Understanding
Investigations II Radiology
As respiratory di o common in paediatric practice, it is very important
to be able to accurately interpret chest radiographs. If there is uncertainty,
the film should be discussed with an experienced radiologist.
•
Identify the patient name, date and orientation
(left and right).
•
Check the penetration—the vertebrae should just
be visible behind the heart shadow.
•
Check that the alignment is central by looking
at the head of the clavicles and the shape of the ribs on each side.
•
Comment on any foreign objects such as central
lines.
• Examine the bony structures, looking for
fractures, asymmetry and abnormalities (e.g. hemivertebrae). Rib fractures are
best seen by placing the radiograph on its side.
•
Check both diaphragms and costophrenic angles
are clear. The right diaphragm is higher than the left because of the liver.
Check there is no air beneath the diaphragm (indicates intestinal perforation).
•
Look at the cardiac outline. At its widest, it
should be less than half the width of the ribcage (cardiothoracic ratio <
0.5), although in infants it can be wider due to the anteroposterior way
the radiograph is taken.
•
Look at the mediastinum note that in infants the
thymus gland can givea ‘sail’-like shadow just above the heart.
•
Check lung expansion if there is air trapping
the lung fields will cover more than nine ribs posteriorly, and the heart will
look long and thin.
• Examine the lung fields looking for signs of
consolidation, vascular markings, abnormal masses or foreign bodies.
• Check that the lung markings extend right to the
edge of the lung if not, consider a pneumothorax (dark) or a pleural effusion
(opaque).
•
Consolidation may be patchy or dense lobar
consolidation. A lateral radiograph may be required to determine exactly which
lobe is affected. A rule of thumb is that consolidation in the right middle
lobe causes loss of the right heart border shadow and right lower lobe consolidation
causes loss of the right diaphragmatic shadow.
• Always look at the area ‘behind’ the heart
shadow for infection in the lingula. If the mediastinum is pulled towards an
area of opacity, consider collapse rather than consolidation as the pathology.
Magnetic resonance imaging scans
Magnetic resonance imaging (MRI) uses radio waves and powerful
electromagnetic fields to obtain detailed images, which can high- light
different tissues. Images can be obtained in any plane. MRI has the great
advantage of being free of ionizing radiation. The scanners are often
claustrophobic and can be noisy, so young children may require a general
anaesthetic.
MRI is very good at delineating tissues with high water content from
those with high fat content. MRI can distinguish white matter from grey matter
within the brain. It is the imaging of choice for the investigation of CNS
abnormalities including spinal abnormalities. Increasingly, it is being used
for complex cardiac and joint imaging also. On a standard T2 weighted image,
water (e.g. CSF or oedema) shows up white. On a T1-weighted image, it shows
dark (Figures 6.1 –6.3).
Computed tomography (CT) scans also give ages (‘slices’ through the
body). They have the advantage of being significantly faster to perform than
MRI scans, and the machines are quieter and less claustrophobic, so children
can be scanned while awake. CT is predominant in assessing traumatic brain
injury and in imaging the lungs and is particularly good at detecting acute
haemorrhage. The disadvantage is there is a significant radiation exposure
(Figures 6.4 and 6.5).
Ultrasound
Ultrasound is an excellent investigation for children, since it is safe
and non-invasive, and the ultrasound machine can often be brought to the
patient’s bedside. It is used extensively to obtain images of the abdominal and pelvic organs, and in newborn infants
can be used to image the brain and the lower spinal cord. The examination is
best performed in real time. Increasingly, congenital abnormalities are
detected antenatally by ultrasound examination, usually performed at 18 – 20
weeks gestation (Figures 6.6 and 6.7).
