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Klaus Hahn

Sibylle Fischer
Atlas of
Isky Gordon Bone Scintigraphy
in the Developing
Paediatric Skeleton
The Normal Skeleton, Variants and Pitfalls

In Collaboration with
J. Guillet, A. Piepsz, I. Roca and M. Wioland
ccC: EANM m Under the Auspices of the Paediatric Task Group
EU'OD . . nA"oe,a.,onO.NUC.U .... ·,c,ne of the European Association of Nuclear Medicine

Foreword by David L. Gilday

With 283 Figures in 888 Separate Illustrations

Springer -Verlag
Berlin Heidelberg New York
London Paris Tokyo
Hong Kong Barcelona
Budapest
Prof. Dr. med. KLAUS HAHN
SIBYLLE FISCHER

Klinikum der Johannes Gutenberg-Universitat


Klinik und Poliklinik fur Nuklearmedizin
Postfach 3960, 0-55101 Mainz, Germany

ISKY GORDON, M.D.

The Hospitals for Sick Children


Department of Radiology
Great Ormond Street
London WC1N 3JH, United Kingdom

ISBN -13: 978-3-642-84947-3 e- ISBN -13: 978-3-642-84945-9


DOl: 10.1007/978-3-642-84945-9

Library of Congress Cataloging-in-Publication Data. Habn, K. (Klaus) Altlas of bone scintigraphy in


the developing paediatric skeleton: the \lormal skeleton, variants, and pitfalls/Klaus Habn, Sibylle
Fischer,Isky Gordon: in collaboration with J. Guillet... let al.]. p. cm. "Under the auspices of the
Paediatric Task Group of the European Association of Nuclear Medicine."
ISBN-!3:978-3-642-84947-3 1. Bones - Radionuclide imaging - Atlases. 2. Bone
diseases in children - Radionuclide imaging - Atlases. 3. Human skeleton - Abnormalities - Diagnosis
- Atlases. I. Fischer, Sibylle, 1961 -. n. Gordon, Isky. Ill. European Association of Nuclear Medi-
cine. Paediatric Task Group. IV. Title. [DNLM: 1. Bone and Bones - radionuclide imaging - atlases.
2. Bone Diseases - radionuclide imaging - atlases. 3. Bone Diseases - in infancy & childhood - atlases.
4. Bone Diseases - in adolescence - atlases. WE 17 H148a 1993] RJ482.B65H34 1993
618.92'7107575 - dc20 DNLM/DLC for Library of Congress 93-5678 CIP

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Foreword

Since the introduction of technetium -99m polyphosphate in 1972 by Dr.


M. Subramanian, bone scintigraphy has become an integral part of the evalu-
ation of paediatric musculoskeletal disorders. Using the current high-
resolution gamma cameras and technetium -99m MDP or DPD, the quality
of images that we interpret is very high. From the very earliest days, there has
been confusion over normal bone physiology as depicted by the bone
scintigram in paediatric patients. This has resulted in a number of difficulties
in detecting abnormalities, especially near the physes (growth zones).
Primary examples of abnormalities that might be confused with normal
activity are osteomyelitis, bucket handle fractures of the long bones, and
neuroblastoma and leukaemic metastases.
Early in the course of interpreting bone scintigrams in children, we
realized that there was a significant difference in the appearance of the physes
in the first years of life compared to that in the more mature child. The growth
zone is globular at birth and becomes discoid later in childhood. The process
is completed in about 2 years. The maturation of the physes varies con-
siderably, especially between males and females. As the growth zone fuses,
there is a blurring of the normal linear pattern until eventually the adult ap-
pearance emerges. The time at which this occurs varies according to the
child's degree of physical activity and its state of health and nutrition. As you
will see in this atlas, there is an obvious general pattern to the closure of the
growth zones. It is extremely important to understand this information so that
one can determine whether there is premature closure secondary to focal dis-
ease or therapy. It is extremely important too to be aware of the presence of
normal apophyses, sychondroses and sutures.
An important observation is that a child who ceases to use a limb for even
as little as 24h, particularly one who has not reached skeletal maturity, will
suffer a 50% reduction of bone activity in that limb. This can be due simply
to pain, even if it is not related to a musculoskeletal problem. In such cir-
cumstances, it is necessary to question the child or family carefully to deter-
mine whether or not there is a reason for the reduction in the use of that limb.
The purpose of this atlas is to familiarize diagnosticians with the normal
appearance of the skeleton in children of ages from the newborn to the young
adult. A good understanding of this progression of skeletal development is
extremely important, since one may otherwise misinterpret normal structures
as lesions and, vice versa, miss abnormalities by thinking they are normal. As
the majority of paediatric bone scintigrams are interpreted by nonpaediatric
nuclear physicians, the availability of this reference atlas should improve the
care of children.

The Hospital for Sick Children, DAVID L. GILDAY


Toronto/Canada

v
Contents

Introduction ........................................... 1
Chapter 1 Age 0- 6 Months 7
Chapter 2 Age 6-12 Months 17
Chapter 3 Age 1- 2 Years 29
Chapter 4 Age 2- 3 Years 41
Chapter 5 Age 3- 4 Years 57
Chapter 6 Age 4- 5 Years 75
Chapter 7 Age 5- 6 Years 89
Chapter 8 Age 6- 7 Years 103
Chapter 9 Age 7- 8 Years 119
Chapter 10 Age 8- 9 Years 135
Chapter 11 Age 9-10 Years 151
Chapter 12 Age 10-11 Years 169
Chapter 13 Age 11-12 Years 185
Chapter 14 Age 12-13 Years 201
Chapter 15 Age 13-14 Years 217
Chapter 16 Age 14-15 Years 233
Chapter 17 Age 15-17 Years 249
Chapter 18 Age 17-22 Years 263
Chapter 19 Knees ................................................ 273
Chapter 20 Hips ................................................. 293

VII
Orientation: On each page you will fmd a maximum of six images,
which are all located in the same order. If fewer than six images are dis-
played, then the numbering is as shown below.

1 4

2 5

3 6

VIn
Introduction
Introduction

The paediatric skeleton is in the process of maturing from birth to adult-


hood. This maturation involves the growth of every bone, whereby this
growth is principally located at the epiphyseal plates. Since the 99mTc bone
scanning agents are absorbed onto the hydroxyapatite, the bone scan
reflects active bone turnover. In the developing skeleton, the appearances
of the rapidly growing areas, are therefore, different at different stages of
maturation.
The members of the Paediatric Task Group of the European Associa-
tion of Nuclear Medicine (EANM) are all regularly consulted for their
opinion on bone scans obtained in their respective countries. It became
obvious that only physicians who were experienced in paediatric nuclear
medicine could recognise immediately the appearances of "normal" bone
scan. The crucial importance of maintaining high-quality bone images
was another feature which emerged as being important. This was the
stimulus that led the Paediatric Task Group to produce an atlas of bone
scintigraphy in the developing paediatric skeleton as one of its
collaborative projects.
To produce an atlas of the scintigraphic features of the usual devel-
oping skeleton, over 1700 bone scans considered normal were collected
from the following Peadiatric Nuclear Medicine Centres:
- Hospital for Sick Children, Department of Radiology, London, Great
Britain (Dr. Isky Gordon).
- Service de Biophysique, Centre Hospitalier d' Agen, Agen, France (Dr.
Jacques Guillet).
- Klinik und Poliklinik fUr Nuklearmedizin der UniversiHit Mainz,
Mainz, Germany (Professor Klaus Hahn).
- Hospital St. Pierre, Akademisch Ziekenhuis, Department of Radiology,
Brussels, Belgium (Professor Amy Piepsz).
- Hospital General Vall d'Hebron, Department of Nuclear Medicine,
Barcelona, Spain (Dr. Isabel Roca).
- Assistance Publique, Hospiteaux de Paris, Saint-Antoine, Service de
Medicine Nucleaire, Paris, France (Dr. Michel Wioland).
The authors selected repr-esentive images from the pool of images col-
lected by S. Fischer in the Department of Nuclear Medicine in Mainz,
Germany.

Patient Inclusion Criteria

No "normal" children underwent bone scans, so the scans included here


were rather from children who had undergone bone scintigraphy for
clinical reasons but in whom it was considered highly probable that the
skeleton was normal. The Paeadiatric Task Group of the EANM dermed
the following groups of children for inclusion: .
1. Focal symptoms thought to be due to bone pathology in a healthy
child, if the child did not have any skeletal pathology on follow-up,
and ifthe cause ofthe symptoms was found to lie outside the selekton.
This group underwent bone scans mainly for suspected infection or
trauma.

2
Introduction

2. Generalized symptoms: The bone scintigraphy was carried out if dia-


gnosis was not clear. Only those children were included, who had un-
dergone bone scans within 72 h after the onset of symptoms. All these
children were ambulatory and not confined to bed prior to the bone
scan. There was no alteration of skeletal metabolism or radionuclide
uptake. Clinical follow-up in all these children ensured that no child-
ren were included who were later found to have any malignancy or
bone pathology.
3. Known malignancy: Children with certain solid tumours, such as rhab-
domyosarcoma, teratoma, Wilms' and yolk sac tumours were included
only if the bone scan had been carried out prior to the administration
of any chemo-therapeutic agents. These patients were ambulatory
prior to and at the time of bone scintigraphy.
4. Localized benign bone tumours: Only those parts of the skeleton not
affected by the benign bone tumours were included.
5. Suspected fracture: If whole body images were obtained in those
children with suspected single acute fracture, the images from the non-
affected areas were included.
6. Children with localized pain, but without certain evidence of bone
disease: most of these children were suffering from backache.
7. Children with ichthyosis.
In age, the "normal children" ranged from neonates to 22-years-olds.

Materials and Methods

Technique. The radiopharmaceuticals 99mTc-methylene diphosphonate


(MOP; from various companies) or 99mTc-2,3-dicarboxypropane-l, 1-
diphosphonic acid (OPO; Behring). The dose used followed the recom-
mendations of the Paediatric Task Group of the EANM (Table 1).

Blood Pool Images. Static gamma camera images were completed with-
in 5 min ofthe injection. The minimum acquired count rate was 100000
counts. The maximum time per image was 3 min. Using whole body
scans, imaging was started directly after the injection of the radioisotope
using a scan speed of 30 cm/min.

Bone Scan Images. The images were acquired no sooner than 3h post
injection, with a minimum count rate of 50000 counts for hands and feet;
100000 counts for the knee joint; and 200000 counts for the skull. From
250000 to 500000 counts were acquired for images of the pelvis and the
remaining skeleton. Static images were acquired with an Elscint, Picker
or Siemens gamma camera, with the child lying directly on top of the head
of the gamma camera (Figs. 1,2).

Whole body scans were acquired with a speed of 8 cm/min in children up


to the age of 8 years; 10 cm/min in children ranging from 8 to 12 years;
and a scan speed of 12 cm/min in children ranging from 12 to 16 years;

3
Introduction

Table 1

ediatric Task Group

3 g . 01 050 2 kg. 0 78

4 kg 014 053 4 kg 080

g .. 019 2 kg 0.5 kg-082

8 g . 023 28 kg 058 48 g. 0 85

10 kg • 027 30 kg 062 50 kg - 088

12kg - 032 32 kg. 0 5 5254 kg - 0 90

34kg 0 8 5 56 kg. 0 92

16 g . 0,40 3 kg 071 6062 kg - 0

18 kg 0 38 9 073 6466 kg - 0 98

20 g - 04 40 9 076 68kg.099

Recommend d Adult and Mmimum Amount m MBq

Radloph rm c ut cal

4
Introduction

Fig.

Fig.

beyond this age, the scan speed was 15 cm/min. Whole body scans were
required on an Elscint or Siemens system.
Sedation. There was no routine sedation. If required, mild sedation with
Dominal (prothipendyl) Or Dormicum (midazolam) was used.

Immobilisation. Various techniques were used for immobilisation, as


shown in Figs. 3 and 4.

5
Introduction

Fig. 3

Fig. 4

Hard-copy Recording. The primary images were recorded on X-ray film


or photographic paper. All selected images were prepared in the same
filmlaboratory in the KIinik fUr Nuklearmedizin, University Hospital,
Mainz, Germany (head of department, Mrs. A. Keuchel).

Chapters 1-18 show blood pool images and bone scans of all parts of the
skeleton in different age groups. In the hips and knees, different patholo-
gies occur at different ages, and the scintigraphic features are clinically
important. For this reason, Chaps. 19 and 20 are concerned with these
areas, whereby most of the images shown here can also be seen in the
Chaps. 1-18 under the appropriate age grouping.

6
1: Age 0-6 Months
1: Age 0-6 Months Blood Pool Images

Fig. 1. Posterior view of skull,


upper limbs and thorax

Fig. 2. Posterior view of


spine, pelvis and lower limbs 2

Technical Comments
- Note the sagittal suture in the skull in Fig. 1
- Note extravasation of isotope at the site of injection in the scalp in
Fig. 1

8
Skull and Thorax 1: Age 0-6 Months

Fig. 4. Posterior view of skull,


4 thorax and upper limbs

Fig. 2. Right lateral view of skull


2 5 and anterior view of thorax and
upper limbs

Fig. 5. Left lateral view of skull


and anterior view of thorax and
upper limbs

Technical Comments
The coronal suture is seen in Figs. 2 and 5, note the difference in up-
take between the left and right sides
The transverse sinus is clearly seen in Fig. 4
Note the increased activity at the growing ends ofthe bone, i. e. costo-
chondral junctions and the epiphyseal plates of the upper humeri
The indistinct lateral aspects of the ribs in Fig. 4 are due to "shine
through" from the costa-chondral junctions

~ Potential Pitfalls
Decreased activity is noted in the region of the anterior fontanelle in
Figs. 2 and 5. This should not be mistaken for a depressed fracture of
the skull
Posterior thorax shows increased activity laterally in Fig. 4 which
should not be mistaken for multiple rib fractures. This increased acti-
vity is not in line with the posterior ribs and is due to the increased
activity from the costa-chondral junctions

9
1: Age 0-6 Months Skull, Thorax, Upper Limbs and Pelvis

Fig. 1. Anterior view of skull


and thorax 4

Fig. 4. Posterior view of skull,

-
thorax and upper limbs

Fig. 2. Right lateral view of


skull, right upper limb and anteri- 2 5
or view of thorax

Fig. S. Left lateral view of skull,


left upper limb and anterior view
of thorax

Fig. 3. Anterior view of thorax,


pelvis and upper limbs 3

Technical Comments
At this age the upper limbs may be imaged either with the skull (Figs.
2 and 5) or thorax (Fig. 3). Good positioning allows clear separation of
the distal radius from the ulna
- Note extravasation of isotope at the site of injection in the scalp in Fig.2

~ Potential Pitfalls
- Decreased activity in the region of the anterior fontanelle in Figs. 2 and
5 should not be mistaken for a depressed fracture of the skull
- Increased activity seen laterally in Fig. 4 should not be mistaken for
multiple rib fractures. This increased activity is not in line with the
posterior ribs and is due to the increased activity in the region of the
costo-chondral junctions. Also see p. 9
10
Skull, Thorax, Spine and Pelvis 1: Age 0-6 Months

Fig. 1. Left lateral view of skull


and anterior view of thorax

Fig. 2. Left lateral view of skull,


2 anterior view of thorax and upper
limbs

- ...
Fig. 3. Anterior view of thorax,
3 spine and pelvis

Technical Comment
- Note the clarity of the lower lumbar spine on the anterior view in Fig. 3

~ Potential Pitfall
Note the difference in activity in the coronal sutures in Figs. 1 and 2.
This variation makes the diagnosis of suture fusion difficult

11
1: Age 0-6 Months Thorax and Pelvis

Fig. 1. Right anterior oblique


view of thorax and pelvis

Fig. 2. Left anterior oblique view


of thorax and pelvis 2

Technical Comments
- The sternum is well seen in both images
- Note the high activity in the full bladder in Fig. 1
- The anterior view of pelvis should not be obtained at the same time as
the oblique views of the thorax

12
Thorax, Spine, Pelvis and Upper Limbs 1: Age 0-6 Months

Fig. 1. Posterior view of thorax,


spine, pelvis and upper limbs

Fig. 2. Posterior view of thorax,


spine, pelvis and upper limbs

Fig. 3. Posterior view of thorax,


3 spine, pelvis and upper limbs

Technical Comments
The epiphysis of the scapula is seen in Fig. 2
Note the difference in renal excretion, in Fig. 2 both kidneys are clear-
ly seen, this is within normal limits
Note lack of differentiation between distal radius and ulna due to poor
positioning of the hands in all images

~ Potential Pitfall
Note the loss of clarity of the ribs in the axilla on all three images. This
is due to the increased activity at the costo-chondraljunctions and is not
pathological

13
1: Age 0-6 Months Spine, Pelvis and Lower Limbs

Fig. I. Anterior view of spine


and pelvis

Fig. 2. Anterior view of pelvis


and lower limbs

Fig. 3. Anterior view of pelvis


and lower limbs

Technical Comments
The full bladder in Figs. 1 and 3 precludes adequate visualization of the
hips
- Note in Fig. 2 that the feet are facing laterally whilst in Fig. 3 the toes
are facing medially, "the radiographic neutral position". This is the rea-
son that the fibulae are clearly seen in Fig. 3 but not in Fig. 2

14
Thorax, Spine, Pelvis and Lower Limbs 1: Age 0-6 Months

Fig. 1. Posterior view of thorax,


1 spine and pelvis

Fig. 2. Posterior view of pelvis


2 and lower limbs

Fig. 3. Posterior view of pelvis


3 and lateral view of lower limbs

Technical Comments
Urine contamination of the nappy below the pelvis is seen in Fig. 2
Fig. 3 shows the projection which is required for images of the feet, this
position is not ideal for imaging the knees (see Chap. 19: Knees)

15
1: Age 0-6 Months "Babygram" Views

Fig. I. Posterior view of thorax,


spine, pelvis and lower limbs 1

Fig. 2. Left lateral view of skull


and posterior view of upper limbs, 2
thorax, spine and pelvis

Technical Comments
It is tempting to obtain whole body imaging on a large field of view
gamma camera at this age. The quality of the images is unacceptable
Spot images, with appropriate patient positioning and use of magnifi-
cation, is preferable

16
2: Age 6-12 Months
2: Age 6-12 Months Blood Pool Images

Fig. I. Posterior view of skull


and thorax

Fig. 2. Left lateral view of skull


and posterior view of thorax 2

Fig. 3. Right lateral view of skull


and posterior view of thorax 3

Technical Comments
Note the clarity of the venous sinuses on all the views
The "hot" epiphyseal plates at the upper ends of the humeri are also
clearly seen, this is normal

18
Blood Pool Images 2: Age 6-12 Months

Fig. 1. Posterior view of thorax,


1
spine, pelvis and upper limbs

Fig. 2. Posterior view of thorax,


2 spine, pelvis and upper limbs

Fig. 3. Posterior view of thorax,


3 spine and pelvis

Technical Comments
- Fig. 3 is an image 1 minute after the injection of tracer since no activi-
ty is yet seen in the bladder, while Figs. 1 and 2 are at 4-5 minutes with
activity noted in the bladder
Fig. 2 shows a photon deficient area above the left kidney. This is due
to a full stomach

~ Potential Pitfall
- Curvilinear radioactivity between and below the kidneys in Fig. 2 is
probably due to the tortuous ureter, this is normal

19
2: Age 6-12 Months Blood Pool Images

Fig. 1. Posterior view of pelvis


and lower limbs 1

Fig. 2. Posterior view of pelvis


and lateral view of lower limbs 2

TechniCal Comments
- Note the normal increased perfusion of the epiphyseal plates of the
lower limbs
The position of the lower limbs in Fig. 1 is ideal for the knees and tibiae
while in Fig. 2 the position is ideal for the feet
- Bladder activity is noted in Fig. 2

20
Skull, Thorax and Upper Limbs 2: Age 6-12 Months

Fig. 1. Anterior view of skull


4
and thorax

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of skull,


5 left upper limb and posterior
view of thorax

Fig. 5. Left lateral view of skull,


right upper limb and posterior
view of thorax

Technical Comment
- Note the difference between the coronal sutures on the lateral images
in Figs. 2 and 5

~ Potential Pitfalls
- Fig. 1 shows asymmetry in the activity of the skull vault. This is due to
rotation and should not be mistaken for a subdural haematoma
- Focal increased activity is seen over the ribs laterally of Figs. 2,4 and 5,
this is due to activity from the costo-chondral junctions (see pp.9 and
10)

21
2: Age 6-12 Months Skull, Thorax and Upper Limbs

Fig. 1. Anterior view of skull


and thorax 4

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of


skull, right upper limb and right 2 5
anterior oblique view of thorax

Fig. 5. Left lateral view of skull,


left upper limb and anterior
view of thorax

Technical Comments
Focal increased activity is seen over the ribs laterally in Fig. 4, this is
due to activity from the costo-chondral junctions (see p. 21)
Note extravasation of isotope at the site of injection in the left elbow in
Fig. 5

22
Skull, Thorax, Pelvis and Upper Limbs 2: Age 6-12 Months

Fig. 1. Left lateral view of skull,


anterior view of thorax and
both upper limbs

Fig. 2. Anterior view of thorax


and spine

Fig. 3. Anterior view of thorax,


spine, pelvis and upper limbs

Technical Comments
Note the position of the upper limbs in Fig. 1 versus Fig. 3, both are ade-
quate at this age
- There is variability in the ossification of the sternum. The entire ster-
num is clearly seen in Fig. 2. This is not true in Fig. 1 or Fig. 3 (Note
also Fig. 1, p. 21; Figs. 1 and 5, p. 22; Figs. 1 and 4, p. 24)
- In Fig. 3 the anterior thorax is obliquely positioned and the bladder is
full of activity. These factors make this image difficult to interpret

~ Potential Pitfall
- There is asymmetry between the kidneys in Fig. 3, with the right kid-
ney having more activity than the left, this is a variation of normal

23
2: Age 6-12 Months Skull and Thorax

Fig. 1. Right anterior oblique


view of thorax 4

Fig. 4. Left lateral view of skull,


left anterior oblique view of
thorax and upper limbs

Technical Comment
Fig. 4 is of poor quality because of the slight movement causing blurring
of the upper limbs. The distal left radius and ulna overlie the skull, this is
not ideal.

24
Thorax, Spine and Pelvis 2: Age 6-12 Months

Fig.I. Posrerior view of thorax


1 and spine

Fig. 2. Posterior view of thorax,


2
spine, pelvis and upper limbs

Fig. 3. Posterior view of thorax,


3 spine, pelvis and upper limbs

Technical Comments
Note the different positioning of the upper limbs, this results in varia-
tion of the appearances of the scapulae in Fig. 1 compared with Fig. 2
The renal activity is different between the two kidneys in Figs. 2 and 3.
These appearances are within normal limits

~ Potential Pitfall
Focal patchy increased activity is noted in the lateral aspect of the ribs
in all images. This is due to the normal increased activity in the costo-
chondral junctions "shining through" on this projection

25
2: Age 6-12 Months Spine, Pelvis and Lower Limbs

Fig. I. Anterior view of pelvis


and upper portion of lower limbs 1 4

Fig. 4. Posterior view of spine,


pelvis and upper portion of lower
limbs

Fig. 5. Posterior view of pelvis


and lower limbs 5

Technical Comments
Urine contamination medial to the left femur is seen in Fig. 5
Fig. 1 shows good positioning of the left knee and foot, this allows
visualization of the left fibula. The fibula is not seen on the right due to
poor positioning of both the knee and the foot, the same is seen in Fig. 5

26
Lower Limbs 2: Age 6-12 Months

Fig. I. Anterior view of lower


1 4 limbs and feet

Fig. 4. Posterior view of lower


limbs

Fig. 2. Lateral view of lower


2 5 limbs and feet

Fig. S. Posterior view of lower


limbs and feet

Technical Comments
- Note the shape of the epiphyseal plates around the knees
- Fig. 1 shows good positioning of the right knee and foot, this allows
visualization of the right fibula. The fibula is not seen on the left due to
poor positioning of both the knee and the foot, the same is seen in Fig. 5
- Fig. 2 is a lateral view of the lower limbs, this is good for the feet but
inadequate for the knees

27
3: Age 1-2 Years
3: Age 1-2 Years Blood Pool Images

Fig. 1. Posterior view of skull


and thorax 4

Fig. 4. Posterior view of thorax,


spine and pelvis

Fig. 2. Posterior view of lower


limbs 2 5

Fig. 5. Posterior view of lower


limbs

Technical Comments
- Note the photon deficient area above the left kidney in Fig. 4 due to a
full stomach
- Slight rotation of the head in Fig. 1 causes an apparent deviation of the
sagittal sinus

30
Blood Pool Images 3: Age 1-2 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note rotation of the head causing apparent deviation of the sagittal
sinus
Note extravasation of isotope at the site of injection in the right hand
Marker on child's right side

31
3: Age 1-2 Years Whole Body Scan

- A single headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

32
Skull,'Thorax and Upper Limbs 3: Age 1-2 Years

Fig.i. Posterior view of skull and


4 thorax

Fig. 4. Posterior view of skull


with chin down and thorax

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
- Note the different appearances of the skull in the posterior projection
dependent on the degree of flexion ofthe head (see p. 34)
- Note the clear separation of the distal radius and ulna in Figs. 2 and 5
- The anterior ribs and sterno-clavicular joints are well seen Figs. 2 and 5
The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

33
3: Age 1-2 Years Skull, Thorax and Upper Limbs

Fig. I. Posterior view of skull


and thorax 4

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
- Note the different appearances of the skull in the posterior projection
dependent on the degree of flexion of the head (see p. 33)
- The anterior ribs and sterno-clavicular joints are well seen in Figs. 2
and 5
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly
- Note extravasation of isotope at the site of injection in the right elbow
in Fig. 2

34
Thorax and Spine 3: Age 1-2 Years

Fig. 1. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


2 5 and spine

Fig. 5. Anterior view of thorax


and spine

Technical Comments
The variability in sternal ossification is clearly seen
The lumbar vertebrae are very clearly seen in Figs. 1 and 5. This appea-
rance on the anterior thoracic view of the lumbar spine will be seen on
other anterior thoracic images
The different positions of the upper limbs in the three illustrations re-
sult in the scapulae having a different appearance on the illustrations

35
3: Age 1-2 Years Thorax and Spine

Fig. 4. Posterior view of thorax


and spine 4

Fig. 2. Anterior view of thorax


and spine 2 5

Fig. S. Posterior view of thorax


and spine

Fig. 6. Posterior view of thorax


and spine 6

~ Potential Pitfall
Increased activity in the lateral aspect of the ribs posteriorly best seen
in Figs. 4 and 6 are due to the nonnal increased activity in the costo-
chondral junction clearly seen in Fig. 2

36
Thorax and Spine 3: Age 1-2 Years

Fig. 1. Right anterior oblique


4
view of thorax

Fig. 4. Left anterior oblique view


of thorax

Technical Comment
- Note the variability in sternal ossification

37
3: Age 1-2 Years Pelvis and Femora

Fig. I. Anterior view of pelvis


and femora 1 4

Fig. 4. Posterior view of pelvis


and femora

Fig. 2. Anterior view of pelvis


and femora 2 5
Fig. 5. Posterior view of pelvis
and femora

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 1 and 2

38
Hips 3: Age 1-2 Years

Fig. I. Pinhole view of right hip


1
Fig. 4. Pinhole view of left hip

39
3: Age 1-2 Years Lower Limbs

Figs. I. Posterior view of lower


limbs and feet 4

Figs. 4. Anterior view of lower


limbs and feet

Figs. 2. Lateral view of lower


limbs and feet 2 5

Figs. S. Lateral view of lower


limbs and feet

Technical Comments
Figs. 1 and 4 are good positioning for the knees, tibia and fibula. The
fibula is clearly seen separate from the tibia
Figs. 2 and 5 are the position for imaging the feet. This position is inad-
equate for the knees since there is overlapping of the epiphyseal plates
of the tibia and fibula

40
4: Age 2-3 Years
4: Age 2-3 Years Blood Pool Images

Fig. 1. Posterior view of skull


1 2
and upper limbs

Fig. 4. Left lateral view of skull

Fig. 2. Posterior view of thorax


and spine 3

Fig. 3. Posterior view of spine,


pelvis and lower limbs 4

Technical Comments
Note the venous sinuses in Fig. 1
Focal accumulation of isotope in the mid portion of the image in Fig. 3,
this is due to isotope in the bladder
Note extravasation of isotope at the site of injection in the left hand in
Fig. 1

42
Blood Pool Images 4: Age 2-3 Years

Fig. 1. Posterior view of pelvis


and upper part of lower limbs

Fig. 2. Posterior view of lower


2 part of lower limbs

Fig. 3. Posterior view of lower


3 part of lower limbs

Technical Comments
Note the vascularity of the epiphyseal plates showing up as areas of
increased uptake of tracer
Bladder activity in Fig. 1 is noted

43
4: Age 2-3 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note rotation of the head causing apparent deviation of the sagittal
sinus
Note extravasation of isotope at the site of injection in the left hand
Marker on child's right side

44
Whole Body Scan 4: Age 2-3 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior
view
- Right image is the posterior
view

Technical Comments
Note rotation of the head causing asymmetry
Note extravasation of isotope at the site of injection in the left hand
Marker on child's right side

45
4: Age 2-3 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

...

• •

Technical Comments
Note the full bladder, not an ideal situation
- Marker on child's right side

46
Skull,Thorax and Upper Limbs 4: Age 2-3 Years

Fig. I. Anterior view of skull and


1 4 thorax

Fig. 4. Posterior view of skull and


thorax

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
Focal increased activity is noted in the 4th finger of the left hand due to
extravasation of isotope at the site of injection in Fig. 5
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

47
4: Age 2-3 Years Skull, Thorax and Upper Limbs

Fig. 4. Posterior view of skull


4
and thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
- Note the rather poor positioning of the hands in all three figures com-
pared to the images on p. 47
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

48
Thorax and Spine 4: Age 2-3 Years

Fig. 1. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


5 and spine

Fig. 5. Anterior view of thorax


and spine

Technical Comments
Note the right kidney in Fig. 2, this is within normal limits
Note the clarity with which the lower lumbar spine is seen on all three
images

49
4: Age 2-3 Years Thorax and Spine

Fig.t. Posterior view of thorax


and spine 1

Fig. 2. Posterior view of thorax


and spine 2

~ Potential Pitfall
The focal increased activity noted in the mid portion of the posterior
ribs best seen in Fig. 1 is due to activity from the costo-chondral junc-
tions and should not be mistaken for a rib fracture. This is also seen in
Fig. 2

50
Thorax and Spine 4: Age 2-3 Years

4 Fig.!. Right anterior oblique


view of thorax

Fig. 4. Left anterior oblique view


of thorax

5 Fig. 2. Right anterior oblique


2
view of thorax

Fig. S. Left anterior oblique view


of thorax

Technical Comments
The sternum continues to show its variation but all sternal ossification
centres are now present
In Fig. 2 a small amount of activity is noted in the kidney to the left of
the midline, this is normal

51
4: Age 2-3 Years Spine, Pelvis and Femora

Fig. I. Anterior view of pelvis


and femora 1

Fig. 2. Anterior view of spine,


pelvis and femora 2

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 2

52
Spine, Pelvis and Femora 4: Age 2-3 Years

Fig. I. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine,


2 pelvis and femora

Fig. 3. Posterior view of pelvis


3 and femora

Technical Comment
Note that the bladder is virtually empty on all three images, an ideal
situation

53
4: Age 2-3 Years Hips
Fig.i. Pinhole view of right hip

Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip

Fig. 5. Pinhole view of left hip

54
Pelvis, Lower Limbs and Feet 4: Age 2-3 Years

Fig. I. Anterior view of pelvis


1 4
and lower limbs

Fig. 4. Posterior view of lower


limbs

Fig. 2. Anterior view of tibia,


2 5 fibula and feet

Fig. 5. Posterior view of tibia and


fibula

Fig. 3. Lateral view of lower


3 limbs and feet

Technical Comments
Note the clarity of the fibula separate from the tibia in Figs. 1, 2, 4
and 5. This is due to the "radiographic neutral position" of the feet
Lateral views of the feet (Fig. 3) are inadequate for the evaluation of the
knees

55
5: Age 3-4 Years
5: Age 3-4 Years Blood Pool Images

Fig. I. Posterior view of skull


and thorax 1

Fig. 2. Right lateral view of skull


and anterior view of thorax 2 5

Fig. 5. Left lateral view of skull


and anterior view of thorax

Technical Comment
- Note the high activity in the venous sinuses on all images

58
Blood Pool Images 5: Age 3-4 Years

Fig. 1. Posterior view of thorax


1 and spine

Fig. 2. Posterior view of spine


2 and pelvis

Fig. 3. Posterior view of pelvis


3 and lower limbs

Technical Comment
- Note activity in the bladder in Fig. 3

59
5: Age 3-4 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the right hand
Urine contamination below the pelvis is seen on the anterior view
Marker on child's right side

60
Whole Body Scan 5: Age 3-4 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
The left foot is well positioned, with the toes turned inward allowing
good visualization of the fibula
Note extravasation of isotope at the site of injection in the right hand
Marker on child's right side

61
5: Age 3-4 Years Skull, Thorax and Upper Limbs

Fig.1. Anterior view of skull


4
Fig. 4. Posterior view of skull and
thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
- Note the clear visualization of the coronal sutures on both lateral skull
images, compare these to the poor visualization of the sutures seen on
the next page (Figs. 2 and 5, p. 63)
- Note extravasation of isotope at the site of injection in the right hand in
Fig. 2
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

62
Skull, Thorax and Upper Limbs 5: Age 3-4 Years

Fig. 1. Anterior view of skull and·


4
thorax

Fig. 4. Posterior view of skull and


thorax

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
Note the poor visualization of the coronal sutures on both lateral skull
images, compare these to the clarity of the sutures seen on the previous
page (Figs. 2 and 5, p. 62)
Note extravasation of isotope at the site of injection in the right elbow
in Fig. 2
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

63
5: Age 3-4 Years Skull, Thorax and Spine

Fig.I. Anterior view of thorax


and spine 1 4

Fig. 4. Left lateral view of skull


and anterior view of thorax

Fig. 2. Anterior view of thorax


and spine 2 5

Fig. S. Anterior view of thorax


and spine

Technical Comments
Fig. 1 shows activity in the thyroid gland and also in the stomach due
to free 99m-Tc-pertechnetate. This is rather unusual but does occasio-
nallyoccur
Fig. 1 shows the lower lumbar spine to good advantage
Note variation in sternal ossification

64
Skull, Thorax, Spine and Upper Limbs 5: Age 3-4 Years

Fig. 1. Right lateral view of skull,


4
posterior view of thorax, spine
and upper limbs

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax


2 5 and spine

Fig. S. Posterior view of thorax


and spine

Technical Comments
With the upper limbs elevated in Figs. 2 and 5, the scapula clears the
thorax and is well seen
Poor positioning of the hands is noted in Fig. I

65
5: Age 3-4 Years Thorax

Fig.l. Left anterior oblique view


of thorax

Fig. 2. Left anterior oblique view


of thorax 2

66
Spine, Pelvis and Femora 5: Age 3-4 Years

Fig. I. Anterior view of spine,


1 4
pelvis and femora

Fig. 4. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine and


2 5 pelvis

Fig. 5. Anterior view of pelvis


and femora

Technical Comments
Note the clarity of the lower lumbar spine on all images
The bladder in Fig. 4 is of relatively large volume but has little activity
suggesting that the child is well hydrated. The other three images show
high activity and low volume bladders. This is not recommended
Urine contamination below the pelvis is seen in Figs. 2,4 and 5

67
5: 'Age 3-4 Years Spine, Pelvis and Femora

Fig. 1. Posterior view of spine,


pelvis and femora 4

Fig. 4. Posterior view of spine,


pelvis and femora

68
Hips 5: Age 3-4 Years

Fig. 1. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

Fig. 3. Pinhole view of right hip


3 6
Fig. 6. Pinhole view of left hip

Technical Comments
- Different size of pinhole inserts give different degrees of magnification
- The position of the hips in the bottom series (Figs. 3 and 6) is not as
good as in the top two. This is related to the positioning of the knees
and the lack of intuming of the feet. "The radiographic neutral positi-
on" of the feet and knees is essential when doing pinhole views of the
hips

69
5: Age 3-4 Years Lower Limbs

Fig. 1. Posterior view of femora


1 4
and knees

Fig. 4. Posterior view of lower


limbs

Fig. 2. Posterior view of knees,


2 5
tibia, fibula and ankles

Fig. 5. Posterior view of lower


limbs

Technical Comment
The clarity of the fibula on all the images suggests good positioning of
the feet

70
Knees 5: Age 3-4 Years

Fig. 1. Anterior view of knees


4
Fig. 4. Posterior view of knees

Fig. 2. Anterior view of knees


2

71
5: Age 3-4 Years Knees

Fig. I. Lateral view of right knee


and foot

Fig. 2. Anterior pinhole view of


right knee 2 5

Fig. S. Anterior pinhole view of


left knee

. ..

Technical Comment
- The pinhole projections are rather infrequently required clinically

72
Tibia, Fibula and Feet 5: Age 3-4 Years

Fig. I. Posterior view of tibia,


fibula and ankles

Fig. 2. Lateral view of feet


2

73
6: Age 4-5 Years
6: Age 4-5 Years Blood Pool Images

Fig. 1. Posterior view of skull


1 4
Fig. 4. Posterior view of thorax
and spine

Fig. 2. Anterior view of spine


and pelvis 2 5

Fig. 5. Posterior view of spine


and pelvis

Fig. 3. Anterior view of femora


and knees 3

Technical Comments
- The photon deficient area above the left kidney in Fig. 4 represents the
stomach full of food. This is also seen in Fig. 2 immediately above the
left kidney
- Fig. 2 shows focal accumulation of isotope above the bladder on the
left, this may be in the ureter

76
Blood Pool Images 6: Age 4-5 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Isotope is seen in both ureters
The full stomach is seen as a photon deficient area on the anterior view
above the left kidney
Note extravasation of isotope at the site of injection in the right hand
Marker on child's right side

77
6: Age 4-5 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
The left foot is better positioned than the right, with the toes turned
inward allowing good visualization of the fibula
Diffuse parenchymal renal activity is seen, no pathological cause was
evident
Note extravasation of isotope at the site of injection in the left elbow
Urine contamination below the pelvis is seen on the anterior view
Marker on child's right side

78
Skull and Upper Limbs 6: Age 4-5 Years

Fig. 1. Anterior view of skull


1 4
Fig. 4. Posterior view of skull and
thorax

Fig. 2. Right lateral view of skull


2 5 and right upper limb
'.'
Fig. 5. Left lateral view of skull
and left upper limb

Technical Comments
- Note the poor positioning of the left hand in Fig. 5, the thumb cannot
be seen
- The coronal sutures are indistinct in Figs. 2 and 5, this is a variation of
normality
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

79
6: Age 4-5 Years Skull and Upper Limbs

Fig. 4. Posterior view of skull


and thorax 4

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. S. Left lateral view of skull


and left upper limb

Fig. 3. Left lateral view of skull


and both upper limbs 3

Technical Comments
- Fig. 3 shows the difficulty of attempting to image both hands simulta-
neously. Imaging of the right upper limb with the right lateral skull and
the left upper limb with the left lateral skull is recommended
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

80
Skull, Thorax, Spine and Pelvis 6: Age 4-5 Years

Fig. 1. Right lateral view of skull


1
and anterior view of thorax

Fig. 2. Anterior view of thorax,


2 5
spine and pelvis

Fig. S. Left anterior oblique view


of thorax

Fig. 3. Anterior view of thorax,


3 spine and pelvis

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 2

81
6: Age 4-5 Years Thorax, Spine, Pelvis and Upper Limbs

Fig. I. Anterior view of thorax,


spine, upper limbs and pelvis 4

Fig. 4. Posterior view of thorax,


spine and pelvis

-
Fig. 5. Posterior view of thorax
and spine 5

Fig. 6. Posterior view of thorax


and spine 6

Technical Comments
Different positions of the upper limbs have resulted in the different
appearances of the scapulae in Figs. 4 and 5
Urine contamination below the pelvis is seen in- Fig. 1
Asymmetrical renal pelvic activity is noted in the right renal pelvis in
Fig. 1 and in the left in' Fig. 6
Note extravasation of isotope at the site of injection in the right elbow
in Fig. 5

82
Spine, Pelvis and Femora 6: Age 4-5 Years

Fig. 1. Anterior view of spine,


pelvis and femora

2 Fig. 2. Anterior view of spine,


pelvis and femora

Fig. 3. Anterior view of thorax,


3 spine and pelvis

Technical Comments
Urine contamination over the right inferior pubic ramus is seen in Fig. 2
- Note the clarity of the lower lumbar spine on these views

83
6: Age 4-5 Years Spine, Pelvis and Femora

Fig. 1. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine,


pelvis and femora 2

Fig. 3. Posterior view of spine,


pelvis and femora 3

84
Hips 6: Age 4-5 Years

Fig. 1. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

85
6: Age 4-5 Years Pelvis and Lower Limbs

Fig. I. Posterior view of pelvis


and femora 4

Fig. 4. Posterior view of lower


limbs

Fig. 2. Posterior view of lower


limbs 2

Technical Comments
Urine contamination is seen at the upper edge of Fig. 4
- Fig. 1 shows the difference in the activity between the two femoral
necks. The left leg is poorly positioned as evidenced by lack of visu-
alization of the head of the fibula. This has resulted in the greater tro-
chanter rotating and being seen to overlie the femoral neck. The right
side is well positioned.

~ Potential Pitfall
- The lack of clarity of the epiphyseal plates around the knees in Fig. 4 is
due to overexposure during the acquisition

86
Knees 6: Age 4-5 Years

Fig. I. Posterior view of knees


1 4
Fig. 4. Posterior view of knees

Fig. 2. Posterior view of knees


2 5
Fig. 5. Posterior view of knees

Technical Comment
Note the clarity of the heads of the fibulae on all the images. Note the
clarity of epiphyseal plates with their well defined margins

87
6: Age 4-5 Years Tibia, Fibula and Feet

Fig. 1. Posterior view of tibia,


fibula and ankles 4

Fig. 4. Anterior view of both feet

Fig. 2. Lateral view of left lower


limb 2 5

Fig. 5. Lateral view of right


lower limb

Fig. 3. Lateral view of both feet


3

Technical Comment
- The lateral views (Figs. 2 and 5) are of little value for the knees

88
7: Age 5-6 Years
7: Age 5-6 Years Bood Pool Images

Fig. 1. Posterior view of thorax


and spine

Fig. 2. Posterior view of spine


and pelvis 2 5

Fig. 5. Anterior view of pelvis

Fig. 3. Posterior view of femora


and knees 3 6

Fig. 6. Anterior view of lower


limbs

Technical Comments
The full bladder is seen as a photon deficient area in Fig. 2
- The large vessels are clearly seen on the anterior views in Figs. 5 and 6

90
Whole Body Scan 7: Age 5-6 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- The feet are poorly positioned with out-turning of the toes bilaterally

91
7: Age 5-6 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

,.

Technical Comments
Both feet are well positioned with the toes turned inward allowing good
visualization of the fibula
Slight movement of the upper limbs has resulted in blurring of the ima-
ges of the upper limbs
Urine contamination below the pelvis is seen on the anterior view
Marker on child's right side

92
Skull, Thorax and Upper Limbs 7: Age 5-6 Years

4 Fig. I. Anterior view of skull and


1 thorax

Fig. 4. Posterior view of skull and


spine

Fig. 2. Right lateral view of skull,

...
2 5 right upper limb and posterior
view of thorax

Fig. S. Left lateral view of skull,


left upper limb and posterior view
of thorax

Technical Comments
Note the increased activity in the region of the maxillary antra in Fig. 1.
This is within normal limits
The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

93
7: 'Age 5-6 Years Skull and Upper Limbs

Fig. 1. Right lateral view of skull,


both upper limbs and posterior 1 4
view of thorax

Fig. 4. Left lateral view of skull


and both upper limbs

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Fig. 3. Anterior view of both


hands 3 6

Fig. 6. Anterior view of both


hands

Technical Comments
- Note the difficulty of imaging both hands simultaneously in Figs.1
and 4
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

94
Skull, Thorax and Spine 7: Age 5-6 Years

Fig. 1. Anterior view of thorax


4
and spine

Fig. 4. Right lateral view of skull


and anterior view of thorax

Fig. 2. Anterior view of thorax


2 5 and spine

Fig. S. Anterior view of thorax


and spine

Technical Comments
Note the differences in the sternum on these four images
The lumbar spine is clearly seen in Figs. I, 2 and 5
The scapulae appear differently in Figs. 2 and 5 due to the different
positions of the upper limbs

95
7: Age 5-6 Years Thorax, Spine and Pelvis

Fig. 4. Posterior view of thorax


and spine 4

Fig. 2. Left anterior oblique vie\\


of thorax 2 5

Fig. S. Posterior view of thorax,


spine and pelvis

Fig. 6. Posterior view of thorax,


spine and pelvis 6

~ Potential Pitfall
Note increased activity in the left posterior pubic ramus and ischium in
Fig. 6. This is an unusual variant of the normal synchondrosis

96
Spine, Pelvis and Femora 7: Age 5-6 Years

Fig. 1. Anterior view of spine,


4 pelvis and femora

Fig. 4. Anterior view of spine and


pelvis

Fig. 2. Anterior view of spine,


2 5 pelvis and femora

Fig. 5. Anterior view of pelvis


and femora

Technical Comments
Note the clarity of lumbar spine on all views
- Urine contamination below the pelvis is seen in Figs. 1 and 4

97
7: Age 5-6 Years Spine, Pelvis and Femora

Fig. 1. Posterior view of spine


and pelvis 4

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine


and pelvis 2 5

Fig. 5. Posterior view of spine


and pelvis

Fig. 6. Posterior view of spine


and pelvis with lower limbs posi- 6
tioned in abduction

Technical Comments
Urine contamination below the pelvis is seen in Fig. 1
Fig. 6 shows the hips in abduction, an usual view used mainly to look
for slipped capital femoral epiphysis

98
Hips 7: Age 5-6 Years

Fig. 1. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. S. Pinhole view of left hip

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

99
7: Age 5-6 Years Lower Limbs

Fig. 1. Posterior view of lower


limbs

Fig. 2. Posterior view of knees,


tibia, fibula and ankles 2

Fig. 3. Posterior view of knees,


tibia, fibula and feet 3

Technical Comment
Note the "radiographic neutral positioning" of the feet in Figs. 1- 3
resulting in clear visualization of the fibula

100
Knees 7: Age 5-6 Years

Fig. 1. Posterior view of knees

Fig. 2. Posterior view of knees

Fig. 3. Posterior view of knees


3

Technical Comments
The magnified view (Fig. 3) shows the epiphyseal plates to best advan-
tage
The fibula is clearly seen in all figures because the toes were turned
inward during image acquisition

101
7: Age 5-6 Years Ankles and Feet

Fig. I. Lateral view of feet with


straight knees 4

Fig. 4. Anterior view of feet

Fig. 2. Lateral view of feet with


knees flexed and magnification 2

102
~: Age 6-7 Years
8: Age 6-7 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

104
Blood Pool Images 8: Age 6-7 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comment
- Marker on child's right side

105
8: Age 6-7 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
- Note extravasation of isotope at the site of injection in the left hand
- Marker on child 's right side

~ Potential Pitfall
- Note band of apparent increased uptake of isotope in the region of the
orbits on the anterior view. This is due to the positioning of the child

106
Whole Body Scan 8: Age 6-7 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
The child's head is rotated
- Marker on child's right side

~ Potential Pitfall
There is increased activity in the left inferior pubic ramus, best seen on
the anterior view and is due to the normal synchondrosis

107
8: Age 6-7 Years Skull, Thorax and Upper Limbs

Fig. 1. Anterior view of skull and


thorax 1 4

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comment
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

108
Skull and Upper Limbs 8: Age 6-7 Years

Fig. I. Right lateral view of skull


4
and right upper limb

Fig. 4. Left lateral view of skull


and left upper limb

Fig. 2. Anterior view of both


2 upper limbs

Technical Comments
- Note extravasation of isotope at the site of injection in the elbow in
Fig. 2
- The lateral views of the skull (Figs. 1 and 4) were taken posteriorly

109
8: Age 6-7 Years Thorax, Spine and Pelvis

Fig. I. Anterior view of thorax,


spine and pelvis 4

Fig. 4. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax,


spine and part pelvis 2 5

Fig. S. Anterior view of thorax


and spine

Technical Comments
The lower lumbar spine is well seen on these anterior views
The difference between the two kidneys in Fig. 5 is within normal
limits

110
Thorax, Spine and Pelvis 8: Age 6-7 Years

Fig. I. Posterior view of thorax,


4
spine and pelvis

Fig. 4. Posterior view of thorax,


spine and part pelvis

Fig. 2. Posterior view of thorax,


2 5 spine and part pelvis

Fig. S. Posterior view of thorax


and spine

These images are from the same four children as seen in Figs. 1, 2,4 and
5 on p.110

Technical Comment
There is accumulation of isotope in the renal pelvis of the left kidney
in Fig. 5. This is still within normal limits (same child as in Fig. 5,
p.llO)

~ Potential Pitfall
Increased activity over the line of the ribs in the posterior axillary por-
tion, best seen in Fig. 5 on the right are not due to fractures but reflect
"shine-through" from the anterior costa-chondral junctions

111
8: Age 6-7 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine,


pelvis and femora 2

Fig. 3. Anterior view of spine,


pelvis, femora and hands 3

Technical Comment
Urine contamination below the pelvis is seen in Fig. 3

112
Spine, Pelvis and Femora 8: Age 6-7 Years

Fig. 1. Posterior view of spine,


1 pelvis, femora and hands

Fig. 2. Posterior view of spine,


2 pelvis and femora

Fig. 3. Posterior view of spine


3 and pelvis

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 2

~ Potential Pitfall
In Fig. 3 increased activity is noted at the junction of the left ischial
tuberosity and the posterior pubic ramus due to the normal synchon-
drosis at this site

113
8: Age 6-7 Years Hips

Fig. I. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

Fig. 5. Pinhole view of left hip


5

Technical Comment
- The larger size of the hip in Fig. 5 is due to the size of the pinhole insert
used compared to Figs. 1 and 4

114
Lower Limbs 8: Age 6-7 Years

Fig. 1. Posterior view of femora


1 and knees

Fig. 2. Posterior view of knees,


2 tibia, fibula and ankles

Fig. 3. Posterior view of knees,


3 tibia, fibula and ankles

Technical Comment
Note the good positioning of the feet resulting in clear separation of the
fibula from the tibia in Fig. 2
Note the different visualization of the ankles in Fig. 3. This is due to
different positioning of the feet

~ Potential Pitfall
Note the slight but definite increased activity in the mid portion of the
tibial shafts best seen in Fig. 3. As the child grows this will become
more obvious and potentially confusing

115
8: Age 6- 7 Years Knees

Fig. I. Posterior magnified view


of knees

Fig. 2. Posterior view of knees


2

Technical Comment
- Note the clear definition of the growth plate from the adjacent meta-
physes

116
Ankles and Feet 8: Age 6-7 Years

Fig. I. Anterior view of ankles


and feet

Fig. 2. Lateral view of feet


2

117
9: Age 7-8 Years
9: Age 7-8 Years Blood Pool Images

Fig. 1. Posterior view of thorax


and spine

Fig. 2. Posterior view of spine


and pelvis 2

Fig. 3. Anterior view of pelvis


and femora 3 6
Fig. 6. Anterior view of pelvis
and femora

120
Blood Pool Images 9: Age 7-8 Years

Fig. 1. Anterior view of both


hands

Fig. 2. Anterior view of knees


2 5
Fig. 5. Posterior view of tibia and
fibula

Fig. 3. Lateral view of feet


3 6
Fig. 6. Lateral view of feet

121
9: Age 7-8 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Distal end of the left upper limb is not seen due to a lead shield follow-
ing extravasation of isotope at the site of injection
Marker on child's right side

122
Whole Body Scan 9: Age 7-8 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

123
9: Age 7-8 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

124
Skull, Thorax and Upper Limb 9: Age 7-8 Years

Fig. 1. Anterior view of skull and


4 thorax

Fig. 4. Posterior view of skull and


thorax

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Fig. 3. Right lateral view of skull


and anterior view of thorax

Technical Comments
- The coronal suture is clearly seen in Fig. 3. This is not the case in
Figs. 2 and 5
- The thyroid gland is seen in Figs. 1 and 3 due to free 99m-Tc-pertech-
netate
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

125
9: Age 7-8 Years Skull, Spine and Upper Limbs

Fig. I. Right lateral view of skull


and right upper limb

Fig. 4. Left lateral view of skull


.• 4
0 •

and left upper limb

Fig. 2. Anterior view of upper


limbs and hands 2 5

Fig. 5. Anterior view of hands

Technical Comments
- The hands in Fig. 5 are poorly positioned compared to Fig. 2
- The lateral views of the skull (Figs. 1 and 4) were taken posteriorly
- Note that part of the occipital bone in Fig. 4 has been excluded from the
field of view

126
Thorax, Spine and Pelvis 9: Age 7-8 Years

Fig. 1. Anterior view of thorax,


1 4 spine and pelvis
Fig. 4. Anterior view of thorax
and spine

Fig. 2. Anterior view of thorax


2 and spine

Fig. 3. Left anterior oblique view


of thorax

Technical Comments
Note the clarity of the lumbar spine, especially in Fig. 2
The sternum is best seen with slight obliquity of the thoracic cage as in
Figs. 1 and 3

127
9: Age 7-8 Years Thorax, Spine and Pelvis

Fig. 1. Posterior view of thorax


and spine 4

Fig. 4. Posterior view of thorax,


spine and part pelvis

Fig. 2. Posterior view of thorax,


spine and pelvis 2 5

Fig. S. Posterior view of thorax,


spine and pelvis

128
Thorax, Spine, Pelvis and Femora 9: Age 7-8 Years

Fig. I. Anterior view of pelvis


4 and femora
Fig. 4. Anterior view of thorax,
spine and pelvis

Fig. 2. Anterior view of spine and


pelvis

Technical Comments
Note that the bladder is virtually empty on all the images
- Urine contamination below the pelvis is seen in Fig. 2

129
9: Age 7-8 Years Spine, Pelvis and Femora

Fig. I. Posterior view of spine,


pelvis and femora 4

Fig. 4. Posterior view of spine


and pelvis

Fig. 2. Posterior view of pelvis


and femora 2

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 2

130
Hips 9: Age 7-8 Years

Fig. 1. Pinhole view of right hip

Fig. 4. Pinhole view of left hip

131
9: Age 7-8 Years Lower Limbs

Fig. 1. Posterior view of femora


and knees 1 4

Fig. 4. Posterior view of hips,


femora and knees

Fig. 2. Posterior view of tibia,


fibula and ankles 2 5

Fig. S. Posterior view of knees,


tibia, fibula and ankles

Technical Comments
Note the clarity and the separation of the epiphysis of the fibula from
the tibia due to the good positioning of the feet. This is not true for the
left knee in Fig. 1, especially when compared to the right knee
Urine contamination below the pelvis is seen in Fig. 1

132
Knees 9: Age 7-8 Years

Fig.t. Posterior magnified view


1 of knees

Fig. 2. Posterior magnified view


2 of knees

Fig. 3. Posterior view of knees


3

Technical Comment
There is clear separation between the upper tibia and the fibula due to
good positioning of the feet in all images, apart from the right knee in
Fig. 2 where the fibula cannot be clearly seen

133
9: Age 7-8 Years Ankles and Feet

Fig. I. Posterior view of feet


4
Fig. 4. Lateral view of feet

Fig. 2. Posterior view of feet


2 5
Fig. S. Lateral view of feet

134
10: Age 8-9 Years
10: Age 8-9 Years Blood Pool Images

Fig. 1. Anterior view of pelvis

Fig. 2. Posterior view of knees


2

Fig. 3. Anterior view of tibia,


fibula and feet 3

136
Blood Pool Images 10: Age 8-9 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view


Technical Comments
Note on the posterior view the difference between the two straight sinu-
ses with more isotope entering the right than the left. This is a variati-
on of normality
Note extravasation of isotope at the site of injection in the right hand
Marker on child's right side

~ Potential Pitfall
Focal increased uptake of isotope is seen on the anterior view in the
region of the maxillary sinus. This is probably due to sinusitis

137
10: Age 8-9 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

138
Whole Body Scan 10: Age 8- 9 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
The child's head is rotated causing asymmetry especially to the facial
bones
Note extravasation of isotope at the site of injection in the left elbow
Marker on child's right side

139
10: Age 8-9 Years Skull and Thorax

Fig. I. Anterior view of skull and


thorax 4

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of skull


2
Fig. 5. Left lateral view of skull

Fig. 6. Left lateral view of skull


and anterior view of thorax

Technical Comments
- Note the sterno-clavicular joints in Figs. 1 and 6, the asymmetry of the
joints is due to rotation of the patient
- The lateral views of the skull (Figs. 2 and 5) were taken anteriorly

140
Upper Limbs 10: Age 8-9 Years

Fig. 1. Anterior view of hands


1 4
Fig. 4. Anterior view of hands
and upper limbs

141
10: Age 8-9 Years Thorax and Spine

Fig. I. Anterior view of thorax


and spine 1

Fig. 2. Anterior view of thorax


and spine 2

Fig. 3. Right anterior oblique


view of thorax
3

Technical Comments
- The lumbar spine in Fig. 2 is clearly seen
- The asymmetry of the sterno-clavicular joints in Fig. 2 is due to the
slight rotation
- Abnormal accumulation of isotope in a dilated left renal pelvis is noted
in Fig. 2

142
Thorax and Spine 10: Age 8-9 Years

Fig. 1. Posterior view of thorax,


spine and part pelvis

Fig. 2. Posterior view of thorax,


2 spine and part pelvis

~ Potential Pitfall
- The tracer is seen in abnormal calyces and renal pelvis of both kidneys
in Fig. 2

143
10: Age 8-9 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of spine,


pelvis and femora 4

Fig. 4. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine and


pelvis 2 5

Fig. 5. Anterior view of spine,


pelvis and femora

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 1, 2 and 5

144
Spine, Pelvis and Femora 10: Age 8-9 Years

Fig. 1. Posterior view of spine,


4
pelvis and femora

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine,


2 5 pelvis and femora

Fig. 5. Posterior view of spine,


pelvis and femora

Fig. 3. Pelvic inlet view. This


3 view is infrequently required in
paediatrics

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 3- 5

145
10: Age 8-9 Years Hips

Fig. 1. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

Technical Comment
- Figs. 2 and 5 show a change in magnification creating an apparent dif-
ference between the sizes of the two hips .

146
Lower Limbs 10: Age 8- 9 Years

Fig. I. Posterior view of femora


and knees

Fig. 2. Posterior view of knees,


2 tibia and fibula

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 1

147
10: Age 8- 9 Years Knees

Fig. 1. Posterior view of knees


1 4
Fig. 4. Anterior view of knees

Fig. 2. Medial lateral view of left


knee 2 5

Fig. 5. Medial lateral view of


right knee

Fig. 3. Lateral lateral view of


right knee 3 6
Fig. 6. Lateral lateral view of left
knee

Technical Comment
The pair of lateral knees in Figs. 2 and 5 represent medial lateral knees
while Figs. 3 and 6 represent lateral knees in the lateral projection. This
accounts for the clarity of the fibula in the lower series and the diffi-
culty in seeing the fibula in the upper series

148
Tibia, Fibula, Ankles and Feet 10: Age 8-9 Years

Fig. 1. Posterior view of tibia,


1 4 fibula and ankles

Fig. 4. Posterior view of feet

Fig. 2. Lateral view of feet


2 5
Fig. 5. Lateral view of feet

~ Potential Pitfalls
- Note the slightly increased activity in the mid-shaft of the tibia more
marked on the right than on the left in Fig. 1. This is a variation of
normality
- The lack of clarity of the epiphyseal plates around the knees in Fig. 1 is
due to overexposure during the acquisition

149
11: Age 9-10 Years
11: Age 9-10 Years Blood Pool Images

Fig. 1. Anterior view of thorax,


spine and pelvis 4

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Anterior view of pelvis


and femora 2 5

Fig. 5. Posterior view of pelvis


and femora

Fig. 3. Anterior view of hands


3

Technical Comments
Fig. 2 shows a photon deficient area in the region of the bladder. This
is due to a bladder full of urine at the time of injection of radiotracer
The photon deficient area above the left kidney in Figs. 1 and 4 is due
to a full stomach

152
Blood Pool Images 11: Age 9-10 Years

Fig. 1. Posterior view of knees


4
Fig. 4. Anterior view of knees,
tibia, fibula and ankles

Fig. 2. Posterior view of feet


2

153
11: Age 9-10 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the right elbow
- The photon deficient area in the region of the bladder on the anterior
view is due to a bladder full of urine at the time of injection of radio-
tracer
Marker on child's right side

154
Whole Body Scan 11: Age 9-10 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
There is better positioning of the left foot, with the toes turned inward
compared to the right foot. The consequent improved images of the left
knee are noted.
The child's pelvis is rotated causing asymmetry
- Marker on child's right side, posterior view only

155
11: Age 9-10 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- There is poor positioning of the feet, with the toes turned outward

156
Skull, Thorax and Upper Limbs 11: Age 9-10 Years

Fig. 1. Anterior view of skull and


thorax

Fig. 4. Posterior view of skull and


thorax

Fig. 2. Right lateral view of skull


2 and right upper limb

Fig. S. Left lateral view of skull


and left upper limb

Technical Comments
There is slightly increased activity in the right maxillary region in
Fig. 1, this is due to rotation of the head
The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

157
11: Age 9-10 Years Skull, Thorax and Upper Limbs

Fig. 1. Anterior view of skull and


thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. S. Left lateral view of skull


and left upper limb

Technical Comment
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

158
Thorax and Upper Limbs 11: Age 9-10 Years

Fig. I. Anterior view of right


4 hemithorax and right upper limb

Fig. 4. Anterior view of left


hemithorax and left upper limb

Fig. 2. Right anterior oblique


2 5 view of thorax

Fig. 5. Left anterior oblique view


of thorax

Technical Comments
- Figs. 1 and 4 show the difficulty in obtaining good images of the upper
limbs with the anterior thoracic views. The upper limbs should be ima-
ged at the time of lateral skull images
- Retention of tracer is noted in the dilated right renal pelvis in Fig. 2

159
11: Age 9-10 Years Thorax, Spine and Pelvis

Fig. 1. Anterior view of thorax,


spine and part pelvis 4

Fig. 4. Anterior view of thorax,


spine and pelvis

Fig. 2. Anterior view of thorax,


spine and part pelvis 2 5

Fig. S. Anterior view of thorax,


spine and pelvis

Technical Comment
The lower lumbar spine is clearly seen on the anterior views in Figs. 2,
4 and 5

160
Thorax, Spine and Pelvis 11: Age 9-10 Years

Fig. 1. Posterior view of thorax,


1 4 spine and part pelvis

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax,


2 5 spine and pelvis

Fig. 5. Posterior view of thorax,


spine and pelvis

Technical Comment
The scapula is clearly seen in all images, the differences are due to the
varying positions of the upper limbs

~ Potential Pitfall
Focal increased activity is seen in the region of the posterior aspect of
the left 3rd rib in Fig. 4. This is due to the activity from the overlying
left sterno-clavicular joint "shining through"

161
11: Age 9-10 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of pelvis


and femora

Fig. 2. Anterior view of spine,


pelvis and femora 2

Fig. 3. Anterior magnified view


of pelvis and femora 3

Technical Comments
Urine contamination below the pelvis is seen in Fig. 1
- The bladder is full of isotope in Fig. 3

162
Spine and Pelvis 11: Age 9-10 Years

Fig. 1. Posterior view of spine


1 and pelvis

Fig. 2. Posterior view of spine


2 and pelvis

Fig. 3. Posterior view of spine


3 and pelvis

Technical Comment
In Fig. 2 notice the slight different rotation of the greater trochanter
which is not separately seen on the left but is seen to overlie the femo-
ral neck. This is due to poor positioning of the left knee and foot

~ Potential Pitfall
The increased activity seen over the lower ribs in Fig. 2 is due to reten-
tion of tracer in the collecting system of the horseshoe-kidney

163
11: Age 9-10 Years Hips

Fig. 1. Pinhole view of right hip

Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2
Fig. S. Pinhole view of left hip

164
Lower Limbs 11: Age 9-10 Years

Fig. 1. Posterior view of femora


4
and knees

Fig. 4. Posterior view of femora


and knees

Fig. 2. Posterior view of knees,


2 5 tibia, fibula and ankles

Fig. S. Posterior view of tibia,


fibula and ankles

Technical Comments
Note the in-turning of the feet in Figs. 2 and 5 into the "radiographic
neutral position"
The difference between the greater trochanters in Fig. 1 is a variation
of normality
Urine contamination between the femora is seen in Fig. 4

165
11: Age 9-10 Years Knees

Fig. I. Posterior view of knees


4
Fig. 4. Posterior view of knees

Fig. 2. Posterior view of knees


2

Fig. 3. Anterior oblique view of


knees 3

Technical Comments
Fig. 3 is an oblique view of the knees obtained when the medial femo-
ral condyles need to be imaged, not frequently used in paediatrics
- The patella is seen overlying the lateral aspect of the femoral epiphy-
seal plate in Fig. 3

166
Tibia, Fibula, Ankles and Feet 11: Age 9-10 Years

Fig. I. Posterior view of knees,


tibia, fibula and ankles

Fig. 2. Lateral view of foot


2

Fig. 3. Lateral view of feet


3

167
12: Age 10-11 Years
12: Age 10-11 Years Blood Pool Images
Fig. 1. Posterior view of skull and
thorax

Fig. 2. Anterior view of pelvis


2 5
Fig. 5. Anterior view of lower
limbs

Fig. 3. Posterior view of spine


and pelvis 3 6

Fig. 6. Anterior view of lower


limbs

Technical Comment
The skull is rotated in Fig. 1 causing the sagittal sinus to appear off
center

170
Blood Pool Images 12: Age 10-11 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the right elbow
- Marker on child's right side

171
12: Age 10-11 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- Marker on child's right side

172
Skull, Thorax and Upper Limbs 12: Age 10-11 Years

Fig. I. Anterior view of skull and


4 thorax

Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comment
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

173
12: Age 10-11 Years Skull, Thorax and Upper Limbs

Fig. I. Anterior view of skull and


thorax 4

Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Fig. 3. Forearms

Technical Comments
- The image of the forearms in Fig. 3 reveals overlap of the upper radius
and ulna; this should be compared to Figs. 2 and 5 where there is clear
separation of radius from ulna
- The differences between the mastoid areas in Fig. 4 are due to rotation
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

174
Thorax, Spine and Part Pelvis 12: Age 10-11 Years

Fig. 1. Anterior view of thorax

Fig. 2. Anterior view of thorax,


2 spine and part pelvis

Fig. 3. Anterior view of thorax,


3 spine and part pelvis

~ Potential Pitfall
Note the sternum in Fig. 1 where increased activity is noted in two
areas. This represents normal growth centers of the sternum, and
should not be confused with a fracture

175
12: Age 10-11 Years Thorax

Fig. 1. Right anterior oblique


view of thorax 4

Fig. 4. Left anterior oblique view


of thorax

Fig. 2. Right anterior oblique


view of thorax 2

Technical Comment
Note the different appearances of the sternum due to different degrees
of obliquity

176
Thorax, Spine and Part Pelvis 12: Age 10-11 Years

Fig. 1. Posterior view of thorax,


spine and part pelvis

Fig. 2. Posterior view of thorax,


2 spine and part pelvis

Fig. 3. Posterior view of thorax,


3 spine and part pelvis

177
12: Age 10-11 Years Pelvis and Femora

Fig. 1. Anterior view of pelvis


and femora

Fig. 2. Anterior view of pelvis


and femora 2

178
Spine, Pelvis and Femora 12: Age 10-11 Years

Fig. 1. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of pelvis


2 and femora

Fig. 3. Posterior view of spine,


3 pelvis and femora

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 3

179
12: Age 10-11 Years Spine and Pelvis

Fig. I. Pelvic inlet view

Fig. 2. Sitting view of spine and


part pelvis 2

180
Hips 12: Age 10-11 Years

Fig. I. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

181
12: Age 10-11 Years Lower Limbs

Fig. 1. Posterior view of femora


1 4
Fig. 4. Posterior view of femora
and knees

Fig. 2. Posterior view of knees,


tibia, fibula and ankles 2 5

Fig. 5. Posterior view of knees,


tibia, fibula and ankles

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 1

182
Knees 12: Age 10-11 Years

4 Fig. 1. Posterior magnified view


of knees

Fig. 4. Posterior view of knees

Fig. 2. Anterior pinhole view of


2 5 right knee

Fig. S. Anterior pinhole view of


left knee

Technical Comment
Note that the fibula is better seen on the posterior view in Figs. 1 and 4
than on the anterior pinhole views in Figs. 2 and 5

183
12: Age 10-11 Years Knees, Tibia, Fibula and Feet

Fig. 1. Posterior view of knees,


tibia, fibula and ankles

Fig. 2. Lateral view of feet


2

Fig. 3. Lateral lateral view of


foot 3

184
13: Age 11-12 Years
13: Age 11-12 Years Blood Pool Images

Fig. 1. Posterior view of thorax


and spine

Fig. 4. Right lateral view of skull


and posterior view of upper limbs

Fig. 2. Posterior view of pelvis


2
Fig. S. Anterior view of pelvis

Fig. 3. Posterior view of knees


3
Fig. 6. Lateral view of feet

186
Blood Pool Images 13: Age 11-12 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
The photon deficient area between the heart, spleen and left kidney on
the anterior view is due toa full stomach
Marker on child's right side

187
13: Age 11-12 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comment
- Marker on child's right side

188
Whole Body Scan 13: Age 11-12 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

189
13: Age 11-12 Years Skull, Thorax and Upper Limbs

Fig. I. Anterior view of skull and


thorax 1 4

Fig. 4. Posterior view of skull


and thorax

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Fig. 3. Anterior view of skull and


thorax

Technical Comments
- On the posterior view of thorax in Fig. 4 the angles of the scapulae
show up as focal areas of increased activity especially on the right, this
is normal
- Focal increased activity is noted to the left of the midline in the man-
dible in Fig. 3. The cause for this is uncertain but may be related to the
teeth
The distal end of the humerus has been excluded from the field of view
in Figs. 2 and 5. This is due to the difficulty in positioning both the skull
and upper limb at the same time in children at this age
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

190
Upper Limbs 13: Age 11-12 Years

Fig. I. Anterior view of hands


1

Fig. 2. Anterior view of part right


2 5
thorax and right upper limb

Fig. 5. Anterior view of part left


thorax and left upper limb

Technical Comment
- Figs. 2 and 5 show the difficulty of obtaining high quality images of the
upper limbs adjacent to the thorax. Compare with p. 159

191
13: Age 11-12 Years Thorax, Spine and Part Pelvis

Fig. 1. Anterior view of thorax

Fig. 2. Anterior view of thorax,


spine and part pelvis 2

Fig. 3. Anterior view of thorax


and spine 3

Technical Comments
The unusual activity in the neck and in the left hypochondrium in Fig. 3
suggests 99m-Tc-pertechnetate in both the stomach and thyroid gland
The clarity of the lower lumbar spine on the anterior views in Figs. 2
and 3 is again noted

192
Thorax and Spine 13: Age 11-12 Years

4 Fig. 1. Posterior view of thorax


and spine

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax


2 5 and spine

Fig. S. Posterior view of thorax


and spine

Technical Comments
The scapulae appear different due to the varying positions of the hume-
ri in these images
There is retention of isotope in the right kidney in Fig. 2

193
13: Age 11-12 Years Thorax

Fig. 1. Right anterior oblique


view of thorax

Fig. 4. Left anterior oblique view


of thorax

194
Spine, Pelvis and Femora 13: Age 11-12 Years

4 Fig. 1. Anterior view of spine,


pelvis and femora

Fig. 4. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of pelvis


5 and femora

Fig. 5. Anterior view of spine,


pelvis and femora

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 4

~ Potential Pitfall
Focal increased activity is noted in the region of the right synchondro-
sis in Fig. 5. This represents urine contamination and does not represent
pathology in the pubic bone

195
13: Age 11-12 Years Spine, Pelvis and Femora

Fig. I. Posterior view of spine,


pelvis and femora 1 4

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine,


pelvis and femora 2 5

Fig. S. Posterior view of spine,


pelvis and femora

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 1, 2 and 4

196
Hips 13: Age 11-12 Years

Fig. I. Pinhole view of right hip


1
Fig. 4. Pinhole view of left hip

197
13: Age 11-12 Years Lower Limbs

Fig. 1. Posterior view of femora


and knees 4

Fig. 4. Posterior view of femora


and knees

Fig. 2. Posterior view of tibia,


fibula and ankles 2 5

Fig. 5. Posterior view of tibia,


fibula and ankles

Technical Comment
Note the rather patchy asymmetrical distribution of the isotope in the
mid-portions of the tibia in Fig. 5. Although the authors are unable to
offer a physiological explanation, nevertheless the observation has
been made frequently with no clinical consequence of this observation

198
Knees 13: Age 11-12 Years

Fig. I. Posterior view of knees


4
Fig. 4. Posterior view of knees

Fig. 2. Anterior view of knees


2 5
Fig. S. Posterior view of knees

Technical Comment
The epiphyseal plate of the femur is not well defined in Fig. 2, the ante-
rior view, because the patella overlies the epiphyseal plate

199
13: Age 11-12 Years Tibia, Fibula, Ankles and Feet

Fig. I. Posterior view of tibia,


fibula and ankles (Same figure as
Fig. 2, p. 198)

Fig. 2. Anterior view of ankles


and feet 2

200
14: Age 12-13 Years
14: Age 12-13 Years Blood Pool Images

Fig. I. Posterior view of thorax


and spine 1

Fig. 2. Anterior view of knees


2

202
Blood Pool Images 14: Age 12-13 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- Marker on child's right side

203
14: Age 12-13 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
- Poor positioning of the right foot is noted
- Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

~ Potential Pitfall
- Increased activity is noted in the inferior pubic ramus due to the syn-
chondrosis, this should not be mistaken for pathology

204
Skull, Thorax and Upper Limbs 14: Age 12-13 Years

Fig. 1. Anterior view of skull and


thorax

Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


2 and right upper limb

Fig. S. Left lateral view of skull


and left upper limb

Technical Comment
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

205
14: Age 12-13 Years Skull and Thorax

Fig. 1. Anterior view of skull and


thorax

Fig. 2. Right lateral view of skull


and posterior view of thorax 2 5

Fig. S. Left lateral view of skull


and posterior view of thorax

206
Hands 14: Age 12-13 Years

4 Fig. I. Anterior view of hands

Fig. 4. Anterior view of hands

207
14: Age 12-13 Years Thorax and Spine

Fig. I. Anterior view of thorax


and spine

Fig. 4. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


and spine

Fig. 5. Anterior view of thorax

Fig. 3. Left anterior oblique view


of thorax

Technical Comment
Note the variation of the sternum in these different anterior and anteri-
or oblique projections

208
Thorax, Spine and Part Pelvis 14: Age 12-13 Years

Fig. 1. Posterior view of thorax


1 4
and spine

Fig. 4. Posterior view of thorax,


spine and part pelvis

Fig. 2. Posterior view of thorax


2 5 and spine

Fig. 5. Posterior view of thorax


and spine

Technical Comments
Asymmetrical activity is noted in the renal pelvis in Fig. 5, this is with-
in normal limits
The appearances of the scapulae vary with the positioning of the upper
limbs

209
14: Age 12-13 Years Spine and Pelvis

Fig. I. Anterior view of spine


and pelvis

Fig. 2. Anterior view of spine


and pelvis 2

Fig. 3. Anterior view of spine


and pelvis 3

Technical Comments
Note the clarity of the lower lumbar spine on these anterior views
Urine contamination below the pelvis is seen in Fig. 2

~ Potential Pitfall
- The pubic rami show normal increased uptake of tracer in all images

210
Spine and Pelvis 14: Age 12-13 Years

Fig. I. Posterior view of spine


and pelvis

Fig. 2. Posterior view of spine


2 and pelvis

Fig. 3. Posterior view of spine


3 and pelvis

Technical Comments
Note the isotope in the left renal pelvis seen in Fig. 3 suggesting dilati-
on of the renal pelvis
Urine contamination below the pelvis is seen in Fig. 2

211
14: Age 12-13 Years Hips

Fig. I. Pinhole view of right hip

Fig. 4. Pinhole view of left hip

212
Lower Limbs 14: Age 12-13 Years

Fig. 1. Posterior view of femora


and knees

Fig. 2. Posterior view of knees,


2 tibia, fibula and ankles

Technical Comments
- Slight increased activity is noted in the left mid tibia in Fig. 2, similar
to the appearances in Fig. 5, p. 198
- Urine contamination below the pelvis is seen in Fig. 1

213
14: Age 12-13 Years Knees

Fig. I. Anterior view of knees


4
Fig. 4. Anterior view of knees

Fig. 2. Anterior pinhole view of


right knee 2 5

Fig. 5. Anterior pinhole view of


left knee

Fig. 3. Lateral view of left knee


3 6
Fig. 6. Lateral view of right knee

Technical Comment
The fibula is not seen in Figs. 3 and 6 because the images are medial
lateral views

214
Knees, Tibia, Fibula, Ankles and Feet 14: Age 12-13 Years

Fig. 1. Posterior view of knees,


1 4 tibia, fibula and ankles

Fig. 4. Anterior view of feet

~ Potential Pitfall
- The lack of clarity of the epiphyseal plates around the knees in Fig. 1 is
due to overexposure during the acquisition

215
15: Age 13-14 Years
15: Age 13-14 Years Blood Pool Images

Fig. 1. Posterior view of skull and


upper limbs 1

Fig. 2. Anterior view of spine and


pelvis 2

Fig. 3. Anterior view of knees


3

Technical Comment
The full bladder is seen as a photon deficient area in Fig. 2

218
Blood Pool Images 15: Age 13-14 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
Note extravasation of isotope at the site of injection in the left hand
- Marker on child's right side

219
15: Age 13-14 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Urine contamination below the pelvis is seen
- Marker on child's right side

220
Whole Body Scan 15: Age 13-14 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- Both feet are poorly positioned

221
15: Age 13-14 Years Skull

Fig. 1. Anterior view of skull

Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


2 5
Fig. 5. Left lateral view of skull

Technical Comment
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

222
Skull and Upper Limbs 15: Age 13-14 Years

4 Fig. 1. Right lateral view of skull


and right upper limb

Fig. 4. Left lateral view of skull


and left upper limb

Fig. 2. Anterior view of right


2 upper limb

Fig. 5. Anterior view of left upper


limb

Technical Comment
- The lateral views of the skull (Figs. 1 and 4) were taken posteriorly

223
15: Age 13-14 Years Thorax and Spine

Fig. I. Anterior view of thorax

Fig. 4. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


and spine 2

Fig. S. Anterior view of thorax

Fig. 3. Left anterior oblique view


of thorax 3

Technical Comments
Note the differences in the sternum on both the anterior projections and
also the anterior oblique
- Note the clarity of the lower lumbar spine in Figs. 2 and 4

224
Thorax and Spine 15: Age l3-14 Years

Fig. I. Posterior view of thorax


4
and spine

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax


2 5 and spine

Fig. 5. Posterior view of thorax


and spine

Technical Comment
Note the difference in the positions of the scapulae in Fig. 1, compared
to Fig. 4, this is due to the different position of the upper limbs

225
15: Age 13-14 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of spine,


pelvis and femora 1 4

Fig. 4. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine,


pelvis and femora 2 5

Fig. 5. Anterior view of pelvis


and femora

Technical Comments
The lower lumbar spine is again clearly seen on the anterior views in
Figs. 1,2 and 4
Urine contamination adjacent to the left ischium is seen in Fig. 2

226
Spine, Pelvis and Femora 15: Age 13-14 Years

4 Fig. 1. Posterior view of spine,


1
pelvis and femora

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine


2 5 and pelvis

Fig. 5. Posterior view of pelvis


and femora

227
15: Age 13-14 Years Hips

Fig. I. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

228
Lower Limbs 15: Age 13-14 Years

Fig. I. Posterior view of femora


4
and knees

Fig. 4. Posterior view of femora


and knees

Fig. 2. Posterior view of tibia,


2 5 fibula and ankles

Fig. 5. Posterior view of tibia and


fibula

229
15: Age 13-14 Years Knees

Fig. 1. Anterior view of knees


4
Fig. 4. Posterior view of knees

Fig. 2. Anterior pinhole view of


right knee 2 5

Fig. S. Anterior pinhole view of


left knee

Fig. 3. Lateral view of knees


3 6
Fig. 6. Lateral view of knees

Technical Comment
- Figs. 3 and 6 represent lateral images of the knees, on the left there is a
medial lateral and a lateral lateral while on the right it is the reverse
order. The lateral lateral images show the head of the fibula clearly
while the medial lateral show the head of the fibula within the tibia but
below the epiphyseal plate

230
Tibia, Ankles and Feet 15: Age 13-14 Years

Fig. 1. Lateral view of tibia and


1 ankles

Fig. 2. Anterior view of feet


2 5
Fig. S. Lateral view of feet

Technical Comment
- Note external rotation of the feet in Fig. 1, resulting in non visualiza-
tion of the epiphyseal plate at the distal end of the fibula

231
16: Age 14-15 Years
16: Age 14-15 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comment
- Marker on child's right side

234
Whole Body Scan 16: Age 14-15 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note on the anterior projection (on the left) that the epiphyseal plates
at the elbow, the wrists and knees are not as distinct as on the posterior
view (on the right). This is due to the greater distance of the patient
from the detector on the anterior view
Marker on child's right side

235
16: Age 14-15 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note the increased activity in the sternum on the anterior view, this is
within the normal range. Sternal fusion has not yet occurred
Urine contamination below the pelvis is seen
Marker on child's right side

236
Skull, Thorax and Upper Limbs 16: Age 14-15 Years

Fig. 1. Anterior view of skull and


thorax

Fig. 4. Posterior view of skull and


thorax

Fig. 2. Right lateral view of skull


2 and right upper limb

Fig. s. Left lateral view of skull


and left upper limb

Technical Comments
- The fingers of the hands in Figs. 2 and 5 have been excluded from the
field of view because of the child's size
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly

237
16: Age 14-15 Years Skull and Upper Limbs

Fig. 1. Right lateral view of skull


4
and right upper limb

Fig. 4. Left lateral view of skull


and left upper limb

Fig. 2. Anterior view of hands


2 5
Fig. 5. Anterior view of hands

Technical Comments
- Note that part of the occipital bone in Fig. 1 has been excluded from the
field of view
The lateral views of the skull (Figs. 1 and 4) were taken posteriorly
- There is a marker adjacent to the right hand in Figs. 2 and 5

238
Thorax and Spine 16: Age 14-15 Years

Fig. 1. Anterior view of thorax

Fig. 4. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


2 and spine

Fig. 5. Anterior view of thorax

Technical Comment
Note the variation of the sternum in these four different children, all
within the normal range

239
16: Age 14-15 Years Thorax

Fig. I. Right anterior oblique


view of thorax 4

Fig. 4. Left anterior oblique view


of thorax

240
Thorax and Spine 16: Age 14-15 Years

Fig. 1. Posterior view of thorax


4
and spine

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax


2 5 and spine

Fig. 5. Posterior view of thorax


and spine

Technical Comment
- Note the variation of the appearances of the scapulae

~ Potential Pitfall
- Focal increased activity is noted in Fig. 5 in the region of the mid-
portion of the left third rib, this represents activity from the sterno-
clavicular joint not a fracture of the rib

241
16: Age 14-15 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of spine 4


and pelvis

Fig. 4. Anterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine,


2 5
,
pelvis and femora

Fig. 5. Anterior view of spine


and pelvis

Technical Comment
- Urine contamination to the left of the pubic bone is seen in Fig. 1

~ Potential Pitfall
The apparent increased activity in the right sacro-iliac joint and also the
asymmetry between the anterior superior iliac spines in Figs. 2 and 4 is
due to rotation and tilting of the pelvis and is not pathological

242
Spine, Pelvis and Femora 16: Age 14-15 Years

Fig. I. Posterior view of spine,


4
pelvis and femora

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Posterior view of spine,


5 pelvis and femora

Fig. 5. Posterior view of spine


and pelvis

Technical Comment
Note in Fig. 2 the non-unifonnity of activity in both sacro-iliac joints
with a relatively cool area in the mid-portion of the joints, this is with-
in the nonnal range

243
16: Age 14-15 Years Hips

Fig. 1. Pinhole view of right hip


1
Fig. 4.Pinhole view of left hip

244
Lower Limbs 16: Age 14-15 Years

Fig. 1. Posterior view of femora


4
Fig. 4. Posterior view of femora
and knees

Fig. 2. Posterior view of tibia,


2 5 fibula and ankles

Fig. 5. Posterior view of tibia,


fibula and ankles

Technical Comment
Note the non-homogeneous distribution of isotope in the tibia with
apparent slight increase in the mid-portion in Figs. 2 and 5. Both these
children underwent 10 years follow up and no abnormality has been
detected (see also pp. 198 and 213)

245
16: Age 14-15 Years Knees

Fig. 1. Posterior view of knees


1

Fig. 2. Anterior pinhole view of


2 5
right knee

Fig. 5. Anterior pinhole view of


left knee

246
Tibia, Fibula and Ankles 16: Age 14-15 Years

Fig. 1. Posterior view of tibia,


1 4 fibula and ankles

Fig. 4. Posterior view of tibia,


fibula and ankles

Technical Comment
- Note the patchy distribution of the isotope in the fibulae in Fig. 4

247
17: Age 15-17 Years
17: Age 15-17 Years Blood Pool Images

Fig. I. Posterior view of pelvis

Fig. 2. Anterior view of knees

250
Blood Pool Images 17: Age 15-17 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note extravasation of isotope at the site of injection in the right elbow
- Marker on child's right side

251
17: Age 15-17 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
Isotope in the breasts causes indistinctness of the ribs on the anterior
view
- Marker on child's right side

252
Whole Body Scan 17: Age 15-17 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
Isotope in the breasts causes indistinctness of the ribs on the anterior
view
Marker on child's right side

253
17: Age 15-17 Years Skull and Upper Limbs

Fig. 1. Anterior view of skull


4
Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


and right upper limb 2 5

Fig. 5. Left lateral view of skull


and left upper limb

Fig. 3. Anterior view of hands


3

Technical Comments
Note the significant difference between the activity in the epiphyseal
plates of the wrist in Figs. 2, 3 and 5
- The lateral views of the skull (Figs. 2 and 5) were taken posteriorly
- The tips of the fingers have not been included in the field of view of the
gamma camera in Figs. 2 and 5

254
Skull and Upper Limbs 17: Age 15-17 Years

Fig. 1. Anterior view of skull


4
Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


2 5 and right upper limb

Fig. 5. Left lateral view of skull


and left upper limb

Technical Comments
The lateral views of the skull (Figs. 2 and 5) were taken anteriorly
The tips of the fingers have not been included in the field of view of the
gamma camera in Figs. 2 and 5

255
17: Age 15-17 Years Thorax and Spine

Fig. I. Anterior view of thorax


and spine 4

Fig. 4. Anterior view of thorax


and spine

Fig. 2. Anterior view of thorax


and spine

Fig. 3. Left anterior oblique view


of thorax

256
Thorax and Spine 17: Age 15-17 Years

Fig. 1. Posterior view of thorax


4
and spine

Fig. 4. Posterior view of thorax


and spine

Fig. 2. Posterior view of thorax


2 and spine

257
17: Age 15-17 Years Spine, Pelvis and Femora

Fig. 1. Anterior view of spine,


pelvis and femora 4

Fig. 4. Posterior view of spine,


pelvis and femora

Fig. 2. Anterior view of spine,


pelvis and femora 2 5

Fig. 5. Posterior view of spine


and pelvis

TechniCal Comment
- Urine contamination below the pelvis is seen in Fig. 2

258
Hips 17: Age 15-17 Years

Fig. I. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

259
17: Age 15-17 Years Lower Limbs

Fig. 1. Posterior view of femora


4
Fig. 4. Posterior view of femora

Fig. 2. Posterior view of tibia,


fibula and ankles 2 5

Fig. 5. Posterior view of tibia,


fibula and ankles

260
Knees and Feet 17: Age 15-17 Years

Fig.t. Posterior view of knees


4
Fig. 4. Posterior view of knees

Fig. 2. Anterior view of knees


2 5
Fig. S. Posterior view of knees

Fig. 3. Posterior view of feet .


3 6
Fig. 6. Lateral view of feet

Technical Comment
- Note the differences in maturation of the epiphyseal plates in Figs. I, 2,
4 and 5

261
18: Age 17-22 Years
18: Age 17-22 Years Blood Pool Images

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Note the mature skeleton with no visualization of the epiphyseal plates
- Marker on child's right side

264
Whole Body Scan 18: Age 17-22 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

Technical Comments
Isotope in the breasts causes indistinctness of the ribs on the anterior
view
Poor positioning of the feet is noted
The focal area of apparent increased uptake in the left orbital region
seen only on the anterior view is probably due to rotation of the head
Note the mature skeleton with no visualization of the epiphyseal plates
Note extravasation of isotope at the site of injection in the left elbow
Urine contamination below the pelvis is seen

265
18: Age 17-22 Years Whole Body Scan

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view

• •

Technical Comments
Isotope in the breasts causes indistinctness of the ribs on the anterior
view
- Note the relatively mature skeleton with most of the epiphyseal plates
virtually fused
Marker on child's right side

266
Whole Body Scan 18: Age 17-22 Years

- A double headed whole body


gamma camera was used
- Left image is the anterior view
- Right image is the posterior
view


Technical Comments
Isotope in the breasts causes indistinctness of the ribs on the anterior
view
Note the relatively mature skeleton with most of the epiphyseal plates
virtually fused
Marker on child's right side

267
18: Age 17-22 Years Skull

Fig. 1. Anterior view of skull 4


Fig. 4. Posterior view of skull

Fig. 2. Right lateral view of skull


2 5
Fig. 5. Left lateral view of skull

268
Skull and Upper Limbs 18: Age 17-22 Years

Fig. I. Right lateral view of skull


1 4
Fig. 4. Left lateral view of skull

Fig. 2. Posterior view of left


2 5 humerus

Fig. 5. Posterior view of right


humerus

Fig. 3. Anterior view of hands


3

Technical Comment
Note the variation in the maturity ofthe skeleton in this age group. The
epiphysis around the hands and wrists are not yet fused in this particu-
lar child (Fig. 3)

269
18: Age 17-22 Years Thorax, Spine and Pelvis

Fig. 1. Anterior view of thorax


4
Fig. 4. Posterior view of thorax
and spine

Fig. 2. Anterior view of spine


and pelvis 2 5

Fig. S. Posterior view of spine


and pelvis

Fig. 3. Pinhole view of right hip


3 6
Fig. 6. Pinhole view of left hip

270
Lower Limbs 18: Age 17-22 Years

Fig. 1. Posterior view of femora

Fig. 2. Posterior view of tibia,


2 fibula and ankles

271
18: Age 17-22 Years Knees and Feet

Fig. 1. Anterior view of knees


1 4
Fig. 4. Posterior view of knees

Fig. 2. Anterior view of feet


2 5
Fig. S. Posterior view of feet

272
19: Knees
19: Knees Age: 0-6 Months

Fig. 1. Anterior view


1 -

Technical Comment
- The toes are facing medially, "the radiographic neutral position". This
is the reason that the fibula is clearly seen

274
Age: 6-12 Months 19: Knees

Fig. 1. Anterior view

Fig. 2. Anterior view


2

Technical Comments
- Fig. 1 shows good positioning of the left knee and foot, this allows
visualization of the left fibula. The fibula is not seen on the right due to
poor positioning of both the knee and the foot
- Fig. 2 shows good positioning of the left knee and foot, this allows
visualization of the left fibula
- Note the shape of the epiphyseal plates around the knees

275
19: Knees Age: 1-2 Years

Fig. I. Anterior view


1 4
Fig. 4. Posterior view

Technical Comment
Good positioning for the knees, tibia and fibula. The fibula is clearly
seen separate from the tibia

276
Age: 2-3 Years 19: Knees

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view


5
Fig. 5. Posterior view

Technical Comments
Note the clarity of the fibula separate from the tibia in Figs. 1, 2, 4
and 5. This is due to the "radiographic neutral position of the feet"
Note the progressive changes in the epiphyseal plates with maturation

277
19: Knees Age: 3-4 Years

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 5. Posterior view


5

Technical Comment
- The clarity of the fibula on all the images suggests good positioning of
the feet

278
Age: 4-5 Years 19: Knees

Fig. 1. Posterior view


4
Fig. 4. Posterior view

Fig. 2. Posterior view


2 5
Fig. S. Posterior view

Technical Comment
Note the clarity of the heads of the fibulae on all the images. Note the
clarity of epiphyseal plates with their well defined margins

279
19: Knees Age: 5-6 Years

Fig. 1. Posterior view

Fig. 2. Posterior magnified view


2

Technical Comments
- The magnified view (Fig. 2) shows the epiphyseal plates to best ad-
vantage
- The fibula is clearly seen in both figures because the toes were turned
inward during image acquisition

280
Age: 6-7 Years 19: Knees

Fig. 1. Posterior magnified view

Fig. 2. Posterior view


2

Technical Comment
Note the clear definition of the growth plate from the adjacent meta-
physes

281
19: Knees Age: 7-8 Years

Fig. 1. Posterior magnified view

Fig. 2. Posterior magnified view


2

Fig. 3. Posterior view


3

Technical Comments
There is clear separation between the upper tibia and the fibula due to
good positioning of the feet in all images
Slight overexposure as seen in Fig. 2 shows the tibia better but causes
overexposure of the epiphyseal plates. This is the reason for the diffe-
rent appearance of this image compared to Figs. 1 and 3

282
Age: 8-9 Years 19: Knees

Fig. 1. Posterior view


1 4
Fig. 4. Anterior view

Fig. 2. Medial lateral view of left


2 5 knee

Fig. 5. Medial lateral view of


right knee

Fig. 3. Lateral lateral view of


3 6 right knee

Fig. 6. Lateral lateral view of left


knee

Technical Comment
The pair of lateral knees in Figs. 2 and 5 represent medial lateral knees
while Figs. 3 and 6 represent lateral knees in the lateral projection. This
accounts for the clarity of the fibula in the lower series and the diffi-
culty in seeing the fibula in the upper series

283
19: Knees Age: 9-10 Years
Fig. 1. Posterior view
4
Fig. 4. Posterior view

Fig. 2. Posterior view


2

284
Age: 10-11 Years 19: Knees

Fig. 1. Posterior magnified view


1 4
Fig. 4. Posterior view

Fig. 2. Anterior pinhole view of


2 5 right knee

Fig. s. Anterior pinhole view of


left knee

Technical Comment
Note that the fibula is better seen on the posterior view in Figs. 1 and 4
than on the anterior pinhole views in Figs. 2 and 5

285
19: Knees Age: 11-12 Years

Fig. 1. Posterior view


1

Fig. 2. Posterior view


2

286
Age: 12-13 Years 19: Knees

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior pinhole view of


2 5 right knee

Fig. 5. Anterior pinhole view of


left knee

Fig. 3. Lateral view of left knee


3 6
Fig. 6. Lateral view of right knee

Technical Comment
The fibula is not seen in Figs. 3 and 6 because the images are medial
lateral views

287
19: Knees Age: 13-14 Years

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior pinhole view of


right knee 2 5

Fig. 5. Anterior pinhole view of


left knee

Fig. 3. Lateral view


3 6
Fig. 6. Lateral view

Technical Comment
- Figs. 3 and 6 represent lateral images of the knees, on the left there is a
medial lateral and a lateral lateral while on the right it is the reverse
order. The lateral lateral images show the head of the fibula clearly
while the medial lateral show the head of the fibula within the tibia but
below the epiphyseal plate

288
Age: 14-15 Years 19: Knees

1 Fig. 1. Posterior view

Fig. 2. Anterior pinhole view of


2 5 right knee

Fig. 5. Anterior pinhole view of


left knee

289
19: Knees Age: 15-17 Years

Fig. I. Posterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. 5. Posterior view

Technical Comment
Note the differences in maturation ofthe epiphyseal plates in Figs. I, 2,
4 and 5

290
Age: 17-22 Years 19: Knees

Fig. 1. Anterior view


1 4
Fig. 4. Posterior view

Technical Comment
Note the epiphyseal plates are distinct as the skeleton approaches ma-
turity

291
20: Hips
20: Hips Age: 0-6 Months

Fig. 1. Posterior view

294
Age: 6-12 Months 20: Hips

Fig. I. Posterior view

295
20: Hips Age: 1-2 Years

Fig. 1. Posterior view

Fig. 2. Pinhole view of right hip


2 5
Fig. S. Pinhole view of left hip

296
Age: 2-3 Years 20: Hips

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. S. Posterior view


5

Technical Comments
Note that the bladder is virtually empty on all three images, an ideal
situation
Urine contamination below the pelvis is seen in Figs. I and 5

297
20: Hips Age: 2-3 Years

Fig. I. Pinhole view of right hip

Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip

Fig. 5. Pinhole view of left hip

Technical Comment
- The femoral heads are well seen in Figs. 1 and 4 while poor visualiza-
tion is noted in Figs. 2 and 5 because of poor positioning of the knees
and feet

298
Age: 3-4 Years 20: Hips

Fig. I. Anterior view


4
Fig. 4. Posterior view

Technical Comments
- The bladder in Fig. I is of relatively large volume but has little activity
suggesting that the child is well hydrated
- Urine contamination below the pelvis is seen in Fig. I

299
20: Hips Age: 3-4 Years

Fig. I. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

Fig. 3. Pinhole view of right hip


3 6
Fig. 6. Pinhole view of left hip

Technical Comments
- Different size of pinhole inserts give different degrees of magnification
- The position of the hips in the bottom series (Figs. 3 and 6) is not as
good as in the top two. This is related to the p()sitioning of the knees
and the lack of in-turning of the feet. The "radiographic neutral positi-
on of the feet and knees" is essential when doing pinholes of the hips

300
Age: 4-5 Years 20: Hips

Fig. I. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

Fig. 3. Pinhole view of right hip

Fig. 6. Pinhole view of left hip

301
20: Hips Age: 5-6 Years

Fig. I. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. 5. Posterior view

Technical Comment
- Urine contamination below the pelvis is seen in Fig. 1

302
Age: 5-6 Years 20: Hips

Fig. I. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

303
20: Hips Age: 6-7 Years

Fig. 1. Anterior view


1 4
Fig. 4. Posterior view

Fig. 5. Posterior view


5

Fig. 3. Pinhole view of right hip


3 6
Fig. 6. Pinhole view of left hip

Technical Comment
Urine contamination below the pelvis is seen in Fig. 4

~ Potential Pitfall
In Fig. 5 increased activity is noted at the junction of the left ischial
tuberosity and tl:le posterior pubic ramus due to the normal synchon-
drosis at this site

304
Age: 7-8 Years 20: Hips

Fig. 1. Anterior view


1 4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. S. Posterior view

Fig. 3. Anterior view


3 6
Fig. 6. Posterior view

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 2 and 5

305
20: Hips Age: 7-8 Years

Fig. 1. Pinhole view of right hip


1 4
Fig. 4. Pinhole view of left hip

306
Age: 8-9 Years 20: Hips

Fig. 1. Anterior view


1 4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. s. Posterior view

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 1 and 5

307
20: Hips Age: 8-9 Years

Fig. 1. Pinhole view of right hip


4
Fig. 4. Pinhole view of left hip

Fig. 2. Pinhole view of right hip


2
Fig. 5. Pinhole view of left hip

Technical Comment
- Figs. 2 and 5 show a change in magnification creating an apparent dif-
ference between the sizes of the two hips.

308
20: Hips Age: 9-10 Years

Fig. 1. Anterior view

Fig. 4. Posterior view

Fig. 2. Pinhole view of right hip


2
Fig. S. Pinhole view of left hip

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

309
20: Hips Age: 10-11 Years

Fig. I. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. 5. Posterior view

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

310
Age: 11-12 Years 20: Hips

4 Fig. 1. Anterior view


1
Fig. 4. Posterior view

Fig. 2. Pinhole view of right hip


2
Fig. 5. Pinhole view of left hip

Technical Comment
Urine contamination below the pelvis is seen in Figs. 1 and 4
Figs. 2 and 5 show a change in magnification creating an apparent
difference between the sizes of the two hips

311
20: Hips Age: 12-13 Years

Fig. 1. Anterior view


1
Fig. 4. Posterior view

Fig. 2. Anterior view


2
Fig. 5. Posterior view

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

Technical Comment
- Urine contamination below the pelvis is seen in Figs. 1 and 4

~ Potential Pitfall
- The pubic rami show normal increased uptake of tracer in Figs. 1 and 2

312
Age: 13-14 Years 20: Hips

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view


2 5
Fig. S. Posterior view

Fig. 3. Pinhole view of right hip


3 6
Fig. 6. Pinhole view of left hip

Technical Comment
- Urine contamination adjacent to the left ischium is seen in Fig. 2

313
20: Hips Age: 14-15 Years

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Anterior view

Fig. S. Posterior view

Fig. 3. Pinhole view of right hip


3
Fig. 6. Pinhole view of left hip

Technical Comment
- Urine contamination to the left of the pubic bone is seen in Fig. 1

~ Potential Pitfall
- The apparent increased activity in the right sacra-iliac joint in Fig. 2 is
due to rotation of the pelvis and is not pathological

314
Age: 15-17 Years 20: Hips

Fig. 1. Anterior view


1 4
Fig. 4. Posterior view

Fig. 2. Pinhole view of right hip


2
Fig. 5. Pinhole view of left hip

Technical Comment
- The maturity of the skeleton has resulted in decreased uptake of the
epiphyseal plates

315
20: Hips Age: 17-22 Years

Fig. 1. Anterior view


4
Fig. 4. Posterior view

Fig. 2. Pinhole view of right hip


2 5
Fig. 5. Pinhole view of left hip

316
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