Infant shoulder sonography: technique, anatomy, and pathology

BACKGROUND

In the infant, shoulder injury due to birth trauma and infection in joint and bone may be difficult to detect radiographically. Shoulder ultrasound provides a dynamic, noninvasive method of evaluation.

OBJECTIVE

To develop a technique to evaluate the infant shoulder and to successfully demonstrate pathology.

MATERIALS AND METHODS

Using a multiplanar, dynamic technique, 24 normal and 12 symptomatic infants (age range, 3 days to 9 months) were examined (49 shoulders).

RESULTS

Sonographic findings were normal in 41 shoulders and abnormal in 8 shoulders. Abnormalities included subluxation, fracture, abnormal cartilage, soft-tissue mass, and inflammatory collections, including effusion.

CONCLUSION

Ultrasound can be used successfully to evaluate the infant shoulder for instability, fracture, and infection.

Pediatric hip sonography. Diagnosis and differential diagnosis

As with any sonographic study, the accuracy of the examination is related to the skill and experience of the examiner. In this review of pediatric hip sonography, we have reviewed pitfalls and differential diagnoses for the infant suspected of DDH and for the older child presenting with a painful hip. The learning process for DDH evaluation is prolonged and more difficult than learning to assess the hip for effusion.

Cost-effective imaging approach to the nonbilious vomiting infant

OBJECTIVE

To develop a cost- and time-effective algorithm for differentiating hypertrophic pyloric stenosis (HPS) from other medical causes of emesis in infants referred from community-based pediatricians and family practitioners to the imaging department of a tertiary children's care facility.

METHODS

Eighty-nine vomiting infants (22 females, 67 males) between the ages of 11 and 120 days (mean, 43.5 days) had received nothing by mouth for at least 1 hour before the study. Each child was assessed for duration of vomiting, status of body weight, time and volume of last ingestion, and time of last emesis. A #8 French (Sherwood Medical, St Louis, MO) nasogastric feeding tube was placed in the child's stomach. The contents were aspirated and measured to determine likelihood of HPS. An aspirated volume >/=5 mL implicated gastric outlet obstruction, and ultrasonography (US) was performed. If this study was positive for HPS, the patient was referred for surgery. If US was negative, an upper gastrointestinal series (UGI) was performed. An aspirated stomach contents volume <5 mL suggested a medical cause for the emesis, and UGI was performed. Pediatric surgeons with no knowledge of the volume results palpated the abdomens of 73 of 89 infants (82%).

RESULTS

Twenty-three of 89 patients (25%) had HPS. The aspirate criteria for HPS had a sensitivity of 91%, a specificity of 88%, and an accuracy of 89%. Of the false-positive studies (total = 8), six were related to recent significant ingestion (within 2 hours of the study), and two were attributable to antral dysmotility. The surgeons palpated the mass in 10 of 19 patients (53%). Sensitivity and specificity were 53% and 93%, respectively. Only 6 of 89 infants (7%) required both US and UGI to determine the etiology of the nonbilious vomiting. By performing the UGI in 66 patients, it was also found that 14% had slow gastric emptying and 79% had gastroesophageal reflux. Eighty-one percent of the gastroesophageal reflux was significant.

CONCLUSION

The volumetric method of determining the proper imaging study is cost- and time-effective in the evaluation of the nonbilious vomiting infant for pyloric stenosis. If US was performed initially in all patients referred for imaging, two studies would have been performed in 68 of 89 patients (76%) to define the etiology of the emesis. Because we used the volumetric method, 62 fewer imaging studies were performed, representing a savings of $4464 and 30 hours of physician time. If children are given nothing by mouth for 3 to 4 hours before gastric aspiration, the specificity of the volumetric method improves to 94%, and the accuracy improves to 96%.

Ultrasonography and developmental dysplasia of the infant hip

Hip sonography has been developed, refined, and critiqued for over 18 years. It is now widely accepted as a highly sensitive and useful technique for both the diagnosis and management of developmental dysplasia of the infant hip. Controversy continues surrounding the issue of when and how often hip sonography should be performed. Currently, clinical screening of newborns is the standard of care in the United States, with sonography employed selectively based on clinical findings. Universal ultrasound screening has been used in some countries and is under consideration by many investigators, using a variety of algorithms. This review will focus on recent reports dealing with issues of screening for developmental dysplasia of the infant hip and also will highlight techniques suggested for use in the treatment of development dysplasia of the infant hip.

Mesenchymal chondrosarcoma of the cervical spine in a child

Mesenchymal chondrosarcoma is a rare small-cell neoplasm of bone and soft tissue. After reviewing the literature, we believe that the patient in this report is the youngest in whom mesenchymal chondrosarcoma originating in a cervical vertebra has been diagnosed.

Chiari malformation and tonsillar ectopia in twin brothers and father with autosomal dominant spondylo-epiphyseal dysplasia tarda

We describe twin brothers and father with autosomal dominant spondylo-epiphyseal dysplasia (SED) tarda. The proband presented at 17 years with nystagmus and esotropia due to a severe Chiari malformation. A milder, asymptomatic Chiari I malformation was seen in his brother and tonsillar ectopia in his father. Although these malformations have not been described in patients with SED, they are relatively common in other bony abnormalities, particularly those involving the cranio-cervical junction. The concordance of the Chiari malformations or tonsillar ectopia in all three family members with SED suggests that this association is not coincidental. It seems possible that the downward displacement of the cerebellum occurs secondary to primary osseous abnormality, rather than due to a primary disturbance of embryological development. The lack of additional brain malformations in our patients is consistent with this theory.

Ultrasonography of nondevelopmental dysplasia of the hips

We examined 45 infants with nondevelopmental dysplasia of the hip (non-DDH), including congenital deficiency of the femur (CDF) (20 infants), neuromuscular syndrome (five infants), skeletal dysplasia (15 infants), and infection (five infants), and present the sonographic findings. Dysmorphic proximal femora, coxa vara, and abnormal echogenicity of the soft tissue and cartilage are features which differentiate patients with non-DDH from those with typical DDH.

Hypervitaminosis A as a complication of treatment for neuroblastoma

A case of hypervitaminosis A (HVA) as a complication of therapy for stage-IV neuroblastoma is presented. The patient was randomized to a trial of 13-cis -retinoic acid (a vitamin A-related compound) after completing routine chemotherapy. This acid was given as a means of maturing potential minimal residual disease. A routine follow-up bone scan revealed areas of increased activity, initially along the midshaft of the right ulna and subsequently bilaterally, which were ultimately found to be due to HVA. Hypervitaminosis A has not been previously reported in this setting, and awareness of the condition is important in centers where this treatment is contemplated.

Sedation in pediatric imaging using intranasal midazolam

Intranasal midazolam offers an attractive alternative for use as a sedative agent for medical imaging studies in children. Its convenient administration and rapid onset are significant advantages over intravenous and oral agents. Because of its short duration, it is effective only for short procedures and as an adjunct to other sedative agents. When younger children present with such requirements, a dose of 0.2 mg/kg has been safe and effective in our experience. We advocate its use with adherence to guidelines for sedation published by the American Academy of Pediatrics.

Infant hip sonography: current concepts

Sonography of the infant hip has gained wide acceptance in the decade since its introduction. The two principle techniques of Graf and Harcke have been combined with the proposal of a Dynamic Standard Minimum Examination. Whereas sonography is used increasingly to manage developmental dislocation and/or displasia of the hip, there is no agreement on the use of sonography for universal newborn screening. This article describes in detail the Dynamic Standard Minimum Sonographic Examination of the infant hip. In addition, this article reviews the classification and management of infant hip disorders.

Sonography in congenital deficiency of the femur

Dynamic hip sonography was performed in 15 infants (19 hips) with congenital abnormalities of the hip. Radiographs of all 15 patients revealed congenital deficiency of the femur (CDF), type I-V, using the classification described by Kalamchi et al. Sonography was accurate in delineating hip position and morphology in all cases, and was a helpful adjunct to radiography in defining the hip joints in 13 hips with type II and type III deficiency of the femur.

Performing dynamic sonography of the infant hip

Real-time sonography is gaining wide acceptance as the method of choice for imaging the infant hip. The dynamic technique of hip sonography incorporates motion and stress maneuvers that are based on accepted clinical examination techniques. The multiview dynamic assessment emphasizes hip position and stability, but includes assessment of acetabular development. It has been found to be effective in the initial detection of infant hip abnormalities and in monitoring treatment.

Evaluation of the musculoskeletal system with sonography

Although musculoskeletal sonography historically has received little attention, its use in certain specific situations has clear advantages over use of other imaging techniques. The wide availability of sonography, its modest cost, and its lack of ionizing radiation are other reasons that its use in musculoskeletal conditions is expected to increase. We have reviewed potential applications; some of these applications are new and have been used in a small series of patients, and others, such as infant hip sonography, have already been used in thousands of cases. Additional applications may be possible [64]. Those learning the techniques of musculoskeletal sonography will find that progress is made most quickly when there is close cooperation between the sonographer and the clinician. While experience is being gained, each party must endeavor to understand what the technique is able to determine and what it cannot determine. Only through close cooperation, and with adequate opportunity to learn, will the sonographer and the clinician develop confidence in the technique to the point that it becomes the effective imaging alternative that best suits the needs of the patient.

Common congenital skeletal anomalies of the thorax

Bony anomalies of the thorax may occur as isolated problems, but are also seen in conjunction with other skeletal or organ anomalies. Among the most common thoracic osseous anomalies are pectus excavatum, pectus carinatum, sternal ossification abnormalities, and deformity of the spine, ribs, clavicle, or scapula. The presence of any of these anomalies should increase the index of suspicion for associated problems. Review of the history and physical examination, combined with a knowledge of commonly associated malformations, will allow appropriate additional imaging studies to be selected. Many osseous anomalies of the thorax do not require treatment; in some instances, however, problems with function, progressive deformity, or cosmetic considerations may necessitate surgical treatment.