Pediatric Emergency Imaging — MCQs
The Salter Harris classification is used for classifying which type of injuries?
Ideal imaging method for diagnosis of hydrocephalus in infant is
A child presented to the casualty department with fever, unconsciousness, and papilledema. What is the next step?
A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?
A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?
4 year old child presented to the clinic with a history of fall on outstretched hand. Radiographs revealed a broken anterior cortex with an intact posterior cortex of the radius with an exaggerated bowing of the radius. The fracture sustained is known as -
In a radiograph of suspected non-accidental injury, which of the following fractures is LEAST specific for child abuse?
What is the most common differential diagnosis for appendicitis in children?
Investigation of choice for diagnosis of splenic rupture –
Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:
Pediatric Emergency Imaging Indian Medical PG Practice Questions and MCQs
Question 1: The Salter Harris classification is used for classifying which type of injuries?
- A. Soft tissue injuries in pediatric patients
- B. Long bone fractures without growth plate involvement
- C. Joint dislocations in pediatric orthopedics
- D. Fractures involving the physis in children (Correct Answer)
Explanation: ***Fractures involving the physis in children*** - The **Salter-Harris classification system** is specifically designed for classifying fractures that involve the **growth plate (physis)** in children. - This system helps predict the risk of **growth disturbance** and guides treatment decisions based on the fracture pattern. *Soft tissue injuries in pediatric patients* - The Salter-Harris classification does not apply to **soft tissue injuries** like sprains or strains. - Soft tissue injuries are assessed using different classification systems or descriptive terms. *Long bone fractures without growth plate involvement* - Fractures in children that do not involve the growth plate are classified using descriptive terms, such as **transverse**, **oblique**, or **spiral fractures**, or other systems like the **AO pediatric classification**, not Salter-Harris. - The Salter-Harris system is unique to physis involvement. *Joint dislocations in pediatric orthopedics* - **Joint dislocations** involve the displacement of bones at a joint and are classified by the direction of displacement (e.g., anterior, posterior). - They do not involve a fracture of the growth plate itself, so the Salter-Harris system is not applicable.
Question 2: Ideal imaging method for diagnosis of hydrocephalus in infant is
- A. X-Ray
- B. MRI
- C. CT Scan
- D. USG (Correct Answer)
Explanation: ***USG*** - **Ultrasound (USG)** is the preferred initial imaging method for diagnosing hydrocephalus in infants due to their **open fontanelles**, which allow for excellent visualization of intracranial structures without radiation exposure. - It's **non-invasive**, portable, and can be performed at the bedside, making it ideal for critically ill or unstable infants. *X-Ray* - **X-rays** provide limited detail of soft tissues and are generally unable to directly visualize the ventricles or cerebrospinal fluid accumulation, making them unsuitable for diagnosing hydrocephalus. - While skull X-rays might show signs of increased intracranial pressure in chronic cases (e.g., **suture diastasis**), they are not a primary diagnostic tool for hydrocephalus. *MRI* - **MRI** offers superior soft tissue contrast and detailed anatomical information, making it excellent for characterizing hydrocephalus and its underlying causes in older children and adults. - However, it typically requires **sedation** in infants due to the need for prolonged immobility and is less readily available or rapid than ultrasound for initial diagnosis. *CT Scan* - **CT scans** provide good bony detail and can quickly identify ventricular enlargement, but they involve **ionizing radiation**, which is a significant concern in infants due to their radiosensitivity. - While useful in acute emergencies where rapid assessment is critical and USG is inconclusive, it's generally avoided as the first-line diagnostic tool for hydrocephalus in infants.
Question 3: A child presented to the casualty department with fever, unconsciousness, and papilledema. What is the next step?
- A. Oxygenation
- B. Intubation (Correct Answer)
- C. CT scan
- D. All of the options
Explanation: **Intubation** - The presence of **unconsciousness** indicates a compromised airway and breathing, making immediate **airway management** and **ventilatory support** a priority. - Papilledema, fever, and unconsciousness suggest increased **intracranial pressure** which can lead to brainstem herniation and respiratory arrest, necessitating **controlled ventilation** to reduce CO2 and ICP. *Oxygenation* - While **oxygenation** is critical, it is often insufficient alone in an unconscious patient with a compromised airway. - **Intubation** ensures a patent airway and delivers controlled oxygenation and ventilation more effectively than oxygenation via mask in this situation. *CT scan* - A **CT scan** is a diagnostic tool, but it should only be performed after the patient is **stabilized** hemodynamically and respiratory-wise. - Transporting an **unconscious** patient with potential increased ICP for a CT scan without securing the airway carries significant risks. *All of the options* - While all listed steps are important in managing a child with these symptoms, **intubation** (airway and breathing stabilization) is the **most immediate and critical next step**. - The sequence of medical interventions follows the **ABC (Airway, Breathing, Circulation)** protocol, making airway management the top priority before diagnostics or other treatments.
Question 4: A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?
- A. 3D MCU (Correct Answer)
- B. MR UROGRAM
- C. 3D CT UROGRAM
- D. IVP
Explanation: ***3D MCU (Micturating Cystourethrogram)*** - **Gold standard** for diagnosing **vesicoureteral reflux (VUR)**, the most common cause of recurrent UTIs in children - In a child with **2-year history of recurrent UTIs** (fever + frequent micturition), VUR is the primary concern that needs to be ruled out - MCU provides **dynamic imaging** during bladder filling and voiding, allowing direct visualization of **reflux** and assessment of **bladder and urethral anatomy** - **Standard of care** recommended by IAP (Indian Academy of Pediatrics) and major pediatric nephrology guidelines - Though it involves ionizing radiation, the **diagnostic benefit far outweighs risks** in this clinical scenario - Cost-effective and widely available in Indian healthcare settings *MR Urogram* - Provides excellent anatomical detail of the **upper urinary tract** (kidneys, ureters) without radiation - However, it is **NOT the first-line investigation** for recurrent UTI workup in children - Does not adequately assess **dynamic VUR** like MCU does - More expensive, requires sedation in many children, and less accessible - Reserved for specific indications like suspected anatomical anomalies after initial screening *3D CT Urogram* - Excellent for detailed anatomical evaluation but involves **high radiation dose** - Not appropriate as first-line investigation in a **chronic, non-acute pediatric case** - Reserved for complex cases where MR is contraindicated or for acute complications *IVP (Intravenous Pyelogram)* - **Obsolete modality** that has been replaced by ultrasound, MCU, and modern cross-sectional imaging - Provides limited functional and anatomical information - Higher radiation exposure with inferior image quality compared to modern techniques - Not used in current pediatric practice
Question 5: A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?
- A. Hypertrophic pyloric stenosis
- B. Acute appendicitis
- C. Jejunal atresia
- D. Malrotation with volvulus (Correct Answer)
Explanation: ***Malrotation with volvulus*** - The acute onset of **bilious vomiting** in a 1-week-old infant is a **surgical emergency** and highly suggestive of intestinal obstruction, with malrotation with volvulus being a critical consideration. - The barium enema image (B) shows the **ligament of Treitz** located to the right of the midline, indicating **intestinal malrotation** and a **corkscrew pattern** of the duodenum, which is pathognomonic for **midgut volvulus**. *Hypertrophic pyloric stenosis* - Typically presents with **non-bilious projectile vomiting** and palpable **pyloric olive mass**, usually appearing between 3 to 6 weeks of age, not at 1 week with bilious vomiting. - Imaging would reveal an **elongated, narrowed pyloric channel** (string sign) and thickened pyloric muscle, not the findings seen in the barium study. *Acute appendicitis* - This is an **extremely rare diagnosis** in a 1-week-old infant and typically presents with localized pain, fever, and leukocytosis, which are not the primary symptoms described. - Acute appendicitis would not explain the **bilious vomiting** or the specific findings on the barium study related to intestinal rotation. *Jejunal atresia* - Presents with bilious vomiting and abdominal distension, often diagnosed prenatally or shortly after birth due to proximal dilation and distal collapse of the bowel. - While it causes obstruction, the barium study in jejunal atresia would show a **blind-ending jejunum** and not the distinct malrotation and volvulus features (e.g., corkscrew sign, abnormal Treitz location).
Question 6: 4 year old child presented to the clinic with a history of fall on outstretched hand. Radiographs revealed a broken anterior cortex with an intact posterior cortex of the radius with an exaggerated bowing of the radius. The fracture sustained is known as -
- A. Torus Fracture
- B. Greenstick fracture (Correct Answer)
- C. Galleazi Fracture
- D. Monteggia Fracture Dislocation
Explanation: ***Greenstick fracture*** - This fracture type involves a **broken anterior cortex** but an **intact posterior cortex**, leading to an exaggerated bowing of the bone, characteristic of a greenstick fracture. - It occurs predominantly in **children** due to their softer, more flexible bones, which tend to bend rather than fully break when subjected to force like a fall on an outstretched hand. *Torus Fracture* - A torus fracture, or **buckle fracture**, involves compression of the bone leading to a bulging or buckling of the cortex, usually on one side, without a complete break in the bone. - While it occurs in children, it presents as a compression injury and not with a broken cortex and intact posterior cortex with bowing. *Galleazi Fracture* - A Galleazi fracture is a fracture of the **distal radius** with **dislocation of the distal radioulnar joint (DRUJ)**. - This fracture pattern involves two bones and two distinct injuries (fracture and dislocation), which is fundamentally different from the described single-bone incomplete fracture. *Monteggia Fracture Dislocation* - A Monteggia fracture involves a fracture of the **proximal ulna** with **dislocation of the radial head** at the elbow. - This injury also involves two bones and two distinct components (fracture and dislocation) and affects a different anatomical location (ulna and elbow) than described.
Question 7: In a radiograph of suspected non-accidental injury, which of the following fractures is LEAST specific for child abuse?
- A. Metaphysis corner fracture
- B. Costochondral & rib junction fracture
- C. Parietal bone fracture (Correct Answer)
- D. Sternal fracture
Explanation: ***Parietal bone fracture*** - While **parietal bone fractures** are commonly seen in both accidental and non-accidental pediatric head trauma, they are **less specific for child abuse** compared to the classic skeletal injuries listed below. - Isolated skull fractures, particularly **simple linear parietal fractures**, can result from accidental falls and require additional clinical context (age, mechanism, associated injuries) to determine if abuse is suspected. - Complex, multiple, or depressed skull fractures are more concerning, but a simple parietal fracture alone is less diagnostic than the pathognomonic fractures of NAI. *Metaphyseal corner fracture* - Also known as **"bucket handle"** or **"corner" fractures**, these are **highly specific and virtually pathognomonic** for **non-accidental injury** in infants and young children. - They result from violent **shaking, twisting, or pulling forces** applied to the extremities, causing avulsion at the metaphyseal-epiphyseal junction. - These fractures are rarely seen in accidental trauma. *Costochondral & rib junction fracture* - **Posterior rib fractures** and **costochondral junction fractures** are **highly specific for NAI** in infants. - They result from **anteroposterior chest compression** during forceful squeezing or gripping of the thorax. - Accidental rib fractures in children are rare due to chest wall elasticity, making these fractures particularly suspicious. *Sternal fracture* - **Sternal fractures** are extremely rare in children due to the **flexibility of the pediatric sternum** and chest wall. - Their presence, especially without a history of **severe high-impact trauma** (e.g., motor vehicle collision), is **highly suspicious for non-accidental injury**. - Often result from direct forceful blows or severe compression injuries.
Question 8: What is the most common differential diagnosis for appendicitis in children?
- A. Intussusception
- B. Meckel's diverticulitis
- C. Mesenteric lymphadenitis (Correct Answer)
- D. Gastroenteritis
Explanation: ***Mesenteric lymphadenitis*** - **Mesenteric lymphadenitis** commonly mimics appendicitis in children due to similar symptoms like **abdominal pain**, **fever**, and **vomiting**. - It often follows a **viral infection** and causes enlarged lymph nodes in the mesentery, leading to pain in the **right lower quadrant**. *Gastroenteritis* - While gastroenteritis also causes **abdominal pain**, **vomiting**, and often **diarrhea**, the pain is usually more generalized or diffuse, unlike the localized **right lower quadrant pain** of appendicitis. - Furthermore, patients with gastroenteritis typically do not present with the progressive, worsening pain characteristic of appendicitis. *Intussusception* - Intussusception usually presents with sudden onset of **crampy, intermittent abdominal pain** and **currant jelly stools** in younger children (typically 3 months to 3 years), which is distinct from appendicitis pain. - A palpable **sausage-shaped mass** in the abdomen can also be a key diagnostic feature, rarely seen in appendicitis. *Meckel's diverticulitis* - **Meckel's diverticulitis** can mimic appendicitis very closely in its presentation of **right lower quadrant pain** and inflammation. - However, it is a less common condition than mesenteric lymphadenitis and appendicitis itself, making it a differential rather than the **most common differential diagnosis**.
Question 9: Investigation of choice for diagnosis of splenic rupture –
- A. MRI
- B. Peritoneal lavage
- C. Ultrasound
- D. CT scan (Correct Answer)
Explanation: **CT scan** - A **CT scan** with intravenous contrast is the investigation of choice for splenic rupture due to its high sensitivity and specificity in detecting **splenic injury**, **hematomas**, and **free intraperitoneal fluid**. - It provides detailed anatomical information, crucial for grading the injury and guiding management decisions, especially in hemodynamically stable patients. *MRI* - **MRI** offers excellent soft tissue contrast, but it is **time-consuming** and often **not readily available** in emergency settings for acute trauma. - It is typically reserved for more chronic or complex cases where detailed soft tissue characterization is not immediately needed in acute trauma. *Peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is an **invasive procedure** that is less specific than imaging for diagnosing splenic rupture. - It detects the presence of **intraperitoneal bleeding** but does not localize the injury or provide information about the extent of organ damage. *Ultrasound* - **Ultrasound (FAST exam)** is a rapid, non-invasive tool for detecting **free fluid** in the abdomen but has limited sensitivity for directly visualizing the spleen or accurately grading splenic injuries. - While useful for rapid assessment of **hemodynamically unstable** patients, a **negative FAST exam does not rule out splenic injury**, especially in stable patients.
Question 10: Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:
- A. USG (Correct Answer)
- B. Barium meal
- C. Barium meal follow through
- D. CT scan with contrast
Explanation: ***USG*** - **Ultrasound** is the preferred initial imaging modality due to its non-invasiveness, lack of radiation, and high accuracy in visualizing the thickened pyloric muscle. - The classic ultrasound findings include a **pyloric muscle thickness** of ≥ 4 mm and a **pyloric channel length** of ≥ 14 mm. *Barium meal* - While a barium meal can show findings like the "string sign" or "shoulder sign," it involves **radiation exposure** and is generally considered a second-line investigation. - Its diagnostic accuracy is good, but it is less convenient and riskier than ultrasound for this condition. *Barium meal follow through* - This procedure tracks barium through the entire gastrointestinal tract, which is **excessive and unnecessary** for diagnosing pyloric stenosis, which is a localized obstruction. - It also involves significant **radiation exposure** and a prolonged examination time. *CT scan with contrast* - A **CT scan** involves significant **radiation exposure** and is not typically used for diagnosing congenital hypertrophic pyloric stenosis. - It is also less sensitive than ultrasound for visualizing the specific soft tissue changes in the pyloric muscle.
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