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Treatment Individualization Using Pharmacokinetic Studies and Joint Ultrasound Imaging in Pediatric Patients With Hemophilia. J Pediatr Hematol Oncol 2022; 44:237-242. [PMID: 34486567 DOI: 10.1097/mph.0000000000002323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/13/2021] [Indexed: 01/19/2023]
Abstract
Hemophilia is characterized by bleeding diathesis, primarily affecting the joints. Prophylactic use of missing factor aims at limiting the number of bleeds and, in the long term, the risk of permanent joint damage. However, standard prophylactic regimens are usually applied empirically, not adjusting for variations in bleeding phenotype or drug metabolism. Aim of the present study was to evaluate the need for individualizing prophylaxis, with guidance of pharmacokinetic (PK) studies and joint ultrasound in a setting of everyday clinical practice. To evaluate adequacy of applied regimens, joint status was assessed using the Hemophilia Joint Health Score as well as ultrasound imaging, while PK studies were performed using the Web-Accessible Population Pharmacokinetic Service-Hemophilia. Imaging results were consistent with early joint damage in a large proportion of pediatric patients, whereas PK measures were indicative of inadequate prophylaxis in many cases-despite the limited number of bleeds reported by patients. The study revealed the need for prophylaxis adjustment in the majority of patients. Real world data confirm that traditional prophylaxis is often unable to achieve therapeutic goals, while an individualized approach, guided by the use of novel modalities, may be of great benefit to young hemophilia patients.
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González-Mantilla P, Abril A, Bedoya MA. Brachial Plexus Birth Palsy: Practical Concepts for Radiologists. Semin Musculoskelet Radiol 2022; 26:182-193. [PMID: 35609579 DOI: 10.1055/s-0042-1742392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.
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Affiliation(s)
| | - Angela Abril
- Geisinger Autism & Developmental Medicine Institute, Lewisburg, Pennsylvania
| | - Maria Alejandra Bedoya
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Chauvin NA, Khwaja A. Musculoskeletal imaging in neonates: use of ultrasound. Pediatr Radiol 2022; 52:765-776. [PMID: 34490498 DOI: 10.1007/s00247-021-05152-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/01/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
High-resolution US is a practical, cost-effective modality to evaluate the musculoskeletal system in neonates. US can be performed portably in the neonatal intensive care unit so that the critically ill infant can be evaluated with minimal distress. Sonography is noninvasive and does not require sedation; typical questions that might require the use of MRI or CT in older children can be rapidly resolved with US. Dynamic imaging can be used in real time to stress joints and see how articular structures relate. Given the advantages of US within the neonatal population, it has been widely used to evaluate for neonatal fractures, congenital joint abnormalities, limb deficiencies as well as muscular and soft-tissue abnormalities.
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Affiliation(s)
- Nancy A Chauvin
- Department of Radiology, Penn State Children's Hospital, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, 500 University Drive, Hershey, PA, 17033, USA.
| | - Asef Khwaja
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Chambers G, Kraft J, Kingston K. The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 27:6-19. [PMID: 30774694 DOI: 10.1177/1742271x18759807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 12/28/2017] [Indexed: 11/15/2022]
Abstract
Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.
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Affiliation(s)
- Greg Chambers
- Department of Radiology, Leeds General Infirmary, Leeds Teaching Hospital Trust, UK
| | - Jeannette Kraft
- Department of Radiology, Leeds General Infirmary, Leeds Teaching Hospital Trust, UK
| | - Kate Kingston
- Department of Radiology, York Hospital, York Teaching Hospital NHS Foundation Trust, UK
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Abstract
PURPOSE OF REVIEW Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations. RECENT FINDINGS Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports. SUMMARY Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.
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Bignotti B, Zaottini F, Airaldi S, Martinoli C, Tagliafico A. Extraneural findings during peripheral nerve ultrasound: Prevalence and further assessment. Muscle Nerve 2017; 57:65-69. [DOI: 10.1002/mus.25646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Bianca Bignotti
- Department of Health Sciences (DISSAL)University of GenoaLargo Rosanna Benzi 8, 16132Genoa Italy
| | - Federico Zaottini
- Department of Health Sciences (DISSAL)University of GenoaLargo Rosanna Benzi 8, 16132Genoa Italy
| | - Sonia Airaldi
- Department of Health Sciences (DISSAL)University of GenoaLargo Rosanna Benzi 8, 16132Genoa Italy
| | - Carlo Martinoli
- Department of Health Sciences (DISSAL)University of GenoaLargo Rosanna Benzi 8, 16132Genoa Italy
| | - Alberto Tagliafico
- University of Genova and Azienda Ospedaliera Universitaria (AOU) Istituto di Ricovero e cura a carattere scientifico (IRCCS) San Martino Istituto Nazionale per la Ricerca sul Cancro (IST)Genoa Italy
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Abstract
Lower extremity avulsion fractures are uncommon in the pediatric population and can be misdiagnosed without proper imaging and/or clinical suspicion for these injuries. The most common locations of avulsion injuries are the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. Less often, avulsion fractures occur in the tibial tubercle, calcaneus, and greater and lesser trochanters. When treated properly with rest and altered weight bearing, most of these injuries heal without complication. Although surgical intervention is rarely necessary, it has a high degree of success when it is used. However, avulsion injuries are often misdiagnosed as muscle strains or apophysitis and are mistakenly treated with early range of motion. An error in diagnosis and/or management can cause nonunion or further displacement, which may require surgery. Improper identification of these injuries can also lead to nerve irritation, chronic pain, and gait dysfunction. Awareness of these injuries and their natural history is important because healed avulsion fractures may resemble neoplastic bone on radiographs.
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Somashekar DK, Wilson TJ, DiPietro MA, Joseph JR, Ibrahim M, Yang LJS, Parmar HA. The current role of diagnostic imaging in the preoperative workup for refractory neonatal brachial plexus palsy. Childs Nerv Syst 2016; 32:1393-7. [PMID: 27179536 DOI: 10.1007/s00381-016-3106-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/02/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite recent improvements in perinatal care, the incidence of neonatal brachial plexus palsy (NBPP) remains relatively common. CT myelography is currently considered to be the optimal imaging modality for evaluating nerve root integrity. Recent improvements in MRI techniques have made it an attractive alternative to evaluate nerve root avulsions (preganglionic injuries). AIM We demonstrate the utility of MRI for the evaluation of normal and avulsed spinal nerve roots. We also show the utility of ultrasound in providing useful preoperative evaluation of the postganglionic brachial plexus in patients with NBPP.
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Affiliation(s)
- Deepak K Somashekar
- Department of Radiology, University of Michigan, 1500 E. Medical Center Dr., Room B1-132A TC, Ann Arbor, MI, 48109-5302, USA
| | - Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109-5302, USA
| | - Michael A DiPietro
- Department of Radiology, University of Michigan, 1500 E. Medical Center Dr., Room B1-132A TC, Ann Arbor, MI, 48109-5302, USA
| | - Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109-5302, USA
| | - Mohannad Ibrahim
- Department of Radiology, University of Michigan, 1500 E. Medical Center Dr., Room B1-132A TC, Ann Arbor, MI, 48109-5302, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109-5302, USA
| | - Hemant A Parmar
- Department of Radiology, University of Michigan, 1500 E. Medical Center Dr., Room B1-132A TC, Ann Arbor, MI, 48109-5302, USA.
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Somashekar DK, Di Pietro MA, Joseph JR, Yang LJS, Parmar HA. Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy. Pediatr Radiol 2016; 46:695-703. [PMID: 26718200 DOI: 10.1007/s00247-015-3524-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/26/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ultrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology. OBJECTIVE To determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies. MATERIALS AND METHODS In this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management. RESULTS Ultrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting. CONCLUSION Ultrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.
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Affiliation(s)
- Deepak K Somashekar
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Radiology, Section of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael A Di Pietro
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jacob R Joseph
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Hemant A Parmar
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Department of Radiology, Section of Neuroradiology, University of Michigan Health System, Ann Arbor, MI, USA.
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Maurer K. Musculoskeletal ultrasound in childhood. Eur J Radiol 2014; 83:1529-37. [PMID: 24856860 DOI: 10.1016/j.ejrad.2014.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 11/30/2022]
Abstract
Ultrasonography is one of the first line imaging modalities for the evaluation of musculoskeletal disorders in children. This article provides an overview of the most important pathologic entities in which ultrasonography significantly contributes to the diagnostic workup.
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Affiliation(s)
- Kathrin Maurer
- Medical University Innsbruck, Department of Radiology, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Miotto e Silva VB, Faquin G, Nicácio A, Regacini R, Lederman H, Esteves Hilário MO, Lemos Ramos Ascensão Terreri MTDSE. Associação entre achados ultrassonográficos e clínicos do quadril de pacientes com artrite idiopática juvenil. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000400002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Musculoskeletal ultrasonography of the lower extremities in infants and children. Pediatr Radiol 2013; 43 Suppl 1:S8-22. [PMID: 23478916 DOI: 10.1007/s00247-012-2589-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/08/2012] [Accepted: 11/15/2012] [Indexed: 12/26/2022]
Abstract
Ultrasonography is a powerful diagnostic imaging tool for evaluating lower extremity anatomy and pathology in children. Indications for pediatric musculoskeletal lower extremity sonography include developmental dysplasia of the hip, hip joint sonography for the child with a painful hip, evaluation and characterization of superficial soft-tissue masses, evaluation for deep venous thrombosis, and foreign body localization, characterization and removal. This review highlights these established indications, but primarily focuses on additional US applications for evaluation of the lower extremities, including diagnosis and characterization of arthritis and monitoring of therapy, evaluation of tendon tears and muscle strain injuries, characterization of soft-tissue masses and evaluation of certain congenital abnormalities of the lower extremities. Techniques for optimal utilization of musculoskeletal US in children are also discussed.
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Musculoskeletal Ultrasound in Physical Medicine and Rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-012-0003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Meyers AB, Laor T, Zbojniewicz AM, Anton CG. MRI of radiographically occult ischial apophyseal avulsions. Pediatr Radiol 2012; 42:1357-63. [PMID: 22825776 DOI: 10.1007/s00247-012-2453-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute avulsions of unossified ischial apophyses in children may go undetected on radiography. Therapy includes rest and rehabilitation; however, substantial displacement may require surgery. OBJECTIVE Our purpose is to illustrate the utility of MRI in the detection of these radiographically occult injuries in skeletally immature children. MATERIALS AND METHODS This retrospective study of more than 5 years included children with ischial avulsions who were evaluated with both radiography and MRI within 3 weeks of acute injury. Initially, radiographs were reviewed to identify those children with unossified ischial apophyses. Subsequently, their MRI examinations were assessed for physeal disruption, bone/soft tissue edema, periosteal/perichondrial elevation and disruption. Initial and follow-up radiographs (if available) were reviewed. Patient age, symptoms and offending activity were determined from clinical records. RESULTS Five children met inclusion criteria. All initial radiographs were normal. MRI showed: edema (n = 5), periosteal elevation (n = 4), periosteal/perichondrial disruption (n = 4), >5.5 mm displacement (n = 0). Follow-up radiographs in two children (2 and 2.5 months from MRI) showed osseous ischial irregularity. The apophyses remained unossified. CONCLUSIONS Acute unossified ischial apophyseal avulsions in children may be radiographically undetected. In the setting of correlative clinical symptoms, MRI can be used to identify these injuries and to help direct appropriate therapy.
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Affiliation(s)
- Arthur B Meyers
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039, USA
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Patil P, Dasgupta B. Role of diagnostic ultrasound in the assessment of musculoskeletal diseases. Ther Adv Musculoskelet Dis 2012; 4:341-55. [PMID: 23024711 PMCID: PMC3458614 DOI: 10.1177/1759720x12442112] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The wide availability and recent improvement in technology coupled with portability, low cost and safety makes ultrasound the first choice imaging investigation for the evaluation of musculoskeletal diseases. Diagnostic use of ultrasound findings is greatly enhanced by knowledge of the clinical presentation. Conversely, ultrasound skills with its prerequisite anatomical knowledge make the clinical diagnosis more precise and reduce uncertainty in the choice of therapy. Therefore, it is essential for rheumatologists to acquire ultrasonography skills in order to improve patient care. Ultrasound examination provides an excellent opportunity for patient education and to explain the rationale for therapy. This review summarizes the indications for musculoskeletal ultrasound and describes its role in diagnosis, monitoring and prognosis.
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Affiliation(s)
- Pravin Patil
- Southend University Hospital - Rheumatology, Prittlewell Chase, Westcliff-on-Sea, Essex SS0 0RY, UK
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