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Bartoloni A, Aparisi Gómez MP, Cirillo M, Allen G, Battista G, Guglielmi G, Tomà P, Bazzocchi A. Imaging of the limping child. Eur J Radiol 2018; 109:155-170. [PMID: 30527299 DOI: 10.1016/j.ejrad.2018.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/28/2018] [Accepted: 10/20/2018] [Indexed: 01/09/2023]
Abstract
Limping is a challenging symptom in the pediatric patient as the diagnosis can range from traumatic, malformative, infectious/inflammatory and neoplastic diseases. In this paper, we propose a schematic imaging algorithm to the limping child in three different age groups (Toddler: 1-3years, child: 4-10 years; adolescent: 11-16 years) based on presence of signs of infection, any specific localization of pain, and history of trauma. In this setting, the most common imaging pitfalls are also summarised. Finally, a literature review of the main differential causes of limping in the pediatric patient is reported.
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Affiliation(s)
- Alessandra Bartoloni
- Department of Imaging, IRCCS Bambino Gesù Children's Hospital, Piazza Sant' Onofrio 4, 00165 Roma, Italy
| | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, 2 Park Road, Grafton, 1023 Auckland, New Zealand; Department of Radiology, Hospital Nueve de Octubre, Calle Valle de la Ballestera, 59, 46015 Valencia, Spain
| | - Marco Cirillo
- Department of Imaging, IRCCS Bambino Gesù Children's Hospital, Piazza Sant' Onofrio 4, 00165 Roma, Italy
| | - Georgina Allen
- Department of Radiology, St Lukes Radiology Oxford Ltd, Oxford, UK
| | - Giuseppe Battista
- Department of Specialized, Diagnostic, and Experimental Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Giuseppe Guglielmi
- Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71100 Foggia, Italy; Department of Radiology, Scientific Institute "Casa Sollievo della Sofferenza" Hospital, Viale Cappuccini 1, 71013 San Giovanni Rotondo, Foggia, Italy
| | - Paolo Tomà
- Department of Imaging, IRCCS Bambino Gesù Children's Hospital, Piazza Sant' Onofrio 4, 00165 Roma, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, 40136 Bologna, Italy.
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Nguyen JC, Lee KS, Thapa MM, Rosas HG. US Evaluation of Juvenile Idiopathic Arthritis and Osteoarticular Infection. Radiographics 2017; 37:1181-1201. [PMID: 28696851 DOI: 10.1148/rg.2017160137] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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. © RSNA, 2017.
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Affiliation(s)
- Jie C Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Mahesh M Thapa
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
| | - Humberto G Rosas
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, Wis (J.C.N., K.S.L., H.G.R.); and the Department of Radiology, Seattle Children's Hospital, Seattle, Wash (M.M.T.)
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Ultrasound imaging of synovial inflammation in juvenile idiopathic arthritis. Pediatr Radiol 2017; 47:1160-1170. [PMID: 28779188 DOI: 10.1007/s00247-017-3934-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/05/2017] [Accepted: 06/23/2017] [Indexed: 01/17/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common rheumatic entity of childhood. The hallmark feature of all subtypes is joint inflammation. Imaging is used to evaluate the extent and severity of inflammation, degree of joint damage and response to treatment, which in turn impacts patient management. Ultrasound has become a useful adjunct to clinical examination because it shows promise in evaluating clinical and subclinical inflammation (synovitis, enthesitis) as well as cartilage and bone erosive changes. However more collaborative research is needed to help define the normal appearance of the growing skeleton, clarify the significance of subclinical findings and develop useful definitions, imaging protocols and scoring systems of disease.
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Septic arthritis in immunocompetent and immunosuppressed hosts. Best Pract Res Clin Rheumatol 2015; 29:275-89. [PMID: 26362744 DOI: 10.1016/j.berh.2015.05.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/08/2015] [Indexed: 12/12/2022]
Abstract
Septic arthritis has long been considered an orthopedic emergency. Historically, Neisseria gonorrhoeae and Staphylococcus aureus have been the most common causes of septic arthritis worldwide but in the modern era of biological therapy and extensive use of prosthetic joint replacements, the spectrum of microbiological causes of septic arthritis has widened considerably. There are also new approaches to diagnosis but therapy remains a challenge, with a need for careful consideration of a combined medical and surgical approach in most cases.
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Jaimes C, Jimenez M, Shabshin N, Laor T, Jaramillo D. Taking the stress out of evaluating stress injuries in children. Radiographics 2012; 32:537-55. [PMID: 22411948 DOI: 10.1148/rg.322115022] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pediatric stress injuries result from a mismatch between (a) the burden of activity on growing bone and cartilage and (b) their intrinsic biomechanical properties. Although the presentation of stress injuries varies with the specific physical activity and the site of injury, in children it varies primarily with the degree of skeletal maturation. During the past several years, there has been a substantial increase in the incidence of pediatric stress injuries. The differential diagnosis of a stress injury in a child or adolescent can be challenging because the injury sometimes can appear aggressive at imaging assessment. Awareness of the spectrum of imaging features of stress injuries can help the radiologist to reach the correct diagnosis and prevent unnecessary anxiety. This review depicts the range of stress injuries in children and adolescents in various anatomic locations, with emphasis on their appearances at magnetic resonance imaging.
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Affiliation(s)
- Camilo Jaimes
- Department of Radiology, Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, 3NW 39, Philadelphia, PA 19104, USA.
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Functional imaging of infection: conventional nuclear medicine agents and the expanding role of 18-F-FDG PET. Pediatr Radiol 2011; 41:803-10. [PMID: 21607605 DOI: 10.1007/s00247-011-2013-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
Abstract
A growing body of literature suggests that 18-fluorine fluorodeoxyglucose positron emission tomography ((18)F-FDG PET), particularly when combined with CT, is a useful tool for the detection of infectious and inflammatory disease processes. This article will briefly review the data to date on the use of FDG PET in diagnosing musculoskeletal infections and fever of unknown origin, comparing it to conventional scintigraphic techniques in both adults and, when available, in children.
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