Imaging of spinal injury in abusive head trauma: a retrospective study

Background

Spinal imaging has been a neglected part of abusive head trauma (AHT) imaging. As most of the radiographs and CT spine are negative in AHT in infants, the cervical spine is assumed to be normal. There is increasing evidence in the role of injury to brainstem and cervical cord in the pathogenesis of AHT. In addition, in courts of law, there is fierce debate about AHT, its mimics and other disparate nontraumatic diagnoses explaining the neuroradiological and skeletal findings. However, this discussion ignores the evidence and significance of spinal injury. We sought to study the cervical spine in an AHT cohort to understand the true prevalence of spinal injuries in AHT and contrast it with cohorts of accidental and nontraumatic groups to give the clinicians a robust diagnostic tool in evaluating AHT.

Objective

The purpose of this study is to compare the relative incidence of spinal ligamentous and soft-tissue abnormalities on spinal MRI among three groups of children ages <48 months: 1) those with AHT, 2) those with accidental trauma, and 3) those with nontraumatic conditions.

Materials and methods

This comparative study included 183 children who underwent spine MRI: 67 with AHT, 46 with accidental trauma and a clinical suspicion of spinal injury, and 70 with nontraumatic conditions. Clinical and radiographic findings were collected in all cases and were analyzed retrospectively to identify MRI evidence of traumatic spinal injuries. The incidence of spinal injuries among the three groups was compared. The incidence of spinal ligamentous injuries was calculated for those with and without radiographic evidence of hypoxic-ischemic encephalopathy. All comparisons were performed using Fisher exact test with P?Results Cervical spine ligamentous injuries (predominantly the nuchal, atlanto-occipital and atlanto-axial ligaments) were present in 78% of the AHT group, 46% of the accidental trauma group and 1% of the nontraumatic group; all of these differences were statistically significant. Among the AHT group, ligamentous injuries were statistically correlated with evidence of brain ischemia.

Conclusion

Injury to the cervical spinal posterior ligamentous complex is common in AHT and even more prevalent than in clinically symptomatic traumatic cases. The high correlation between the radiographic findings of occipitocervical ligamentous injuries and hypoxic-ischemic brain injury is consistent with an interpretation that transient upper occipitocervical spinal cord injury in AHT leads to disordered breathing and results in hypoxic-ischemic encephalopathy. We recommend imaging the entire spine in AHT to properly identify and classify these injuries.     

Head injury pattern in children can help differentiate accidental from non-accidental trauma

Objectives

Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury.

Methods

Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996–2011.

Results

Of 2,015 children with TBI, 71 % had accidental injury and 29 % had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p < 0.0001) and had a higher mortality rate (15 vs 5 %; p < 0.0001). Patients with AHT had higher rates of diffuse axonal injury (14 vs 8 %; p < 0.0001) and subdural hemorrhage (76 vs 23 %; p < 0.0001). Children with accidental injury had higher rates of skull fractures (52 vs 21 %; p < 0.0001) and epidural hemorrhages (11 vs 3 %).

Conclusions

AHT occurred in 29 % of children and resulted in increased mortality rates. These children had higher rates of subdural hemorrhages and diffuse axonal injury. Physicians initially evaluating injured children must maintain a high index of suspicion for abuse in those who present with subdural hematoma or diffuse axonal injury.     

Cerebellar lesions in pediatric abusive head trauma

Pediatric abusive head trauma (AHT) or non accidental head trauma (NAHT) is a major cause of death from trauma in children under 2 years of age. Main etiological factor for non accidental head trauma is shaking a baby, causing brain injury by rotational head acceleration and deceleration. The consequent brain damage as shown by magnetic resonance imaging (MRI) is subdural haemorrhage and to a lesser extent parenchymal injuries of variable severity. Involvement of the cerebellum has very rarely been described.We report the clinical history and the development of cerebral magnetic resonance imaging findings in two children with serious brain injury following probable shaking who presented the typical “triad” with subdural haematoma, retinal haemorrhage and encephalopathy. We want to draw attention to cerebellar involvement characterized by cortico-subcortical signal alterations most prominent on T2w images following diffusion changes during the acute period. We discuss cerebellar involvement as a sign of higher severity of AHT which is probably underrecognized.     

MRI of radiographically occult ischial apophyseal avulsions

Background

Acute avulsions of unossified ischial apophyses in children may go undetected on radiography. Therapy includes rest and rehabilitation; however, substantial displacement may require surgery.

Objective

Our purpose is to illustrate the utility of MRI in the detection of these radiographically occult injuries in skeletally immature children.

Materials and methods

This retrospective study of more than 5?years included children with ischial avulsions who were evaluated with both radiography and MRI within 3?weeks of acute injury. Initially, radiographs were reviewed to identify those children with unossified ischial apophyses. Subsequently, their MRI examinations were assessed for physeal disruption, bone/soft tissue edema, periosteal/perichondrial elevation and disruption. Initial and follow-up radiographs (if available) were reviewed. Patient age, symptoms and offending activity were determined from clinical records.

Results

Five children met inclusion criteria. All initial radiographs were normal. MRI showed: edema (n?=?5), periosteal elevation (n?=?4), periosteal/perichondrial disruption (n?=?4), >5.5?mm displacement (n?=?0). Follow-up radiographs in two children (2 and 2.5?months from MRI) showed osseous ischial irregularity. The apophyses remained unossified.

Conclusions

Acute unossified ischial apophyseal avulsions in children may be radiographically undetected. In the setting of correlative clinical symptoms, MRI can be used to identify these injuries and to help direct appropriate therapy.     

Straddle Injuries in Female Children and Adolescents: 10-year Accident and Management Analysis

Objective

To analyze unintentional straddle injuries in girls with regards to epidemiology, etiology and injury management.

Methods

The hospital database was retrospectively reviewed (1999–2009) for female patients managed for genital trauma. Patients were evaluated based on age, causative factors, type of injury, area of genitals affected, management and outcomes.

Results

Straddle injuries were documented in 91 girls with age ranging from 1 to 15 y (mean?=?6.3 y; median?=?6.1 y). The causes of injuries were falls at home (n?=?31) or outdoors (n?=?27), and sport activities (swimming pool n?=?11, skating n?=?11, bicycle n?=?9 and scooter n?=?2). Most of the injuries were lacerations. Injuries involved major labia (n?=?56), minor labia (n?=?45) and introitus vaginae (n?=?15). Twelve children received outpatient treatment. Inspection under anesthesia was performed in 79 patients, with 76 requiring sutures. While hematuria was observed in 18 patients, cystoscopy did not reveal lesions in the urethra or bladder. Associated injuries were femur fracture (n?=?1), lower extremity lacerations (n?=?4) and anal lesions (n?=?2). Follow-up investigations were uneventful; however one patient developed a secondary abscess and another secondary hyperplasia of the labia minor.

Conclusions

Falls and sports are major causes of straddle injuries with a peak at the age of six years. Lacerations are the most common injuries and often require surgical management. Urinary tract injuries and other associated injuries are relatively uncommon in girls with straddle injuries.     

The impact of preparation and support procedures for children with sickle cell disease undergoing MRI

Background

Children with sickle cell disease (SCD) often undergo MRI studies to assess brain injury or to quantify hepatic iron. MRI requires the child to lie motionless for 30–60?min, thus sedation/anesthesia might be used to facilitate successful completion of exams, but this poses additional risks for SCD patients. To improve children’s ability to cope with MRI examinations and avoid sedation, our institution established preparation and support procedures (PSP).

Objective

To investigate the impact of PSP in reducing the need for sedation during MRI exams among children with SCD.

Materials and methods

Data on successful completion of MRI testing were compared among 5- to 12-year-olds who underwent brain MRI or liver R2*MRI with or without receiving PSP.

Results

Seventy-one children with SCD (median age 9.85?years, range 5.57–12.99?years) underwent a brain MRI (n?=?60) or liver R2*MRI (n?=?11). Children who received PSP were more likely to complete an interpretable MRI exam than those who did not (30 of 33; 91% vs. 27 of 38; 71%, unadjusted OR?=?4.1 (P?=?0.04) and OR?=?8.5 (P?<?0.01) when adjusting for age.

Conclusion

PSP can help young children with SCD complete clinically interpretable, nonsedated MRI exams, avoiding the risks of sedation/anesthesia.     

Association of initial CT findings with quality-of-life outcomes for traumatic brain injury in children

Background

Traumatic brain injury (TBI) is a leading cause of acquired disability in children and adolescents.

Objective

To demonstrate the association between specific findings on initial noncontrast head CT and long-term outcomes in children who have suffered TBI.

Materials and methods

This was an IRB-approved prospective study of children ages 2–17?years treated in emergency departments for TBI and who underwent a head CT as part of the initial work-up (n?=?347). The change in quality of life at 12?months after injury was measured by the PedsQL scale.

Results

Children with TBI who had intracranial injuries identified on the initial head CT had a significantly lower quality-of-life scores compared to children with TBI whose initial head CTs were normal. In multivariate analysis, children whose initial head CT scans demonstrated intraventricular hemorrhage, parenchymal injury, midline shift ≥5?mm, hemorrhagic shear injury, abnormal cisterns or subdural hematomas ≥3?mm had lower quality of life scores 1?year after injury than children whose initial CTs did not have these same injuries.

Conclusion

Associations exist between findings from the initial noncontrast head CT and quality of life score 12?months after injury in children with TBI.     

Hepatic involvement of Langerhans cell histiocytosis in children—imaging findings of computed tomography,magnetic resonance imaging and magnetic resonance cholangiopancreatography

Background

Langerhans cell histiocytosis is a rare disease that occurs mainly in children, and hepatic involvement is generally a poor prognostic factor.

Objective

To describe CT and MRI findings of hepatic involvement of Langerhans cell histiocytosis in children, especially the abnormal bile duct manifestation on magnetic resonance cholangiopancreatography (MRCP).

Materials and methods

Thirteen children (seven boys, six girls; mean age 28.9 months) were diagnosed with disseminated Langerhans cell histiocytosis. They underwent CT (n?=?5) or MRI (n?=?4), or CT and MRI examinations (n?=?4) to evaluate the liver involvement.

Results

Periportal abnormalities presented as band-like or nodular lesions on CT and MRI in all 13 children. The hepatic parenchymal lesions were found in the peripheral regions of the liver in seven children, including multiple nodules on MRI (n?=?6), and cystic-like lesions on CT and MRI (n?=?3). In 11 of the 13 children the dilatations of the bile ducts were observed on CT and MRI. Eight of the 13 children underwent MR cholangiopancreatography, which demonstrated stenoses or segmental stenoses with slight dilatation of the central bile ducts, including the common hepatic duct and its first-order branches. The peripheral bile ducts in these children showed segmental dilatations and stenoses.

Conclusion

Stenosis of the central bile ducts revealed by MR cholangiopancreatography was the most significant finding of liver involvement in Langerhans cell histiocytosis in children.     

ICD-10-CM Codes for the Identification of Abusive Head Trauma in Administrative Datasets

ObjectiveWe sought to develop and validate a list of ICD-10-CM codes identifying abusive head trauma (AHT).MethodsSubjects included all children under 2 years with head trauma seen in the emergency department or admitted to one of 5 medical centers. Cases were classified as AHT, accidental head injury, or indeterminate based on chart review of the medical record. ICD-10-CM code list to identify cases of AHT was developed based on prior head injury code lists. Sensitivity and specificity of the final code list were calculated.ResultsThere were 2883 patients in the study population of whom 524 had AHT, 2123 had accidental injury, and 236 were indeterminate cases. The final list of AHT codes had a sensitivity of 76.1% (95% CI 72.5–79.8) and a specificity of 98.5% (95% CI 98.0–99.0) when limiting analyses to the groups with identified cause of injury (accidental vs abusive). Misclassification of cases based on codes resulting in false positives and false negatives was due to coding errors.ConclusionsThe list of ICD-10-CM codes can be utilized to identify and track cases of AHT at a national level in large administrative datasets though likely underestimates true injury burden.     

Imaging features of medulloepithelioma: report of four cases and review of the literature

Background

Intraocular medulloepithelioma is a childhood tumor arising from the nonpigmented primitive ciliary neuroepithelium. Although rarer than retinoblastoma, it remains the second most common primary intraocular neoplasm in children. The rarity of intraocular medulloepithelioma creates the challenge in establishing a clinical diagnosis, and radiologically the tumor is often confused with other intraocular masses.

Objective

To describe the clinical, imaging and pathological features of intraocular medulloepithelioma with emphasis on the role of imaging to enable its differentiation from more common intraocular pathology.

Materials and methods

We retrospectively analyzed the clinical, histopathological and imaging data of four children with intraocular medulloepithelioma.

Results

All four children had medulloepithelioma arising from the ciliary body. The children were imaged with US (n?=?3), MRI (n?=?4), whole-body ^99mTc-MDP scintigraphy (n?=?2) and CT (n?=?1). All four children had enucleation of the involved eye. One tumor was a malignant teratoid variant, two tumors were malignant nonteratoid variants and one was a nonteratoid variant of uncertain malignant potential. None of the tumors had extraocular extension on histopathology or imaging. Two children had associated retinal detachment on US and MRI examinations. All tumors were iso/hyperintense to vitreous on T1-weighted and hypointense on T2-weighted MRI and showed marked contrast enhancement of the solid components. No calcifications were identified on US or CT examinations.

Conclusion

Our findings are consistent with previously reported cases of medulloepithelioma. This series emphasizes the roles of various imaging modalities, with pathological correlation, in differentiating the tumor from other ciliary body masses, in detecting tumor extension and in identifying associated ocular complications. In this series we also describe the results of postsurgical follow-up for tumor recurrence.     

Apparent diffusion coefficient histogram analysis of neonatal hypoxic–ischemic encephalopathy

Background

Diffusion-weighted imaging is a valuable tool in the assessment of the neonatal brain, and changes in diffusion are seen in normal development as well as in pathological states such as hypoxic–ischemic encephalopathy (HIE). Various methods of quantitative assessment of diffusion values have been reported. Global ischemic injury occurring during the time of rapid developmental changes in brain myelination can complicate the imaging diagnosis of neonatal HIE.

Objective

To compare a quantitative method of histographic analysis of brain apparent coefficient (ADC) maps to the qualitative interpretation of routine brain MR imaging studies. We correlate changes in diffusion values with gestational age in radiographically normal neonates, and we investigate the sensitivity of the method as a quantitative measure of hypoxic–ischemic encephalopathy.

Materials and methods

We reviewed all brain MRI studies from the neonatal intensive care unit (NICU) at our university medical center over a 4-year period to identify cases that were radiographically normal (23 cases) and those with diffuse, global hypoxic–ischemic encephalopathy (12 cases). We histographically displayed ADC values of a single brain slice at the level of the basal ganglia and correlated peak (s-sD_av) and lowest histogram values (s-sD_lowest) with gestational age.

Results

Normative s-sD_av values correlated significantly with gestational age and declined linearly through the neonatal period (r ²?=?0.477, P?<?0.01). Six of 12 cases of known HIE demonstrated significantly lower s-sD_av and s-sD_lowest ADC values than were reflected in the normative distribution; several cases of HIE fell within a 95% confidence interval for normative studies, and one case demonstrated higher-than-normal s-sD_av.

Conclusion

Single-slice histographic display of ADC values is a rapid and clinically feasible method of quantitative analysis of diffusion. In this study normative values derived from consecutive neonates without radiographic evidence of ischemic injury are correlated with gestational age, declining linearly throughout the perinatal period. This method does identify cases of HIE, though the overall sensitivity of the method is low.     

Alveolar soft part sarcoma—radiologic patterns in children and adolescents

Background

Alveolar soft part sarcoma is a rare but highly malignant tumour and little is known about its radiologic pattern in children.

Objective

To describe the radiologic features of alveolar soft part sarcoma in children and adolescents.

Materials and methods

We retrospectively analysed the clinical and imaging data of six children age 7–17 years at diagnosis, with histologically or genetically proven alveolar soft part sarcoma.

Results

The tumours were located deep within muscles of the limbs (n?=?4), in chest wall muscle (n?=?1) and in the orbit (n?=?1). High-flow feeding arteries, large drainage veins and intense enhancement were consistent findings by all imaging modalities. At MRI, all tumours demonstrated high signal intensity on T2-weighted images and high or iso-intense signal on T1-W imaging compared to muscle. In tumours larger than 70 mm in one dimension (n?=?3/6), large vessels converging toward the tumour centre led to a highly vascularised central stellar area pattern. Five children demonstrated synchronous (n?=?4/5) and metachronous (n?=?1/5) lung metastases.

Conclusion

Alveolar soft part sarcoma should be suggested when a highly vascularised, intramuscular mass demonstrating large feeding and drainage vessels converging toward a central stellar area is seen in children, especially if synchronous lung metastases are present.     

Decreasing the effective radiation dose in pediatric craniofacial CT by changing head position

Background

Children are exposed to ionizing radiation during pre- and post-operative evaluation for craniofacial surgery.

Objective

The primary purpose of the study was to decrease effective radiation dose while preserving the diagnostic quality of the study.

Materials and methods

In this prospective study 49 children were positioned during craniofacial CT (CFCT) imaging with their neck fully extended into an exaggerated sniff position, parallel to the CT gantry, to eliminate the majority of the cervical spine and the thyroid gland from radiation exposure. Image-quality and effective radiation dose comparisons were made retrospectively in age-matched controls (n?=?49).

Results

When compared to CT scans reviewed retrospectively, the prospective examinations showed a statistically significant decrease in z-axis length by 16% (P?<?0.0001) and delivered a reduced effective radiation dose by 18% (P?<?0.0001). The subjective diagnostic quality of the exams performed in the prospective arm was maintained despite a slight decrease in the quality of the brain windows. There was statistically significant improvement in the quality of the bone windows and three-dimensional reconstructed images.

Conclusion

Altering the position of the head by extending the neck during pediatric craniofacial CT imaging statistically reduces the effective radiation dose while maintaining the diagnostic quality of the images.     

Correlative BOLD MR imaging of stages of synovitis in a rabbit model of antigen-induced arthritis

Background

Because of the ability of blood-oxygen-level-dependent (BOLD) MRI to assess blood oxygenation changes within the microvasculature, this technique holds potential for evaluating early perisynovial changes in inflammatory arthritis.

Objective

To evaluate the feasibility of BOLD MRI to detect interval perisynovial changes in knees of rabbits with inflammatory arthritis.

Materials and methods

Rabbit knees were injected with albumin (n?=?9) or saline (n?=?6) intra-articularly, or were not injected (control knees, n?=?9). Except for two rabbits (albumin-injected, n?=?2 knees; saline-injected, n?=?2 knees) that unexpectedly died on days 7 and 21 of the experiment, respectively, all other animals were scanned with BOLD MRI on days 0, 1, 7, 14, 21 and 28 after induction of arthritis. T2*-weighted gradient-echo MRI was performed during alternate 30?s of normoxia/hyperoxia. BOLD MRI measurements were compared with clinical, laboratory and histological markers.

Results

Percentage of activated voxels was significantly greater in albumin-injected knees than in contralateral saline-injected knees (P?=?0.04). For albumin-injected knees (P?P?=?0.009), the percentage of activated BOLD voxels varied over time. A quadratic curve for on-and-off BOLD difference was delineated for albumin- and saline-injected knees over time (albumin-injected, P?=?0.047; saline-injected, P?=?0.009). A trend toward a significant difference in synovial histological scores between albumin-injected and saline-injected knees was noted only for acute scores (P?=?0.07).

Conclusion

As a proof of concept, BOLD MRI can depict perisynovial changes during progression of experimental arthritis.     

Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury

Background Abusive head trauma (AHT) in young children usually has a severe outcome when associated with hypoxic-ischemic encephalopathy (HIE), which is best characterized by MRI in the acute or subacute phase utilizing diffusion-weighted imaging (DWI). HIE in this setting has been hypothesized to result from stretching of the spinal cord, brainstem, or vasculature. Objective To provide clinical correlation in patients with unilateral HIE and to postulate a mechanism in the setting of suspected AHT. Materials and methods IRB approval was obtained. Over a 5-year period, the medical records and images were reviewed of the 53 children ≤3 years of age who presented with acute head trauma according to the hospital registry. The children were subselected in order to determine how many suffered either HIE or AHT, and to detect those with unilateral HIE. Results In 11 of the 53 children, the etiology of the head trauma was highly suspicious for abuse. In 38 the head trauma was accidental and in 4 the trauma was of unknown etiology and at the time of this report was unresolved legally. Of the 53, 4 suffered HIE confirmed by CT or MRI. In three of these four with HIE the trauma was considered highly suspicious for AHT. Two of these three were the only patients with unilateral HIE, and both (7 months and 14 months of age) presented with early subacute phase HIE seen on DW MRI (range 4–7 days) and are described in detail with clinical correlation. The third child with AHT and HIE had bilateral findings. In the fourth patient the HIE was bilateral and was considered accidental. The work-up for both patients with unilateral HIE included head CT, craniocervical MRI, and craniocervical MR angiography (MRA). In both, there was mostly unilateral, deep white matter restricted diffusion, with subdural hematomas that were small compared to the extent of hypoxic-ischemic insult, and no skull fracture. Craniocervical MRA and axial thin-section fat-saturation images were negative for dissection, brainstem, or cord injury. Legal authorities obtained a confession of inflicted injury in one and a partial confession in the second (which did not fit the extent of injury). Five other children with HIE (based on DWI) were found during this period who had not suffered head trauma; all were bilateral insults. Conclusion HIE associated with AHT might present with largely unilateral white matter injury on DWI following extensive cortical infarction. We propose that unilateral HIE in a young child might be a sign of AHT and might result from cervical vascular compression, whether from kinking during hyperflexion/hyperextension or from direct strangulation.     

Surgical outcomes of pancreaticoduodenal injuries in children

Purpose

To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center.

Methods

We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0.

Results

170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (±?15.1), RTS2 of 6.4(±?2.1), and median age of 6.6 (1.3–13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p?=?0.05 and 3.6 vs. 1.4, p?=?<?0.01), lower RTS2 (7.84 vs. 5.49, p?<?0.01), and lower GCS (9.6 vs. 15, p?=?0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury.

Conclusion

Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.

     

Intramuscular capillary-type hemangioma: radiologic–pathologic correlation

Background

Infantile hemangiomas demonstrate a pattern of proliferative growth in infancy followed by a slow phase of involution. In contrast a rare type of vascular tumor, intramuscular capillary-type hemangioma, usually presents beyond the period of infancy with nonspecific symptoms and no evidence of involution.

Objective

The purpose of this study was to characterize the clinical, imaging, histopathological characteristics and management of intramuscular capillary-type hemangioma.

Materials and methods

We performed a retrospective review of a 20-year period to identify children diagnosed with intramuscular capillary-type hemangioma. Patient demographics, imaging and histopathological findings were recorded.

Results

We included 18 children (10 boys, 8 girls) with histologically proven intramuscular capillary-type hemangioma – and adequate imaging. The mean age at presentation was 8.1 years (range 1 day to 19 years). Twelve lesions involved muscles of the extremities, 4 were located in the trunk and 2 were in the head and neck. MRI had been performed in all children and demonstrated a soft-tissue mass with flow voids, consistent with fast flow. The lesion was well-circumscribed in 16 children and intralesional fat was seen in 14. Doppler US demonstrated a heterogeneous lesion, predominantly isoechoic to surrounding muscle, with enlarged arterial feeders. Enlarged feeding arteries, inhomogeneous blush and lack of arteriovenous shunting were noted on angiography (n?=?5). The most common histopathological findings were lobules of capillaries with plump endothelium and at least some adipose tissue. The lesions were excised in six children. Two children were lost to follow-up. In the remaining 10, follow-up MRI studies ranging from 3 months to 10 years showed that the lesion enlarged in proportion to the child (n?=?7), demonstrated slow growth (n?=?2) or remained stable (n?=?1). There was no change in imaging characteristics on follow-up.

Conclusion

Intramuscular capillary-type hemangioma is a rare benign vascular tumor of skeletal muscle. The most typical imaging features show a heterogeneous intramuscular mass with fast flow, and intralesional fat. Although the lesion is relatively stable in appearance over time, imaging does not obviate the need for a biopsy to rule out sarcoma. The diagnosis can usually be established by typical findings on histopathology.     

Magnetic resonance imaging in children with sickle cell disease—detecting alterations in the apparent diffusion coefficient in hips with avascular necrosis

Background

Avascular necrosis (AVN) is a common morbidity in children with sickle cell disease (SCD) that leads to pain and joint immobility. However, the diagnosis is often uncertain or delayed.

Objective

To examine the ability of apparent diffusion coefficient (ADC) measurements on diffusion-weighted imaging to detect AVN in children with SCD.

Materials and methods

ADC values were calculated at the hips of normal children (n?=?19) and children with SCD who were either asymptomatic with no known previous hip disease (n?=?13) or presented for the first time with clinical symptoms of hip pathology (n?=?12). ADC values were compared for differences among groups with and without AVN using non-parametric statistical methods.

Results

The ADC values were elevated in the hips of children with AVN (median ADC?=?1.57?×?10^?3?mm²/s [95% confidence interval?=?0.86–2.10]) and differed significantly in pairwise comparisons (all P?Conclusion Children with sickle cell disease have elevated apparent diffusion coefficient values in their affected hips on initial diagnosis of avascular necrosis.     

Handlebar injuries in children

Introduction

Handlebar injuries in children may lead to severe organ lesions despite minimal initial signs and without visible skin bruise. We present our experiences applying a diagnostic and therapeutic algorithm for blunt abdominal trauma, and present the history of two selected cases.

Materials and methods

We retrospectively assessed the charts of children below 16 years of age, only who were observed for 24 h or more in our institution due to a handlebar injury between 2004 and 2011. All children were treated according to an institutional algorithm.

Results

40 patients with a median age of 9.5 years were included. Diagnosed lesions were: ruptures of the liver (n = 6), spleen (n = 5), kidney (n = 1), and pancreas (n = 2), small bowel perforation (n = 3), and hernias of the abdominal (n = 2) or thoracic wall (n = 1). Surgical interventions were performed in 8 patients. The outcome was favorable in all the cases. Overall median hospitalization duration was 4.5 days (range 1–19 days). The overall duration between the accident and arrival at our emergency unit was 2.75 h (median, range 1–19 h). 20 children presented directly at our emergency unit after a median of 1.7 h (range 1–19.5 h). 20 children were referred by a family physician or a primary hospital after a median of 4.0 h (range 1–46 h).

Conclusion

Handlebar injuries in children resulted in serious trunk lesions in half of the present patient series. The spectrum of injuries in handlebar accidents varies widely, especially injuries to the abdomen can unmask often only in the course. We advocate close observation of patients with thoracic and abdominal handlebar injuries which may be regarded as blunt stab wounds. An institutional algorithm for blunt abdominal trauma management is supportive for emergency care in patients with handlebar injuries.