School ager with back pain

Radiographs of mechanical back pain — AP, lateral and both oblique radiographs of the lumbar spine are unremarkable and show no evidence of a scotty dog deformity, thus ruling out spondylolysis.

The diagnosis was mechanical back pain.

Toddler with back pain

Radiograph of leukemia of the spine — Lateral radiograph of the thoracic spine shows diffuse osteopenia in the vertebral bodies with loss of height (vertebra plana) in all of the vertebral bodies.

The diagnosis was acute lymphoblastic leukemia involving the spine.

Preschooler with worsening back pain for 3 weeks and then refusal to walk

Radiograph and MRI of Langerhans cell histiocytosis of the spine — Lateral radiograph of the lumbar spine shows loss of height of the L1 vertebral body. Coronal and sagittal T1 MRI with contrast of the lumbar spine shows flattening (vertebra plana) and enhancement of the L1 vertebral body with a small enhancing right sided paravertebral mass.

The diagnosis was Langerhans cell histiocytosis of the spine.

Teenager with low back pain and bilateral radicular pain for 5 months

MRI of disc herniation — Sagittal and axial (at the L5 level) T1 MRI without contrast of the lumbar spine shows central and posterior displacement of the L5 intervertebral disk.

The diagnosis was disc herniation.

School ager with worsening back pain after minor fall

Radiograph and CT of Ewing sarcoma of the spine — Lateral radiograph of the spine shows collapse of the T12 vertebral body. Sagittal 2D reconstruction and axial CT without contrast of the T12 vertebral body in bone windows shows a permeative destructive process affecting it. Axial CT without contrast of the abdomen at the T12 level shows a large left-sided paraspinal soft tissue mass.

The diagnosis was Ewing sarcoma.

Toddler with limp who won’t bear weight on right leg

Radiograph and MRI of diskitis / osteomyelitis — Lateral radiograph of the lumbar spine shows loss of height of the L3-L4 intervertebral disc space. Sagittal T2 MRI of the lumbar spine shows (right top) loss of normal bright signal of the L3-L4 intervertebral disc and an epidural mass just posterior to the L4 vertebral body. Axial T1 MRI with contrast at the L4 level shows the epidural mass to be right sided and to also involve the right psoas muscle.

The diagnosis was osteomyelitis / diskitis.

Toddler with back pain and scoliosis

MRI of astrocytoma of spinal cord — Sagittal T1 (left), T2 (middle) and T1 with contrast (right) MRI of the thoracic spine shows an expansile lesion of the lower thoracic spinal cord that is isointense on T1, hyperintense on T2, and which enhances avidly with contrast.

The diagnosis was an astrocytoma of the spinal cord.

School ager with lower back and left buttock pain and a limp

Radiograph and MRI of aneursymal bone cyst — Lateral radiograph of the lumbar spine shows an expansile lesion in the S2 vertebral body. Axial and sagittal T2 MRI of the lumbar spine shows the S2 expansile lesion to be well defined and to have fluid-fluid levels within it.

The diagnosis was aneurysmal bone cyst of the sacrum.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Teenager with abnormal pleural-based nodules on CXR who had sustained blunt abdominal trauma in the remote past

CXR and CT and Tc-99m sulfur colloid scan of diaphragmatic rupture — CXR AP shows a left-sided large pleural nodule just beneath the clavicle. Axial CT with contrast of the chest shows multiple pleural nodules throughout the left hemithorax and absence of the spleen. Tc-99m sulfur-colloid scan shows normal radiotracer uptake in the liver with no uptake in the region of the spleen (lower left), and nodular uptake throughout the left hemithorax (lower middle) and abdomen (lower right).

The diagnosis was diaphragmatic rupture and post-traumatic splenosis.

Teenager in a motor vehicle accident with chest pain

CXR and CT and angiogram of thoracic aortic injury — CXR AP shows widened mediastinum. Axial CT with contrast of the chest shows dilated caliber of the thoracic aorta at the level of the diaphragm with surrounding mediastinal fluid (above) and normal caliber of the abdominal aorta with evidence of retrocrual hemorrhage tracking into the abdomen (below). Angiogram shows a pseudoaneurysm of the aorta at the level of the diaphragm.

The diagnosis was thoracic aortic injury.

Teenager shot by sibling with pellet gun one day ago with progressive dyspnea and chest pain

CXR and CT of pericardial effusion — CXR AP shows an enlarged cardiac silhouette, bilateral pleural effusions and radioopaque pellets in the right thorax near the hilum and left axilla. Axial and coronal CT with contrast of the chest shows a large amount of fluid in the pericardial space.

The diagnosis was traumatic pericardial effusion.

School ager in a motor vehicle accident with respiratory distress

CXR of tracheobronchial injury of left mainstem bronchus — CXR AP shows air in the superior mediastinum and neck, airspace disease in the left upper lobe, and a small amount of air in the left pleural space.

The diagnosis was tracheobronchial injury of the left mainstem bronchus with pneumomediastinum and a small left pneumothorax.

Teenager who rolled over his all terrain vehicle with chest pain

CXR and CT of pneumatoceles — CXR AP shows patchy airspace disease in the right lung. Axial CT with contrast of the chest shows right-sided airspace disease as well as thin-walled cysts with fluid-fluid levels.

The diagnosis was post-traumatic pneumatoceles.

Teenager in a motor vehicle accident with chest pain

CXR and CT of pulmonary contusion — CXR AP shows patchy airspace disease in the right upper lobe which is much better seen on the axial CT with contrast of the chest.

The diagnosis was right-sided pulmonary contusion.

Obtunded toddler who was being carried down stairs by an adult who fell on top of them

CXR and CT of pneumomediastinum — CXR AP shows air outlining the thymus (thymic sail sign) and that the diaphragm can be traced throughout its course (continuous diagphragm sign). Axial CT with contrast of the chest shows air in the posterior mediastinum in front of the spine.

The diagnosis was pneumomediastinum.

Teenager in a motor vehicle accident with chest pain

CXR and CT of pneumothorax and pulmonary contusion and rib fracture — CXR AP shows a widened mediastinum and a small right-sided pneumothorax. Axial CT with contrast of the chest with lung (above) and bone (below) windows shows air in the pleural space anterior to the right lung and fluid in the pleural space posterior to the right lung as well as airspace disease in the right lower lobe and a cortical disruption through one of the right ribs posteriorly.

The diagnosis was a right hydropneumothorax, right pulmonary contusion, and right posterior rib fracture. Angiogram was negative for aortic injury.

School ager hit on right side by truck while riding bike with chest pain

CXR and CT of rib fracture and pulmonary contusion — CXR AP shows cortical irregularities of the right 6th and 7th ribs and no evidence of lung injury. Axial CT of the chest shows a large amount of airspace disease in the right lower lobe and a very small amount of free air anteriorly in the right hemithorax.

The diagnosis was right rib fractures and pulmonary contusion and a small anterior pneumothorax.

Teenager playing football struck in chest with chest pain

CT of sternoclavicular joint dislocation — CXR AP shows a widened superior mediastinum. Axial CT with contrast of the chest shows a mediastinal hematoma and a right sternoclavicular joint disruption that was displaced posteriorly. Angiogram was negative for aortic injury. Venogram was negative for large vessel venous injury.

The diagnosis was sternoclavicular joint dislocation with the mediastinal hemorrhage thought to be due to small vessel venous injury.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Toddler in a motor vehicle accident who is obtunded

The diagnosis was hypoperfusion complex.

School ager with a handlebar injury and abdominal pain

CT of bowl trauma / bowel perforation — Initial axial CT with contrast of the abdomen (left images) shows no solid organ injury but a moderate amount of free fluid in the abdomen and pelvis. Repeat axial CT with contrast of the abdomen obtain a day later due to increasing abdominal pain (right images) shows a marked increase in the free fluid within the abdomen and pelvis.

The diagnosis was bowel perforation.

Toddler who has been abused

CT of duodenal hematoma — Contiguous slices from an axial CT with IV and oral contrast of the abdomen shows medial to the ascending colon the contrast-filled lumen of the duodenum narrowing to a point as it nears the midline (above) and then being narrowed as it crosses anterior to the spine (below).

The diagnosis was duodenal hematoma.