Accepted Manuscript Title: Musculoskeletal ultrasound in childhood Author: Kathrin Maurer PII: DOI: Reference:
S0720-048X(14)00175-2 http://dx.doi.org/doi:10.1016/j.ejrad.2014.04.003 EURR 6739
To appear in:
European Journal of Radiology
Received date: Accepted date:
25-3-2014 7-4-2014
Please cite this article as: Maurer K, Musculoskeletal ultrasound in childhood, European Journal of Radiology (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Conflict of Interest
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Conflicts of interests: none
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*Title Page (including paper title & Complete corresponding author details)
Musculoskeletal ultrasound in childhood
Corresponding author: Dr. Kathrin Maurer
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Medical university Innsbruck
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Department of Radiology Anichstrasse 35
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A-6020 Innsbruck Email: [email protected]
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Phone: +43 512 504 23571
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*Manuscript containing Abstract, Sections and References (Without corresponding author details)
1 Musculoskeletal ultrasound in childhood
Abstract:
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Ultrasonography is one of the first line imaging modalities for the evaluation of musculoskeletal disorders in children. This article provides an overview of the most
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important pathologic entities in which ultrasonography significantly contributes to the
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diagnostic workup.
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Introduction:
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Ultrasound, musculoskeletal, children
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Keywords:
Ultrasonography (US) has emerged as an indispensable tool for primarily evaluating a variety of musculoskeletal disorders in children. It has certain advantages over
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other imaging modalities - it is a readily available, convenient and cost effective method. It is non-invasive and there is no need for sedation even in small children. US is particularly well suited for the examination of the immature skeleton with its large portion of cartilaginous, non-ossified structures as it can readily distinguish soft tissue from cartilage and from bone. The capability of real time imaging allows the dynamic assessment of musculoskeletal structures during joint movement and repetitive imaging in motion and at rest is possible. With US it is easy to compare the
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2 symptomatic to the contralateral side. The high sensitivity of US for fluid collections and joint effusions makes it an ideal tool for image guided puncture. By following structures and using Color Doppler sonography (CDS), vessels and nerves can be differentiated, and tissue vascularity can easily be assessed too.
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There are some limitations for the use of US in musculoskeletal disease – US cannot penetrate bone and air, therefore certain regions of the body such as the deeper
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parts of the pelvis or bone marrow lesions cannot be assessed by US. The quality
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and consistency of an US examination rely on the expertise, creativity and patience of the examiner – this may be seen as a disadvantage or as a chance.
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This article emphasizes the value of US in common developmental, infectious, inflammatory and traumatic conditions that affect the musculoskeletal system in
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Technical considerations:
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children.
As most indications refer to structures, that lie relatively superficial, high frequency probes can be used to achieve optimal special resolution. Linear probes are
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preferable due to the lack of distortion. In small children hockey stick transducers allow the access of many regions, where conventional linear transducers would be too large. The use of a stand-off pad enables an optimal visualization of the area close to the body surface. In frightened children it may contribute to calm the situation. An alternative is the use of a water-bath, where the child puts the extremity in and the transducer can be held close without touching the skin thus avoiding pain
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3 or anxious distress in the child. If necessary, a child can even be examined comfortably in the arms of a parent. In the sonographic evaluation of the musculoskeletal system the amplitude of the echo is highly dependent on the angle of insonation. Advances in ultrasound
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technologies have contributed to improvement of image quality. Compound imaging and beam-steering decreases many image artefacts inherent in conventional
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sonography and are especially helpful to avoid anisotropic artefacts in tendons and
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ligaments. Compound imaging also results in improved tissue- plane definition due to speckle noise reduction. Harmonic imaging aids in the differentiation of tissues, but
Developmental anomalies:
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also makes the borders between structures appear artificially thickened.
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Developmental dysplasia of the hip (DDH) is the most common indication for musculoskeletal US in children. It covers a spectrum of congenital abnormalities that ranges from immaturity and only instability to dislocation of the hip. Stabile positioning of the femoral head within the acetabulum is thought to propagate
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acetabular development allowing for remodeling of acetabular dysplasia over time, this is used as a conservative treatment approach. The maximum potential for effective treatment of DDH is in the first 3 months after birth. US is an excellent tool to assess the anatomical details of the cartilaginous parts of the neonatal hip, and is much more informative than radiography in this age group. The accuracy and utility of US in examining neonatal and infant hips is high. A combined understanding of anatomy, pathology and sonography is required. Since
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4 hip US was first described by Graf in 1980 several methods for the assessment of morphology and stability of the neonatal hip have been developed 1. The method proposed by Graf is widely used in central Europe. It assesses hip morphology, but also takes account of hip stability (2). A standard coronal view with the infant in the
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lateral position is acquired. The iliac bone has to be straight and the acetabular labrum as well as the lowest point of the acetabular part of the iliac bone has to be
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visible (Fig.1a). Measurement of alpha and beta angels allows classification into four
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main and 9 sub-types (Fig.1b). A stress test pushing the femur in a cranial and dorsal direction is added to assess hip stability 2. The combined use of a stability test in
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conjunction with the assessment of the acetabular morphology using a standard coronary view defined by Graf and measurement of the alpha angle only was
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propagated by Rosendahl 3. Harcke and coworkers developed a dynamic US examination of the infant hip, which is widely used in the United States 4. A four step
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scanning technique is used based on transverse and coronal planes in neutral and flexed position, at rest and during stress. Hips are classified as normal, lax under
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stress, subluxed or dislocated.
The femoral head coverage technique proposed by Morin and modified by Terjesen assesses the lateralization of the femoral head; it is used widely in France
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Femoral head coverage by the bony acetabular rim of less than 50% is considered
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abnormal.
Treatment is based on the reduction of a displaced hip (Fig.1c) and stabilization of the femoral head within the acetabular fossa. Maintaining is achieved by several devices. With harnesses or splints US follow up is the method of choice until shadowing from the developing ossification center of the femoral head limits its usefulness. With the ossified femoral head radiography can be used to guide further
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5 treatment. MRI is helpful in those cases, where hip reduction cannot be achieved by clinical manipulation and for confirmation of femoral head position with spica casts in situ. A reduction in the rate of patients requiring surgery for DDH was seen after the
universal US screening for DDH is still under debate 9,10.
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introduction of universal US screening in Austria and Germany 7,8, but the value of
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Recommendations for the sonographic evaluation of the neonatal hip were
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elaborated by the DDH Taskforce Group of the European Society of Pediatric
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Radiology. The latest update was issued in May 201111.
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The diagnosis of neonatal foot deformities is commonly based on clinical evaluation and radiography. As tarsal bones are largely cartilaginous and many even lack an
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ossification center US is a valuable means for estimating the severity of the deformity. US can visualize the cartilaginous parts of the neonatal foot und evaluate
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alignment. The examination is based on a series of measurements, such as the medial malleolus-navicular distance, the navicular alignment with the talar head, talar length and the calcaneo-cuboid distance 12,13.
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The ability of US to visualize cartilage allows for further evaluation of limb deformities, where radiographs show only one bone at the forearm or lower leg. Aplasia or hypoplasia with solely cartilaginous Anlage of the radius or fibula can be differentiated (Fig.2a,b).
Anterior chest wall deformities in children are a common cause of parental concern. They are often caused by an abnormal angulation of the cartilaginous rib which
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6 cannot be visualized on radiographs. US is a valuable tool in this setting to exclude a tumor and confirm the benign nature of the condition (Fig.3a,b).
Cranial deformity in infants may result from premature craniosynostosis or positional
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plagiocephaly. Sonography is a good screening tool to distinguish fused from patent cranial sutures (Fig.4a,b), thus reducing the need for 3D-CT to patients with
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inconclusive results on US and preoperative evaluation particularly in complex cases 14,15
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Cellulitis and soft tissue abscess
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Infection:
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Cellulitis is defined as an infection of skin and subcutaneous tissue. US appearance initially resembles edema of subcutaneous fat, showing swelling, increased
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echogenicity and blurring of tissue planes. Further progression leads to hypoechoic strands between hyperechoic fatty lobules. Increased vascularity on CDS suggests an inflammatory process. Accumulation of pus and abscess formation can readily be detected by US and US-guided puncture can be performed for diagnostic and
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therapeutic purposes.
Soft tissue abscesses are characterized by a collection of necrotic tissue, neutrophils, inflammatory cells and bacteria surrounded by a wall of highly vascular connective tissue. The US appearance of the liquefied contents varies widely, from anechoic to hyperechoic (Fig.5). To confirm the liquid nature gentle pressure can be used to evoke fluctuation of the contents, the through-transmission phenomenon must be
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7 observed, and CDS shows absence of flow in the center and hyperemia of the abscess wall 16.
Necrotizing fasciitis
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Necrotizing fasciitis is a rapidly progressive infection of subcutaneous tissue, fascia and surrounding soft tissue associated with a 30 to 70% mortality rate. Group A
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streptococci are the most common offending organism in children. Previous Varicella
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zoster virus infection seems to be a predisposing factor. Ultrasonography shows soft tissue swelling, fascial thickening and accumulation of fluid along fascia (Fig.6a) and
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can demonstrate gas bubbles in the soft tissues (Fig.6b). MRI is essential to document the extent of soft tissue involvement. Prompt extensive surgical 17
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debridement and antibiotic therapy may stop the fatal course of the disease
Pyomyositis
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Suppurative bacterial infection in striated muscle is rare. Children are affected in one third of cases. There is a predilection for muscles in the thigh and pelvis. Staphylococcus aureus is the most common causative organism. Diagnosis may be delayed as fever and malaise can be the only symptoms initially and localization of
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pain may be difficult for the child especially with involvement of pelvic muscles. Abscess formation can readily be shown by US in certain parts of the body. When the full extent of the lesion is not clearly demonstrated by US, MRI is the imaging modality of choice. MRI is particularly useful to exclude bone involvement and in the evaluation of deeper body compartments such as the deep pelvic muscles (Fig.7a). Ultrasound is a valuable tool for image guided percutaneous aspiration and drainage as well as for follow up examinations (Fig.7b).
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8
Osteomyelitis
Osteomyelitis is an infection of bone marrow and bone usually caused by bacteria.
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Infection occurs through three possible routes: hematogenous, which is by far the most common way in children, by contiguity, and by direct implantation. In children
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more than 80% of cases of osteomyelitis occur due to hematogenous seeding after a
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transient episode of bacteremia. Due to the architecture of the supplying vessels the primary site of the infectious process is the metaphyseal region of the long bones.
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Further spread varies according to age and depends on the vascular anatomy of the metaphyseal – epiphyseal region 18. Typical signs and symptoms of acute
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osteomyelitis include fever, local pain and tenderness. However initial signs may be
pseudoparalysis.
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vague and misleading especially in infants, who may only present with
Radiographs should always be the first study obtained in patients with suspected
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osteomyelitis. Deep soft tissue swelling is visible as early as 2 days after onset of symptoms, but it is often difficult to detect. Bone changes are not detectable until after 7 to 10 days. Ultrasound may demonstrate features of acute osteomyelitis within 48 hours 19. The earliest sign is juxtacortical soft tissue swelling followed by periosteal
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elevation with a thin layer of fluid. As periosteal attachment is loose in young children, subperiosteal abscess formation rapidly occurs and is seen as hypoechoic lenticular– shaped fluid collection along the cortex (Fig.8a). In the appropriate clinical setting this finding confirms acute osteomyelitis. After US-guided puncture to obtain material for cultivation of the causative organism antibiotic therapy can be started immediately. Cortical erosions can be seen later in the course of the disease and US is also useful in detecting fistula formation in chronic osteomyelitis 20 (Fig.8b,c).
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9 In children under the age of two years, blood vessels cross the physis thus propagating spread of infection into the epiphysis and into the joint space. This leads to septic osteoarthritis. US is an excellent tool to demonstrate joint effusion and therefore it is extremely useful in neonates and infants suspected to have septic
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osteoarthritis allowing for immediate management by guided aspiration. Ultrasound has been found to be a fast and useful first line diagnostic tool for early 21
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detection of acute osteomyelitis in children, especially in newborns and infants
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50% of affected children are under the age of 3 years, the lack of need for sedation is a great advantage.
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But it has to be strongly emphasized that US cannot exclude osteomyelitis. In patients with suspected osteomyelitis and negative or inconclusive results on US
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urgent MRI is mandatory 22.
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Septic arthritis
Acute septic arthritis is a medical emergency as early diagnosis and treatment is
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mandatory to prevent joint destruction, growth disturbances and early degenerative disease. In children over the age of two years it is mostly caused by hematogeneous seeding, less frequently by contiguous spread from adjacent osteomyelitis. The hip joint is most common involved; knee, shoulder and elbow are other common
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preferred sites. The presenting symptoms are fever, pain, inability of weight bearing, elevated erythrocyte sedimentation rate and C-reactive protein. Ultrasound is highly sensitive to detect joint effusion, but neither seize and echogenicity of the effusion nor adjacent hyperemia on CDS imaging allow distinguishing infectious from non-infectious arthritis. Definite diagnosis of septic arthritis is based on US-guided aspiration of joint fluid 23,24.
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10 Inflammatory disease:
Juvenile idiopathic arthritis (JIA)
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JIA is a heterogeneous group of diseases in children under the age of 16 years, characterized by synovial inflammation of unknown cause that persists for more than
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6 weeks. JIA is the most common chronic rheumatic disorder in children and is a
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leading cause of acquired disability in the pediatric age. Early therapeutic intervention and the use of new disease-modifying therapeutic agents have improved the
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outcome and have led to greater emphasis on the accurate detection of disease activity. The presence of extensive amounts of epiphyseal cartilage in children limits
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the usefulness of conventional radiography in the early stages of the disease. Contrast enhanced MRI and US both are well suited for this application. For pediatric
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patients US offers specific advantages over MRI as it is non-invasive, there is no need for sedation, it allows for assessment of multiple joints in one session and real-
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time dynamic imaging of tendons and joints helps to detect structural abnormalities during joint movement.
US is more sensitive than clinical evaluation and radiography for the detection of synovial proliferation and effusion and is particularly useful in the evaluation of small
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peripheral joints. In experienced hands US allows reliable assessment of further signs of disease like cartilage blurring, thinning and erosions as well as bone erosions, enthesitis and tenosynovitis. The use of CDS provides information about synovial vascularity and hyperemia. Several studies have demonstrated the ability of US to detect subclinical disease and its usefulness in evaluating response to intraarticular therapy 25,26.
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11 US evaluation in JIA has certain limits. In large joints visualization of the entire articular surface may be hindered by bone shadowing, there is insufficient resolution of anatomical details of deeper structures, and US has high false negative rates in subtalar disease. The complexity of the temporomandibular and the sacroiliac joints
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makes contrast-enhanced MRI the preferred method for evaluation of these structures. Contrast-enhanced MRI is the most sensitive technique for detection of
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synovitis and the only modality to demonstrate bone marrow edema 27. The major
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draw-back for its use in young children is the need for sedation.
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Transient synovitis of the hip
Transient synovitis is the most common cause of hip pain in children aged 3 to 8
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years. The clinical features are sudden onset of unilateral hip pain without a history of trauma, limping and restriction of motion, sometimes accompanied by low grade
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fever. A preceding viral infection is reported by many patients. It is a benign, selflimiting disease. Definitive diagnosis can only be made by exclusion of other disorders.
US demonstrates joint effusion in the anterior recess of the hip joint. Normally the
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anterior and posterior parts of the joint capsule are attached closely to each other. A linear echo located centrally marks the interface between the two layers. With joint effusion the anterior joint capsule assumes a convex shape and underlying fluid within the anterior recess can be visualized (Fig. 9 a,b), which may be anechoic or contain particles. This finding is nonspecific 23. Ultrasound evaluation of the femoral epiphysis is mandatory to look for irregularities of the cartilage and ossification center in case of Perthes disease or a physeal step in slipped upper femoral epiphysis
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12 (Fig.10a,b,c,d). If one of these entities is suspected on US, further evaluation by radiography and MRI will establish the extent of the disease in detail. The most important differential diagnosis is septic arthritis due to the devastating consequences to the hip joint in case of delayed diagnosis. Aspiration of joint fluid
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has to be performed immediately in cases where septic arthritis cannot be excluded.
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Trauma:
In animal models ultrasonography has not only comparable sensitivity to that of X-ray
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for the identification of limb fractures but is also equally effective for the diagnosis of fracture type and dislocation 28. Recent studies have shown that distal forearm
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fractures in children can be safely and reliably diagnosed using only US thus avoiding radiation burden to the immature skeleton
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Although promising, this approach has several draw backs till now – it is time consuming and positioning of the limb to evaluate the whole circumference of a bone might be difficult and painful. 24 hour availability of skilled examiners in a busy emergency department might be a limitation too.
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Therefore plain radiography still is the standard primary imaging method in children with a history of trauma. However, there are some instances where US can play an important role in the diagnostic work-up. Due to the immaturity of bone with largely cartilaginous epiphysis fractures at the region of the physis may be undetectable by radiographs. US has proven an effective imaging modality in these settings especially in injuries around the elbow 30. It can even be used for guiding repositioning maneuvers in dislocated epiphysiolysis.
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13 Fractures of phalanges, metacarpals and metatarsals often show only subtle changes on radiographs, whereas on US an interruption of the cortical continuity or a buckle can easily be seen (Fig.11). In a toddler, who refuses to bear weight it may be challenging for the clinician to localize the region of interest. US allows screening for
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a toddlers fracture on a whole extremity and even on both sides. Detection of classical metaphyseal and rip fractures in child abuse can be extremely
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difficult. The use of US may be helpful to visualize the small displaced fragment of a
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corner fracture as well as hematomas in the soft tissue around a rib fracture and fractures within the cartilagineous part of the rib 31 (Fig.12a,b,c).
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A further indication is the search for non-radiopaque foreign bodies (Fig.5,Fig.13 a). Here US is not only an elegant tool useful for detection and US-guided removal 32, it
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Tumor:
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bodies by their US appearance.
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furthermore often allows to differentiate wood splinters form glass and other foreign
In children with a tumor of the musculoskeletal system US often is the first imaging modality. It can help to rule out abscess or hematoma as a cause of the regional
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swelling. Due to the possibility of real time imaging it is especially useful to differentiate a solid tumor from a venolymphatic vascular malformation. If a tumor is detected by US, MRI is the imaging method of choice to establish the extent of the lesion, as well as involvement of bone, vascular structures and nerves. US can be used for image guided puncture and follow up.
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14 A special entity, where the diagnosis is readily established with US and further imaging evaluation or biopsy is rarely required is fibromatosis colli. It is a self-limiting disorder of neonates and young infants. The exact cause is still unknown. The lesion usually gets evident at 2 weeks after birth and may increase in size for a few more
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weeks, resolving spontaneously within 4 to 8 months. On US a fusiform thickening confined to the sternocleidomastoid muscle is seen, which is often hypoechoic or
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focally or diffusely hyperechoic and shows often excessive vasculature on CDS. It 33
(Fig.14).
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may show disruption of the fascicular echotextur of the normal muscle
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Summary
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US has a significant role to play in the investigation of the musculoskeletal system in children. In skillful hands US can provide diagnostic information about
sedation.
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musculoskeletal disorders in infants and children quickly and without the need for
In some instances US can be regarded the most effective means of diagnostic imaging, whereas in others it may be used supplementary to radiography, or is the
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primary imaging tool then complemented by more complex imaging modalities like MRI or CT.
Conflicts of interest: none
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[25] Rebollo-Polo M, Koujok K, Weisser C, et al. Ultrasound findings in patients with
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juvenile idiopathic arthritis in clinical remission. Arthritis Care Res 2011;63(7):1013-1019.
[26] Haslam KE, McCAnn LJ, Wyatt S, et al. The detection of subclinical synovitis by ultrasound in oligoarticular juvenile idiopathic arthritis: a pilot study. Rheumatology 2010;49(1):123-127.
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19 [27] Sheybani EF, Khanna G, White AJ, et al. Imaging of Juvenile Idiopathic Arthritis: A Multimodality Approach. Radiographics 2013;33:1253-1273.
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[28] Moritz JD, Hoffmann B, Meuser SH, et al. Is ultrasound equal to X-ray in pediatric fracture diagnosis?
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Rofo 2010;182(8):706-14.
[29] Eckert K, Ackermann O, Schweiger B, et al. Ultrasound as a viable alternative to
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standard X-rays for the diagnosis of distal forearm fractures in children.
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Z Orthop Unfall. 2012;150(4):409-14. doi: 10.1055/s-0032-1314974.
[30] Davidson RS, Markovitz RI, DormansJ et al. Ultrasonographic evaluation of the
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elbow in infants and young children after suspected trauma.
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J Bone Jt Surg 1994;76:1804-1812.
[31] Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection.
Ped Radiol 2009;39(1):70-72.
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[32] Callegari L., Leonardi A., Bini A., et al. Ultrasound-guided removal of foreign bodies:personal experience. Eur Radiol 2009;19:1273–1279.
[33] Deeg KH, Güttler ., Windschall D. Diagnosis of Fibromatosis Colli via ColorCoded Duplex Sonography in 13 Infants. Ultraschall in Med 2008; 29:226–23
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Figure(s)
Legends
Fig.1. Coronal US scan of the newborn hip (Graf´s technique):
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a. Normal hip: On a standard view showing the deepest point of the ilium within the acetabular fossa (*), the straight upper part of the ilium (arrows) and the
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acetabular labrum (+) the alpha angle (α) is > 60°.
c.
Dislocated hip: The fermoral head (F) is completely dislocated, the cartilage roof (C) is
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b.
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interposed.
Fig .2.
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Three weeks old boy with Holt Oram syndrome.
a. Longitudinal US scan of the forearm. The cartilagineous Anlage of the radius is clearly visible, note
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that there is a fusion of the radial head with the epiphysis of the humerus. b. Radiograph of the right forearm: at the forearm there is only one bone visible, the ulna is
Fig.3.
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abnormally bowed and there is subluxation of the ulna at the elbow. Radial deviation of the hand.
a. Excessive angulation of the cartilagineous part of a rib causing a thoracic pump in a 5 years and 9 months old boy. b. Normal rib.
Fig.4. a. Patent cranial sutures in a 9 months old boy with plagiocephaly: hypoechoic gap (arrow) between hyperechoic calvarial bones. Page 22 of 55
b. Missing of the hypoechoic gap in case of premature closure of the sagittal suture in a 1 months old girl with scaphocephaly. Bony ridge in the dorsal part of the sagittal suture.
Fig.5.
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7 years and 9 months old girl, 5 months after a penetrating injury by the brake handle in a bicycle accident. Turbid fluid collection within the subcutaneous tissue of the thigh, centrally located there is
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an echogenic line with shadowing - abcess containing a little piece of cloth.
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Fig.6.
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a. Necrotizing fasciitis in a 2 years and 7 months old boy, a few weeks after a varicella zoster virus infection. Thickening of the tibialis anterior muscle with hyperechoic changes and fluid
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accumulation within the deep fascia as compared to the contralateral side. b. Necrotizing fasciitis of the abdominal wall in a 6 years and 10 months old boy following
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appendectomy. Thickening of the subcutaneous tissue as well as the abdominal wall muscle.
Fig.7.
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Hypoechoic strands and gas-bubbles between the muscle fibres.
Pymoyositis in an 8 years old boy. a. Axial MRI (contrast enhanced t1 weighted sequence) and b. transverse US scan : Abscess within the external obturator muscle.
Fig.8.
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a. 6 years and 11 months old boy with increasing pain at the left ankle 24 hours after a minor trauma. Logitudinal scan of the distal fibula. Spindle shaped elevation of the periosteum by a turbid fluidcollection (arrows). Osteomyelitis of the distal fibula with subperiosteal abscess. b. 13 months old girl refusing to bear weight on her left leg.
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Longitudinal scan along the medial aspect of the proximal tibia. Lenticular shaped fluid accumulation attached to the metaphyseal cortex(arrows), small abscess in the metaphyseal region(*) and cortical
c. 13 years old girl with pain at her ankle for the last two months.
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defect close to the physis (arrowheads). Acute hematogeneous osteomyelitis of the proxmimal tibia.
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Axial scan at the lateral side of the ankle. Cloaca (arrow) at the metaphyseal region of the distal
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fibula with a small bony sequestrum (*) within a soft tissue abscess( arrow heads) in chronic bacterial
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osteomyelitis.
Fig. 9.
Coronal MRT: Positioning of the US probe to demonstrate hip joint effusion in the anterior
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a.
recess.
6 years old boy with transient synovitis of the hip. US shows fluid accumulation within the
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b.
anterior recess of the hip joint.
a.
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Fig.10.
4 years old boy. US of the left hip joint. Joint effusion(*), widening of the metaphysis with
irregular contour ( arrows), small irregular ossification centre in the femoral head (arrowhead) – Perthes disease
b.
Corresponding radiograph
c. 12 years old boy. Hip joint effusion (*) and step at the physis (arrow). Slipped proximal femoral epiphysis. d. Corresponding radiograph.
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Fig.11 2 years and 8 months old boy refusing to bear weight on his left leg. Longitudinal scan of the lateral aspect of the left foot. Disruption of the cortical line and small bony fragment close to the physis of
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the fifth metatarsal. Fracture of the fifth metatarsal.
Fig.12
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a. Left: normal proximal humerus in a young child. Right: 2 months old boy. Longitudinal scan on the left humerus. Small dislocated fragment at the metaphysis with subperiosteal
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hematoma. Classic metaphyseal fracture in child abuse.
b. 7 months old boy. Longitudinal paravertebral scan on the left side of the thorax. Intercostal
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soft tissue hematomas due to rib fractures in child abuse.
c.
Midthoracic axial scan. 3 months old girl. Fracture within the cartilagineous part of the rib (arrow). Surounding hematoma (*). Child abuse.
Fig.13 5 years and 8 months old boy. Wood splinter in a subcutaneous granuloma on the forearm.
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Fig.14 5 weeks old boy, tumorous swelling on the neck. Inhomogenous, hyperechogenic mass within the
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sternocleidomastoid muscle. Fibromatosis colli.
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S0720-048X(14)00175-2 http://dx.doi.org/doi:10.1016/j.ejrad.2014.04.003 EURR 6739
To appear in:
European Journal of Radiology
Received date: Accepted date:
25-3-2014 7-4-2014
Please cite this article as: Maurer K, Musculoskeletal ultrasound in childhood, European Journal of Radiology (2014), http://dx.doi.org/10.1016/j.ejrad.2014.04.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Conflict of Interest
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Conflicts of interests: none
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*Title Page (including paper title & Complete corresponding author details)
Musculoskeletal ultrasound in childhood
Corresponding author: Dr. Kathrin Maurer
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Medical university Innsbruck
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Department of Radiology Anichstrasse 35
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A-6020 Innsbruck Email: [email protected]
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Phone: +43 512 504 23571
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*Manuscript containing Abstract, Sections and References (Without corresponding author details)
1 Musculoskeletal ultrasound in childhood
Abstract:
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Ultrasonography is one of the first line imaging modalities for the evaluation of musculoskeletal disorders in children. This article provides an overview of the most
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important pathologic entities in which ultrasonography significantly contributes to the
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diagnostic workup.
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Introduction:
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Ultrasound, musculoskeletal, children
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Keywords:
Ultrasonography (US) has emerged as an indispensable tool for primarily evaluating a variety of musculoskeletal disorders in children. It has certain advantages over
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other imaging modalities - it is a readily available, convenient and cost effective method. It is non-invasive and there is no need for sedation even in small children. US is particularly well suited for the examination of the immature skeleton with its large portion of cartilaginous, non-ossified structures as it can readily distinguish soft tissue from cartilage and from bone. The capability of real time imaging allows the dynamic assessment of musculoskeletal structures during joint movement and repetitive imaging in motion and at rest is possible. With US it is easy to compare the
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2 symptomatic to the contralateral side. The high sensitivity of US for fluid collections and joint effusions makes it an ideal tool for image guided puncture. By following structures and using Color Doppler sonography (CDS), vessels and nerves can be differentiated, and tissue vascularity can easily be assessed too.
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There are some limitations for the use of US in musculoskeletal disease – US cannot penetrate bone and air, therefore certain regions of the body such as the deeper
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parts of the pelvis or bone marrow lesions cannot be assessed by US. The quality
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and consistency of an US examination rely on the expertise, creativity and patience of the examiner – this may be seen as a disadvantage or as a chance.
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This article emphasizes the value of US in common developmental, infectious, inflammatory and traumatic conditions that affect the musculoskeletal system in
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Technical considerations:
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children.
As most indications refer to structures, that lie relatively superficial, high frequency probes can be used to achieve optimal special resolution. Linear probes are
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preferable due to the lack of distortion. In small children hockey stick transducers allow the access of many regions, where conventional linear transducers would be too large. The use of a stand-off pad enables an optimal visualization of the area close to the body surface. In frightened children it may contribute to calm the situation. An alternative is the use of a water-bath, where the child puts the extremity in and the transducer can be held close without touching the skin thus avoiding pain
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3 or anxious distress in the child. If necessary, a child can even be examined comfortably in the arms of a parent. In the sonographic evaluation of the musculoskeletal system the amplitude of the echo is highly dependent on the angle of insonation. Advances in ultrasound
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technologies have contributed to improvement of image quality. Compound imaging and beam-steering decreases many image artefacts inherent in conventional
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sonography and are especially helpful to avoid anisotropic artefacts in tendons and
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ligaments. Compound imaging also results in improved tissue- plane definition due to speckle noise reduction. Harmonic imaging aids in the differentiation of tissues, but
Developmental anomalies:
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also makes the borders between structures appear artificially thickened.
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Developmental dysplasia of the hip (DDH) is the most common indication for musculoskeletal US in children. It covers a spectrum of congenital abnormalities that ranges from immaturity and only instability to dislocation of the hip. Stabile positioning of the femoral head within the acetabulum is thought to propagate
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acetabular development allowing for remodeling of acetabular dysplasia over time, this is used as a conservative treatment approach. The maximum potential for effective treatment of DDH is in the first 3 months after birth. US is an excellent tool to assess the anatomical details of the cartilaginous parts of the neonatal hip, and is much more informative than radiography in this age group. The accuracy and utility of US in examining neonatal and infant hips is high. A combined understanding of anatomy, pathology and sonography is required. Since
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4 hip US was first described by Graf in 1980 several methods for the assessment of morphology and stability of the neonatal hip have been developed 1. The method proposed by Graf is widely used in central Europe. It assesses hip morphology, but also takes account of hip stability (2). A standard coronal view with the infant in the
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lateral position is acquired. The iliac bone has to be straight and the acetabular labrum as well as the lowest point of the acetabular part of the iliac bone has to be
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visible (Fig.1a). Measurement of alpha and beta angels allows classification into four
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main and 9 sub-types (Fig.1b). A stress test pushing the femur in a cranial and dorsal direction is added to assess hip stability 2. The combined use of a stability test in
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conjunction with the assessment of the acetabular morphology using a standard coronary view defined by Graf and measurement of the alpha angle only was
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propagated by Rosendahl 3. Harcke and coworkers developed a dynamic US examination of the infant hip, which is widely used in the United States 4. A four step
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scanning technique is used based on transverse and coronal planes in neutral and flexed position, at rest and during stress. Hips are classified as normal, lax under
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stress, subluxed or dislocated.
The femoral head coverage technique proposed by Morin and modified by Terjesen assesses the lateralization of the femoral head; it is used widely in France
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Femoral head coverage by the bony acetabular rim of less than 50% is considered
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abnormal.
Treatment is based on the reduction of a displaced hip (Fig.1c) and stabilization of the femoral head within the acetabular fossa. Maintaining is achieved by several devices. With harnesses or splints US follow up is the method of choice until shadowing from the developing ossification center of the femoral head limits its usefulness. With the ossified femoral head radiography can be used to guide further
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5 treatment. MRI is helpful in those cases, where hip reduction cannot be achieved by clinical manipulation and for confirmation of femoral head position with spica casts in situ. A reduction in the rate of patients requiring surgery for DDH was seen after the
universal US screening for DDH is still under debate 9,10.
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introduction of universal US screening in Austria and Germany 7,8, but the value of
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Recommendations for the sonographic evaluation of the neonatal hip were
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elaborated by the DDH Taskforce Group of the European Society of Pediatric
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Radiology. The latest update was issued in May 201111.
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The diagnosis of neonatal foot deformities is commonly based on clinical evaluation and radiography. As tarsal bones are largely cartilaginous and many even lack an
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ossification center US is a valuable means for estimating the severity of the deformity. US can visualize the cartilaginous parts of the neonatal foot und evaluate
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alignment. The examination is based on a series of measurements, such as the medial malleolus-navicular distance, the navicular alignment with the talar head, talar length and the calcaneo-cuboid distance 12,13.
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The ability of US to visualize cartilage allows for further evaluation of limb deformities, where radiographs show only one bone at the forearm or lower leg. Aplasia or hypoplasia with solely cartilaginous Anlage of the radius or fibula can be differentiated (Fig.2a,b).
Anterior chest wall deformities in children are a common cause of parental concern. They are often caused by an abnormal angulation of the cartilaginous rib which
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6 cannot be visualized on radiographs. US is a valuable tool in this setting to exclude a tumor and confirm the benign nature of the condition (Fig.3a,b).
Cranial deformity in infants may result from premature craniosynostosis or positional
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plagiocephaly. Sonography is a good screening tool to distinguish fused from patent cranial sutures (Fig.4a,b), thus reducing the need for 3D-CT to patients with
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inconclusive results on US and preoperative evaluation particularly in complex cases 14,15
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Cellulitis and soft tissue abscess
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Infection:
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Cellulitis is defined as an infection of skin and subcutaneous tissue. US appearance initially resembles edema of subcutaneous fat, showing swelling, increased
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echogenicity and blurring of tissue planes. Further progression leads to hypoechoic strands between hyperechoic fatty lobules. Increased vascularity on CDS suggests an inflammatory process. Accumulation of pus and abscess formation can readily be detected by US and US-guided puncture can be performed for diagnostic and
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therapeutic purposes.
Soft tissue abscesses are characterized by a collection of necrotic tissue, neutrophils, inflammatory cells and bacteria surrounded by a wall of highly vascular connective tissue. The US appearance of the liquefied contents varies widely, from anechoic to hyperechoic (Fig.5). To confirm the liquid nature gentle pressure can be used to evoke fluctuation of the contents, the through-transmission phenomenon must be
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7 observed, and CDS shows absence of flow in the center and hyperemia of the abscess wall 16.
Necrotizing fasciitis
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Necrotizing fasciitis is a rapidly progressive infection of subcutaneous tissue, fascia and surrounding soft tissue associated with a 30 to 70% mortality rate. Group A
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streptococci are the most common offending organism in children. Previous Varicella
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zoster virus infection seems to be a predisposing factor. Ultrasonography shows soft tissue swelling, fascial thickening and accumulation of fluid along fascia (Fig.6a) and
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can demonstrate gas bubbles in the soft tissues (Fig.6b). MRI is essential to document the extent of soft tissue involvement. Prompt extensive surgical 17
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debridement and antibiotic therapy may stop the fatal course of the disease
Pyomyositis
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Suppurative bacterial infection in striated muscle is rare. Children are affected in one third of cases. There is a predilection for muscles in the thigh and pelvis. Staphylococcus aureus is the most common causative organism. Diagnosis may be delayed as fever and malaise can be the only symptoms initially and localization of
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pain may be difficult for the child especially with involvement of pelvic muscles. Abscess formation can readily be shown by US in certain parts of the body. When the full extent of the lesion is not clearly demonstrated by US, MRI is the imaging modality of choice. MRI is particularly useful to exclude bone involvement and in the evaluation of deeper body compartments such as the deep pelvic muscles (Fig.7a). Ultrasound is a valuable tool for image guided percutaneous aspiration and drainage as well as for follow up examinations (Fig.7b).
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8
Osteomyelitis
Osteomyelitis is an infection of bone marrow and bone usually caused by bacteria.
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Infection occurs through three possible routes: hematogenous, which is by far the most common way in children, by contiguity, and by direct implantation. In children
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more than 80% of cases of osteomyelitis occur due to hematogenous seeding after a
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transient episode of bacteremia. Due to the architecture of the supplying vessels the primary site of the infectious process is the metaphyseal region of the long bones.
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Further spread varies according to age and depends on the vascular anatomy of the metaphyseal – epiphyseal region 18. Typical signs and symptoms of acute
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osteomyelitis include fever, local pain and tenderness. However initial signs may be
pseudoparalysis.
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vague and misleading especially in infants, who may only present with
Radiographs should always be the first study obtained in patients with suspected
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osteomyelitis. Deep soft tissue swelling is visible as early as 2 days after onset of symptoms, but it is often difficult to detect. Bone changes are not detectable until after 7 to 10 days. Ultrasound may demonstrate features of acute osteomyelitis within 48 hours 19. The earliest sign is juxtacortical soft tissue swelling followed by periosteal
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elevation with a thin layer of fluid. As periosteal attachment is loose in young children, subperiosteal abscess formation rapidly occurs and is seen as hypoechoic lenticular– shaped fluid collection along the cortex (Fig.8a). In the appropriate clinical setting this finding confirms acute osteomyelitis. After US-guided puncture to obtain material for cultivation of the causative organism antibiotic therapy can be started immediately. Cortical erosions can be seen later in the course of the disease and US is also useful in detecting fistula formation in chronic osteomyelitis 20 (Fig.8b,c).
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9 In children under the age of two years, blood vessels cross the physis thus propagating spread of infection into the epiphysis and into the joint space. This leads to septic osteoarthritis. US is an excellent tool to demonstrate joint effusion and therefore it is extremely useful in neonates and infants suspected to have septic
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osteoarthritis allowing for immediate management by guided aspiration. Ultrasound has been found to be a fast and useful first line diagnostic tool for early 21
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detection of acute osteomyelitis in children, especially in newborns and infants
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50% of affected children are under the age of 3 years, the lack of need for sedation is a great advantage.
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But it has to be strongly emphasized that US cannot exclude osteomyelitis. In patients with suspected osteomyelitis and negative or inconclusive results on US
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urgent MRI is mandatory 22.
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Septic arthritis
Acute septic arthritis is a medical emergency as early diagnosis and treatment is
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mandatory to prevent joint destruction, growth disturbances and early degenerative disease. In children over the age of two years it is mostly caused by hematogeneous seeding, less frequently by contiguous spread from adjacent osteomyelitis. The hip joint is most common involved; knee, shoulder and elbow are other common
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preferred sites. The presenting symptoms are fever, pain, inability of weight bearing, elevated erythrocyte sedimentation rate and C-reactive protein. Ultrasound is highly sensitive to detect joint effusion, but neither seize and echogenicity of the effusion nor adjacent hyperemia on CDS imaging allow distinguishing infectious from non-infectious arthritis. Definite diagnosis of septic arthritis is based on US-guided aspiration of joint fluid 23,24.
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10 Inflammatory disease:
Juvenile idiopathic arthritis (JIA)
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JIA is a heterogeneous group of diseases in children under the age of 16 years, characterized by synovial inflammation of unknown cause that persists for more than
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6 weeks. JIA is the most common chronic rheumatic disorder in children and is a
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leading cause of acquired disability in the pediatric age. Early therapeutic intervention and the use of new disease-modifying therapeutic agents have improved the
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outcome and have led to greater emphasis on the accurate detection of disease activity. The presence of extensive amounts of epiphyseal cartilage in children limits
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the usefulness of conventional radiography in the early stages of the disease. Contrast enhanced MRI and US both are well suited for this application. For pediatric
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patients US offers specific advantages over MRI as it is non-invasive, there is no need for sedation, it allows for assessment of multiple joints in one session and real-
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time dynamic imaging of tendons and joints helps to detect structural abnormalities during joint movement.
US is more sensitive than clinical evaluation and radiography for the detection of synovial proliferation and effusion and is particularly useful in the evaluation of small
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peripheral joints. In experienced hands US allows reliable assessment of further signs of disease like cartilage blurring, thinning and erosions as well as bone erosions, enthesitis and tenosynovitis. The use of CDS provides information about synovial vascularity and hyperemia. Several studies have demonstrated the ability of US to detect subclinical disease and its usefulness in evaluating response to intraarticular therapy 25,26.
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11 US evaluation in JIA has certain limits. In large joints visualization of the entire articular surface may be hindered by bone shadowing, there is insufficient resolution of anatomical details of deeper structures, and US has high false negative rates in subtalar disease. The complexity of the temporomandibular and the sacroiliac joints
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makes contrast-enhanced MRI the preferred method for evaluation of these structures. Contrast-enhanced MRI is the most sensitive technique for detection of
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synovitis and the only modality to demonstrate bone marrow edema 27. The major
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draw-back for its use in young children is the need for sedation.
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Transient synovitis of the hip
Transient synovitis is the most common cause of hip pain in children aged 3 to 8
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years. The clinical features are sudden onset of unilateral hip pain without a history of trauma, limping and restriction of motion, sometimes accompanied by low grade
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fever. A preceding viral infection is reported by many patients. It is a benign, selflimiting disease. Definitive diagnosis can only be made by exclusion of other disorders.
US demonstrates joint effusion in the anterior recess of the hip joint. Normally the
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anterior and posterior parts of the joint capsule are attached closely to each other. A linear echo located centrally marks the interface between the two layers. With joint effusion the anterior joint capsule assumes a convex shape and underlying fluid within the anterior recess can be visualized (Fig. 9 a,b), which may be anechoic or contain particles. This finding is nonspecific 23. Ultrasound evaluation of the femoral epiphysis is mandatory to look for irregularities of the cartilage and ossification center in case of Perthes disease or a physeal step in slipped upper femoral epiphysis
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12 (Fig.10a,b,c,d). If one of these entities is suspected on US, further evaluation by radiography and MRI will establish the extent of the disease in detail. The most important differential diagnosis is septic arthritis due to the devastating consequences to the hip joint in case of delayed diagnosis. Aspiration of joint fluid
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has to be performed immediately in cases where septic arthritis cannot be excluded.
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Trauma:
In animal models ultrasonography has not only comparable sensitivity to that of X-ray
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for the identification of limb fractures but is also equally effective for the diagnosis of fracture type and dislocation 28. Recent studies have shown that distal forearm
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fractures in children can be safely and reliably diagnosed using only US thus avoiding radiation burden to the immature skeleton
29
.
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Although promising, this approach has several draw backs till now – it is time consuming and positioning of the limb to evaluate the whole circumference of a bone might be difficult and painful. 24 hour availability of skilled examiners in a busy emergency department might be a limitation too.
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Therefore plain radiography still is the standard primary imaging method in children with a history of trauma. However, there are some instances where US can play an important role in the diagnostic work-up. Due to the immaturity of bone with largely cartilaginous epiphysis fractures at the region of the physis may be undetectable by radiographs. US has proven an effective imaging modality in these settings especially in injuries around the elbow 30. It can even be used for guiding repositioning maneuvers in dislocated epiphysiolysis.
Page 14 of 55
13 Fractures of phalanges, metacarpals and metatarsals often show only subtle changes on radiographs, whereas on US an interruption of the cortical continuity or a buckle can easily be seen (Fig.11). In a toddler, who refuses to bear weight it may be challenging for the clinician to localize the region of interest. US allows screening for
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a toddlers fracture on a whole extremity and even on both sides. Detection of classical metaphyseal and rip fractures in child abuse can be extremely
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difficult. The use of US may be helpful to visualize the small displaced fragment of a
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corner fracture as well as hematomas in the soft tissue around a rib fracture and fractures within the cartilagineous part of the rib 31 (Fig.12a,b,c).
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A further indication is the search for non-radiopaque foreign bodies (Fig.5,Fig.13 a). Here US is not only an elegant tool useful for detection and US-guided removal 32, it
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Tumor:
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bodies by their US appearance.
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furthermore often allows to differentiate wood splinters form glass and other foreign
In children with a tumor of the musculoskeletal system US often is the first imaging modality. It can help to rule out abscess or hematoma as a cause of the regional
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swelling. Due to the possibility of real time imaging it is especially useful to differentiate a solid tumor from a venolymphatic vascular malformation. If a tumor is detected by US, MRI is the imaging method of choice to establish the extent of the lesion, as well as involvement of bone, vascular structures and nerves. US can be used for image guided puncture and follow up.
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14 A special entity, where the diagnosis is readily established with US and further imaging evaluation or biopsy is rarely required is fibromatosis colli. It is a self-limiting disorder of neonates and young infants. The exact cause is still unknown. The lesion usually gets evident at 2 weeks after birth and may increase in size for a few more
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weeks, resolving spontaneously within 4 to 8 months. On US a fusiform thickening confined to the sternocleidomastoid muscle is seen, which is often hypoechoic or
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focally or diffusely hyperechoic and shows often excessive vasculature on CDS. It 33
(Fig.14).
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may show disruption of the fascicular echotextur of the normal muscle
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Summary
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US has a significant role to play in the investigation of the musculoskeletal system in children. In skillful hands US can provide diagnostic information about
sedation.
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musculoskeletal disorders in infants and children quickly and without the need for
In some instances US can be regarded the most effective means of diagnostic imaging, whereas in others it may be used supplementary to radiography, or is the
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primary imaging tool then complemented by more complex imaging modalities like MRI or CT.
Conflicts of interest: none
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15 References
[1] Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic
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Combound treatment.
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Arch Orthop Trauma Surg 1980;97:117-33.
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Berlin Heidelberg New York: Springer, 2006.
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[2] Graf R. Hip Sonography: Diagnosis and Management of Infant Hip Dysplasia.
[3] Rosendahl K, Markestad T, Lie RT. Ultrasound in the early diagnosis of congenital
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Pediatr Radiol 1992;22:430-433.
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dislocation of the hip: the significance of hip stability versus acetabular morphology.
[4] Harcke HT, Clarke NM, Lee MS et al. Examination of the infant hip with real time
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ultrasonography. J Ultrasound Med 1984;3:131-137.
[5] Morin C, Harcke HT, Mac Ewen GD. The infant hip: real-time US assessment of the acetabular development.
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Radiology 1985;157(3):673-677.
[6] Terjesen T, Bredland T, Berg V. Ultrasound for hip assessment in the newborn. J Bone Joint Surg Br 1989;71:767-773.
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16 [7] Grill F, Mueller D. Results of hip ultrasonographic screening in Austria. Orthopade 1997;26:25–326.
[8] Von Kries R, Ihme N, Oberle D et al. Effect of ultrasound screening on the rate of
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first operative procedures for developmental hip dysplasia in Germany.
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Lancet 2003;362:1883–1887.
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[9] Bracken J, Ditchfield M. Ultrasonography in developmental dysplasia of the hip: what have we learned?
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Pediatr Radiol 2012;42:1418-1431.
[10] Riccabona M, Schweintzger G, Grill F, et al. Screening for developmental hip
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dysplasia (DDH) - clinically or sonographically? Comments to the current discussion and proposals.
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Pediatr Radiol 2013;43:637-640.
[11] European Society of Paediatric Radiology DDH task force 2011. http://www.espr.org/index.php?option=com_content&view=article&id=207:recommen
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dations-on-hip-screening&catid=131:ddh-taskforce-recommendations&Itemid=216
[12] Aurell Y, Johansson A, Hansson G et al. Ultraosund anatomy in the normal neonatal and infant foot: an anatomic introduction to ultrasound assessment of foot deformities. Eur Radol 2002;12:2306-2312.
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17 [13] Martinoli C, Valle M, Malattia C, et al. Pediatric musculoskeletal US beyond the hip joint. Pediatr Radiol 2011;41(Suppl1):S113-S124.
differential of scaphocephaly and occipital plagiocephaly.
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Int J Oral Maxillofac Surg 2012;41(7):797-800.
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[14] Krimmel M, Will B, Wolff M, et al. Value of high-resolution ultrasound in the
[15] Simanovsky N, Hiller N, Koplewitz B, et al. Effectiveness of ultrasonographic
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evaluation of the cranial sutures in children with suspected craniosynostosis.
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Eur Radiol. 2009;19(3):687-92.
[16] Roben SGF. Ultrasonography of musculoskeletal infections in children.
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Eur Radiol 2004;14: L65-L77.
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[17] Chao HC, Kong MS, Lin TY. Diagnosis of necrotizing fasciitis in children. J Ultrasound Med 1999;18:277-281.
[18] Offiah A.C. Acute osteomyelitis, septic arthritis and discitis: Differences between
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neonates and older children. Eur J Radiol 2006;60:221-232.
[19] Pienda C, Vargas A, Rodriguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am 2006;20(4):789-825.
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18 [20] Mah ET, LeQuesne GW, Gent RJ, et al. Ultrasonic features of acute osteomyelitis in children. J Bone Joint Surg 1994;76B:969-74.
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[21] Keller MS. Musculoskeletal sonography in the neonate and infant.
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Pediatr. Radiol 2005;35:1167-1173.
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[22] Mellado Santos JM. Diagnostic imaging of pediatric hematogenous osteomyelitis: lessons learned from a multi-modality approach.
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[23] Zawin JK, Hoffer FA, Rand FF, et al. Joint effusion in children with irritable hip: US diagnosis and aspiration.
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[24] Ranson M. Imaging of Pediatric Musculoskeletal Infection. Sem Musculoskelet Radiol 2009;13:277-300.
[25] Rebollo-Polo M, Koujok K, Weisser C, et al. Ultrasound findings in patients with
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juvenile idiopathic arthritis in clinical remission. Arthritis Care Res 2011;63(7):1013-1019.
[26] Haslam KE, McCAnn LJ, Wyatt S, et al. The detection of subclinical synovitis by ultrasound in oligoarticular juvenile idiopathic arthritis: a pilot study. Rheumatology 2010;49(1):123-127.
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19 [27] Sheybani EF, Khanna G, White AJ, et al. Imaging of Juvenile Idiopathic Arthritis: A Multimodality Approach. Radiographics 2013;33:1253-1273.
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[28] Moritz JD, Hoffmann B, Meuser SH, et al. Is ultrasound equal to X-ray in pediatric fracture diagnosis?
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Rofo 2010;182(8):706-14.
[29] Eckert K, Ackermann O, Schweiger B, et al. Ultrasound as a viable alternative to
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standard X-rays for the diagnosis of distal forearm fractures in children.
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Z Orthop Unfall. 2012;150(4):409-14. doi: 10.1055/s-0032-1314974.
[30] Davidson RS, Markovitz RI, DormansJ et al. Ultrasonographic evaluation of the
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elbow in infants and young children after suspected trauma.
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J Bone Jt Surg 1994;76:1804-1812.
[31] Kelloff J, Hulett R, Spivey M. Acute rib fracture diagnosis in an infant by US: a matter of child protection.
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[32] Callegari L., Leonardi A., Bini A., et al. Ultrasound-guided removal of foreign bodies:personal experience. Eur Radiol 2009;19:1273–1279.
[33] Deeg KH, Güttler ., Windschall D. Diagnosis of Fibromatosis Colli via ColorCoded Duplex Sonography in 13 Infants. Ultraschall in Med 2008; 29:226–23
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Figure(s)
Legends
Fig.1. Coronal US scan of the newborn hip (Graf´s technique):
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a. Normal hip: On a standard view showing the deepest point of the ilium within the acetabular fossa (*), the straight upper part of the ilium (arrows) and the
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acetabular labrum (+) the alpha angle (α) is > 60°.
c.
Dislocated hip: The fermoral head (F) is completely dislocated, the cartilage roof (C) is
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b.
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interposed.
Fig .2.
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Three weeks old boy with Holt Oram syndrome.
a. Longitudinal US scan of the forearm. The cartilagineous Anlage of the radius is clearly visible, note
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that there is a fusion of the radial head with the epiphysis of the humerus. b. Radiograph of the right forearm: at the forearm there is only one bone visible, the ulna is
Fig.3.
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abnormally bowed and there is subluxation of the ulna at the elbow. Radial deviation of the hand.
a. Excessive angulation of the cartilagineous part of a rib causing a thoracic pump in a 5 years and 9 months old boy. b. Normal rib.
Fig.4. a. Patent cranial sutures in a 9 months old boy with plagiocephaly: hypoechoic gap (arrow) between hyperechoic calvarial bones. Page 22 of 55
b. Missing of the hypoechoic gap in case of premature closure of the sagittal suture in a 1 months old girl with scaphocephaly. Bony ridge in the dorsal part of the sagittal suture.
Fig.5.
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7 years and 9 months old girl, 5 months after a penetrating injury by the brake handle in a bicycle accident. Turbid fluid collection within the subcutaneous tissue of the thigh, centrally located there is
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an echogenic line with shadowing - abcess containing a little piece of cloth.
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Fig.6.
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a. Necrotizing fasciitis in a 2 years and 7 months old boy, a few weeks after a varicella zoster virus infection. Thickening of the tibialis anterior muscle with hyperechoic changes and fluid
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accumulation within the deep fascia as compared to the contralateral side. b. Necrotizing fasciitis of the abdominal wall in a 6 years and 10 months old boy following
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appendectomy. Thickening of the subcutaneous tissue as well as the abdominal wall muscle.
Fig.7.
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Hypoechoic strands and gas-bubbles between the muscle fibres.
Pymoyositis in an 8 years old boy. a. Axial MRI (contrast enhanced t1 weighted sequence) and b. transverse US scan : Abscess within the external obturator muscle.
Fig.8.
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a. 6 years and 11 months old boy with increasing pain at the left ankle 24 hours after a minor trauma. Logitudinal scan of the distal fibula. Spindle shaped elevation of the periosteum by a turbid fluidcollection (arrows). Osteomyelitis of the distal fibula with subperiosteal abscess. b. 13 months old girl refusing to bear weight on her left leg.
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Longitudinal scan along the medial aspect of the proximal tibia. Lenticular shaped fluid accumulation attached to the metaphyseal cortex(arrows), small abscess in the metaphyseal region(*) and cortical
c. 13 years old girl with pain at her ankle for the last two months.
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defect close to the physis (arrowheads). Acute hematogeneous osteomyelitis of the proxmimal tibia.
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Axial scan at the lateral side of the ankle. Cloaca (arrow) at the metaphyseal region of the distal
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fibula with a small bony sequestrum (*) within a soft tissue abscess( arrow heads) in chronic bacterial
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osteomyelitis.
Fig. 9.
Coronal MRT: Positioning of the US probe to demonstrate hip joint effusion in the anterior
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a.
recess.
6 years old boy with transient synovitis of the hip. US shows fluid accumulation within the
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b.
anterior recess of the hip joint.
a.
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Fig.10.
4 years old boy. US of the left hip joint. Joint effusion(*), widening of the metaphysis with
irregular contour ( arrows), small irregular ossification centre in the femoral head (arrowhead) – Perthes disease
b.
Corresponding radiograph
c. 12 years old boy. Hip joint effusion (*) and step at the physis (arrow). Slipped proximal femoral epiphysis. d. Corresponding radiograph.
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Fig.11 2 years and 8 months old boy refusing to bear weight on his left leg. Longitudinal scan of the lateral aspect of the left foot. Disruption of the cortical line and small bony fragment close to the physis of
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the fifth metatarsal. Fracture of the fifth metatarsal.
Fig.12
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a. Left: normal proximal humerus in a young child. Right: 2 months old boy. Longitudinal scan on the left humerus. Small dislocated fragment at the metaphysis with subperiosteal
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hematoma. Classic metaphyseal fracture in child abuse.
b. 7 months old boy. Longitudinal paravertebral scan on the left side of the thorax. Intercostal
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soft tissue hematomas due to rib fractures in child abuse.
c.
Midthoracic axial scan. 3 months old girl. Fracture within the cartilagineous part of the rib (arrow). Surounding hematoma (*). Child abuse.
Fig.13 5 years and 8 months old boy. Wood splinter in a subcutaneous granuloma on the forearm.
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Fig.14 5 weeks old boy, tumorous swelling on the neck. Inhomogenous, hyperechogenic mass within the
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sternocleidomastoid muscle. Fibromatosis colli.
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