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Occurrence Bone tumors Benign tumors Almost 40% of all bone tumors in children and ado- Distal end of the femur lescents occur in the knee area purchase confido 60caps otc. The distal femur is the The tumor that most commonly occurs in the area of the commonest site for bone tumors cheap confido 60 caps mastercard, accounting for 21% distal femoral metaphysis is the osteochondroma (car- of cases discount confido 60 caps with mastercard, followed by the proximal tibia in second place tilaginous exostosis; chapter 5. There is a logical explanation for this situation: often interferes with the knee mechanics it occasionally the epiphyseal plates in this area are the most active in has to be resected. The distal femoral epiphyseal plate alone for non-ossifying bone fibromas. Primary bone tumors of the distal femur, proximal lower leg and lower leg shaft in children and adolescents (n=805) compared to adults (n=849). A reli- able diagnosis can usually be made on the basis of a plain x-ray, and treatment is unnecessary since non-ossifying bone fibromas either disappear spontaneously or ossify after completion of growth (⊡ Fig. Moreover, the patients are almost always asymptomatic and the fibroma is almost invariably diagnosed by chance. Non-ossifying bone fibromas form at the sites where the tendons and ligaments radiate out in the vicinity of the epiphyseal plates and the great majority are encountered around the knee. A very typical tumor in adolescents at this site is the chondroblastoma (⊡ Fig. In contrast with the two aforementioned tumors, which almost always occur in ⊡ Fig. Lateral x-ray of the left knee of a 15-year old girl with a non-ossifying bone fibroma. The clear demarcation with marginal scle- the metaphyses, the chondroblastoma is primarily always rosis and the lobular structure are typical observed in the epiphyseal area. AP x-ray (a) and sagittal MRI (b) of the left knee of a 15-year old girl with chondroblastoma in the lateral femo- ral condyle. Such a finding should not be confused with a case of osteochondrosis a b dissecans ( Chapter 3. AP and lateral x-rays (a) of the left knee of a 16-year ary aneurysmal bone cyst. By comparison with adults, the giant cell tumors and enchondromas in particular are underrepresented in 3 children and adolescents (⊡ Table 3. In contrast with the situation for the proximal femur, solitary bone cysts hardly ever affect this area. In general, the ratio of benign to ma- lignant tumors in the statistical data for our register tends to favor the malignant type, since many benign tumors neither need to be biopsied nor treated and therefore do not appear in the statistics. Proximal tibia and fibula For the most part, the same tumors form on the proximal lower leg as on the distal femur (⊡ Table 3. They can almost always be diagnosed reliably on the basis of a plain x-ray. Non-ossifying bone fibromas are even more frequently encountered in the proximal tibial metaphysis ⊡ Fig. AP and lateral x-rays of the left knee of a 11-year old girl than in the distal femur. Giant cell tumors and fibrous with an aneurysmal bone cyst in the tibial shaft dysplasia are also slightly more common here. This is a particularly typical site for the rare chondromyxoid fibroma. On the other hand, giant cell tumors are rare compared to their frequency of occurrence in adults [24, 29]; this also applies to the enchondroma. Here, too, many more benign tumors occur in this part of the body, in absolute terms, than would be suggested by the statisti- cal records. Tibial shaft Tumors in the tibial shaft are fairly rare (as generally applies for diaphyses). In addition to osteoid osteomas, enchondromas, aneurysmal bone cysts (⊡ Fig. A condition that particularly affects the tibial shaft is osteofibrous dyspla- sia according to Campanacci (⊡ Fig.

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It is likely that the condition occurs in less than one percent of the population order 60 caps confido visa, and is nearly always seen at the time of adolescence and puberty discount confido 60caps with mastercard. The most common coalition is that between the calcaneus and the navicular (Figure 5 cheap 60caps confido fast delivery. Oblique radiograph clearly demonstrating calcaneal navicular Clinically the condition presents as a painful bar (tarsal coalition). The presence of a painful stiff foot in the adolescent age range should immediately alert the physician to the possibility of a tarsal coalition. The diagnosis is then established by appropriate radiographic examination of the Figure 5. Computed tomography image demonstrating medial facet talocalcaneal coalition. If clinical suspicion is not satisfied, then a CT scan of the hindfoot is indicated, and is probably the most accurate means of determining the presence or absence of a hindfoot coalition. Although conservative treatment in the form of casting and orthotics is occasionally successful, the vast majority of patients will become recalcitrant, and continue with symptomatology, warranting surgical intervention. Current surgical management includes the use of operative procedures designed to separate the coalition by resection of the bar, or fusion of the joints involved (triple or subtalar arthrodesis). Surgical treatment has been successful in roughly 90 percent of all cases. The primary physician’s role is to be cognizant of the clinical presentation and to institute appropriate orthopedic referral. Adolescence and puberty 94 Recurrent subluxation (dislocation) of the patella Recurrent subluxation, or dislocation of the patella, is a condition most commonly seen in adolescents and teenagers, most commonly occurs in females, with a definite familial background. A congenital form is recognized and is most commonly associated with other disorders or syndromes (Down syndrome, skeletal dysplasias, Ehlers–Danlos syndrome, and arthrogryposis). When seen in its most common form it is nearly always associated with generalized ligamentous laxity. In association with ligamentous laxity there is evidence of contracture of the lateral soft tissue supports of the patella, particularly the lateral retinaculum and capsule and vastus lateralis Figure 5. Abnormal patellar “tracking” seen during knee extension in tendon insertion. The most common presenting symptoms are that of episodes of “giving way” with pain in the knee and occasional “popping. The source of these symptoms is believed to be due to the malalignment of the patella within the femoral intercondylar groove, and most likely is related to a roughened area on the patella “rubbing” onto the synovial surface. The diagnosis is established by examining the “tracking” of the patella as the knee is brought from full flexion into full extension. Commonly a “figure four” sign is seen, or a “Q” sign, which relates to the movement of the patella within the intercondylar groove as the knee is brought into full extension (Figure 5. In full extension it is usually 95 Pain syndromes of adolescence possible to displace the patella laterally with very little pressure (light thumb pressure). Provocative pressure on the patella in an attempt to sublux the patella laterally will often elicit “guarding” or apprehension on the patient’s behalf. Not uncommonly, there will be tenderness over the medial capsule and retinaculum on direct pressure. Although radiographs may be occasionally helpful in discerning the relative degree of formation of the lateral condyle and the position of the patella within the groove, the diagnosis is established on a clinical basis. Long-term disability encountered with this condition relates to the degree of subluxation and dislocations and the length of time the dislocations have been occurring. Chronic dislocations will likely result in wear and tear changes on the undersurface of the patella as well as on the lateral femoral condyle, and can indeed precipitate premature patellofemoral arthritis. An awareness of the diagnostic features will facilitate appropriate orthopedic referral by the primary care physician. Although treatment is often conservative, with exercises to maintain quadriceps strength, and occasional bracing to inhibit lateral subluxation, a number of youngsters will fail conservative care and will require surgical realignment. A variety of surgical realignment approaches are available, with satisfactory results to be anticipated in the majority of cases if performed prior to the development of patellofemoral arthritis.

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Lateral soft tissue neck This projection may be required to investigate a suspected foreign body or soft tissue swelling buy cheap confido 60caps online. The patient is seated so that the median sagittal plane is paral- lel to the cassette buy confido 60 caps mastercard. The chin is raised and the head and neck are carefully posi- tioned to reduce lateral rotation purchase confido 60caps. A rectangular sponge placed between the cassette and the child’s head may assist in maintaining the position and with immobilisation. The arms are relaxed at the side of the patient and, in young children, it may be advantageous for the guardian to be seated in front of the child, holding the arms and encouraging them to maintain the position. A long rectangular sponge is placed behind the patient’s back to assist in immobilisation. The horizontal beam is centred midway between the sternal notch and the mastoid process. Radiographic assessment criteria of lateral soft tissue neck The mandibular rami should be superimposed and the pharynx and trachea down to the level of the thoracic inlet should be included and outlined with air. Post-nasal space A well-collimated lateral projection of the post-nasal space will demonstrate soft tissue encroachment onto the air-filled pharynx (e. The head is then rotated so that the median sagittal plane is parallel to the cassette. Immobilisation is achieved by ensuring that both hands hold the erect cassette holder (Fig. For examination of a young child, a suit- ably protected guardian may need to hold the head still. Exposure should be made with the patient’s mouth closed on gentle inspiration. The primary beam should be centred over the middle of the mandibular ramus and to the centre of the film. Note: Careful collimation should be undertaken to avoid irradiation of the thyroid gland and the lens of the eyes. Radiographic assessment criteria of post-nasal space The mandibular rami should be superimposed and the nasopharynx clearly out- lined with air. Note the child’s arms are positioned around the erect cassette holder to assist in immobilisation. Age Focal Kilovoltage mAs FFDa Relative screen/ Grid AECb (years) spot (kV) (cm) film speed <1 Fine 60 2 150 400–800 No No 1–4 Broad 75 2 150 400–800 No No 4–10 Broad 75 4 150 400–800 Yes No 10+ Broad 80–120 AEC 150–180 400–800 Yes/No Yes (dependent (dependent on size) on size) aFocus-to-film distance. Exposure factors and radiation protection The European Guidelines14 recommend a fast film screen combination, 400–800 speed class, for use in paediatric chest radiography combined with an exposure time of less than 10ms to reduce the risk of recorded movement unsharpness. The use of automatic exposure control (AEC) is not recommended for infants and small children due to the relatively large size of the chamber compared to the area of interest and the difficulty of positioning the chamber to an appropri- ate anatomical area. A relatively high kV should be used to reduce the radiation dose (Table 4. If difficulties in using high kV are encountered as a result of being unable to set sufficiently low mAs values then increasing the filtration within the tube is advocated. This will reduce tube output per mAs thereby allowing tube potential to be increased for infant examinations15. Additional filtration will also reduce the amount of low energy photons within the radiation beam and therefore assist in the reduction of patient dose. The use of an anti-scatter grid or Bucky is not appropriate for chest radiogra- phy on small children. These examples assume that additional filtration has been added to the x-ray tube as recommended by the European Guidelines14. Summary Although frequently undertaken, many radiographers are still uncomfortable performing paediatric chest examinations and it is hoped that, by providing a description of suitable techniques, including associated radiographic assessment criteria and common chest pathologies, the radiographer will be able to improve 62 Paediatric Radiography not only their technical ability, but also their understanding of paediatric pul- monary diseases. However, the use of ionising radiation for imaging the paediatric abdomen is increasingly being questioned and radiographers must ensure that plain film radiography is justified as there are an increasing number of clinical presentations for which plain film radiography is no longer appropriate as the first-line imaging investigation. Structural and functional anatomy The abdomen is defined by the diaphragm superiorly and the pelvic inlet infe- riorly.

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