Wednesday, August 31, 2011

Olecranon Spur-Plain Film

Olecranon spurs are common in males who do heavy manual labor, such as heavy machine operators and saw-mill workers.

Pseudomyxoma peritonei-CT

The diagnostic CT criteria for pseudomyxoma peritonei are scalloping of the visceral surfaces (particularly the liver), septated ascites or ascites with attenuation slightly higher than that of water, and hypoattenuating peritoneal implants that may cause extrinsic pressure on the bowel loops.


Tuesday, August 30, 2011

Coronary CT Angiography- Anatomical Considerations



The left coronary artery (LCA) is also known as the left main. The LCA arises from the left coronary cusp. The aortic valve has three leaflets known as the left coronary cusp (L), the right coronary cusp (R) and the posterior non-coronary cusp (N). The LCA divides almost immediately into the circumflex artery (Cx) and left anterior descending artery (LAD). The right coronary artery arises from the anterior sinus of Valsalva and courses through the right atrioventricular (AV) groove between the right artium and right ventricle to the inferior part of the septum. In 65% of cases the posterior descending artery (PDA) is a branch of the RCA (right dominant circulation).  The PDA supplies the inferior wall of the left ventricle and inferior part of the septum. 






BRANCHES
Left Main or left coronary artery 
-Left anterior descending (LAD)
diagonal branches (D1, D2)
septal branches

-Circumflex (Cx)
Marginal branches (M1,M2)

Right coronary artery 
Acute marginal branch (AM)
AV node branch
Posterior descending artery (PDA)

Monday, August 29, 2011

MR Mammography-3.0 Tesla


Mammography on 3.0 T is brilliant with especially with Tx model and  fat suppression is complete, In this case 
there is only right axillary tail prominence which was felt on clinical and sonography.  





Retained Products of Conception Versus Differentials-MRI



A 30 yr old lady with history of dilatation and curettage few weeks earlier for early pregnancy, has presented with persistent vaginal bleeding. Sonography reveals a complex mixed echogenic intracavitary lesion in cervical region with   relatively normal  uterine cavity except for small leiomyoma . Endo-myometrial junction is normal . MRI has been done to delineate the lesion better as beta-HCG is mildly elevated. Case submitted by – DR MGK Murthy.



Teaching points
·         Retained products of conception are  easily picked up on MR imaging particularly in sagittal and on fat suppression with higher magnetic strength
·        In this case relatively normal uterine cavity with no tell tale sign of embryo having been harbored previously there, raises the possibility of   either  the pregnancy and evacuation is of  relatively longer history , OR       to start with it was  cervical  OR we are dealing with primary problem at cervix
·        Relatively raised beta-HCG again contributes to confusion as it should get back to normal in about 2 weeks after evacuation or go skyrocketing in trophoblastic neoplasm up to 1000mIU/ml
·          Contrast would add information without conclusion,    as b-HCG (slightly raised ) suggests , some  viable trophoblastic tissue in retained products and that would enhance
·        So what do we do?
·        We apply the famous law of TWO ( followed with great success !)
·        Just simply let them do conservative management/ reevacuation- leave  it to them and ask for review  sonography and MR after 2- 3 weeks  preferably along with b-HCG—will simply unravel the truth!!!!
·        Any takers or differing view points ??

Now Joint Commission issues Alert on Radiation Risk

The Joint Commission has issued a new Sentinel Event Alert urging organizations to take action to reduce repeated doses of radiation to patients from diagnostic radiation tests.  Several recent studies have raised concerns about the increased risk of cancer from diagnostic imaging, particularly in children, young adults and pregnant women. Full article can be accessed here- Becker's ASC REVIEW

Saturday, August 27, 2011

Post Dialysis-Subclavian Pseudoaneurysm


Clinical data: Pulsatile neck swelling following dialysis..


An oblong swelling measuring 6.3 x 5.8cm in the left root of neck showing relatively well defined walls and some stranding in the surrounding tissue with neck along with layering of contrast in the arterial phase within the lesion with neck of the lesion lying in relation to the left subclavian artery possibly indicating pseudoaneurysm of the left subclavian artery, possibly due to iatrogenic injury during dialysis cannula injection.

Friday, August 26, 2011

Future of CT technology -Interior Tomography

According to an article in Diagnostic Imaging- "Engineers at Virginia Tech – Wake Forest University and GE Global Research Center are developing a prototype cardiac CT scanner built on the concept of “interior tomography.” This concept calls for up to seven x-ray sources focused on a region of interest; in this case, the heart. The beams generate data that are processed to mathematically “skip” the bone and muscle that otherwise degrade image quality and necessitate high radiation dose."

Looks like we have something more to look forward in terms of technology from Conventional CT to Spiral CT to Multislice CT to Dual Energy Source CT to.... Future sure looks exciting.


Sumer's Radiology Site Featured on Webicina

Our weblog has been featured as one of the top radiology web 2.0 resources in a compilation by Webicina. We have been around as probably one of the oldest adapters of the web 2.0 technology in Radiology by starting this blog in 2004. It has been 7 years now and we have been featured in various newspapers, Journals and website, awards etc. Thank you all for active readership.


radiology and web 2.0

Thursday, August 25, 2011

Is this a fracture on the plain film?


There is this query which we all radiologists find in plain films in this era of MRIs and PETs and this section of ours is usually dealing with apparently innocuous questions like in this case “is this a fracture?” Professor Resident series by Dr MGK Murthy.


What is it?
There is vertical line across the metaphysis of 1st metatarsal with no significant soft tissue swelling or articular  abnormality

Is it fracture in view of history of injury ?
 No you can clearly see on invert image it is not identified and hence represents vessel

Any further imaging is needed?
No , we need to take radiological call  at this stage it is not fracture

 How to write  report?
There is vertical lucency seen across the middle of metaphysis of 1st Metatarsal  possibly representing  vessel with no soft tissue or joint involvement – represents vessel. However if there is local tenderness,  MRI / follow-up Xray after 2 weeks would help

Wednesday, August 24, 2011

Post Traumatic ICA dissection-CT angiography


Clinical data: 26 year old female, trauma followed by right sided weakness.

Cerebral & extracerebral CT Angiogram: was performed utilizing axial source images using multislice CT and  were reconstructed with multiple intensity projection algorithms to yield MPR and 3D of the carotid system. 


Angiogram images particularly the reconstruction images show abrupt tapering of the contrast column of left ICA which is confirmed on the axial images as well just beyond the bifurcation. Initial portion of ICA shows true and false lumen and beyond which contrast column is not visualized. These findings are consistent with post traumatic left ICA dissection. 

Contrast Reaction and Teleradiology

There is an interesting query raised in the Sep 2011 edition of American Journal of Roengtenology which discussed the liability issue of a teleradiology group reading radiology reads remotely with regards to the anaphylaxis and anaphylactoid reactions. This is what the debate starts as. Full article can be accessed at- AJR September 2011 197:W537doi:10.2214/AJR.10.5533

"Does a radiology group that pays to outsource contrast reaction coverage to another physician group (for example, emergency department physicians), on a “perclick” basis, paying those physicians to cover for any and all reactions on site while the radiologists interpret the radiologic studies remotely off site, expose the radiology group to increased risk medicolegally? Or is the risk decreased because most people would rather be resuscitated by an emergency department physician than by a radiologist."

Monday, August 22, 2011

Dilemma of a wife of a Radiologist



These are some things which play on the mind of the spouse of a radiologist about her husband’s profession usually. Shared here for pure humour.
1)      How can someone find reading black and white images so interesting? Why is he so passionate about stupid black-white films?
2)      Why are all gross diseases, “beautiful” to him? Well not in literal sense, we all rads love to see characteristic text book images and find them beautiful.
3)      Why does not he answer or why does he get confused when the airline staff is asking for a doctor on board?
4)      Why is his right-left orientation  bit different from rest of us?
5)      His job is supposed to be one of the lighter one in medicine, still he is working even from home on his big computers that he calls work stations.
6)      Is he a doc or computers guy, speaks their language talks of pixels, 3D data, image sets, bandwidth, internet speed, download, cache etc and sits in front of “workstation” dictates some jargon?
7)      Why is it so difficult to explain to my  non-medico friends that my husband is a teleradiologist? *&#$$$??
8)      He seems to observe everything so closely and noting minor changes from previous day is a norm with him.

Dear Radiologist friends-Anything else  your spouse finds difficult to understand?  Share here with other colleagues.


Reference -
Random talks with my wife. :-)

Basilar Artery Thrombosis-MRI


An adult male in sixth  decade , hypertensive, presents with loss of consciousness after prolonged intercontinental flight (Canada to India) with no deep venous thrombosis of the lower extremity or cardiac disease. MRI shows acute ischemia pons with no bleed, with MRA showing lack of flow signal of midthird basilar , possibly  due to atheromatous  thrombosis  with  Brainstem DWI  score of 6 suggesting  moderate prognosis. Case submitted by Dr MGK Murthy, Mr Hari om and Mr Sahadev Gupta.



Teaching points:

·         Basilar is formed  at pontomedullary junction
·         Most important branches are AICA, PCAs with internal auditory meatal arteries at times directly arising from it
·         Proximal and distal basilar blocks are due to embolism  usually, while middle third is typically  thrombotic

Posterior  Circulation Acute Stroke Prognosis: Early CT Score(PCASP-ECTS) is calculated with the help  of CTA source images :

(a)          Total is taken as 10 points , with 0= ischemia in all and 10 =No Ishaemia

(b)          1 point each deducted for hypoattenuation in Left/ Right Thalamus,L/R Cerebellum and L/R  PCA territory

(c)          2 points each deducted for hypoattenuation Midbrain/Pons


 A   2009  Study has suggested  pretreatment , baseline , Brain stem Diffusion weighted Imaging Score,  as independent clinical predictor for prognosis

(a)          Total  is taken as 22 points , with 0= No ischemia in posterior circulation  and 22= Whole Brainstem ischemia
(b)          No of arterial territories with abnormal Diffusion signal at each  brainstem level including  anteromedial, anterolateral, lateral, and posterior  regions  is calculated.
(c)          0-8 is allotted for medulla  and  mid brain , with pons 0-6 only.

Can radiologists take the front seat in patient care?


I believe we can by doing the following:

1)      Start playing central role in decision making in terms of imaging, we should be telling the clinicians about appropriate imaging required rather than waiting for his orders. 
2)      Communicate our findings to our colleagues verbally and in case discussions to prevent radiology being seen as a commodity rather than a specialty. Lets be Specialists not image readers.
3)      More and more of us should subspecialise  and make our reports valuable aid for the clinicians. We should be able to tell them more than they already know.
4)      Increasing participation in interventional radiology will also help.
5)      Following up our diagnosis with pathologists and findings with surgeons  will help us stay at our front seat as well.
6)      Upgrading ourselves at pace with the technology so that we continue to have that edge in terms of image interpretation.
7)      Participating in medical school education.

What are your thoughts on this? Do you think radiologists are back seat drivers or do you think they  can TAKE THE FRONT SEAT?

Pericardial fat and Coronary atherosclerosis-MRI



According to an article Published online before print August 16, 2011, doi:10.1148/radiol.11110346, Pericardial fat volume, rather than BMI and waist circumference, was more strongly related to plaque eccentricity as a measure of coronary atherosclerotic plaque burden. The results support the proposed role of pericardial fat in association with atherosclerosis. The coronary artery eccentricity (ratio of maximal to minimal coronary artery wall thickness) was determined by using magnetic resonance (MR) imaging and served as an index of plaque burden. The pericardial fat volume was determined by using computed tomography. 

Sunday, August 21, 2011

Functional MRI with motor strip activation.


An adult with  top frontoparietal  glioma, by imaging and MRS parameters  with no neurological deficit so far needs surgery. Functional MRI (fMRI) is ordered to delineate the motor strips. Motor strips on both sides are equally and adequately  delineated , with the lesion anteriorly located in relation to the ipsilateral strip. In addition, supplementary motor activation area in parasagittal location is identified in posterior and medial location to the lesion. Case submitted by Dr MGK Murthy, Mr Sahadev and Abdul Hamid.


Teaching points

·         fMRI is preneurosurgical investigation to localize eloquent cortices controlling language, motor, and memory functions   based on BOLD sequences i.e.-Blood level Oxygen dependent sequence  studying the mapping of oxygen extraction
·         Motor mapping is fairly reliable and easy to perform even for cognitively impaired patients , by simply doing finger tapping
·         Ideal is to perform cued motor movements of fingers/feet/and/or  tongue  depending on the location of the lesion
·         Shows spatial relationship between tumor and  motor activation area, contralateral motor activation and supplementary motor activation
·         It could be decreased on the  side of the lesion depending on the mass effect and vascularity
·         MR report should be specific and brief,  for example- Motor strip on the side of the  lesion is  seen medial/lateral to and anterior/posterior  to the  lesion. Supplementary motor activation is noted /absent. Activity appears decreased / same  as contralateral activity. Preferably film should depict sagittal and axial images.

Thursday, August 18, 2011

Brain in Situs Inversus may also be reversed-Interesting


While reporting a case of situs inversus, came across this very interesting note in Anat Embryol (Berl). 2003 Feb;206(3):199-202. Epub 2003 Jan 18 titled "Intracranial anatomic asymmetry in situs inversus totalis". According to the authors- "They examined the gross anatomy of an elderly cadaveric female for a possible "situs inversus" of the intracranial contents. This study has found that many structures commonly dominant on one side in the intracranial compartment were reversed in this specimen. These findings support the concept that a reversal of more commonly found intracranial anatomy may occur in situs inversus totalis, and this should alert the clinician performing invasive procedures in this population. "

Fibular osteosarcoma-Imaging


29 year old adult with pain in his leg. case submitted by Dr MGK Murthy, Mr Hari Om and Mr Sahadev.

Plain Film: There is large  ill defined , diffuse , grossly destructive , predominantly  bone forming  lesion seen involving the metadiaphyseal regions of fibula with wide zone of transition, large soft tissue swelling.  Possibility of primary bone tumor of malignant etiology at this stage.


Next most cost effective  investigation: Today MRI (preferably  with contrast)  combined with Fluorine (F18) bone scan is considered as the Platinum standard in Clinical Practice , as it would give us bone(CT in it), Chest (F18bone scan being whole body)(for excluding secondaries/infective focus), MR for Soft tissue evaluation, contrast for showing  soft tissue invasion of the tumor tissue

MRI findings:  It shows large, ill defined, mildly expansile and grossly destructive metadiaphyseal  lesion of fibula upperend with complete loss of Soft tissue  differentiation(suggesting involvement), with areas of new bone formation , and loss of periosteal definition.


MR is supposed to show non-mineralized tissue as intermediate on T1 and bright on T2, new bone formation as persistently low on all sequences, loss of tissue interfaces including intermuscular fat planes and presence of blood as varying heterogenous signals , along with sunburst appearance/codman’s triangle for periosteal contact etc. Other relevant features expected to helpfor surgery are vessel encasement and extension across the knee  joint  surface, and tibiofibular syndesmosis

Follow up: Chest X ray in this case was negative and bone Biopsy revealed Primary-bone forming malignant neoplasm – osteosarcoma  of possibly intramedullary variety .

Wednesday, August 17, 2011

Online Medical Games-New eLearning Method

Online games are now an effective learning method for healthcare as well. Philips has an online learning centre with  Clinical Challenge Medical Games.  Worth checking out.

Saturday, August 13, 2011

"Canned" Macro Errors-Frustrating at times


Other day, was talking to surgeon friend of mine, who was commenting on another radiologist saying that he was not good, and he said he sometimes had "prostate" n the female patients ultrasound. I just smiled as i knew this was not his fault and was to do with careless review of transcribed report and probably has happened to all of  us at some point of time in a busy practice. Another thing that  i find difficult to manage sometimes is gall bladder in post cholecystectomy status and uterus in post hysterectomy status. Somehow they manage to get onto the reports where should not have been.  Gradually, i replaced uterus/prostate with pelvic viscera to keep it safe. And made the GB line in macro as a blank line so that it does not go normal without my noting it. Although, on careful review it is obvious usually it is a typographical error, but trust me sometimes it is difficult to explain to a patient. Once a friend had a patient who had cholecystectomy and by mistake report had said gall bladder normal, and patient was suspicious that the surgeon did not remove it! and he had a hard time explaining. What are your views on this? All comments and experiences are welcome.

All that can be said is - 
"WE NEED TO BE CAREFUL & WE NEED MORE TRAINED RADIOLOGY ASSISTANTS!"

Thursday, August 11, 2011

Olecranon-Is this a fracture?


A child with injury and pain. Resident-Professor series by Dr MGK Murthy.



1.      What is  the finding
Well defined opacity seen in the tip of olecranon in the proximal part with no donor site or significant soft tissue abnormality.

2.      What is it?
At first look it looks like fracture. But absence of Soft issue and donor site should warrant other possibilities

3.      What are they?
Olecranon is known to  start  to ossify by secondary ossification centre between  9 -10 yrs and can appear up to 11 yrs.

4.      What about satellite opacity?
it could represent unusual bipartite or multipartite olecranon in some children

5.      Any other possibility?
Yes occasionally we get patella cubitus –sesamoid bone in the tendon of triceps which ultimately fuses with olecranon

6.      What will help now ?
Since then is no local tenderness we can wait for 2 weeks and repeat by the usual rule of Law of TWO- broken bone will never remain same density.

7.      Any role for cross sectional imaging?
MR would help but not mandatory as the treatment with this is conservative and  we have cost effective alternative of follow up xray.

Monday, August 08, 2011

7 Tesla MRI in Epilepsy-Extra-large Size may matter soon


In a recent online article in Radiology -- "Ultrahigh-field-strength MR imaging permitted detection of selectively greater Ammon horn atrophy in patients with Temporal lobe epilepsy and hippocampal sclerosis. Paucity of digitations is a deformity of the hippocampal head that was detected independent of hippocampal atrophy in patients with mesial TLE" 

Looks like soon 7-Tesla may become the new gold standard for Temporal Lobe Epilepsy.

Reference Published online before print July 11, 2011, doi:10.1148/radiol.11101651

How to decide on a Teleradiology Service Provider?




Telerad Providers are a leading teleradiology service provider based out of India.


1. Are the Radiologists reading your studies well qualified and have the subspecialist experience? 
We recently tied up with different centres in Indian subcontinent, once was looking for Cardiac CT reads and other was looking for second opinions on MRI studies.
2. Is the main radiologist the owner as well? 
Well particularly in India there are many software companies venturing into reading as well and usually lack the expertise and level of care a radiologist owner will give.
3 Key images added to report. 
We do this routinely and our referring centres love it.
4. Having dedicated radiologist assigned, this helps in building the trust and comfort of the referring physicians.
5. Web and cloud based software.  
We have our own cloud based dedicated server, which ensures  client access to reports all the time. 
6 Quality control process.

BMJ article questions benefit of mammography


Recent article published in the July, British Medical Journal, has raised some controversy by  comparing the reduction in breast cancer deaths from 1989 to 2006 in several Northern European countries and concluded that improved disease management – not mammography – could most likely be credited with the decrease in deaths. Responding to this in a joint statement  ACR and the Society of Breast Imaging concluded that study had several flaws. Detailed ACR statement

Sunday, August 07, 2011

Inferior Rectus Anomalies-MRI


8 yr old child with inability to look down   referred for MRI with clinical suspicion of inferior rectus anomaly. MRI shows hypoplasia of right inferior rectus belly compared with other muscles , possible accessory extraocular muscle just above it, with absence of left inferior rectus. Case submitted by Dr MGK  Murthy.




Teaching points

  • All extraocular  muscles have been described to be absent congenitally, with most common being inferior recti, superior recti, and superior oblique , in that order
  • Presence of accessory extraocular muscles with hypoplasia /aplasia  has recently been described. Associated with craniofacial  dysostosis, Neurofibromatosis , though isolated cases are common
  •  Symptoms could be Hypertropia on the affected side, with limited depression of more affected side 

Pulmonary Angiography- Beautiful 128 Slice CT images


An elderly male with clinically possible pulmonary embolism with wells score of 6.0,  undergoes Perfusion scan in nuclear medicine  which suspects underperfused apices possibly thrombotic . MDCT angio with 128 slices machine, shows attenuated and patent upper lobar arteries due to large bullous disease on account of COPD and that explains clinical breathlessness with MPA and the main branches completely patent. Case submitted by Dr MGK Murthy and Mr Shekhar (CT technologist)





Teaching points :

·         Definition of  Pulmonary embolism= Blockage of MPA or one of its branches
·         Incidence increases  with age and reaches about 300 cases per 100,000 population/yr in western world by 8th decade
·         Mortality in untreated reaches about 30% even today
·         D-Dimer test( a protein fragment found in blood after blood clot is degraded by thrombolysis)can practically rule out thrombus if negative
·         Nuclear medicine  role is reducing nowadays with  increased number of false positives  due to interlobar fissure, COPD, pneumonia, and atelectasis
·         MDCT angio with specific acquisition of images before the contrast reaches aorta(as in our case ), by placing  the bolus chase in Right ventricle , highly specific and sensitive  even in segmental branches
·         Radiation doses have significantly decreased over time  with average of 23-119 CXR equivalent , depending on the  No of slices machine and body habitus deciding the factors
·         False negative of MDCT is usually due to septic emboli(peripherally) and subsegmental defects
·         In our case 60 ml (serum creatinine was  marginally elevated and  test was done in view of positive perfusion scan and clinical  suspicion) of omnipaque at 5ml/ sec was injected with bolus chase in Right ventricle with saline chase of 30mlwith 4 ml/sec rate .

Friday, August 05, 2011

Possible jacoud’s arthropathy-Plain Xray


37 yr old known case of Lupus complaints of pain in pain in 3rd digit and Knee. Resident-professor series by Dr MGK Murthy



1.      What do they show?
PIP joint shows soft tissue shadow around the articulation  without joint widening or erosions or significant deformity
MCP joints are normal. Bone density is normal
Knee shows apparently reduced  joint space and soft tissues on medial aspect with focal lucency of lateral tibial condyle with reduced femoropatellar joint space as well

2.      How do we interpret?
In known case lupus, jacoud’s arthropathy is the first diagnosis to be considered

3.      What is it?
It is typically nonerosive, progressive, deforming polyarthropathy, typically involving MCP joints , PIP joints of digits , wrists and knees. It was originally described in  recurrent Rheumatic fever

4.      What is the difference with other Rheumatoid which is classical synovitis?
Yes , that is the point , it is non synovitis arthropathy. It has been proven on MR that there is no synovial inflammation or fluid or widened joint spaces , yet produces deformities

5.      How does it produce?
Ligament and muscle laxity along with atrophy plays the vital role

6.      what is unique in this case?
MCP joints are normal ,there is no significant deformities and soft tissues as well as muscles are not appreciably atrophied , lateral tibial condyle shows focal lucency with no segonds fracture

7.      How do we proceed and how do we explain?
The symptoms in this case are of short duration , and I presume , it is jacouds arthropathy  - very early  and needs  periodic review  to see the progress. Lucency of tibial condyle could be explained by steroid  effect or weight bearing symmetrical normal variant finding

8.      Would you advise MRI?
No it is clinically known case and radiologically not conflicting, and hence MR is not indicated. In fact what would help is  lab data including parat hormone levels, and periodic good quality digital X -rays of the joints involved 

Trigeminal Neuralgia-MRA

An adult with left trigeminal neuralgia on MRA shows a tortuous enlarged vascular loop of anterior inferior cerebellar artery pressing upon ipsilateral trigeminal nerve. This MRA was done by 3 Tesla MR scanner. Case submitted by Dr MGK Murthy, Mr Hariom, Mr Sahadev






 
Teaching Points :

• Trigeminal neuralgia (Tic Douloureux) is by definition intermitant shooting pain lasting from few seconds to less than 2 minutes, along the distribution of the trigeminal nerve.

• Commonest cause is an enlarged looping artery / vein pressing upon the nerve, others being multiple sclerosis / neoplasms / other space occupying lesions in  the vicinity.

• MRI along with MRA is considered as an ideal modality for delineation of the vessels.

• Anterior inferior cerebellar artery, a branch of the same, vertebral artery, superior cerebellar arteries are usually responsible for this syndrome.

• Commonest area of the contact is root entry zone of preganglionic segment  of the trigeminal nerve.

• Slow flow / Thrombous could occasionally be demonstrated.

• Coronal projection shows AICA vessels leading to the nerve with superior  cerebellar vessel in the cranial aspect.

Tuesday, August 02, 2011

Physiological periostitis versus Trampoline Injury-Plain Xray


Young child of 3 years with  trampoline injury (most common). Resident-Professor series by Dr MGK Murthy.


1. How do you read it?
AP is unremarkable
Lateral suggests symmetrical periosteal response
In view of history of trauma, it could suggest traumatic etiology

2. why not physiological periostitis of children?
Good question
Periosteum is biologically active in children throughout , but physiological periostitis(PP)  is known to occur exclusively in infants between 1- 6months only

3. How to confirm PP?
Simple  we follow law of two and do other  side X ray.

4. What about the stippled epiphysis both edges?
Since it is symmetrical and no physis is widening is suggested, it is likely to represent normal  growth process. Moreover the physis is not widened

5. Any other lesson to carry from this radiograph?
§  we need to keep the age of injury in mind and if it is more than 7 days, infective etiology needs to be kept in mind
§  dating of fractures in children is inexact science as brought out by extensive review in AJR.
§  Reasonable conclusion could be periosteal response could be seen as early as 4 days and is  present in at least 50% by 2 weeks  ,and remodeling peaks by 8 weeks
§  If there is associated corner or bucket handle fracture, child abuse needs consideration(10% of children younger than 5 years, brought to emergency room are victims of child abuse )

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