Pediatrics

Radiographic findings may include:

  • linear or curvilinear decreased density dividing a bone into two or more segments
  • abnormal positional relationship between two bones
  • abnormal angular measurement between two bones
  • irregular ossification of a bone
  • multiple centers of ossification for a single bone

Podcast

The following enhanced podcast includes images. Save it to your computer (right-click→Save As...). (Left-clicking on the podcast link will only play the audio portion with no images.)

Here are presentations of pediatric pathology (with *interpretations):

  • Case 1
  • *Case 1
  • Case 2
  • *Case 2
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • Case 8
  • *Case 8
  • Case 9
  • *Case 9
  • Case 10
  • *Case 10
a pes planovalgus dp b pes planoivalgus lateral
a pes planovalgus dp marked b pes planovalgus lateral marked

Dorsoplantar (a) and lateral (b) foot views.
In the DP view, the talocalcaneal angle is 18 degrees, the talo-first metatarsal angle is 43 degrees, and the calcaneal axis points through the center of the cuboid. In the lateral view, the talocalcaneal angle is 80 degrees, the talo-first metatarsal angle is 54 degrees, and the tibio-calcaneal angle is 61 degrees. The talocalcaneal index is 98 degrees.
Diagnosis: Pes planovalgus.

a met adductus dp b met adductus lateral
a met adductus dp marked b met adductus lateral marked

Dorsoplantar (a) and lateral (b) foot views.
In the DP view, the talocalcaneal angle is 17 degrees, the talo-first metatarsal angle is -8 degrees, and the calcaneal axis runs near the center of the cuboid. In the lateral view, the talocalcaneal angle is 46 degrees, the talo-first metatarsal angle is 10 degrees, and the tibio-calcaneal angle is 75 degrees. The talocalcaneal index is 63 degrees.
Diagnosis: Metatarsus adductus.

SEver's osteochondrosis
Sever's osteochondrosis marked

Lateral foot view.
The calcaneal apophysis is increased in density relative to the body. A well-defined, curvilinear decreased density divides the apophysis into two segments (arrow). The adjacent metaphysis has a jagged appearance (black arrow).
Diagnosis: Normal variants (osteochondrosis of calcaneal apophysis; jagged metaphysis).

a clubfoot dp view b clubfoot lateral view
a clubfoot dp view marked b clubfoot lateral view marked

Dorsoplantar (a) and lateral (b) foot views.
In the DP view, the talocalcaneal angle is 14 degrees, the talo-first metatarsal angle is -47 degrees, and the calcaneal axis runs lateral to the cuboid. In the lateral view, the talocalcaneal angle is 11 degrees, the talo-first metatarsal angle is 34 degrees, and the tibio-calcaneal angle is 72 degrees. The talocalcaneal index is 25 degrees.
Diagnosis: Talipes equinovarus (TEV, clubfoot).

a calcaneal varus lateral view b calcaneal varus calcaneal axial view
a calcaneal varus lateral view marked b calcaneal varus calcaneal axial view marked

Lateral (a) and calcaneal axial (b) foot views.
In the lateral view, the talocalcaneal angle is 45 degrees, the talo-first metatarsal angle is 17 degrees, and the tibio-calcaneal angle is 63 degrees. The calcaneal angle in the axial view is 64 degrees varus.
Diagnosis: Calcaneal varus. Pes cavus.

a Pes planus dp view b Pes planus lateral view
a Pes planus dp view marked b Pes planus lateral view marked

Dorsoplantar (a) and lateral (b) foot views.
In the DP view, the talocalcaneal angle is 39 degrees, the talo-first metatarsal angle is 20 degrees, and the calcaneal axis runs through the center of the cuboid. The cuboid abduction angle is 0 degrees. In the lateral view, the talocalcaneal angle is 49 degrees, the talo-first metatarsal angle is 25 degrees, and the tibio-calcaneal angle is 83 degrees. The talar declination angle is 39 degrees, the calcaneal inclination angle is 5 degrees, and the first metatarsal declination angle is 14 degrees. The talocalcaneal index is 88 degrees.
Diagnosis: Pes planus.

a Hallux physeal fracture DP view b hallux physeal fracture lateral view
a hallux physeal fracture DP view marked b hallux physeal fracture lateral view marked

Dorsoplantar (a) and lateral (b) foot views.
Ill-defined decreased density involves the entire metaphyseal aspect of the physis of the hallux distal phalanx base and gives the appearance of widening of the physis. There is no gross evidence of epiphyseal or metaphyseal involvement.
Diagnosis: Salter-Harris type 1 fracture.

a Tibial metaphyseal fracture ap view b Tibial metaphyseal fracture lateral view
a Tibial metaphyseal fracture ap view marked b Tibial metaphyseal fracture lateral view marked

Anteroposterior and lateral views, distal leg/ankle.
A curvilinear, faint decreased density runs through the distal tibial diametaphysis from posterior-superior-medial to anterior-inferior-lateral, ending at the physis (arrows). Multiple geographic decreased densities are seen along the anterior half of the physis (arrowheads). There does not appear to be any epiphyseal involvement.
Diagnosis: Salter-Harris type 2 fracture.

tibial epiphysis fracture mortise view
tibial epiphysis fracture mortise view marked

Mortise ankle/distal leg view.
A linear decreased density runs obliquely through the distal tibial epiphysis separating it into two segments. There is no gross evidence of metaphyseal involvement.
Diagnosis: Salter-Harris type 3 fracture.

bipartite basal epiphysis
bipartite basal epiphysis marked

Dorsoplantar foot view.
A well-defined, curvilinear decreased density (black arrows) divides the hallux proximal phalanx basal epiphysis into two segments.
Diagnosis: bipartite basal epiphysis versus Salter-Harris type 3 fracture.
FYI: This patient experienced direct trauma to the first metatarsophalangeal joint region, which was painful, so it was diagnosed and treated as a fracture.

Should a radiographic study be ordered for pediatric pathology?

Yes, if indicated.

What are the best views to order?

At a minimum order dorsoplantar (or AP, if ankle) and lateral views in weight-bearing or simulated weight-bearing position.

Other information

Angular measurements, especially of the child, don't always fall into the range of expectation. This is probably due to foot positioning, especially in the infant. Furthermore, the bones of the developing skeleton are frequently irregular and ever-changing in form until physeal closure, making axis placement extremely variable. Therefore, pay more attention to bony relationships than to actual measurements.

References:

  1. Christman RA: Foot and Ankle Radiology, 2nd edition, Lippincott Williams & Wilkins, 2015.
  2. Oestrich AE: How to Measure Angles from Foot Radiographs. A Primer. Springer-Verlag New York Inc., 1990.
  3. Vanderwilde R, Staheli LT, Chew DE, Malagon V: Measurements on radiographs of the foot in normal infants and children. J Bone Joint Surg Am. 70:407-415, 1988.
  4. Keats, Theodore: Normal Roentgen Variants that May Simulate Disease (any edition).
  5. Hoerr NL, Pyle I, Francis CC: Radiographic Atlas of Skeletal Development of the Foot and Ankle, CC Thomas Publ., 1965
  6. Resnick, D and Niwayama G: Diagnosis of Bone and Joint Disorders, 2nd Ed., WB Saunders Co., Philadelphia, 1989.