Infant with enterocolitis

Gross pathological image of Hirschsprung disease — Pathological image shows a narrow caliber rectum and sigmoid colon (to the lower right) until a transition zone is encountered in the caliber of the colon (in the middle right) at which point the caliber of the colon is dilated all the way back to the hepatic flexure (upper left). The caliber of the ascending colon, appendix (middle left) and terminal ileum (lower left) are normal.

The diagnosis was Hirschsprung disease with a transition zone in the sigmoid colon.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager hit by an all terrain vehicle with neck pain

CT of retroclival hematoma — Sagittal 2D reconstruction from CT without contrast of the cervical spine shows a rounded area of increased density inferior to the tip of the clivus and superiorly and posteriorly to the C2 vertebral body.

The diagnosis was a retroclival hematoma with no associated cervical spine fracture.

School ager with neck pain whose brother sat on his back

CT and MRI of C7 spinous process fracture / Clay shoveler fracture — Lateral radiograph of the cervical spine shows a lucency through the middle part of the spinous process of the C7 vertebral body. Sagittal STIR MRI without contrast of the cervical spine shows bright signal representing edema in the interspinous ligaments between the C6-C7 and C7-T1 vertebral bodies.

The diagnosis was a spinous process of the C7 vertebral body (Clay shoveler) fracture with associated interspinous ligamentous sprain.

Teenager in motor vehicle accident with neck pain

CT of C7 spinous process fracture / Clay shoveler fracture — Axial and sagittal 2D reconstruction from a CT without contrast of the cervical spine shows a lucency through the middle part of the spinous process of the C7 vertebral body.

The diagnosis was a spinous process of the C7 vertebral body (Clay shoveler) fracture.

School ager in motor vehicle accident with neck pain

CT of fracture of C2 vertebral body / Hangman fracture — Axial CT without contrast of the cervical spine (upper left) shows lucencies through both pedicles of the C2 vertebral body. Midline sagittal 2D reconstruction (upper right) shows anterior dislocation of the C2 vertebral body on the C3 vertebral body. Left sagittal (lower left) and right sagittal 2D reconstructions (lower right) again show lucencies through the bilateral C2 pedicles and bilateral anterior perching of the C2 inferior facets on the C3 vertebral body.

The diagnosis was fracture / dislocation of the C2 vertebral body with bilateral perched facets (Hangman fracture).

Teenager with neck pain who was tackled by caregiver

CT of fracture / dislocation of C6 vertebral body with perched facets — Sagittal 2D reconstructions from a CT without contrast of the cervical spine shows the C6 vertebral body displaced anteriorly in relation to the C7 vertebral body (left) and anterior perching of the left inferior C6 facet (middle) and right inferior C6 facet (right) upon the C7 vertebral body.

The diagnosis was fracture / dislocation of the C6 vertebral body with bilateral perched facets.

Teenager in a rollover MVA with neck pain

CT of fracture of the left pedicle of the C6 vertebral body — Axial CT (left) without contrast of the cervical spine with sagittal 2D reconstruction (right) shows a lucency through the left pedicle of the C6 vertebral body.

The diagnosis was a fracture through the left pedicle of C6.

Teenager with neck pain who dove into a shallow pond and felt a pop in their neck

CT of compression fracture of C6 vertebral body — Axial (above) and coronal (left below) 2D reconstruction from CT without contrast of the cervical spine shows a lucency through the center of the C6 vertebral body. Sagittal 2D reconstruction (lower right) shows loss of height of the C6 vertebral body.

The diagnosis was compression fracture of C6.

Teenager ejected from the car in a motor vehicle accident with neck pain

CT of compression fracture of C7 vertebral body — Coronal (left) and sagittal (right) 2D reconstructions from a CT without contrast of the cervical spine show lucencies through the anterior and posterior aspects of the C7 vertebral body with loss of vertebral body height noted best on the sagittal image.

The diagnosis was a compression fracture of C7.

Teenager in motor vehicle accident with neck pain

CT of C2 vertebral body / Hangman fracture — Axial CT without contrast of the cervical spine (top) shows a lucency extending through the left C2 facet and another lucency extending through the right transverse process and involving the right transverse foramen which raised concern for possible right vertebral artery injury which was ruled out on a subsequent CT angiogram of the neck. Sagittal 2D reconstructions from the left, center and right of the cervical spine shows lucencies through the left C2 facet (left image), right transverse process (right image) and anterior inferior aspect of the C2 vertebral body (center 2 images).

The diagnosis was a fracture of C2 (Hangman fracture) without anterolisthesis of C2 on C3.

Teenager in motor vehicle accident with neck pain

CT of fracture / distraction of C2 vertebral body — Sagittal (left) and coronal (right) 2D reconstructions from a CT without contrast of the cervical spine shows an oblique lucency through the C2 vertebral body with distraction of the fracture fragments. There is marked prevertebral soft tissue swelling throughout the cervical spine.

The diagnosis was a fracture-distraction of C2.

Teenager with neck pain who hit his head on the ground while wrestling with a friend

CT of fracture of C1 vertebral body / Jefferson fracture — Axial CT without contrast of the cervical spine (upper left) shows lucencies through the left anterior and posterior arches of the C1 vertebral body with displacement of the fracture fragments. Coronal 2-D reconstruction (lower left) and the 3-D reconstruction (right) which simulates an open-mouth odontoid radiograph shows the lateral masses of the C1 vertebral body are now wider than the lateral masses of the C2 vertebral body.

The diagnosis was displaced fracture of the anterior and posterior arches of C1, a Jefferson fracture.

Teenager who has neck pain after a diving accident

The diagnosis was a minimally displaced fracture of the anterior and posterior arches of C1, a Jefferson fracture.

Teenager with neck pain after hitting a tree with an all terrain vehicle

CT of C1 vertebral body fracture — Axial CT without contrast of the cervical spine shows a lucency through the anterior arch of the C1 vertebral body.

The diagnosis was a non-displaced fracture of the anterior arch of C1.

Infant in motor vehicle accident with neck pain

CT of atlanto axial rotatory subluxation — Axial CT without contrast of the cervical spine obtained after the accident shows C1 vertebral body rotated 45 degrees to the right (upper left) on the C2 vertebral body (lower left). Axial CT without contrast of the cervical spine obtained 1 day later shows C1 vertebral body now normally aligned (upper right) with the C2 vertebral body (lower right)

The diagnosis was atlanto axial rotatory subluxation that resolved in a day

Our DDX For This Week Is

Infant who had been abused

Gross pathological image of posterior rib fractures in child abuse — CXR (above) and complete skeletal survey showed no evidence of rib fractures. Gross pathological image (below) shows callus formation along the posterior aspect of the left 4th-8th ribs.

The diagnosis was left 4th-8th chronic posterior rib fractures which were not detected on the skeletal survey in a child abuse patient.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Infant who became unresponsive and underwent 30 minutes of CPR

CT of hypoperfusion complex / shock bowel in child abuse — Axial CT with contrast of the abdomen shows periportal edema in the liver, diffusely dilated and hyperenhancing loops of small bowel and a narrow caliber inferior vena cava.

The diagnosis was hypoperfusion complex in a child abuse patient.

Toddler who was abused who is vomiting after eating

Upper GI of duodenal hematoma in child abuse — AP image from an upper GI exam shows diffuse persistent narrowing of the lumen of the second and third portions of the duodenum.

The diagnosis was duodenal hematoma in a child abuse patient.

Infant with respiratory distress

AXR of chylous ascites in child abuse — CXR AP (left) shows the lungs to be poorly expanded and clear but there are dense areas of callus along the lateral aspect of the right 3rd-5th ribs. Centralization of the loops of bowel were also incidentally noted and confirmed on a subsequent AXR AP (right).

The diagnosis was chronic right 3rd-5th lateral rib fractures and low lung volumes due to ascites which was found to be chylous when tapped in a child abuse patient.

Infant who has been shaken

CT of diffuse cerebral edema in child abuse — Axial CT without contrast of the brain shows normal density in the rounded top of the cerebellum (in the center of the left image) compared to the diffuse low-density throughout the cerebrum. There is obliteration of the basal cisterns and loss of the normal gray matter-white matter differentiation. There is also a small left sided high density extra-axial cresenteric fluid collection that tracks medially along the entire falx.

The diagnosis was diffuse cerebral edema and a left-sided acute subdural hematoma with interhemispheric extension in a child abuse patient.

Infant with swollen right leg

CT of tricompartmental chronic subdural hematomas in child abuse — Axial CT without contrast of the brain shows very large low density extra-axial fluid collections supratentorially around the left and right cerebral hemispheres and infratentorially around the cerebellum. There is also a round high density focus along the posterior right falx.

The diagnosis was tricompartmental chronic subdural hematomas with a small focus of right posterior acute subdural hematoma as well in a child abuse patient.

Infant with decreased responsiveness

CT of acute and chronic subdural hematomas in child abuse — Axial (above) and coronal (below) CT without contrast of the brain shows a right moderate sized high density cresenteric extra-axial fluid collection that extends around the entire right cerebral hemisphere as well as interhemispherically. There is also a left moderate sized low-density cresenteric extra-axial fluid collection.

The diagnosis was a right acute subdural hematoma and a left chronic subdural hematoma in a child abuse patient.