Sanjeeb Kumar Sarma (Down Town Hospital/Guwahati/India)  

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3 Years  

Male  

Generalized diseases  

other  

3 years old emaciated male patient brought to our hospital with inability to stand or walk properly.  

The skeletal effects of rickets are due to lack of calcification of osteoid. As a result most obvious changes are seen at metaphysis where the most rapid growth occurs. The earliest changes are loss of normal “zone of provisional calcification” adjacent to metaphysis featuring as indistinctness of metaphyseal margin. This progressed to a “frayed” appearance with widening of the growth plate due to lack of calcification of metaphyseal bone. Weight bearing and stress on the uncalcified bone give rise to “splaying” and “cupping” of the metaphysis. A similar but less marked effect occurs in the sub-periosteal layer causing loss of distinctness of cortical margin. Generalized osteopenia occurs, however, looser’s zones are distinctly uncommon.
In severe cases additional deformities like bowing of long bones particularly of lower bones, thoracic kyphosis with a pigeon chest, enlargement of anterior ribs causing ricketic rosary and bossing of the skull. In low birth weight premature babies features of rickets may be very severe with spontaneous fractures and respiratory difficulty. Affected infants are usually bellow 1000 g in weight or less than 28 weeks of gestation.
Treatment is dietary supplement of vitamin D.  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.

 

Expert's opinion  

Hypophosphatasia, NAI etc  

Prognosis is good with timely intervention.  

Patient is undergoing treatment.  

N/A  

N/A  

Rickets, vitamin D, splaying, fraying, cupping  

Sanjeeb Kumar. Rickets. PedRad [serial online] vol 10, no. 1.
URL: www.PedRad.info/?search=20100128133421  

Dirk Schaper (Klinik für Kinderchirurgie Krankenhaus St. Elisabeth und St. Barbara in Halle)  

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13 Years  

Male  

N/A  

N/A  

Incidental findings in sonographic examination due to acute pain in the right scrotal area.
Left side without complaints with. On the right side, we found testicular torsion and could detorque the testes. The sonographic examination of the left side showed unchanged findings.
Palpatory findings showed morphologically normal testes and epididymis. There were two indolent, soft masses felt at the head of the epidydimis.  

The etiology of a spermatocele is not known in-depth. One assums that it could form due to an obstruction of the epididymal tubuli. This obstruction could be of inflammatory or traumatic origin.
If sperm are found in the cystic process, one can speak of a spermatocele. If there are no sperm found, it is an epididymal cyst.  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.


 

N/A  

Epididymal cyst, Epididymal lymphangioma, Tunica albuginea cyst, epidermoid cyst.  

In our patient, a prophylactic pexy was planned, so that in this surgical procedure, the cystic structures could be removed. It proved to be a spermatocele in histology.
Normally, a spermatocele is not an indication for surgery. Usually, the patients are symptomless and don't even know that they have it. 30% of the asymptomatic patients who are sonographically examined show a spermatocele.
A surgical indication is only warranted in pain and very large cysts, which can cause a feeling of heaviness. Since spermatoceles are rarely larger than 10 mm, a larger mass should be investigated further.
The most fit treatment is the open surgical removal through a scrotal cut. A puncture treatment is generally dismissed, due to the risk of infection. Sclerotherapy should not be considered in reproductive years, due to the risk of abacterial epididymitis.  

N/A  

N/A  

1. Medline:
Frauscher,F., Klauser, A.,Stenzl, A., Helweg, G.,Amort, B., zur Nedden,D.
US findings in the scrotum of extreme mountain bikers
Radiology 2001; 219:427-431

2. Medline:
Dogra,V.S., Gottlieb,R.H., Oka,M., Rubens,D.J.
Sonography of the scrotum
Radiology 2003; 227:18-36

3. Medline:
Absikafi,N.F.
Spermatocele
www.emedicine.com  

Spermatocele, Epididymal cyst, epididymis, sonography, testes, ultrasound  

Dirk Schaper. Spermatocele. PedRad [serial online] vol 5, no. 11.
URL: www.PedRad.info/?search=20051118133428  

Dirk Schaper (Klinik für Kinderchirurgie-Krankenhaus St. Elisabeth und St. Barbara Halle)  

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7 Years  

Male  

N/A  

N/A  

7 year-old boy with slight abdominal discomfort for 10 days. No vomiting, no fever. No other symptoms.
Abdomen is soft, no localized pain upon pressure.
Spontaneous pain in the right lower quadrant.  

N/A  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.


 

N/A  

Typical appendicitis  

In the first sonographic examination there was a suspicion of appendicitis (images 1-3). The increased size of the internal space, which was larger than the limits of 6 mm and the fact that you could not compress the structure led us to this train of thought. The missing paraclinic and symptoms were factors that led us away from this diagnosis, and we did not operate on the patient and waited 3 days to perform our follow-up examination. Clinically, there was no further or new findings. In the ultrasound, there was an appendix that was less filled (image 4 & 5). In the follow up images (6 & 7), the appendix showed an increase if fullness, but the patient was symptomless. An operation was not yet performed. We have never seen a persistence of this before. In doppler studies, no increased in circulation was seen on any day. Since the appendix was barely compressable and since it did not empty during the examination, we assume that there was a temporary obstruction with spontaneous regression. The option of a laparoscopic appendectomy was agreed upon with the patient's parents if the symptoms persisted.  

N/A  

N/A  

N/A  

appendicitis, appendix, temporary obstruction, abdominal pain, appendix obstruction, appendectomy  

Dirk Schaper. Temporary Obstruction of the Appendix. PedRad [serial online] vol 5, no. 11.
URL: www.PedRad.info/?search=20051117133349  

D. Weber (Uniklinik Leipzig)  

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8 Years  

Female  

N/A  

N/A  

8 year-old girl with a 3 week history of diarrhea, weight loss of about 2 kg and reoccurring stomach aches.  

Immunological with genetic determination.

Gliadine/Gluten induced morphological changes of the small intestinal mucosal membranes with atrophy of the villi.

Clinic: malabsorption

Begin of illness is mostly in the 6th - 18th month of live, but it can also occur later. Which factors contribute to the clinical manifestation is still unclear.

Increased rate for lymphomas.  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.



<- view Ultrasound 1

Ultrasound 1: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis (red arrow), but without wall-thickening (yellow arrow).




<- view Ultrasound 2

Ultrasound 2: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis, but without wall-thickening. Minimal free fluid (red arrow).




<- view Ultrasound 3

Ultrasound 3: Multiple mesenterial lymph nodes (green arrows) reaching up to 19x12mm in size without hyperperfusion.




<- view Ultrasound 4

Ultrasound 4: In the initial examination, "bulls-eye" is seen in the left middle abdominal region (light blue arrow), without acute clinical signs. Apparently, this is a small intestinal invagination, which is, in the follow-up exam not seen anymore.

 

N/A  

Mesenterial lymphadenitis, enteritis  

Although all sonographic findings are unspecific, there are some that are often found in children with celiac disease:

- slightly dilated small intestinal loops
- slight, diffuse intestinal wall thickening
- increased peristalsis
- slightly enlarged mesenterial lymph nodes
- slight widened superior mesenteric artery (increased perfusion)
- slight widened superior mesenteric vein
- free fluid
- increased echogenicity of the liver

Gluten-free diet lessens the clinical symptoms. A life-long diet is needed.  

The ultrasound findings are unspecific. It is not uncommon, however, to find unspecific changes in children with celiac disease!

Do the mesenterial lymph-nodes always belong to the clinical picture?  

N/A  

4. Medline:
Rettenbacher T, Hollerweger A, Macheiner P, Huber S, Gritzmann N.
Adult celiac disease: US signs.
Radiology. 1999 May;211(2):389-94

5. Medline:
Riccabona M, Rossipal E.
Value of ultrasound in diagnosis of celiac disease
Ultraschall Med. 1996 Feb;17(1):31-3.

6. Medline:
Dietrich CF, Brunner V, Seifert H, Schreiber-Dietrich D, Caspary WF, Lembcke B.
Intestinal B-mode sonography in patients with endemic sprue. Intestinal sonography in endemic sprue
Ultraschall Med. 1999 Dec;20(6):242-7.
 

celiac disease, glutenenteropathy, nontropical sprue, invagination, mesenterial, mesentery, gluten, gliadin, enteritis, celiac, disease  

D Weber. Celiac disease. PedRad [serial online] vol 4, no. 2.
URL: www.PedRad.info/?search=20040207222335  

M. Paetzel (Leipzig)  

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11 Months  

Male  

N/A  

N/A  

11 month-old boy with high fever, respiratory distress, no cough.

1. X-ray on the day of admission.
2. X-ray after 14 days. However, on the 8th day of treatment, worsening of fever and cough and a child in obvious distress.  

A pathogen could not be found in this case. Also no evidence of specific and pathologically increased IgM-antibodies.

Based on imaging findings, this case demonstrates an alveolar infiltrate in the sense of a typical pneumonia (lobar pneumonia).

Under intravenous Claforan therapy, initially significant improvement, however after 8 days fever rose and cough worsened. It is considered that a secondary infection occurred, because the x-ray showed signs of a partial bronchial affection/obstruction with atelectasis, but without signs of airspace infiltrate anymore.  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.



<- view Ultrasound 1

Ultrasound 1: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis (red arrow), but without wall-thickening (yellow arrow).




<- view Ultrasound 2

Ultrasound 2: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis, but without wall-thickening. Minimal free fluid (red arrow).




<- view Ultrasound 3

Ultrasound 3: Multiple mesenterial lymph nodes (green arrows) reaching up to 19x12mm in size without hyperperfusion.




<- view Ultrasound 4

Ultrasound 4: In the initial examination, "bulls-eye" is seen in the left middle abdominal region (light blue arrow), without acute clinical signs. Apparently, this is a small intestinal invagination, which is, in the follow-up exam not seen anymore.


<- view X-Ray 1

X-Ray 1: Frontal view: Homogeneous opacification of the left midle and lower lung zones. Slightly thickened pleura with a small left pleural effusion identified on the lateral view.




<- view X-Ray 2

X-Ray 2: Lateral view: Decreased transparency in the retrocardial space. Small left pleural effusion.






<- view X-Ray 3

X-Ray 3: Image performed after 14 days: no homogeneous opacification anymore, but clearly increased reticular densities in both upper lung zones. Small atelectasis on the right at the basal border of the upper lung zone.





<- view X-Ray 4

X-Ray 4: Image performed after 1.5 months: There is still mild bihilar prominence, most likely due to the persisting enlarged lymph nodes. Otherwise a normal chest radiograph for this age.


 

N/A  

Lobar pneumonia, atelectasis, foreign object aspiration  

N/A  

N/A  

N/A  

7. Medline:
Lichenstein R, Suggs AH, Campbell J.
Pediatric pneumonia
Emerg Med Clin North Am. 2003 May;21(2):437-51.  

Lobar pneumonia, atelectasis, foreign body aspiration, pneumonia, Lobular pneumonia  

M Paetzel. Lobar pneumonia without proven pathogen. PedRad [serial online] vol 3, no. 12.
URL: www.PedRad.info/?search=20031223165339  

M. Paetzel (Leipzig)  

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14 Years  

Male  

N/A  

N/A  

14 year old boy, presentation after fist hit on the nasal root.  

N/A  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.



<- view Ultrasound 1

Ultrasound 1: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis (red arrow), but without wall-thickening (yellow arrow).




<- view Ultrasound 2

Ultrasound 2: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis, but without wall-thickening. Minimal free fluid (red arrow).




<- view Ultrasound 3

Ultrasound 3: Multiple mesenterial lymph nodes (green arrows) reaching up to 19x12mm in size without hyperperfusion.




<- view Ultrasound 4

Ultrasound 4: In the initial examination, "bulls-eye" is seen in the left middle abdominal region (light blue arrow), without acute clinical signs. Apparently, this is a small intestinal invagination, which is, in the follow-up exam not seen anymore.


<- view X-Ray 1

X-Ray 1: Frontal view: Homogeneous opacification of the left midle and lower lung zones. Slightly thickened pleura with a small left pleural effusion identified on the lateral view.




<- view X-Ray 2

X-Ray 2: Lateral view: Decreased transparency in the retrocardial space. Small left pleural effusion.






<- view X-Ray 3

X-Ray 3: Image performed after 14 days: no homogeneous opacification anymore, but clearly increased reticular densities in both upper lung zones. Small atelectasis on the right at the basal border of the upper lung zone.





<- view X-Ray 4

X-Ray 4: Image performed after 1.5 months: There is still mild bihilar prominence, most likely due to the persisting enlarged lymph nodes. Otherwise a normal chest radiograph for this age.



<- view X-Ray 1

X-Ray 1: Underneath the nasal bone suture a translucent line with mild shifting about 1 mm.



 

N/A  

Nasal bone suture  

N/A  

N/A  

N/A  

N/A  

Nasal bone, Fracture, Nasal bone fracture, Nose, Nasal trauma, Nose injury, Nose fracture, Broken nose  

M Paetzel. Nasal fracture. PedRad [serial online] vol 3, no. 12.
URL: www.PedRad.info/?search=20031217133642  

Dirk Schaper (Halle[Kinderchirurgie St. Barbara-Krankenhaus])  

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3 Months  

N/A  

N/A  

N/A  

3 month old baby, fall from table, no loss of consciousness, acute vomiting, increased swelling left parietal, neurological unsuspicious  

N/A  

<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.



<- view Ultrasound 1

Ultrasound 1: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis (red arrow), but without wall-thickening (yellow arrow).




<- view Ultrasound 2

Ultrasound 2: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis, but without wall-thickening. Minimal free fluid (red arrow).




<- view Ultrasound 3

Ultrasound 3: Multiple mesenterial lymph nodes (green arrows) reaching up to 19x12mm in size without hyperperfusion.




<- view Ultrasound 4

Ultrasound 4: In the initial examination, "bulls-eye" is seen in the left middle abdominal region (light blue arrow), without acute clinical signs. Apparently, this is a small intestinal invagination, which is, in the follow-up exam not seen anymore.


<- view X-Ray 1

X-Ray 1: Frontal view: Homogeneous opacification of the left midle and lower lung zones. Slightly thickened pleura with a small left pleural effusion identified on the lateral view.




<- view X-Ray 2

X-Ray 2: Lateral view: Decreased transparency in the retrocardial space. Small left pleural effusion.






<- view X-Ray 3

X-Ray 3: Image performed after 14 days: no homogeneous opacification anymore, but clearly increased reticular densities in both upper lung zones. Small atelectasis on the right at the basal border of the upper lung zone.





<- view X-Ray 4

X-Ray 4: Image performed after 1.5 months: There is still mild bihilar prominence, most likely due to the persisting enlarged lymph nodes. Otherwise a normal chest radiograph for this age.



<- view X-Ray 1

X-Ray 1: Underneath the nasal bone suture a translucent line with mild shifting about 1 mm.




<- view X-Ray 1

X-Ray 1: Soft line of opacity in the right parietal bone.




<- view Ultrasound 1

Ultrasound 1: B-image presentation of an interuption of continuity in a otherwise homogenous image of the bone structure.




<- view Ultrasound 2

Ultrasound 2: B-image of an obvious fracture.

 

N/A  

normal cranial sutures, diploic veins, accessory suture.  

Because of the nature of the accident, the assumption of a suture fracture was made. Radiologically, the diagnosis was proven using ultrasound. After initial hospitalisation and surveillance, the child was discharged into ambulatory care.  

Note from the author:
The presentation of the cranial fractures with the help of high-resolution ultrasound is always better. Furthermore, the intracranial structures can be assessed if the fontanelles are open. This is particularly important in regard to an accompanying intracranial hemorrhage. It is possible that in the future one can completely disregard a conventional x-ray.

Note from the editors:
The proof of a cranial fracture has per se no clinical worth, rather the proof of an intracerebral hemorrhage is most important. Therefore, a conventional x-ray is not needed in a case of a cranial trauma. This is because no therapeutic decisions are dependent on the proof (or missing proof) of a fracture.

The ultrasound: Seeing the fracture on the x-ray is almost always seen in the ultrasound as well; however the reverse (searching for fractures without an x-ray image) is often frustrating and often painful. In our opinion, sonography is not indicated in searching for fractures, but rather needed for ruling out a hemorrhage when the fontanelle is open.

Comments to both notes are welcomed.  

N/A  

8. Medline:
Steiner S, Riebel T, Nazarenko O, Bassir C, Steger W, Vogl T, Felix R.
Skull injury in childhood: comparison of ultrasonography with conventional X-rays and computerized tomography
Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 1996 Oct;165(4):353-8

9. Medline:
Decarie JC, Mercier C.
The role of ultrasonography in imaging of paediatric head trauma.
Childs Nerv Syst. 1999 Nov;15(11-12):740-2  

cranial fracture, parietal cranial fracture, head injury, head trauma  

Dirk Schaper. Cranial fracture - parietal. PedRad [serial online] vol 3, no. 11.
URL: www.PedRad.info/?search=20031122115033  

Dirk Schaper (Halle/S.)  

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4,5 Years  

Female  

N/A  

N/A  

4 and a half year-old girl with acute swelling in the right thoracic area laterally. No pain, no previous maladies, no pain on pressure, no redness and no localized hyperthermia. Slight blue glimmering, taut elastic resistance. Lab values contained no pathological findings.  

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<- view X-Ray 1

X-Ray 1: Splaying, fraying, cupping, widening of growth plates of bilateral distal radius and ulna.




<- view X-Ray 2

X-Ray 2: Coned down view of right wrist.





<- view X-Ray 3

X-Ray 3: Lateral view of both wrist showing all the finding as in Fig1.





<- view X-Ray 4

X-Ray 4: Same findings also noted in bilateral distal femur and proximal tibia and fibula.


<- view Ultrasound 1

Ultrasound 1: 10x6mm large, echoless mass in the upper testicular pole/head of the epididymis.





<- view Ultrasound 2

Ultrasound 2: Shown are two echoless masses at the head of the epididymis. 8x6mm and 11x7mm





<- view Ultrasound 3

Ultrasound 3: Echoless mass at the upper pole of the testes.



<- view Ultrasound 1

Ultrasound 1: Initial sonographic examination: right lower quadrant (RLQ), tubular swollen, non-echogenic structure with echogenic, intermittent internal echoes. Non-compressable, no compression pain with transducer. In the longitudinal and transverse views, composition of the walls are well-differentiated.





<- view Ultrasound 2

Ultrasound 2: Initial sonographic examination: Bulls-eye in the RLQ with well-differentiated walls (base area)





<- view Ultrasound 3

Ultrasound 3: Initial sonographic examination: Longitudinal image of the tubular structure, which becomes narrower more medially. (base)





<- view Ultrasound 4

Ultrasound 4: Sonographic examination 3 days later: Tubular structure with normal wall structure.





<- view Ultrasound 5

Ultrasound 5: Sonographic examination 3 days later: Transverse view of a bulls-eye structure which is near the cecum with normal wall structure 5.7 mm (base)





<- view Ultrasound 6

Ultrasound 6: Follow-up examination after 7 days: Longitudinal view with a tubular, swollen structure with echogenic contents. Somewhat compressable, layers of the walls normal.





<- view Ultrasound 7

Ultrasound 7: Follow-up examination after 7 days: Longitudinal and transverse views of the same structure.



<- view Ultrasound 1

Ultrasound 1: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis (red arrow), but without wall-thickening (yellow arrow).




<- view Ultrasound 2

Ultrasound 2: Widened fluid-distended intestinal loops in the left middle abdominal region with increased peristalsis, but without wall-thickening. Minimal free fluid (red arrow).




<- view Ultrasound 3

Ultrasound 3: Multiple mesenterial lymph nodes (green arrows) reaching up to 19x12mm in size without hyperperfusion.




<- view Ultrasound 4

Ultrasound 4: In the initial examination, "bulls-eye" is seen in the left middle abdominal region (light blue arrow), without acute clinical signs. Apparently, this is a small intestinal invagination, which is, in the follow-up exam not seen anymore.


<- view X-Ray 1

X-Ray 1: Frontal view: Homogeneous opacification of the left midle and lower lung zones. Slightly thickened pleura with a small left pleural effusion identified on the lateral view.




<- view X-Ray 2

X-Ray 2: Lateral view: Decreased transparency in the retrocardial space. Small left pleural effusion.






<- view X-Ray 3

X-Ray 3: Image performed after 14 days: no homogeneous opacification anymore, but clearly increased reticular densities in both upper lung zones. Small atelectasis on the right at the basal border of the upper lung zone.





<- view X-Ray 4

X-Ray 4: Image performed after 1.5 months: There is still mild bihilar prominence, most likely due to the persisting enlarged lymph nodes. Otherwise a normal chest radiograph for this age.



<- view X-Ray 1

X-Ray 1: Underneath the nasal bone suture a translucent line with mild shifting about 1 mm.




<- view X-Ray 1

X-Ray 1: Soft line of opacity in the right parietal bone.




<- view Ultrasound 1

Ultrasound 1: B-image presentation of an interuption of continuity in a otherwise homogenous image of the bone structure.




<- view Ultrasound 2

Ultrasound 2: B-image of an obvious fracture.


<- view Pathology 1

Pathology 1: Swelling in the right thoracic region laterally.





<- view Ultrasound 1

Ultrasound 1: Overview, tumor is 24 x 10 mm, partly echogenic contents, fluid-sediment level can be seen.




<- view Ultrasound 2

Ultrasound 2: In the horizontal plane of the lying patient. Obvious fluid-sediment level.




<- view Ultrasound 3

Ultrasound 3: In the frontal plane of the sitting patient. Obvious change of the fluid-sediment level according to the sitting position.




<- view OP-Situs 1

OP-Situs 1: Surgical specimen is cut open.