Ku Alexei,  Schmitz Kelli

Final Pr. ID: Poster #: EDU-052

Stress injuries occur when normal bone is subjected to chronic and repeated mechanical loading. Children are at particularly increased risk for these types of injuries compared to adults, due to weaker chondro-osseous junctions, increased physical activity, less muscle mass, narrower bones with thinner cortices, hormonal changes, and decreased mineral content of bones.

Pediatric stress injuries consist of physeal and apophyseal stress injuries and stress fractures. When the primary physes of the long bones sustain repetitive workloads, endochondral ossification is impeded, and unmineralized cartilage extends into the metaphysis. Such repetitive workloads also affect associated apophyses, leading to chondrocyte proliferation, hypertrophy, and inflammation. Stress fractures, also known as fatigue fractures, occur when bone remodeling is given insufficient time to repair “micro-trauma” damage and additional mechanical loading cycles enable damage to accumulate in the bone, ultimately leading to a fracture.

This educational exhibit will review the imaging findings associated with stress injuries of the axial and appendicular skeleton commonly seen in older children and adolescents. The exhibit will draw on case examples of children participating in a wide range of activities to illustrate the range of stress injuries in the pediatric population and their diagnostic findings, including cheerleading, dancing, baseball pitching, climbing, and even bowling and competitive yoga. Read More

Authors:  Ku Alexei , Schmitz Kelli

Keywords:  physis, fracture, athlete

Awdeh Haitham,  Bosserman Andrew,  Tran Michael,  Bawa Pritish,  Kumaravel Manickam

Final Pr. ID: Poster #: SCI-029

To validate the necessity of an MRI when there is high clinical concern of epiphyseal injury with normal radiographic findings Read More

Authors:  Awdeh Haitham , Bosserman Andrew , Tran Michael , Bawa Pritish , Kumaravel Manickam

Keywords:  Salter Harris, Physis injury, Physis

Brahee Deborah,  Chan Andrea,  Emery Kathleen,  Cornwall Roger,  Maloney Thomas

Final Pr. ID: Poster #: SCI-048

Physeal injuries can result in premature physeal fusion. MR imaging is useful for mapping these bony physeal bridges. Resection of the bony bridge does not reliably restore normal physeal function. We have observed subtle loss of the normal low signal intensity line of the zone of provisional calcification (ZPC) extending beyond areas of physeal bar formation in some patients with prior growth plate fractures. This loss is a marker of disrupted endochondral ossification and likely reflects a more extensive region of physeal damage that might be used to better predict treatment outcomes. Given the subjectivity of visual ZPC assessment, we sought to develop a quantitative 3D map of the periphyseal area of the distal radius using a high resolution 3D fast/turbo spin echo sequence. Read More

Authors:  Brahee Deborah , Chan Andrea , Emery Kathleen , Cornwall Roger , Maloney Thomas

Keywords:  Physis, MRI, Imaging

Sharp Paige,  Braithwaite Kiery,  Marshall Kelley

Final Pr. ID: Poster #: EDU-066

The coracoid process serves as a crucial anchor for multiple tendon and ligamentous attachments in the shoulder. While glenohumeral and labral pathology are more commonly implicated in shoulder injuries, the coracoid process can also be a primary pain generator within the shoulder. This educational poster will address normal coracoid anatomy and development, as well as pathologic conditions affecting the coracoid in the pediatric population, including fractures, infection, and neoplasm.

The coracoid is a beak-like projection that extends anteriorly from the ventral scapula. It serves as the origin for the pectoralis minor, coracobrachialis, and short head of the biceps. Ligamentous attachments extend from the coracoid to the clavicle (coracoclavicular ligaments), acromion (coracoacromial ligament), and humerus (coracohumeral ligament). Additionally, the transverse scapular ligament attaches to the coracoid base.

The growth plate at the coracoid base is considered a “bipolar growth plate” and is made up of the primary ossification centers of the coracoid and the adjacent ventral scapula, similar to the tri-radiate cartilage of the acetabulum. The coracoid appears within the first year of life with fusion of the coracoid base growth plate occurring by age 14 to 15.

Physeal injuries occur at the base of the coracoid with imaging characteristics similar to other more typical locations (i.e. the proximal humerus in Little Leaguer’s shoulder). Key features include physeal widening with irregular bony margins, thought to be secondary to chronic repetitive pull from the attached musculature. Additionally, coracoid fractures occur in acute trauma and can be easily overlooked as they are frequently associated with other fractures. Direct blunt trauma by either an external object or the humeral head are associated with fractures of the base of the coracoid. Avulsions of the coracoid tip are seen with acromioclavicular separations with injury to the cocacoclavicular ligaments, more commonly seen in the pediatric population as the ligaments are relatively stronger than their osseous attachments.

While tumors of the coracoid are rare and more commonly occur in adults, primary tumors of the coracoid are seen in the pediatric population with case reports of osteoid osteomas, osteoblastomas, giant cell tumors, and aneurysmal bone cysts. Awareness of pathology affecting the coracoid process is helpful to the radiologist and clinician caring for the child with shoulder pain. Read More

Authors:  Sharp Paige , Braithwaite Kiery , Marshall Kelley

Keywords:  Physis, Fracture, Osteoid osteoma

Boehnke Mitchell,  Jaramillo Diego,  Laor Tal

Final Pr. ID: Poster #: EDU-045

In adults, the terms osteopenia and osteoporosis are used to describe different severities of diminished bone density which can result from a variety of causes. The World Health Organization has defined osteopenia as decreased bone density corresponding to a bone densitometry T-score of -1 to -2.5 and osteoporosis as a more severe deficiency (T score > -2.5). However, the etiology usually is not apparent on radiographs of skeletally mature patients. Osteopenia and osteoporosis are used regardless of the etiology of apparent decreased bone density.

In contradistinction to the ambiguity inherent in adult radiographs, in growing children, the distinctly different etiologies and corresponding histopathologic abnormalities that result in diminished radiographic bone density can be differentiated, thanks to clues offered by the open physis. Disorders that manifest as rickets (the equivalent to adult osteomalacia) result from the decreased ability to deposit calcium hydroxyapatite on a normal amount of osteoid. This causes disruption of endochondral ossification at the physis and results in apparent physeal widening with loss of the zone of provisional calcification. Alternatively, disorders that cause osteoporosis result from diminished osteoid available for subsequent mineralization, show prominent zones of provisional calcification, and are without rickets-like changes.

This educational exhibit will begin with a review of the steps of normal endochondral and intramembranous ossification, followed by a discussion of the pathophysiology of osteomalacia and osteoporosis. Upon this foundation, we will illustrate various etiologies that result in either rickets/osteomalacia or osteoporosis. Finally, we will present the imaging clues that lead to a diagnosis and to the corresponding correct terminology. This use of precise language cannot be stressed enough, as it has important clinical implications. Read More

Authors:  Boehnke Mitchell , Jaramillo Diego , Laor Tal

Keywords:  Osteoporosis, Osteomalacia, Physis

Allen Hailey,  Davis Kirkland,  Noonan Kenneth,  Nguyen Jie

Final Pr. ID: Poster #: EDU-045

Interpreting imaging studies performed on pediatric patients who have undergone orthopedic surgical intervention is a daily occurrence for most radiology practices, both academic and private. These studies are obtained to assess for bony healing, alignment, and complications. An understanding of the general principles of pediatric orthopedics, familiarity with the design features of specific hardware components and why they are used in certain scenarios increases the confidence and ability of a radiologist to report key findings and anticipate possible complications. The aim of this exhibit is to review the anatomy and physiology of the long bone physis, present some of the basic tenets of orthopedic surgery with special attention to those that apply to pediatrics, and provide an image-rich atlas of hardware implements that are utilized in the lower extremities. Read More

Authors:  Allen Hailey , Davis Kirkland , Noonan Kenneth , Nguyen Jie

Keywords:  Surgery, Physis

Jones Chad,  Woodward Connor,  Woo Raymund,  Williams Jennifer

Final Pr. ID: Poster #: EDU-051

The overall incidence of birth trauma ranges from 2-3%, with the large majority consisting of superficial soft tissue injury. Musculoskeletal birth trauma tends to occur most commonly around the shoulder, with clavicle and brachial plexus injuries representing the majority of MSK trauma. Perinatal long bone fractures are quite rare, with most affecting the humeral/femoral diaphysis. Physeal fractures represent an even more uncommon entity and can be radiographically occult due to non-ossification of the epiphysis in neonates. In our educational poster, we present a variety of perinatal fractures of the physis which were initially occult on radiograph, but became evident on further workup with MR. Read More

Authors:  Jones Chad , Woodward Connor , Woo Raymund , Williams Jennifer

Keywords:  Fracture, Physis, Perinatal

Wyers Mary,  Ganesh Ashwin,  Samet Jonathan

Final Pr. ID: Poster #: EDU-037

Background & Purpose:

Fractures on MRI can be difficult to see, particularly if they are small or surrounded by edema and other heterogeneous signal changes. This is made more challenging if an x-ray is not available for review when reading an MRI, or if the injury on x-ray is subtle. The purpose of this exhibit is to review the different appearances and types of fractures by MRI, including avulsion, acute osteochondral, physeal related, and stress fractures, and help the learner develop a pattern-based approach when reviewing an MRI, in order to improve detection and confidence.

Learning Objectives:

1. Recognize the different ways an acute fracture can appear by MRI, including understanding mechanisms of injury and any associated ligamentous or tendinous involvement.
2. Learn to approach each MRI the same way, with a careful assessment of bone marrow edema heterogeneity, joint fluid heterogeneity, and articular surfaces.
3. Develop awareness of subtle, small, or unusual fractures that may be hiding amidst edema or fluid.

Content:

This exhibit will portray and explain the imaging appearances of different fractures on MRI including: incomplete, avulsion, acute osteochondral, physeal related, and stress fractures. Different joint centered abnormalities will be emphasized, particularly the knee, shoulder, and pelvis. A pattern based approach will be reviewed in order to avoid missing subtle findings. This will include:
1. Searching within the heterogeneity of marrow edema patterns on both T1 and T2 weighted sequences to find linearity, subtle cortical depressions, or incomplete fracture lines.
2. Looking for healing or more chronic changes, including periosteal reaction by MRI.
3. Following articular cartilage and the physis to make sure they have normal contours and are smooth.
4. Examining joint fluid for avulsed joint bodies, with attention to any linear appearing signal changes in the dependent recesses of joints. Read More

Authors:  Wyers Mary , Ganesh Ashwin , Samet Jonathan

Keywords:  fracture, MRI, Physis