Pediatric and Adolescent Musculoskeletal MRI: A Case-Based Approach
Abstract
Since radiologists learn by seeing, this book’s case-based format is ideal. The 102 cases unknown and 217 supplemental cases throughout depict scenarios commonly encountered in daily practice, with special emphasis on the rapidly growing area of sports injuries and traumatic disorders in older children and adolescents. The cases are heavily illustrated with nearly 600 high-resolution MRI images, as well as complementary plain films, scintigrams, and CT scans. Each case outlines the clinical history, findings, and differential diagnosis. Clinical pearls, questions and answers, and concluding summaries are also included. An orthopedic surgeon provides clinical commentary where appropriate to share the insight gained from sports medicine.
Chapters (96)
This is a 13-year-old boy who fell two days ago and has had persistent pain and swelling in his right knee. Radiographs of his right knee (not shown) demonstrated a large joint effusion only.
This is a 13-year-old girl with chronic right knee pain. She is otherwise well, without fever or systemic symptoms. CBC and ESR were normal.
This is a 10-year-old boy with right knee swelling following remote minor knee trauma. Radiographs demonstrated only a large joint effusion (not shown).
This is a 17-year-old boy with a several-year history of an enlarging painful left forearm mass.
This is a 5-year-old girl with a 2-week history of lower extremity weakness, especially when walking up stairs. Four days ago, she developed a rash on the chest, face, and dorsum of her fingers.
This is a 9-year-old boy with bilateral ankle pain. There is no history of trauma, and he is relatively short for his age.
This is a 9-year-old girl who noticed progressive swelling and pain over her right clavicle. She has a history of psoriatic arthritis that is well controlled with medications.
This is a 15-year-old girl with persistent ankle pain. Her history is significant for a twisting ankle injury while jumping on a trampoline 1.5 years ago.
This is an 11-year-old boy who had a twisting injury 6 days ago. Radiographs were normal (not shown).
This is a 10-year-old girl with a 1-week history of left sided hip pain and decreased range of motion.
This is a 17-year-old girl who sustained a right tibial fracture 2 months ago. An MRI was subsequently ordered because the fracture was not healing properly.
This is a 10-year-old girl with acute left hip pain for one week. She is unable to bear weight, has a temperature of 38.1C, a chronic reactive protein (CRP) of 11.4 mg/dl (normal <0.50), erythrocyte sedimentation rate (ESR) of 95 mm/hr (normal 0–20), and a WBC of 9.5k/uL.
This is a 5-year-old girl who has a longstanding bowleg deformity, left greater than right. She also has left in-toeing.
This is a 4-year-old boy with acute lymphoblastic leukemia (ALL) on cyclic chemotherapy. He presented with episodic right hip pain. The initial radiographs of the right hip were normal (not shown).
This is a 12-year-old girl with left calf swelling for 1 week. She has no history of trauma. Radiographs of the knee were normal (not shown).
This is a 5-year-old boy undergoing treatment for acute lymphoblastic leukemia (ALL), now with knee pain.
This is a 7-year-old boy with no history of trauma. He presents for imaging because his left leg is shorter than his right.
This 10-year-old boy had a comminuted supracondylar fracture of the humerus 2 months ago. At the time, he had closed reduction with percutaneous pinning. The pins were routinely removed one month after the reduction. There was persistent drainage from the cutaneous pin tracts and restricted elbow range of motion at his 2-month follow-up visit. An MRI was subsequently ordered.
This is a 2-year-old girl with an abnormal gait and a short right leg. She is status post partial amputation of the right foot. She also has left developmental dysplasia of the hip.
This is a 9-year-old boy with a 4-week history of right knee pain and swelling. The patient had minor knee trauma while skiing six weeks ago.
This is a 4-year-old boy with sickle cell disease with a new left limp, thigh pain, and fever. He also has a history of periorbital rhabdomyosarcoma and is on chemotherapy. The initial radiographs of the left femur obtained 2 days earlier were normal (not shown).
This is a 1-year-old-boy with a 1-week history of a left leg limp and a temperature of 103 degrees. There was no history of trauma.
This is a 9-year-old girl with a history of developmental dysplasia of the left hip and prior inominate osteotomy.
This is a 6-year-old girl with left hand and wrist pain, swelling, and decreased range of motion for several months.
This 11-year-old girl fell on her left upper arm during gymnastics 2 weeks ago. One day prior to the MRI, she developed severe arm pain and redness. She had a temperature of 39 C, and was confused. A radiograph of the arm was normal (not shown).
This is a 12-year-old boy who had trauma to his left calf while playing baseball 12 days ago. He presents after increasing mid-calf pain and 3 days of fever. A radiograph of the lower leg and ankle was normal (not shown).
This is a 14-month-old boy with acute onset of left lower extremity non-weightbearing. He is afebrile, has an ESR of 31, and a normal WBC. There is no history of trauma. His parents had taken him camping in New Hampshire two months earlier. Radiographs revealed a knee joint effusion, but were otherwise normal (not shown).
This is a 15-year-old boy, an avid basketball player with left knee pain for the past few weeks.
These three patients have an underlying malignancy. What type of supportive medication did they all receive while undergoing chemotherapy?
This is a 7-month-old boy with multiple liver lesions noted on a prior CT scan performed elsewhere following a reported fall.
This is an 11-year-old girl with right arm pain for 3 months that has become worse over the last few weeks.
This is a 7-year-old girl with a right popliteal fossa mass. Her right leg is 5 cm longer than the left.
This is a 17-month-old girl with an enlarging right buttock mass. She is otherwise healthy. There is no history of recent buttock injections or trauma.
This is an 11-year-old girl with a known leg-length discrepancy (the right leg is 1 cm longer than the left) and new left-sided knee pain.
This is a 3-year-old boy with an enlarging right great toe mass. Radiographs of the toe demonstrated enlargement of the soft tissues without evidence of calcifications or osseous abnormality (not shown).
This is a 12-month-old boy with left third digit swelling. There was no history of trauma or fever.
This is a 14-year-old boy with a history of left slipped capital femoral epiphysis (SCFE) with new left hip pain, decreased range of motion, and hip clicking. Similar but lesser symptoms were also present on the right.
This is a 4-year-old previously well girl with a 1-month history of severe constipation associated with abdominal pain and fever. She is now unable to walk.
This is a 3-week-old boy born at 36 weeks gestation, who recently stopped moving his left arm. A radiograph is normal and the proximal humoral secondary ossification center has not appeared (not shown).
This is a 5-year-old girl with left knee pain. At an outside hospital, an osteolytic lesion was incidentally found on radiographs.
This is a 2-year-old boy who sustained a fall on his left knee. He had swelling that resolved after 3 days. However, the swelling returned a month later and has persisted. He does not have a fever, is able to weight bear on his left knee, and his WBC is normal.
This is a 13-year-old boy with a left buttock mass present since the age of 3 years that has recently increased in size. Plain radiographs of the pelvis were normal (not shown).
This is a 15-year-old girl who jumped 5 stairs and landed on her left heel. She has had constant throbbing in the back of her left foot since then. The radiographs were normal (not shown).
This is a 17-year-old girl dancer. She has left hip pain with occasional snapping and locking.
This is a 13-year-old girl with a 4- to 6-week history of left elbow pain. She is an avid basketball player (and is left handed), but there is no history of a specific traumatic event. She recently noticed that her left arm was enlarging. She is afebrile and otherwise healthy.
This 13-year-old boy injured his right knee after falling off a motorbike. The initial plain radiographs showed a small effusion but no fracture (not shown).
This is a 9-year-old girl with a 2-month history of left heel pain. There is no history of trauma.
This 15-year-old girl had bilateral anterior shin pain for the last 3 weeks. She is a track runner in high school. She has anterior point tenderness 6 cm distal to her knees bilaterally.
This is a 5-year-old boy who fell off a trampoline and injured his left elbow. Radiographs, including stress views, were negative for fracture or effusion (not shown).
... In 13 % of cases, the disease manifests itself in the first year of life with neoplasms in the extremities, deformity, limitation of motion, shortening of bones, gait disturbances, pain, and the abolition of function [20]. Pathological fractures may arise [4,9,15]. ...
... Lesions of the peripheral skeleton (metaphyses of long tubular bones, the pectoral and pelvic girdles) are typical of the disease, while in the axial skeleton the ribs are affected more often (18 %) [10,15,[20][21][22][23][24]. Extremely rarely (less than 6 %) the spine is affected, which is accompanied by severe deformities [11,14], including fatal complications due to hypoventilation and pneumonia [25]. ...
Objective: to present different variants of the clinical course and surgical treatment of an extremely rare vertebral pathology – enchondromatosis with involvement of the cervical vertebrae in children. Two cases of local and multiple forms of bone dyschondroplasia with damage
to the cervical vertebrae, accompanied by orthopedic and neurological complications in children aged 7 and 11, are described. As a result of
the operation, complaints were completely stopped in one child and neurological disorders were eliminated in another. The diagnosis was
verified histologically. The results were followed up for more than 2 years and 1 year after the operation, respectively. Present-day data on
Ollie’s disease in children are presented. Indications, timing and volume of surgical intervention for bone dyschondroplasia are determined
individually, depending on the size, location, and number of enchondromas. However, if the cervical spine involvement is complicated by
increasing pain and neurological disorders, it is precisely decompression of the spinal cord that should be set as a priority aim of the surgery.
... Technisch ist auf eine Schichtdicke ≤ 3 mm und eine ausreichende Ortsauflösung zu achten. Die MRT ist in der Lage, nicht nur knöcherne, sondern auch knorpelige und fibröse Coalitiones abzubilden[15]. In sagittaler Schichtorientierung zeigt sich die Coalitio calcaneonavicularis, in koronarer Schichtung die Coalitio talocalcanearis. 3-D-Sequenzen (z. ...
In pediatric flat foot a differentiation has to be made between the flexible and the rigid form. The diagnosis is based on the history, clinical examination as well as pedobarography, gait analysis and imaging techniques. It is important to rule out neuropediatric conditions such as muscular dystrophies, Ehlers-Danlos- or Marfan syndrome. In children six years of age and younger a flexible flat foot is nearly always physiological (97% of all 19 months old children). Up to the age of ten years the medial column of the foot is developing. Only a minority of children (4% in ten year olds) has a persistent or progressive deformity. Beyond to age of ten there is a danger of deformity decompensation as well as an increased rigidity. Only a minority of children develops some pain (< 2%). A clear risk factor for persistent pediatric flat foot is obesity (62% of six year old children with flat foot are obese). Pathogenetic factors include muscular, bony or soft tissue conditions. However, there specific rule is still unclear. Prevention consists in a thorough parent information about the normal development as well as encouragement of regular sportive activities. Soft and large enough shoes should be carried as a protection. Barfoot walking has to be encouraged on uneven grounds. If physiotherapy is needed different methods can be applied. Orthosis treatment should include a proprioceptive approach. Surgical interventions in children are rare. If surgical treatment is planned a detailed algorhythm should be used before utilizing one of the many different surgical methods.
Georg Thieme Verlag KG Stuttgart · New York.
... The recurrent hemarthrosis results in synovial inflammation leading to synovial hyperplasia, early physeal closure, epiphyseal overgrowth and advance maturation, erosions, and degenerative changes-all findings that can be seen radiographically. 5 Laboratory abnormalities in large venous malformations may show elevated D-dimers and hypofibrinogenemia due to continuous formation of intralesional microthrombi. On physical exam, venous malformations usually escape detection because they are usually situated deep within the intrafascial compartment. ...
Initial clinical presentation of knee venous malformation can mimic that of juvenile idiopathic arthritis, posing a diagnostic dilemma. In this communication, we discuss the diagnostic challenges encountered in children with venous malformation of the knee who were misdiagnosed as having juvenile idiopathic arthritis. We highlight the clinical and imaging differences between these 2 disorders with the goal of preventing these diagnostic pitfalls in the future.
We conducted a comprehensive search of our databases at Children's Hospital Boston over the last 11 years (1999 to 2009) for patients with venous malformation of the knee who were initially given the diagnosis of juvenile idiopathic arthritis. A retrospective review of the medical records, photographs, and imaging studies was performed.
Of the 56 patients found to have venous malformations of the knee, 6 patients (0 to 13 y, 4 females) were initially misdiagnosed as juvenile idiopathic arthritis and managed as such. Five of the 6 patients received nonsteroidal anti-inflammatory drugs. Of these 5, corticosteroids were also administered in 2 patients, and 1 also received methotrexate. One patient was treated conservatively.
Venous malformation of the knee can present as a clinical mimicker of juvenile idiopathic arthritis. Familiarity with the clinical presentation and imaging findings of these 2 disorders should minimize misdiagnosis of knee venous malformation as juvenile idiopathic arthritis and thus avoid inappropriate or delayed therapy.
Types of Studies: Diagnostic Studies-Investigating a Diagnostic Test, Level III.
Bacterial arthritis and osteomyelitis are usually acute diseases, which in this way differ from the often insidious course of nonbacterial osteomyelitis; however, there is often an overlap both in less acute courses of bacterial illnesses and also in nonbacterial osteitis. The overlapping clinical phenomena can be explained by similar pathophysiological processes. In bacteria-related illnesses the identification of the pathogen and empirical or targeted anti-infectious treatment are prioritized, whereas no triggering agent is known for nonbacterial diseases. The diagnostics are based on the exclusion of differential diagnoses, clinical scores and magnetic resonance imaging (MRI). An activity-adapted anti-inflammatory treatment is indicated.
Clinical/methodological issue:
Bone and soft tissue tumours are often incidental findings in children. Because they are usually benign tumours, nonspecialised radiologists generally have little experience in the diagnosis and differentiation from malignant tumours. Various imaging techniques are used in the diagnosis of skeletal tumours.
Standard radiological methods:
Imaging techniques used to evaluate bone and soft tissue tumours include sonography, computed tomography (CT) and magnetic resonance imaging (MRI).
Methodological innovations:
An algorithm to determine malignancy of bone and soft tissue tumours in children is proposed.
Performance:
By using the presented algorithms, further diagnostic procedures such as biopsies can be avoided in the majority of children with bone and soft tissue tumours. Aggressive bone lesions and unclear soft tissue tumours are guided to biopsy to confirm diagnosis.
Achievements:
The algorithms presented are based on the proposals of European professional societies and have been adapted by the authors for use in children and adolescents.
Practical recommendations:
In the clarification of soft tissue tumours, sonography is the first diagnostic tool; depending on the sonographic findings, MRI is the technique for further clarification. Biopsy confirmation of the diagnosis in unclear cases or in cases of probable malignancy should be carried out in a paediatric oncology centre.
Gutartige Knochentumoren sind klinisch wie biologisch sehr diverse Läsionen. Sie werden nach der jeweils vorherrschenden Gewebematrix geordnet. Klinisch sind sie oft asymptomatisch; einige verursachen unspezifische, lediglich Osteoidosteome führen zu charakteristischen Beschwerden. Röntgenuntersuchungen in 2 Ebenen erlauben dem kinderradiologisch Erfahrenen zusammen mit Anamnese und klinischem Befund oft die korrekte Diagnosestellung oder sind für das weitere Vorgehen wegweisend. Die weitere Diagnostik und Therapie richtet sich nach der Art und Lage der Läsion und den von ihr verursachten Beschwerden: Während bei manchen Tumoren eine Do-not-touch-Strategie angezeigt ist, sollten andere kürettiert oder reseziert werden. Medikamentöse Therapien spielen, von wenigen Situationen abgesehen, eine untergeordnete Rolle. Bestrahlung sollte, wenn möglich, vermieden werden.
In children, the skeleton undergoes multiple changes with age. These age-related transformations determine the distribution
of disease, the patterns of injury, and their imaging characteristics. During development, cartilage is converted to bone
and hematopoietic marrow to fatty marrow. Most epiphyses and apophyses are cartilaginous at birth and become increasingly
ossified [1]. Epiphyseal cartilage has intermediate signal intensity on Tl-weighted images and low signal intensity on water-sensitive
images. Epiphyseal cartilage is normally hypointense along the body’s weight-bearing regions [2]. Within the epiphyseal cartilage there is no capillary network; instead, there are multiple vascular canals which contain
the veins and arteries that bring nutrients to the chondrocytes [3]. These can be visible as parallel striations on neonatal sonograms, and Doppler interrogation demonstrates flow within them
[4]. Following contrast administration, magnetic resonance imaging (MRI) will show the vascular canals, which become arranged
in a radial pattern as the ossification centers develop [5].
ResearchGate has not been able to resolve any references for this publication.