features of CRMO involving the spine are nonspecific and can mimic other disease processes like infection or malignancy. Since imaging plays a very important role in the diagnosis and management of CRMO, we intend to highlight various imaging patterns of spinal CRMO alongside its clinical features and briefly discuss its imitators, management and outcomes.

Objective.Serial magnetic resonance imaging (MRI) examinations are often needed in chronic nonbacterial osteomyelitis (CNO) to determine the objective response to treatment. Our objectives in this study were (1) to develop a consensus-based MRI scoring tool for clinical and research use in CNO; and (2) to evaluate interrater reliability and agreement using whole-body (WB)-MRI from children with CNO.Methods.Eleven pediatric radiologists discussed definitions and grading of signal intensity, size of signal abnormality within bone marrow, and associated features on MRI through monthly conference calls and a consensus meeting, using a nominal group technique in July 2017. WB-MRI scans from children with CNO were deidentified for training reading and an interrater reliability study. The reading by each radiologist was conducted in a randomized order. Interrater reliability for abnormal signal and severity were assessed using free-marginal κ statistics.Results.Radiologists reached a consensus on grading CNO-specific MRI findings and on describing bone units based on anatomy. A total of 45 sets of WB-MRI scans, including 4 sets of non-CNO MRI examinations, were selected for the final reading. The mean κ of each category of bones was > 0.7 with majority > 0.9 demonstrating substantial/almost perfect interrater reliability of readings among radiologists. The agreement on signal intensity and the size of signal abnormality within the most commonly affected bones (femur and tibia) were lower than those of other bones.Conclusion.The chronic nonbacterial osteomyelitis magnetic resonance imaging scoring (CROMRIS) tool is a comprehensive standardized scoring tool for MRI in children with CNO. Our interrater study demonstrated good interrater reliability and agreement of readings.

Ligamentous injuries of the pediatric wrist, once thought to be relatively uncommon, are increasingly recognized in the context of acute high-energy mechanism trauma and chronic axial loading, including those encountered in both recreational and high-performance competitive sports. Recent advances in MR-based techniques for imaging the pediatric wrist allow for sensitive identification of these often radiographically occult injuries. Detailed knowledge of the intrinsic and supportive extrinsic ligamentous complexes, as well as normal developmental anatomy and congenital variation, are essential to accurately diagnose injuries to these structures. Early identification of ligamentous injury of the pediatric wrist is essential within the conservative treatment culture of modern pediatric orthopedics because treatment of these lesions often necessitates surgery, and outcomes often depend on early and sometimes aggressive intervention. In this article, we review MR arthrogram technique and pediatric wrist anatomy, and correlate appearances on MR and selected ligamentous pathologies of the pediatric wrist.

Skeletal dysplasia is a heterogeneous group of abnormalities affecting growth and development of bone and cartilage characterized by disproportionate shortening of the limbs and/or spine. A systematic radiographic approach combined with pertinent clinical details can help guide specific genetic testing and treatment. We provide a discussion and examples of a few common and notable skeletal dysplasias to help familiarize general, pediatric, and musculoskeletal radiologists who do not commonly encounter children with these entities in their daily practices.

Background: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic arthritides presenting in patients aged ≤16 years, with a prevalence of 16 to 150 per 100,000. Juvenile osteochondritis dissecans (OCD) is an idiopathic disease of articular cartilage and subchondral bone, has an onset age of 10 to 16 years, and often affects the knee, with a prevalence of 2 to 18 per 100,000. Currently, there are few studies that have evaluated the relationship between JIA and OCD. Hypothesis: OCD is more prevalent in children with JIA, and when diagnosed in such patients, OCD often presents at an advanced state. Study Design: Case series; Level of evidence, 4. Methods: The medical records of patients with diagnoses of both JIA and OCD treated between January 2008 and March 2019 at a single children’s hospital were retrospectively reviewed. Associations between timing of diagnoses, number and types of corticosteroid treatments, category of arthritis, timing of diagnoses, and lesion stability were examined with Spearman correlation coefficients. Results: A total of 2021 patients with JIA were identified, 20 of whom (19 female, 1 male) had OCD of the knee and/or talus for a prevalence of 1 in 100 or 1000 in 100,000, or approximately 50 to 500 times that of the general population. These 20 patients had a total of 28 OCD lesions: 43% (9 femur, 3 talus) were radiographically stable over time, 50% (10 femur, 2 patella, 2 talus) were unstable at initial diagnosis, and 7% (2 femur) were initially stable but progressed to unstable lesions despite drilling. Twelve patients (60%) underwent surgery: 4 (20%) with stable femoral lesions for persistent symptoms despite prolonged nonoperative treatment and 8 (40%) for treatment of their unstable lesions (femoral and patellar). Within our study design, we could identify no significant associations between lesion stability and timing of diagnoses, number of joint injections, or limb deformities, nor were there associations between timing of JIA and OCD diagnoses and category of arthritis. Conclusion: In our population of patients with JIA, OCD lesions were found to be 50 to 500 times more prevalent when compared with published rates in the general population and often presented at an advanced state, with instability or delayed healing requiring surgery for stabilization or resolution of symptoms.

Academic radiologists on the clinician–educator track are required to provide a teaching portfolio as well as a curriculum vitae (CV) for academic promotion. The specific components of a teaching portfolio vary slightly depending on the institution. Traditionally academicians have collected the necessary documentation in paper format, often stuffing them in a binder or a desk drawer. However in the digital age most academic works are readily available in electronic format and can be accessed online. An electronic portfolio is the ideal method to efficiently organize this digital material. In this article, we describe the specific advantages of an online academic portfolio, explain how to set one up and review many options available to build an online electronic portfolio.

In children, MR arthrography is typically performed using fluoroscopic guidance. This article explores the role of US-guided joint injections as an alternative for MR arthrography in children, discussing its advantages and disadvantages compared to standard methods. We describe techniques for performing US-guided injection of the shoulder, elbow, hip, knee, ankle and posterior subtalar joints, highlighting pertinent anatomy, routes of access and unique considerations for this modality in children. Written descriptions, images and links to video clips are used to illustrate proper arthrographic technique. We conclude that US provides effective guidance for intra-articular injection prior to MR arthrography, with the advantages of improved visualization of internal structures, reduced radiation exposure, convenience of performing the procedure portably and ease of performance. Although this paper does not address therapeutic steroid injections, these techniques could easily be translated for such purposes. We propose US guidance as a viable alternative to fluoroscopic technique for arthrography in children.

OBJECTIVE. The purpose of this article is to provide a comprehensive overview of the imaging of brachial plexus palsy, including both pathologic conditions of the spine and shoulder and clinical background and management. CONCLUSION. Brachial plexus birth palsy can result in permanent disability and limb deformity. Identifying the lesion type and associated sequelae is important in clinical management aimed at optimizing outcome. The imaging algorithms used are guided by clinical presentation and are designed to assess the extent of injury to guide possible surgical intervention.

Objective.The validity of our current definitions for clinically inactive disease (CID) in juvenile idiopathic arthritis (JIA) based on physical examination is challenged by the development of advanced musculoskeletal imaging tools. We aimed to prospectively determine the prevalence of abnormal ultrasound (US) findings in children with CID in JIA and their clinical significance.Methods.Children aged ≥ 4 years with CID and a history of arthritis from a single tertiary center were approached over 1 year. Standard US of knees, tibiotalar joints, subtalar joints, and wrists were performed at baseline and at a followup visit. US images were scored by 2 pediatric musculoskeletal radiologists.Results.Forty children with CID were enrolled and followed clinically. The median duration of inactive disease was 1 year. The most common International League of Associations for Rheumatology JIA categories were extended oligoarticular JIA (30%) and rheumatoid factor–negative polyarthritis (38%). At baseline, among a total of 289 joints scanned, 24 joints (8%) had at least 1 abnormal finding in 18 (45%) of 40 subjects. When evaluated at the individual joint level against flares identified during followup exams, these baseline US findings had a sensitivity of 15% and a positive predictive value of 12%. The predictive performance of the second US was even less.Conclusion.Our study demonstrates that nearly half of children with CID had abnormal US findings in 1 of 8 commonly affected joints. These findings did not correlate with subsequent clinical flares in up to 2 years of followup.

Juvenile idiopathic arthritis (JIA) and osteoarticular infection can cause nonspecific articular and periarticular complaints in children. Although contrast material-enhanced magnetic resonance imaging is the reference standard imaging modality, musculoskeletal ultrasonography (US) is emerging as an important adjunct imaging modality that can provide valuable information relatively quickly without use of radiation or the need for sedation. However, diagnostic accuracy requires a systemic approach, familiarity with various US techniques, and an understanding of maturation-related changes. Specifically, the use of dynamic, Doppler, and/or multifocal US assessments can help confirm sites of disease, monitor therapy response, and guide interventions. In patients with JIA, ongoing synovial inflammation can lead to articular and periarticular changes, including synovitis, tenosynovitis, cartilage damage, bone changes, and enthesopathy. Although these findings can manifest in adult patients with rheumatoid arthritis, important differences and pitfalls exist because of the unique changes associated with an immature and maturing skeleton. In patients who are clinically suspected of having osteoarticular infection, the inability of US to evaluate the bone marrow decreases its sensitivity. Therefore, the US findings should be interpreted with caution because juxtacortical inflammation is suggestive, but neither sensitive nor specific, for underlying osteomyelitis. Similarly, the absence of a joint effusion makes septic arthritis extremely unlikely but not impossible. US findings of JIA and osteoarticular infection often overlap. Although certain clinical scenarios, laboratory findings, and imaging appearances can favor one diagnosis over the other, fluid analysis may still be required for definitive diagnosis and optimal treatment. US is the preferred modality for fluid aspiration and administering intra-articular corticosteroid therapy.

The authors describe our experience in planning, organizing, and running a radiology CME conference at a hotel (rather than at a stand-alone conference or convention center). Much of the information described should also be useful for other medical and nonmedical conferences. This experience should provide new conference organizers with useful information to ensure a more efficient and successful conference, so there are fewer "If I knew then what I know now" moments over the years.

Radiography is the mainstay for initial evaluation of paediatric foot and ankle pathology. MRI is the preferred exam for further characterisation of the majority of these conditions. The modality features high sensitivity and specificity for this purpose with few exceptions. Findings on MRI will often dictate patient referral and further management, and are frequently required for surgical planning. This article will provide an overview of a variety of pathologies that afflict the foot and ankle in children. These include tarsal coalition, osteochondral lesions, osteonecrosis, osteochondroses, stress fractures, osteomyelitis, inflammatory arthritis, neoplasms of bone and soft tissue, and foreign bodies. Their respective imaging manifestations on MRI are the focus of the paper. Technical parameters and marrow signal variation are also discussed.

High-resolution sonography using a stand-off pad or a gel mound is a standard technique for the evaluation of soft-tissue structures of the hands and feet in children. However, the complex curved surfaces of the hands and feet often yield suboptimal contact between the transducer and the skin. Additionally, the small field of view, relative compressibility of the soft-tissue structures by the transducer, patient motion and discomfort from contact of the transducer with the pathology often limit conventional US evaluation. A water-bath technique overcomes these limitations. We present our experience of water-bath technique of superficial sonography in 23 children. Water-bath technique was performed with good patient cooperation and was superior to the standard technique for depiction of shallow skin ulcers, subcutaneous masses, vascular malformations, osteomyelitis and foreign bodies.

OBJECTIVE. Cartilage development has a profound impact on musculoskeletal growth. The objective of this article is to offer insights about the maturation of hyaline cartilage through MRI. We begin by briefly describing the molecular make up of hyaline cartilage. We will then follow with a discussion of the basic principles to apply to optimize hyaline cartilage imaging. The remainder of the article will focus on the MR appearances of the distinct histologic types of hyaline cartilage, normal variations in cartilage development, and the sequelae of cartilage injury on normal skeletal development. CONCLUSION. Knowledge of the normal and abnormal appearances of hyaline cartilage on MRI of pediatric patients will allow readers to avoid mistaking the changes associated with skeletal maturation for pathologic findings.

OBJECTIVE. Pediatric elbow trauma is challenging because of the complex nature of the growing skeleton. The objectives of this article are to review the anatomy and radiographic landmarks and to discuss common acute and chronic injuries sustained. CONCLUSION. Radiographic evaluation of elbow trauma in the acute setting requires a firm understanding of developmental anatomy, radiographic landmarks, and the common injury patterns. Both radiography and MRI are vital tools for diagnosing chronic elbow overuse injuries in adolescent athletes.

We present a pictorial review of MRI features of various closed spinal dysraphisms based on previously described clinicoradiological classification of spinal dysraphisms proposed. The defining imaging features of each dysraphism type are highlighted and a diagnostic algorithm for closed spinal dysraphisms is suggested.

We thank Dr. Johannes Roth for his comments1 on our recent publication2. Dr. Roth raises several important points. The first is that for a Doppler signal to be considered abnormal it must exist within thickened synovium. This is based on adult studies and a recent consensus conference defining ultrasound (US) requirements for the pediatric population3. Physiologic blood flow may exist within the joint space of children without abnormal structural changes of the synovium. Thus, if these new definitions of Doppler signal detection in synovitis for children are applied to the images for our study, the presence of synovitis would have been much less frequent in … Address correspondence to Dr. Y. Zhao, MA 7.110, 4800 Sand Point Way NE, Seattle, Washington 98105, USA. E-mail: yongdong.zhao{at}seattlechildrens.org

Cytomegalovirus (CMV) is a ubiquitous virus that usually results in asymptomatic or clinically benign infection. However, there are two groups of patients whose response to CMV infection is much more severe: those who are infected during fetal development and those who are immunocompromised. Although the manifestations of these types of infection differ, both often result in substantial neurologic sequelae. Imaging plays a key role in the diagnosis of both congenital and acquired CMV infection. Neurologic findings of congenital CMV infection include intracranial calcification, migrational abnormalities, cerebral and cerebellar volume loss, ventriculomegaly, and white matter disease. The presence of these findings in children with neurodevelopmental delays is suggestive of congenital CMV infection, even if the child was asymptomatic at birth. Certain imaging features also may indicate future neurologic deficits in symptomatic infants. Acquired CMV infection is potentially deadly in immunocompromised patients such as those infected with human immunodeficiency virus or with acquired immune deficiency syndrome and those with a history of solid organ or bone marrow transplantation. Imaging findings of acquired CMV infection often are nonspecific; however, they may indicate a need for further serologic analysis to determine if CMV infection is present. Early recognition and treatment of central nervous system CMV infection is vital for effective treatment, and familiarity with the imaging findings of this common infection is important for accurate diagnosis.

Received November 19, 2008; accepted after revision March 14, 2009. 1Department of Radiology, Seattle Children’s Hospital, M/S R-5417 PO Box 5371 Seattle, WA 98105. Address correspondence to M. M. Thapa (thapamd@u.washington.edu). 2Department of Radiology, University of Washington, Seattle, WA 98105. AJR 2010;194:S51–S58 0361–803X/10/1946–S51 © American Roentgen Ray Society Objective The purpose of this article is to discuss the radiographic assessment of pediatric foot alignment. Clinical scenarios are included to orient the learner to the evaluation of pediatric foot alignment. Abnormalities discussed include, but are not limited to, talipes equinovarus (congenital clubfoot), planovalgus, and vertical talus. Practice questions are included to assess understanding of the subject matter.

Rationale and Objectives Podcasts and vodcasts (video podcasts) have become popular means of sharing educational information via the Internet. Materials and Methods In this article, we introduce another method, an enhanced podcast, which allows images to be displayed with the audio. Bookmarks and URLs may also be imbedded within the presentation. This article describes a step-by-step tutorial for recording and distributing an enhanced podcast using the Macintosh operating system. Enhanced podcasts can also be created on the Windows platform using other software. An example of an enhanced podcast and a demonstration video of all the steps described in this article are available online at web.mac.com/mthapa. Results An enhanced podcast is an effective method of delivering radiological information via the Internet. Viewing images while simultaneously listening to audio content allows the user to have a richer experience than with a simple podcast. Incorporation of bookmarks and URLs within the presentation will make learning more efficient and interactive. Conclusion The use of still images rather than video clips equates to a much smaller file size for an enhanced podcast compared to a vodcast, allowing quicker upload and download times.

Developing hyaline cartilage at ends of long bones consists of the epiphyseal, physeal, and articular cartilage components, each of which has specific imaging characteristics that reflect biochemical and macromolecular composition. Standard MR imaging protocols used in adults do not provide sufficient information when used for children, and MR imaging techniques need to be tailored to the developmental stage of the child. This article presents the biochemical and histologic features of normal hyaline cartilage and its MR imaging characteristics, followed by a practical approach to optimizing imaging protocols for cartilage imaging. Finally, common abnormalities and advanced hyaline cartilage imaging techniques are described.

The growth of ectopic glioneuronal tissue in the middle cranial fossa region is an uncommon event, with very few cases reported in the literature. In this paper the authors document 4 cases of ectopic glioneuronal tissue in the middle cranial fossa in children and briefly describe the clinical course and pathology. All of the children presented within the first 6 months of life. Two children presented with facial masses, 1 with airway obstruction, and another with proptosis of the right eye. Each child underwent a customized surgery dependent on the location and characteristics of the harbored lesion. Ectopic glioneuronal masses in the middle cranial fossa are rare and benign congenital tumors, and affected newborns can present with airway obstruction, feeding difficulties, and facial deformity depending on the lesion location. Determining an appropriate surgical approach and strategy is a significant challenge and may involve a multidisciplinary team of craniofacial plastic surgeons, otolaryngologists, and neurosurgeons. Although these lesions share clinical and anatomical similarities, because of their histopathological heterogeneity, it is unlikely that they represent a single pathological entity. The long-term outcome in these children is still unknown and is an area for future study. The pathogenesis of these lesions also remains unknown and may be revealed in future research.

We present a case of non-Peutz Jegher hamartomatous polyps causing jejuno-jejunal intussusception and small bowel obstruction in a pediatric patient. In addition, we also provide an intraoperative video of the intussusception reduction process. Polyps causing small bowel intussusception are uncommon but not rare. However, we could not find in the medical literature any videos of the intussusception reduction process. We feel this case report, the discussion provided, and the intraoperative video correlation will offer a unique educational perspective to this disease entity. In addition, this case report will also show the importance of considering small bowel intussusception in the differential of a child who presents with vague but persistent abdominal symptoms.

Video podcasts, or vodcasts, are an innovative tool for teaching and learning that allow the efficient distribution of tutorials, lectures, and other educational content. Certain types of content lend themselves to presentation in a video format. For example, vodcasts are well suited to teaching radiologic procedures. Vodcasts might also be quite useful in demonstrating the use of an audience response system and how one system differs from another, providing background content before an active-learning session, comparing magnetic resonance imaging pulse sequences, and teaching valuable interpersonal skills such as how to deliver bad news to a patient or how to maintain professionalism in the work environment. The authors present a step-by-step text-and-video tutorial on how to create, edit, and export vodcasts using a variety of software tools, describing both the "how" and the "why" of creating vodcasts. Interested readers are encouraged to examine both the print and online versions of this article to gain a more comprehensive knowledge of the ideas presented by the authors. Online supplemental material is available for this article.

OBJECTIVE. The purpose of this review is to describe the use of several essential techniques and tools in Adobe Photoshop image-editing software. The techniques shown expand on those previously described in the radiologic literature. CONCLUSION. Radiologists, especially those with minimal experience with image-editing software, can quickly apply a few essential Photoshop tools to minimize the frustration that can result from attempting to navigate a complex user interface.

Musculoskeletal US is becoming more widely performed in children. Although overlap between pediatric and adult pathology exists, particularly in older children who have a more mature skeleton, there are significant differences when assessing patients who have cartilaginous ossification centers, particularly in the context of trauma. Lack of ionizing radiation and dynamic imaging capabilities are significant advantages compared to CT and MRI. Although MRI provides excellent evaluation of soft tissues, the need for general anesthesia in a subset of patients is undesirable, particularly when US can provide similar information. Radiography is the primary modality to evaluate trauma; however, musculoskeletal US can be useful to assess alignment of unossified structures, fractures that extend to involve the unossified epiphyses, occult fractures, physeal separation, presence of intra-articular bodies (particularly those that are not ossified), ligamentous injury and the occasionally encountered periosteum trapped between fracture fragments. The purpose of this article is to review commonly encountered pathologies unique to the pediatric upper extremities that are ideally imaged with sonography. Some pathology that overlaps with the adult population such as infection and sports injuries are briefly covered.

The authors describe our experience in planning, organizing, and running a radiology CME conference at a hotel (rather than at a stand-alone conference or convention center). Much of the information described should also be useful for other medical and nonmedical conferences. This experience should provide new conference organizers with useful information to ensure a more efficient and successful conference, so there are fewer "If I knew then what I know now" moments over the years.

Peer review has become an essential component of a comprehensive radiology department quality assurance program. Multiple commercial programs, such as RADPEER, are available to fill this need but may be limited by low radiologist compliance and delayed or limited feedback. Consequently, these peer review programs may not achieve the greater goal of improving diagnostic quality. This article presents data from a peer review system implemented in an academic radiology group at a large urban multidisciplinary children's hospital. The peer review system offered instantaneous feedback with an enhanced comment feature for peer radiologists.Peer review data were collected on 5278 radiologic studies over a 12-month period including 15 radiologists. The data were analyzed for compliance rate, discrepancy rate, and comment usage.The compliance rate for peer review averaged 52% for the 12-month period. The compliance rate trended upward over the course of the year, with a final month's compliance rate of 76%. The discrepancy rate between original interpretation and peer review was 3.6%. Comments were voluntarily included in 7.3% of nondiscrepant peer review scores.Our peer review process was enhanced by real-time comment-enriched feedback on both discrepant and nondiscrepant peer reviews. We show improved radiologist compliance over the course of a year in a peer review program with no incentives or penalties for performing reviews. To our knowledge, no compliance rates exist in current literature for comparison.

OBJECTIVE. The thalami are subject to multiple insults including metabolic and toxic phenomena, acute demyelination, infection, infarction, hemorrhage and neoplastic involvement. The purpose of this article is to review the neuroimaging approach, classification, and imaging of bilateral thalamic lesions with histopathology correlation and application of advanced techniques. CONCLUSION. Neuroimaging of abnormal pediatric thalami uses conventional MRI sequences and advanced techniques to characterize lesions. Although there is considerable imaging overlap, a tailored approach can facilitate diagnosis and management.

Graphic artists have used Adobe Illustrator extensively to create and enhance their digital art. Medical personnel have also utilized Adobe Illustrator to optimize images. The purpose of this resource is to introduce a novel method of creating line art using tools available in the latest versions of Adobe Illustrator. A tutorial with example videos to guide the reader through the process is included. A detailed explanation of how to use Illustrator is also provided. Creating a basic line-art illustration as described in the resource should take about 15 minutes the first time through and much less time with increased experience. We have used the methods described in this resource to create line art for various publications, including web presentations, print publications, and projectors. We hope to utilize other tools in Illustrator and available plug-ins to further improve the process.

The objectives of this article are to review the diagnosis and management of acute nonrenal reactions to iodinated contrast media. We will begin by discussing the types of contrast media and their correlative rates of reaction. The mechanism of contrast reactions, predisposing risk factors, and preventative measures will then be discussed. The remainder of the article will review the assessment of potential reactions, initial management, and treatment algorithms for specific reactions.

Objective Chronic recurrent multifocal osteomyelitis (CRMO) is primarily a disorder of children and adolescents characterized by episodic osseous pain over several years. The objective of this article is to present an overview of this entity with an emphasis on imaging manifestations. Conclusion CRMO can be a difficult diagnosis, often with nonspecific imaging findings. The critical factors leading to its diagnosis are patient demographics, clinical course, and distribution. However, a greater understanding of the imaging appearance during both active and reparative phases may lead to improved detection. Introduction Chronic recurrent multifocal osteomyelitis (CRMO) is a skeletal disorder of unknown cause, occurring primarily in children and adolescents. The entity was first described by Giedion et al. [1] in 1972 as "an unusual form of multifocal bone lesions with subacute and chronic symmetrical osteomyelitis." Later, Bjorksten and Boquist [2] noted its association with pustulosis palmoplantaris and developed the term "chronic recurrent multifocal osteomyelitis." Between 200 and 300 cases of CRMO have been reported in the literature worldwide, consisting mainly of case series with relatively brief follow-up durations [3]. However, because of increasing disease awareness and longer clinical observation periods, this disorder is likely more common than previously realized. CRMO is a diagnosis of exclusion based on the following criteria: lack of causative organism; no abscess formation, fistula, or sequestra; atypical location compared with infectious osteomyelitis, with frequent involvement of the clavicle and often showing multifocality; radiographic appearance of subacute or chronic osteomyelitis; nonspecific histopathologic and laboratory findings compatible with subacute or chronic osteomyelitis; characteristic prolonged, fluctuating course with recurrent episodic pain over several years; and accompanying pustulosis palmoplantaris or acne [2, 4]. Clinical Findings CRMO is characterized by the insidious onset of pain and swelling corresponding to the involved bones [5, 6]. Most cases (up to 85%) occur in females, with a median age of onset of 10 years [7, 8]. The disease course is typically prolonged over several years. punctuated by periodic exacerbations. Symptoms may either recur at sites affected previously or involve new areas with subsequent flare-ups. Patients may experience concomitant systemic symptoms including low-grade fevers and generalized malaise [9]. CRMO may be accompanied by many skin disorders, most commonly pustulosis palmoplantaris, that may recur along with the osseous exacerbations [2, 5, 10]. The lesions are predominantly situated in the metaphyses of tubular bones, followed by the clavicle and spine [2, 6, 11-13]. Within tubular bones there is a predilection for the lower extremities, with the distal femur, proximal tibia, distal tibia, and distal fibula most commonly affected [14]. The disease may less frequently involve the ribs [10, 12, 15-17], sternum [15], and pelvis [18]. Symmetric involvement is common [14], and multifocality is virtually always present. The clinical course of CRMO may last anywhere from 7 to 25 years [3, 11, 19]. Treatment generally involves antiinflammatory agents targeting symptomatic relief, particularly nonsteroidal antiinflammatory drugs (NSAIDs) [20]. NSAIDs are usually effective in symptomatic relief, with response rates of up to 80% [7, 21].