The paediatric curriculum is one of our curriculum articles and aims to be a collection of articles that represent the core paediatric knowledge.
Topics pertaining to paediatric radiology, including paediatric neuroradiology and fetal radiology, although there will be some cross cov...
Necrotising enterocolitis (NEC) is the most common gastrointestinal condition in premature neonates. It is characterised by inflammation, ischaemia, and permeability of the neonatal bowel wall to bacteria. It is potentially life threatening with significant associated morbidity.
The haystack sign on chest x-rays in paediatric patients is indicative of pneumomediastinum. The paediatric heart is surrounded above and below with gas, giving it an appearance of a haystack from Monet's paintings.
Subacute sclerosing panencephalitis (SSPE), also known as Dawson disease, is a rare chronic, progressive and fatal encephalitis that affects primarily children and young adults, caused by a persistent infection of immune resistant measles virus.
1 in 100,000 people infected with ...
Macroglossia means an enlarged tongue. It may be absolute (greater than the 95th centile) or relative (enlarged compared with oral cavity).
Recognised associations include:
tends to be a relative macroglossia
may also have intermi...
Urbach-Wiethe disease, also known as lipoid proteinosis or hyalinosis cutis et mucosae, is a rare autosomal recessive genodermatosis that primarily affects the skin, upper respiratory tract, and central nervous system (CNS).
Urbach-Wiethe disease is a very rare condition, with few...
Bone age assessment is an important part of the diagnostic and management pathway in children with growth and endocrine disorders. It is helpful in the diagnosis of various growth disorders and can provide a prediction of final height for patients presenting with short stature.
Bone age can als...
Sexual differentiation refers to the embryological development of male and female phenotypes. Unlike sexual genotype which is determined at the time of fertilisation, the male and female phenotypes do not begin to differentiate substantially until the seventh week of gestation.
Intussusception occurs when one segment of bowel is pulled into itself or a neighbouring loop of bowel by peristalsis. It is also known as bowel telescoping into itself.
It is an important cause of an acute abdomen in children and merits timely ultrasound examination and reduction to preclude s...
Klippel-Feil syndrome (KFS) is a complex heterogeneous entity that results in cervical vertebral fusion. Two or more non-segmented cervical vertebrae are usually sufficient for diagnosis.
There is a recognised female predilection 1. KFS has an incidence of 1:40,000-42,000 2.
Salter-Thompson classification for Legg-Calve-Perthes disease simplifies the Catterall classification into 2 groups. Based on the radiographic crescent sign, we can distinguish:
group a: including Catteral groups I and II, where the crescent sign involves less than 50% of the femoral head.
Copper beaten skull, also known as beaten brass skull, refers to the prominence of convolutional markings (gyral impressions on the inner table of the skull) seen throughout the skull vault.
The appearance of copper beaten skull is associated with raised intracranial pres...
Duane syndrome, also known as Duane retraction syndrome, is a rare congenital disease characterised by non-progressive strabismus. It is caused by a variable degree of abnormal development of one or both 6th cranial nerves (CN VI).
It presents during childhood and it accounts for ...
Harrison's sulcus or Harrison's groove refers to a groove at the lower end of the rib cage seen in young children / infants with abnormally weak bones (e.g. rickets) or chronic respiratory disease (e.g. severe asthma). The lower chest is drawn in with flaring of the rib margin. The exact cause i...
Cobb's collar(also known as a Moormann's ring) is an uncommon finding on a paediatric voiding/micturating cystourethrogram (VCUG), but an indentation of the bulbar urethra is seen in more than half of boy's who are cystoscoped, as the narrow represents two different phenomena3-4.
Bowing fractures are incomplete fractures of tubular long bones in paediatric patients (especially the radius and ulna) that often require no intervention and heal with remodelling.
Bowing fractures are almost exclusively found in children. However, there have been several case re...
Monteggia fracture-dislocations consist of a fracture of the ulnar shaft with concomitant dislocation of the radial head. The ulnar fracture is usually obvious, whereas the radial head dislocation can be overlooked, with potentially serious functional and medico-legal ramifications.
Galeazzi fracture-dislocations consist of fracture of the distal part of the radius with dislocation of distal radioulnar joint and an intact ulna. A Galeazzi-equivalent fracture is a distal radial fracture with a distal ulnar physeal fracture 2.
Galeazzi fractures are primarily e...
The Frykman classification of distal radial fractures is based on the AP appearance and encompasses the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture. It assesses the pattern of fractures, involvement of the radioulnar joint and presence of a distal u...
Greenstick fractures are incomplete fractures of long bones and are usually seen in young children, more commonly less than 10 years of age. They are commonly mid-diaphyseal, affecting the forearm and lower leg. They are distinct from torus fractures.
Greenstick fractures ...
Torus fractures, also known as buckle fractures, are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They result from trabecular compression from an axial loading force along the long axis of the bone. They are usually seen in children, frequently...
Salter-Harris type I fractures are relatively uncommon injuries that occur in children. Salter-Harris fractures are injuries where a fracture of the metaphysis or epiphysis extends through the physis. Not all fractures that extend to the growth plate are Salter-Harris fractures.
Lateral humeral condyle fractures also referred to simply as lateral condyle fractures (in the appropriate context), are relatively common elbow fractures that predominantly occur in children. They may be subtle but are hugely important to diagnose in a timely manner because if they are missed, ...
Phenylketonuria (PKU) is an inborn error of metabolism resulting from abnormal metabolism of phenylalanine. If untreated, patients can develop central nervous system impairment.
PKU is inherited as an autosomal recessive disorder with an incidence of 1 in 10,000. It is more commo...
Metaphyseal corner fractures, also known as classical metaphyseal lesions (CML) or bucket handle fractures, are observed in young children, less than 2 years old. It is considered pathognomic for non-accidental injury (NAI).
This injury is not only the fracture most specific for NA...
Epicondyle fractures are common injuries in children. They represent 10% of all elbow fractures in children and usually occur in boys after a fall on an outstretched arm.
Medial epicondyle fractures comprise most of these injuries. They can usually be treated with splinting and early physiother...
The Bado classification is one of the more widely used classifications for Monteggia fracture-dislocations and mainly focuses on the radial component. Four types are recognised and are generally based on the principle that the direction in which the apex of the ulnar fracture points is the same ...
The Salter-Harris classification was proposed by Salter and Harris in 1963 1 and at the time of writing (June 2016) remains the most widely used system for describing physeal fractures.
Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR.
Ping pong skull fracture or pond skull fracture refers to a depressed skull fracture of the infant skull caused by inner buckling of the calvarium. It is seen in newborns because of the soft and resilient nature of their bones (like greenstick fractures of long bones) and the fracture line is no...
Salter-Harris type III fractures are an uncommon, intraarticular fracture physeal fractures that occur in children.
The fracture line is often obliquely orientated through the epiphysis to the physis where it will take a horizontal orientation extending to the edge of the physis.
Salter-Harris type II fractures are the most common physeal fractures that occur in children. The fracture line will include the physis and a portion of the metaphysis, leaving a triangular metaphyseal fragment intact, otherwise known as the Thurston Holland fragment.
Salter-Harris fractures ar...
Kernicterus, also known as chronic bilirubin encephalopathy, describes the chronic, toxic, permanent sequelae of high levels of unconjugated bilirubin on the central nervous system of infants. It is part of the spectrum of bilirubin-induced neurologic dysfunction, which also includes acute bilir...
Multilocular cystic renal tumours (MCRT) are rare benign renal neoplasms occurring in a bimodal age distribution, involving young children and adults in the 4th and 5th decades.
For logical reasons, this article will discuss together the two ends of the spectrum of this disease, cystic partiall...
Osgood-Schlatter disease (OSD) is a chronic fatigue injury due to repeated microtrauma at the patellar ligament insertion onto the tibial tuberosity, usually affecting boys between 10-15 years.
Osgood-Schlatter disease is seen in active adolescents, especially those who jump and k...
Rhabdomyosarcoma is a malignant tumour with skeletal muscle cell morphology. It is one of the tumours of muscular origin.
This article focuses on a general discussion of rhabdomyosarcomas. For location specific details, please refer to:
rhabdomyosarcomas of the biliary tract
Chiari I malformation is the most common variant of the Chiari malformations, and it is characterised by a caudal descent of the cerebellar tonsil (and brainstem in its subtype, Chiari 1.5) through the foramen magnum. Symptoms are proportional to the degree of descent. MRI is the imaging modalit...
Haemophagocytic lymphohistiocytosis (HLH) is a nonmalignant disorder of immune regulation characterised by overproduction of cytokines and diminished immune surveillance. It may affect multiple organs.
It typically affects infants and children 5.
The condition can be p...
Perthes disease (also referred to as Legg-Calvé-Perthes disease) refers to idiopathic avascular necrosis (AVN) of the femoral epiphysis seen in children. It should not be confused with Perthes lesion of the shoulder.
It is a diagnosis of exclusion and other causes of avascular necrosis (includi...
Supracondylar humeral fractures, often simply referred to as supracondylar fractures, are a classic paediatric injury which require vigilance as imaging findings can be subtle.
Simple supracondylar fractures are typically seen in younger children, and are uncommon in adults; 90% a...
The harlequin eye deformity may be seen in unilateral (plagiocephaly) or bilateral (brachycephaly) coronal suture synostosis, and refers to the elevation of the superolateral corner of the orbit.
The term harlequin eye derives from the appearance of the eyes on a harlequin mask with their exagg...
Blalock-Taussig shunt, also known as Blalock-Thomas-Taussig shunt, is a palliative procedure designed to increase pulmonary arterial blood flow in patients with right ventricular outflow tract obstruction (e.g. tetralogy of Fallot) or during initial staged repair of hypoplastic left heart syndro...
Triphalangeal thumb is considered a form of pre-axial polydactyly.
Triphalangeal thumbs have an incidence of 1 in 25,000 7.
A triphalangeal thumb, as the name implies, has three phalanges instead of the usual two. There is an autosomal dominant genetic transmission 8....
Radial head dislocation occurs when the radial head is displaced from its normal articulation with the ulna and the humerus.
The dislocation may be acquired or congenital (see the separate article on congenital radial head dislocation). Additionally, radial head dislocation should be distinguis...
Medulloblastomas are the most common malignant brain tumour of childhood. They most commonly present as midline masses in the roof of the 4th ventricle with associated mass effect and hydrocephalus. Treatment typically consists of surgical resection, radiation therapy, and chemotherapy, with the...
Elbow ossification occurs at the six elbow ossification centers in a reproducible order. Being familiar with the order of ossification of the elbow is important in not mistaking an epicodylar fracture for a normal ossification center.
The order of appearances of the elbow os...
Isomerism is a term which in general means 'mirror-image'. It is used in the context of heterotaxy and is of two types:
Mirror image of the structures on the left side of the chest along the left-right axis of the body, i.e. patients with isomeri...
Medial epicondyle fractures represent almost all epicondyle fractures and occur when there is avulsion of the medial epicondyle. They are typically seen in children, and can be challenging to identify. Failure to diagnose these injuries can lead to significant long term disability.
Block vertebra is a type of vertebral anomaly where there is a failure of separation of two or more adjacent vertebral bodies.
In a block vertebra, there is partial or complete fusion of adjacent vertebral bodies.
there is a frequent association with hemivertebrae/abse...
Ghost vertebra is a sign, that is generally used synonymously with bone-within-a-bone vertebra, and as such, the causes form a subset of those causing bone within a bone appearance 2:
Thorotrast administration: bone within a bone appearance due to temporary growth arrest 1
Octreotide scintigraphy uses 111In-labelled octreotide which is a somatostatin analog; it is also known as an OctreoscanTM, a brand name for 111In-labelled pentetreotide; pentetreotide is a DTPA-conjugated form of octreotide, originally manufactured by Mallinckrodt Nuclear Medicine LLC, which no...
Herpes simplex (HSV) encephalitis is the most common cause of fatal sporadic fulminant necrotizing viral encephalitis and has characteristic imaging findings.
Two subtypes are recognised which differ in demographics, virus and pattern of involvement. They are 1:
neonatal herpes encephalitis
Triplane or triplanar fractures are of the distal tibia only occurring in adolescents. As the physiological closure of the physeal plate begins medially, the lateral (open) physis is prone to this type of fracture. The name is due to the fact of the fracture expanding both in frontal and lateral...
Dysplasia epiphysealis hemimelica (DEH), also known as Trevor disease, is an extremely rare, non-hereditary disease that is characterised by osteochondromas arising from the epiphyses.
The incidence is estimated at ~1:1,000,000 3. There is a recognised male predilection (M:F = 3:1...
Ewing sarcoma is the second most common highly malignant primary bone tumour of childhood after osteosarcoma, typically arising from medullary cavity with invasion of Haversian system. They usually present as moth-eaten destructive permeative lucent lesions in the shaft of long bones with large ...
Kartagener syndrome is a subset of primary ciliary dyskinesia, an autosomal recessive condition characterised by an abnormal ciliary structure or function, leading to impaired mucociliary clearance.
The prevalence of primary ciliary dyskinesia is approximately 1 in 12,000-60,000 ...
Aneurysmal bone cysts (ABC) are benign expansile tumour-like bone lesions of uncertain aetiology, composed of numerous blood filled channels, and mostly diagnosed in children and adolescents.
Aneurysmal bone cysts are primarily seen in children and adolescents, with 80% occurring ...
Anterior inferior iliac spine (AIIS) avulsion injuries are one of the six main types of pelvic apophyseal avulsion fractures.
As with many pelvic avulsion injuries, they most often occur in adolescents (mostly between the ages 14-17). There is a slight male predilection and they ...
The radiocapitellar line is one of the key lines used to assess alignment on the elbow radiograph. It is particularly useful in the paediatric setting.
A line drawn down the neck of the radius should intersect the capitellum. It is important to ensure that you draw the line down the r...
Slipped upper femoral epiphysis (SUFE), also known as a slipped capital femoral epiphysis (SCFE), is a relatively common condition affecting the physis of the proximal femur in adolescents. It is one of commonest hip abnormalities in adolescence and is bilateral in ~20% of cases.
Lateral epicondyle fractures are rare epicondylar fractures. They are much rarer than medial epicondyle fractures and represent avulsion of the lateral epicondyle. They are usually seen in the setting of other injuries 1-3.
Incidence typically peaks in the paediatric age group (6...
Humeral condyle fractures represent fractures through the medial or lateral distal humeral condyles.
Gage sign is a V-shaped lucent defect at the lateral portion of the epiphysis and/or adjacent metaphysis. It is pathognomonic for Legg-Calve-Perthes disease.
It may occur early in the disease and is one of the five indicators of a worse prognosis, which are:
calcification lateral t...
The Scham sign of slipped capital femoral epiphysis is one of the subtle signs that may be seen on the AP view of an adolescent hip with early slip.
In the normal adolescent hip, an intraarticular portion of the diaphysis of the collum overlies the posterior wall of the acetabulum inferiomedial...
Robin sequence, also called Pierre Robin syndrome or Pierre Robin anamaloid, is a congenital condition characterised by facial abnormalities. Its aetiology has no genetic base, but rather, is reliant on a sequence of events, one following the other.
Robin sequence is the preferred ...
The metaphyseal blanch sign (a.k.a. metaphyseal blanch sign of Steel) is one of the signs seen on AP views of the adolescent hip indicating posterior displacement of the capital epiphysis.
It is a crescent-shaped area of increased density, that overlies the metaphysis adjacent to the physis on ...
Köhler disease is an eponymous term referring to chilhood onset avascular necrosis of the navicular bone in the foot. Mueller Weiss syndrome is the adult counterpart of navicular bone avascular necrosis. 4,5
It typically presents in the paediatric population (4-6 years age) and th...
Panner disease is an osteochondrosis of the capitellum. It should be distinguished from osteochondritis dissecans of the elbow which also affects the capitellum.
Panner disease is typically seen in children (5-10 years of age), although it is also seen in throwers due to repeated...
Tectal gliomas fall under the grouping of childhood brainstem gliomas and unlike the other tumours in that group they are typically low grade astrocytomas with good prognosis.
Tectal plate gliomas are encountered in children and adolescents 4. A male predilection has sometimes be...
Neonatal neuroblastoma is a type of congenital neuroblastoma, an embryonal tumour arising from the sympathetic nervous system. In the majority of cases (45%), the tumour is localised in the adrenal gland.
Neonatal neuroblastoma accounts for less than 5% of all cases and carries ...
Caffey disease or infantile cortical hyperostosis is a largely self-limiting disorder which affects infants. It causes bone changes, soft-tissue swelling, and irritability.
A rare variant known as prenatal onset cortical hyperostosis is severe and fatal, though it is probably a separate entity ...
Hoffa's fat pad herniation is defined as herniation of infrapatellar fat through a defect in the lateral retinaculum. It is an uncommon cause of an anterolateral knee mass often detected at the fully flexed knee 1.
Mainly occurs in preschool-aged and young children as a p...
Bronchial atresia is a developmental anomaly characterised by focal obliteration of the proximal segment of a bronchus associated with hyperinflation of the distal lung.
On imaging, it commonly presents as a proximal focal tubular shaped opacity radiating from the hilum associated with a dista...
The PRETEXT system proposed by the International Childhood Liver Tumours Strategy Group (previously called Société Internationale d’Oncologie Pédiatrique - Epithelial Liver Tumour Study Group - SIOPEL) aims for staging and risk stratification of liver tumours at diagnosis.
It is used to descri...
Bone within a bone is a descriptive term applied to bones that appear to have another bone within them. There are numerous causes including:
thoracic and lumbar vertebrae (neonates and infants)
growth recovery lines (after infancy)
cortical splitting and new periostitis
sickle cell d...
A useful mnemonic to remember the possible aetiologies of a bone within a bone appearance is:
G: growth arrest lines
H: heavy metal, hypoparathryoid, hypothyroid
S: sickle cell anaemia, scurvy, syphilis
T: thalassamia, tuberculosis
D: disease of Caf...
The leukodystrophies are dysmyelinating disorders which typically, although not invariably, affect children. They include:
lysosomal storage diseases
globoid cell leukodystrophy (Krabbe disease)
Birth trauma relates to those conditions caused by both physical/mechanical and hypoxic injuries.
Birth trauma occurs in ~5 per 1000 births 2.
Sclerosing bone dysplasias comprise a heterogeneous group of disorders (skeletal dysplasias) united by the presence of sclerosis of one form or another. Some of these entities are thought to be related (e.g. osteopoikilosis, melorheostosis and Buschke-Ollendorff syndrome) 1.
Paediatric renal tumours and masses are another group of diseases (just like cystic renal diseases in both the adult and child) that are bewildering in their number, nomenclature and overlapping findings.
Wilms tumour: common in older children 1-8 years old
A generalised acceleration in bone maturation can result from a number of aetiological factors. They include:
idiopathic isosexual precocious puberty
hypothalamic or parathalamic lesion with sexual precocity: e.g.
Coronal vertebral cleft refers to the presence of a radiolucent vertical defect on a lateral radiograph.
It is most often seen in premature male infants 1,3. As they can occur as part of normal variation (especially in the lower thoracic-upper lumbar spine of premature infants) ...
Bent bone dysplasias are a class of dysplasia included in a 2010 classification of genetic skeletal disorders 1.
kyphomelic dysplasias, a diverse class, including
congenital bowing of the long bones
cartilage-hair hypoplasia (CHH; metaphyseal d...
Airway foreign bodies in children are potentially fatal, which is why proper recognition is important. Unfortunately, delayed diagnosis is common.
Children under the age of four years are at increased risk of foreign body (FB) aspiration, with a slight male predominance 1.
Sincipital encephalocoeles are congenital herniations of cerebral parenchyma through a cranial defect. There are three main types 1,2:
frontonasal encephalocoele (~50%): more common in Asia and Latin America 4
naso-ethmoidal encephalocoele (30%): more common in North America 4
Intestinal nonrotation is a congenital anomaly of the intestines that results in the small bowel occupying the right side of the peritoneal cavity and the colon predominantly on the left.
It is sometimes thought of as a subtype of intestinal malrotation.
Nonrotation is estimated ...
Frontal bossing is a calvarial radiographic feature where the front of the skull appears protruding anteriorly. It is best appreciated on a sagittal or lateral image.
This feature can be seen in many conditions (in alphabetical order):
Egg-on-a-string sign, also referred to as egg on its side, refers to the cardiomediastinal silhouette seen in transposition of the great arteries (TGA).
The heart appears globular due to an abnormal convexity of the right atrial border and left atrial enlargement and therefore appears like an ...
Echogenic fetal bowel is an observation in antenatal ultrasound imaging, in which fetal bowel appears to be brighter than it is supposed to be. It is a soft marker for trisomy 21 and has several other associations. When observed, it needs to be interpreted in the context of other associated abno...
Non-ossifying fibromas (NOF) are the most common of non-neoplastic fibrous bone lesions and are essentially a larger version (>3 cm) of a fibrous cortical defect; both are encompassed by the term fibroxanthoma or metaphyseal fibrous defect.
NOFs are very common in children and ado...
Prune belly syndrome, also known as Eagle Barrett syndrome 3 or triad syndrome, is a rare anomaly comprising a specific constellation of features. It consists of three major findings:
gross ureteric dilatation
anterior abdominal wall underdevelopment (resulting in the "prune belly" appearance)...
Neonatal hydronephrosis is most commonly diagnosed antenatally as fetal pylectasis, and in the majority of cases is due to pelvi-ureteric junction (PUJ) obstruction.
pelvi-ureteric junction (PUJ) obstruction (50% of cases 1,6)
vesicoureteric reflux (~20% of cases 5)
The double track sign is a radiological sign described in pyloric stenosis on various imaging modalities.
Double streaks of barium passing through the narrow pylorus 1.
On fluid aided real-time examination, the pyloric fluid is compressed into smaller tracks as it is...
This article lists examples of normal imaging of the paediatric patients divided by region, modality, and age.
premature (27 weeks): example 1
neonate: example 1
6-year-old: example 1
12-year-old: example 1
CT chest: examples needed