This document presents a series of pediatric chest x-ray cases for interpretation and learning. It discusses six cases, providing images and summaries of the findings. The cases include a clavicle fracture, congenital diaphragmatic hernia, normal thymic shadow, duodenal atresia, Hirschsprung's disease, and malpositioned lines and tubes. The goal is to promote mastery of chest x-ray interpretation through discussion of real cases submitted from various medical centers and countries.

1. Pediatric X-Rays of the Month
Bradley Harris, MD
Department of Pediatrics
Carolinas Medical Center & Levine Children’s Hospital
Mary Grady, MD, Faculty Editor
Michael Gibbs, MD, Lead Editor: Chest X-Ray Mastery Project
27th Case Series
2022

2. Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments, and now…
Tanzania and Brazil.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

3. Reading Systematically…
A: for airway
B: for bones
C: for cardiac silhouette
D: for diaphragm
E: for everything else
For more educational content, visit
EMGuidewire.com

4. Normal CXR
For Your
Reference

5. CASE 1:
15-hour-old female infant born at
term via vaginal delivery
complicated by shoulder dystocia.
What do you see?

6. CASE 1:
15-hour-old female infant born at
term via vaginal delivery
complicated by shoulder dystocia.
Non-displace left clavicle fracture.

7. CASE 2:
10-hour-old infant admitted to the
Newborn Nursery and breastfeeding
without difficulty; however, she later
develops respiratory distress and
hypoxemia requiring CPAP. Due to
concerns for a cardiac lesion, the infant
was started on a prostaglandin infusion
at 0.05 via an umbilical vein catheter,
with improved oxygenation.
What do you see?

8. CASE 2:
10-hour-old infant with respiratory
distress
Malpositioned inferior approach
central venous catheter which coils
over the heart and then extends to
the left heart margin. Enteric tube
terminates at lower esophagus.
Endotracheal tube in position. Mild
radiating streaky opacities which
may reflect surfactant deficiency,
infection, or retained amniotic fluid.
Ultimately, the patient is diagnosed
with transposition of great vessels.

9. Always Check Your Lines!

10. CASE 3:
20-hour-old infant with a normal
prenatal ultrasound and reassuring
exam; however, the patient’s heart
sounds are more prominent on the
right.
What do you see?

11. CASE 3:
20-hour-old infant prominent heart
sounds on the right.
Marked rightward mediastinal shift.
Left-sided congenital diaphragmatic
hernia with multiple air-filled loops of
bowels visualized in the left
hemithorax. Hypoplastic left and right
lungs.

12. CASE 4: 12-day-old with no past
medical history admitted for
bronchiolitis and found to have
atelectasis in the RUL two days
prior. A repeat CXR is obtained
given the lack of improvement of
the patient’s respiratory status.
What do you see?

13. CASE 4: 12-day-old with no PMH
admitted for bronchiolitis found
to have atelectasis in the RUL two
days prior. Repeat CXR obtained
given the lack of improvement in
respiratory status.
-Persistent mild RUL atelectasis
and reticular markings consistent
with bronchiolitis
-Normal cardiothymic silhouette
Remember the thymus! The
“mass” is normal thymic shadow.

14. An Approach:
Gasses: What is the bowel gas
pattern and is there air outside
of the bowel?
Masses: Check the
intrabdominal organs.
Bones: Are there fractures,
lesions, or malalignment?
Stones: Calcifications or foreign
bodies?
Leads & Lines: Check the tubes,
lines, and drains.
Let’s Talk About The
Abdomen!

15. CASE 5: 8-hour-old infant with
Trisomy 21 noted to have
projectile non-bloody non-bilious
emesis with every feed
What do you see?

16. CASE 5: 8-hour-old infant with
Trisomy 21 noted to have
projectile non-bloody non-bilious
emesis with every feed
Double Bubble! This is consistent
with duodenal atresia

17. CASE 6:
1-week-old term infant with trisomy
21. Over the last few days, the family
has noticed some constipation and he
was started on Pear Juice. Overnight,
he was noted to have worsening
abdominal distension and was made
NPO
What do you see?

18. CASE 6:
1-week-old term infant with trisomy
21 with abdominal distention.
Large, curvilinear/tubular lucency of
the right abdomen concerning for a
distal obstructive process. In addition,
there are bubble lucencies consistent
with stool vs. pneumatosis.

19. CASE 6:
1-week-old term infant with trisomy 21
with abdominal distention.
A follow up barium enema is consistent
with Hirschsprung's disease.

20. Summary of This
Month’s Diagnoses
• Clavicle Fracture
• Congenital Diaphragmatic Hernia
• Thymic Shadow
• Duodenal Atresia
• Hirschsprung’s Disease
• Lines and Tubes With Malpositioned
UVC and NG
For more educational content, visit
EMGuidewire.com