1
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Schmitt L, Pfirrmann CWA, Buck FM, Hany TF, Rosskopf AB. Value of MR arthrography for evaluation of children and adolescents with clinically suspected intraarticular cause of hip pain. Skeletal Radiol 2024; 53:1269-1278. [PMID: 38206356 PMCID: PMC11093865 DOI: 10.1007/s00256-023-04552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE To evaluate the distribution of intra- and extraarticular MRI findings in children and adolescents with clinically suspected intraarticular cause of hip pain in order to assess the need for additional intraarticular contrast administration. MATERIAL AND METHODS Database was searched over a period of 34 months retrospectively for consecutive hip MR arthrography in young patients (8-17 years) with suspected intraarticular cause of hip or groin pain. Exclusion criteria were prior hip surgery, follow-up examination due to known intraarticular pathology, incomplete examination, qualitatively non-diagnostic examinations, and missing informed consent. Reports of fellowship-trained MSK radiologists were searched for intraarticular versus extraarticular findings explaining hip or groin pain. RESULTS Seventy patients (68% female; median age: 14.5 years; range:10.8-16.9 years) were analyzed. No reason for pain was found in 30 (42.9%) hips, extraarticular reasons in 20 (28.6%) cases, intraarticular in 14 (20.0%), and both (intra- and extraarticular) in 6 (8.6%) hips. Most common extraarticular reasons were apophysitis (14.3%), other bony stress reactions (12.9%), intramuscular edema (7%), tendinitis (5.7%), and trochanteric bursitis (4.3%). Labral pathology was the most common intraarticular finding (overall:34.3%; partial tear:15.7%, complete tear:15.7%), most frequent at the anterosuperior position (81.8%). Cartilage defects (1.4%), intraarticular neoplasia (1.4%), and tear of the femoral head ligament (2.8%) were rarely found. Synovitis and loose bodies were not observed. Cam-(37.1%) and pincer-configurations (47.1%) were common while hip dysplasia was rare (5.7%). CONCLUSION MRI in children and adolescents with hip pain should be done primarily without intraarticular contrast administration since most cases show an extraarticular pain reason or no diagnosis detectable with MRI.
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Affiliation(s)
- Laura Schmitt
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Christian W A Pfirrmann
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Medical Radiological Institute (MRI) Zurich, Schulthess Clinic, Lengghalde 2, CH-8008, Zurich, Switzerland
| | - Florian M Buck
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Medical Radiological Institute (MRI) Zurich, Schulthess Clinic, Lengghalde 2, CH-8008, Zurich, Switzerland
| | - Thomas F Hany
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Medical Radiological Institute (MRI) Zurich, Schulthess Clinic, Lengghalde 2, CH-8008, Zurich, Switzerland
| | - Andrea B Rosskopf
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.
- Medical Radiological Institute (MRI) Zurich, Schulthess Clinic, Lengghalde 2, CH-8008, Zurich, Switzerland.
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Mushtaq N, Osmani H, Patel J, Alwan S, Sarraf K, Ahmed N. Evaluation of paediatric hip pain. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37490445 DOI: 10.12968/hmed.2023.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Hip pain in a child can pose a diagnostic conundrum. In most cases, the cause of a painful hip is often attributed to trauma, but a number of these cases will be atraumatic. The main entities to consider are inflammatory, infective and neoplastic causes. Pathologies such as avascular necrosis and slipped upper femoral epiphysis can also present in a similar manner. A detailed history and clinical examination are crucial in narrowing down the differential diagnosis. In addition, understanding the most appropriate imaging modalities and the characteristic radiological findings is key in ensuring timely treatment and management. This article reviews the various disease processes in children who present with hip pain and outlines the most appropriate assessment and imaging modalities that will aid diagnosis.
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Affiliation(s)
- Nida Mushtaq
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Humza Osmani
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Jugal Patel
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Samir Alwan
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Khaled Sarraf
- Department of Trauma and Orthopaedics, St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | - Naeem Ahmed
- Department of Imaging, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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3
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Loisel M, Henry R, Veron A, Bruneau B, Chouklati K, Charon V, Fraisse B, Marleix S, Lucas G, Violas P. Coronal STIR MRI sequences in unexplained limping in children under 6 years old: A single-center retrospective study of 130 cases. Arch Pediatr 2022; 29:494-496. [PMID: 36100490 DOI: 10.1016/j.arcped.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/22/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Limping is a common presenting symptom in young children. Clinical examination backed up by laboratory analysis, standard radiography, and/or ultrasound may fail to determine the diagnosis, and limping may prove persistent, requiring repeated consultation. Magnetic resonance imaging (MRI) can suggest the etiology or provide welcome reassurance when normal. We advocate the use of MRI in cases of persistent unexplained limping in young children. The study hypothesis was that coronal short TI inversion recovery (STIR) MRI has good negative predictive value (NPV) in unexplained limping in children under 6 years of age. MATERIAL AND METHOD Coronal STIR MRI sequences were analyzed in 130 children younger than 6 years (84 boys, 46 girls) during the period April 2007 to May 2017. They extended from the lower thoracic spine down to the feet. Agreement was analyzed between the radiologist's initially suggested diagnosis and the pediatric orthopedic specialist's final diagnosis. RESULTS Overall, 49 scans were normal (37.7%) and 81 abnormal (62.3%). The mean age at MRI was 32.3 months. Coronal STIR MRI had 98% NPV. There was 99.2% agreement between the radiologist's diagnosis and the final diagnosis. DISCUSSION The recently reported contribution of STIR MRI in bone and joint infections was extended to unexplained limping. CONCLUSION First-line MRI with coronal STIR sequences improved the diagnostic efficacy, thanks to its speed and relative lack of movement artifacts.
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Affiliation(s)
- M Loisel
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - R Henry
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - A Veron
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - B Bruneau
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - K Chouklati
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - V Charon
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - B Fraisse
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - S Marleix
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - G Lucas
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France
| | - P Violas
- C.H.U de Rennes, 16 boulevard de Bulgarie 35056 Rennes, France.
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4
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Freeman A. Paediatric gonad shielding in pelvic radiography: A systematic review and meta-analysis. Radiography (Lond) 2022; 28:964-972. [PMID: 35849887 DOI: 10.1016/j.radi.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 06/05/2022] [Accepted: 06/17/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION The British Institute of Radiology (BIR) and American Association of Physicists in Medicine (AAPM) have recommended that gonad shielding is no longer used during pelvic X-ray examinations. The BIR guidance states that shielding may still be considered for use on males, but should not be used on females. This paper aimed to evaluate if this decision was supported by evidence from practice, by comparing the accuracy of gonad shield placement in paediatric males and females. METHODS A systematic review of databases including EMBASE, MEDLINE and PubMed was performed in February 2021. Studies were considered eligible if they provided data on the use of gonad shielding during pelvic X-ray examinations on male and female patients under the age of 18. Nine studies met the inclusion criteria and data extraction was performed. Quality appraisal was undertaken, and a meta-analysis of shielding accuracy was performed on seven studies. RESULTS The results from the meta-analysis (2187 total radiographs) demonstrated that female patients were significantly more likely (OR 1.38, 95% CI 0.88-1.87) than males to have gonad shields placed inaccurately (p value < 0.001). CONCLUSION Gonad shield placement on paediatric female patients is significantly less accurate than on males, and so the results support the AAPM and BIR guidance to stop the practice for females. Shield application may also be frequently inaccurate for males, but the review does not provide clear evidence for or against continuing the practice for males. IMPLICATIONS FOR PRACTICE Discontinuing the use of gonad shields in paediatric pelvic radiography on female patients is supported. Any continued use on male patients, or for reasons such as psychological reassurance, should be subject to enhanced training and audit to ensure benefits outweigh any risks.
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Affiliation(s)
- A Freeman
- University of Leeds School of Medicine, Worsley Building, Woodhouse, Leeds, LS2 9JT, UK
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5
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Choraria A, O’Donnell P, Saifuddin A. Differential diagnosis of hip pain in children referred to a specialist bone tumour service. Br J Radiol 2022; 95:20211397. [PMID: 35343784 PMCID: PMC10996422 DOI: 10.1259/bjr.20211397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/14/2022] [Accepted: 03/15/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the differential diagnosis of bone lesions causing hip pain in children and the association between radiographic features of aggression and MRI appearances with final diagnosis. METHODS Retrospective review of children with hip pain referred to a specialist musculoskeletal oncology service between September 2018 and December 2020. Patient demographics, lesion location, the radiographic and MRI features, and the final diagnosis, which was made either by image-guided biopsy, surgical curettage or based on typical imaging features were recorded. Statistical analysis examined the association between the Lodwick-Madewell score (determined from available radiographs) and MRI findings with final diagnosis. RESULTS Fifty-nine patients were included, 40 males and 19 females with mean age 10.9 years, (range 3-16 years). Final diagnoses were based on histology in 24 (40.7%) cases and imaging in 35 (59.3%) cases. Eighteen lesions (30.5%) were classed as non-neoplastic, 31 (52.5%) as benign and 10 (16.9%) as malignant, of which four were primary bone sarcomas. There was a significant association between the Lodwick-Madewell score and final diagnosis (p < 0.001). On MRI, bone marrow oedema, presence of a focal lesion, bone expansion and the presence of an extraosseous mass were all significantly associated with final diagnostic classification. CONCLUSION The differential diagnosis of hip pain in children presenting to a bone tumour service is wide. Most cases are due to benign or non-neoplastic conditions, with only 10 out of 59 children having a malignant lesion. Radiography complemented by MRI plays a major role in differentiating non-neoplastic, benign neoplastic and malignant lesions and in determining the requirement for needle biopsy. ADVANCES IN KNOWLEDGE This is the first study to consider how imaging features relate to diagnosis in suspected paediatric hip tumours. Use of this information can help in determining which cases should undergo needle biopsy.
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Affiliation(s)
- Anika Choraria
- Department of Radiology, Royal National Orthopaedic Hospital,
Brockley Hill, Stanmore, Middlesex, HA7,
LP, UK
| | - Paul O’Donnell
- Department of Radiology, Royal National Orthopaedic Hospital,
Brockley Hill, Stanmore, Middlesex, HA7,
LP, UK
| | - Asif Saifuddin
- Department of Radiology, Royal National Orthopaedic Hospital,
Brockley Hill, Stanmore, Middlesex, HA7,
LP, UK
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Karout L, Naffaa L. Pediatric Hip Disorders: Imaging Guidelines and Recommendations. Radiol Clin North Am 2021; 60:149-163. [PMID: 34836561 DOI: 10.1016/j.rcl.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hip disorders are a wide range of conditions commonly affecting patients in the pediatric age group. Reaching an accurate diagnosis of these conditions in children may be challenging. The optimal use of image modalities in the approach of a child with possible hip pathology is essential, which allows radiologists and clinicians to narrow the differential diagnosis and reach a definitive diagnosis, which can consequently result in early and appropriate interventions leading to improved outcomes. Therefore, this article aims to provide practicing radiologists and clinicians with up-to-date and evidence-based imaging spectrum guidelines and recommendations for common pediatric hip disorders.
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Affiliation(s)
- Lina Karout
- Department of Radiology, Massachusetts General Hospital, 25 New Chardon Street, Boston, MA 02114, USA
| | - Lena Naffaa
- Radiology Department, University of Central Florida, Nemours Children's Hospital, 6535 Nemours Parkway, Orlando, FL 32827, USA.
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7
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Karnik A, Lawande A, Lawande MA, Patkar D, Aroojis A, Bhatnagar N. Practice Essentials of Imaging in Early Diagnosis of DDH. Indian J Orthop 2021; 55:1466-1479. [PMID: 35003537 PMCID: PMC8688607 DOI: 10.1007/s43465-021-00539-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/27/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Developmental dysplasia of hip joint (DDH) is a dynamic progressive pathology which can tilt either way. The term strictly applies to primary dysplasia, where etiology is not clearly known. Secondary dysplasia can be due multiple causes, such as neuromuscular disorders, connective tissue disorders or skeletal syndromes. METHODS The etiology being multifactorial, it needs a multidisciplinary team to address the issue at hand. The management starts antenatally with a detailed history of any risk factors and a dedicated ultrasound of the foetus, since forewarned is forearmed. At birth, a paediatrician having a keen sense of DDH will perform Barlow's or Ortolani's manoeuvre and can be the first one to sound the alarm in the event of positive findings. How and when a Radiologist needs to step in will depend on inter-departmental discussions between the paediatrician and the orthopedician. RESULTS In the presence of positive clinical screening tests, and non-availability of ultrasound, a preliminary X ray pelvis AP view including both hip joints should be the requisitioned in a child of any age, particularly, if belonging to the high-risk group. If ultrasound is available, a screening exam till 6 months of age is recommended to rule out DDH. DISCUSSIONS India is known for its vast numbers and little babies with occult diseases are the first to bear the brunt of conditions which have very few symptoms to start with. DDH is one such condition which most unfortunately expresses itself as a symptom only when it's too late, i.e., most often when the child begins to walk. Ultrasound is the modality of choice in neonates; however, since India is a country of modest means, in majority of the regions, radiographs still remain the first line of investigation.
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Affiliation(s)
- Alka Karnik
- Head of Ultrasound Department, Nanavati Superspeciality Hospital, Mumbai, India
| | | | | | - Deepak Patkar
- Department of Imaging, Medical Services and Head, Nanavati Super -Speciality Hospital, Mumbai, India
| | - Alaric Aroojis
- grid.414135.60000 0001 0430 6611Department of Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India
| | - Nidhi Bhatnagar
- Deapratment of Radiology, Max Superspeciality Centre, Panchsheel, E-7, East of Kailash, New Delhi, 110065 India
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8
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Gravel CA, Lynn AQ, Hannon M, Miller AF, Neal JT, Neuman MI, Vieira RL. Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain. J Emerg Med 2021; 61:376-380. [PMID: 34176687 DOI: 10.1016/j.jemermed.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs. OBJECTIVES We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion. METHODS This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds. RESULTS We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82). CONCLUSIONS We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.
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Affiliation(s)
- Cynthia A Gravel
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Alex Q Lynn
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona
| | - Megan Hannon
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts,; Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew F Miller
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Jeffrey T Neal
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts
| | - Rebecca L Vieira
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School, Boston, Massachusetts,; Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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9
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Vial S. COXALGIA EN NIÑOS MENORES DE 10 AÑOS. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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10
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Contributions of nuclear medicine in paediatric non-tumour musculoskeletal pathology. Rev Esp Med Nucl Imagen Mol 2021. [DOI: 10.1016/j.remnie.2021.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Noriega-Álvarez E, Orduña Diez MDP, Domínguez Gadea L, Sanz Viedma S, Loza SM. Contributions of nuclear medicine in paediatric non-tumour musculoskeletal pathology. Rev Esp Med Nucl Imagen Mol 2021; 40:188-201. [PMID: 33824088 DOI: 10.1016/j.remn.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
Non-tumour musculoskeletal pathology in children represents a high percentage of the nuclear medicine studies requested by paediatricians. As these are immature bones and joints, in constant growth and remodelling, they present their own physiological and anatomical peculiarities that require a specific management for the paediatric age group. Using different clinical scenarios frequently observed in medical appointments (limping, back pain or fever, among others), we have summarised the possible findings or artefacts that can be obtained in the different Nuclear Medicine explorations, including bone scintigraphy and hybrid images such as PET/CT. To obtain high quality images requires careful attention to technique and positioning in children. Bone scintigraphy is a common paediatric nuclear medicine procedure and plays an important role in the diagnosis of musculoskeletal pathologies and can be complemented by techniques such as SPECT to improve localisation and diagnostic accuracy. In addition, 18F-FDG PET/CT is increasingly applied in the evaluation of children. This article reviews the usual indications of, mainly, bone scintigraphy and 18F-FDG PET/CT in paediatric non-tumour musculoskeletal diseases, how to interpret them properly, being essential to know the normal physiological distribution of each radiopharmaceutical, as well as the common variants of paediatric growth that can simulate disease, implying possible misinterpretations between normal and pathological structures.
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Affiliation(s)
- E Noriega-Álvarez
- Grupo de Patología Músculo-Esquelética de la SEMNIM; Servicio de Medicina Nuclear, Hospital General Universitario de Ciudad Real, Ciudad Real, España.
| | - M Del Prado Orduña Diez
- Grupo de Patología Músculo-Esquelética de la SEMNIM; Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, España
| | - L Domínguez Gadea
- Grupo de Patología Músculo-Esquelética de la SEMNIM; Servicio de Medicina Nuclear, Hospital Universitario La Paz, Madrid, España
| | - S Sanz Viedma
- Grupo de Patología Músculo-Esquelética de la SEMNIM; Servicio de Medicina Nuclear, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | - S Murias Loza
- Sección de Reumatología Pediátrica, Hospital Universitario La Paz, Madrid, España; Sociedad Española de Reumatología Pediátrica
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12
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Abstract
ABSTRACT The cause of acute onset hip pain in children can be difficult to determine. Once trauma is excluded, the workup revolves around determining whether there is a hip effusion and eliminating orthopedic emergencies. Point-of-care-ultrasound can be used as an adjunct in the workup. In this article, we review (1) differential diagnosis of hip pain, with a focus on toxic synovitis; (2) the evaluation of a hip for the presence of effusion, including the point-of-care ultrasound technique; and (3) the management of toxic synovitis.
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Affiliation(s)
- Prisca Takundwa
- From the Fellow and Associate Professor, Department of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT
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13
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Tu J, Gowdie P, Cassar J, Craig S. Test characteristics of history, examination and investigations in the evaluation for septic arthritis in the child presenting with acute non-traumatic limp. A systematic review. BMJ Open 2020; 10:e038088. [PMID: 33380476 PMCID: PMC7780717 DOI: 10.1136/bmjopen-2020-038088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Septic arthritis is an uncommon but potentially significant diagnosis to be considered when a child presents to the emergency department (ED) with non-traumatic limp. Our objective was to determine the diagnostic accuracy of clinical findings (history and examination) and investigation results (pathology tests and imaging) for the diagnosis of septic arthritis among children presenting with acute non-traumatic limp to the ED. METHODS Systematic review of the literature published between 1966 and June 2019 on MEDLINE and EMBASE databases. Studies were included if they evaluated children presenting with lower limb complaints and evaluated diagnostic performance of items from history, physical examination, laboratory testing or radiological examination. Data were independently extracted by two authors, and quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. RESULTS 18 studies were identified, and included 2672 children (560 with a final diagnosis of septic arthritis). There was substantial heterogeneity in inclusion criteria, study setting, definitions of specific variables and the gold standard used to confirm septic arthritis. Clinical and investigation findings were reported using varying definitions and cut-offs, and applied to differing study populations. Spectrum bias and poor-to-moderate study design quality limit their applicability to the ED setting.Single studies suggest that the presence of joint tenderness (n=189; positive likelihood ratio 11.4 (95% CI 5.9 to 22.0); negative likelihood ratio 0.2 (95% CI 0.0 to 1.2)) and joint effusion on ultrasound (n=127; positive likelihood ratio 8.4 (95% CI 4.1 to 17.1); negative likelihood ratio 0.2 (95% CI 0.1 to 0.3)) appear to be useful. Two promising clinical risk prediction tools were identified, however, their performance was notably lower when tested in external validation studies. DISCUSSION Differentiating children with septic arthritis from non-emergent disorders of non-traumatic limp remains a key diagnostic challenge for emergency physicians. There is a need for prospectively derived and validated ED-based clinical risk prediction tools.
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Affiliation(s)
- Jacky Tu
- Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Peter Gowdie
- Department of Paediatrics and Department of Paediatric Rheumatology, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Simon Craig
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Pediatric Emergency Department, Monash Medical Centre, Emergency Service, Monash Health, Melbourne, Victoria, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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14
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Thompson M, Johnson T, Koberlein G. Radiologic Evaluation of the Child with a Limp. Pediatr Ann 2020; 49:e395-e402. [PMID: 32929515 DOI: 10.3928/19382359-20200821-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A child presenting with a limp can present a diagnostic challenge to pediatricians. Clinical presentation, age, and history all contribute to the initial differential diagnosis; however, imaging plays a key role in the ultimate diagnosis, and the correct imaging study is essential to save time and health care expenses. This article will present a few of the more common causes of a limp and the recently updated imaging recommendations from the American College of Radiology to aid in final diagnosis. [Pediatr Ann. 2020;49(9):e395-e402.].
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Safdar NM, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Garber MD, Lam HFS, Nguyen JC, Siegel A, Widmann RF, Karmazyn B. ACR Appropriateness Criteria ® Acutely Limping Child Up To Age 5. J Am Coll Radiol 2018; 15:S252-S262. [PMID: 30392594 DOI: 10.1016/j.jacr.2018.09.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022]
Abstract
Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. 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.
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Affiliation(s)
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice-Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Roger F Widmann
- Hospital for Special Surgery, New York, New York; American Academy of Orthopaedic Surgeons
| | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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JOURNAL CLUB: Can Coronal STIR Be Used as Screening for Acute Nontraumatic Hip Pain in Children? AJR Am J Roentgenol 2017; 209:676-683. [PMID: 28657842 DOI: 10.2214/ajr.16.17685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate whether coronal STIR MRI can be used as a screening test for nontraumatic acute hip pain in children. MATERIALS AND METHODS From 2008 to 2012, we identified all patients younger than 18 years at our tertiary care facility who underwent pelvic MRI including coronal STIR for the following indications: acute hip pain, limping, or refusal to bear weight. Patients with a history of trauma were excluded. Each MR image was independently reviewed by four radiologists who were blinded to the clinical outcome. After first reviewing the coronal STIR images only, they then reviewed the full MRI studies in a random order different from that used for review of the coronal STIR images. The sensitivity and specificity of STIR-only images in identifying the presence of abnormality and specific diagnoses were calculated, with the full MRI study considered as the reference standard. Kappa values were calculated for STIR-only and full MRI studies. RESULTS A total of 127 patients (67 female patients and 60 male patients; median age, 9 years; range, 5 months to 17 years) were identified. The most common abnormalities (calculated as the mean of frequency values noted by four readers) were hip effusion (52%; range, 46-58%), osteomyelitis (42%; range, 29-48%), and myositis (32%; range, 20-40%). For the detection of any abnormality, STIR-only images had a mean sensitivity of 95% and a mean specificity of 67%. For approximately one-third of STIR-only studies with true-positive results, additional abnormalities were found on full MRI studies. CONCLUSION Coronal STIR imaging of the pelvis has high sensitivity (95%) in the detection of abnormalities associated with acute nontraumatic hip pain in children, but it often misses additional abnormalities.
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Imagen musculoesquelética en la urgencia pediátrica. Lo esencial a través de tres escenarios clínicos. RADIOLOGIA 2016; 58 Suppl 2:104-18. [DOI: 10.1016/j.rx.2016.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/04/2016] [Accepted: 03/13/2016] [Indexed: 12/12/2022]
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Abstract
Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.
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Affiliation(s)
- E S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - S L N Clarke
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK.
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Sarwar ZU, DeFlorio R, Catanzano TM. Imaging of Nontraumatic Acute Hip Pain in Children: Multimodality Approach With Attention to the Reduction of Medical Radiation Exposure. Semin Ultrasound CT MR 2014; 35:394-408. [DOI: 10.1053/j.sult.2014.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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