Vomiting Following Reduction of Intussusception
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 13
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 5-month old female who presented to a
rural emergency department because of lethargy,
fussiness, vomiting, and blood in the stool. An
abdominal mass was noted on exam and
intussusception was suspected. Abdominal films and a
barium enema were done. The barium enema
demonstrated intussusception which was successfully
reduced with the BE. This child was then transported to
a children's hospital for hospitalization under the care of
a pediatric surgeon. Overnight she was kept NPO with
IV fluids infusing. After improving overnight, she was
started on oral fluids in the morning. However, she
vomited twice that afternoon. Her abdominal exam was
benign but because of her previous intussusception, an
abdominal series was ordered.
View Abdominal Series: Upright view.
View Abdominal Series: Supine view.
These radiographs showed some dilated loops and
a paucity of bowel gas. There is a small amount of
barium remaining (following the barium enema done at
the rural hospital). The liver edge is not well defined.
This is sometimes seen in intussusception but it is not
specific. The more specific plain film signs of
intussusception (the crescent sign and the target sign)
are not present (see Case 2 in Volume 1). Her
abdominal radiographs were felt to be non-specific at
this point. She continued to feed and her symptoms
resolved by morning at which time she was discharged.
Her abdominal series discovered a congenital
dislocated left hip (identified by the radiologist) which
was previously undiagnosed on routine newborn
screening exams. She was referred to an orthopedic
surgeon for this condition.
Congenital hip dislocation is part of the spectrum of
congenital dysplasia of the hip. Hip dysplasia can
range from a barely detectable instability of the hip to
a non-reducible dislocation of the hip. Very mild cases
may resolve on their own without any long term
morbidity. More severe cases result in the progression
of symptoms and if not diagnosed at an early stage can
lead to an irreversibly damaged hip.
Early diagnosis and treatment of congenital hip
dysplasia is required to prevent permanent injury to the
hip. Physicians providing primary care for infants
routinely screen for hip dysplasia through routine
screening examination methods. However, there is no
clinical finding or screening method that can reliably
detect all cases. For this reason, patients with an
undiagnosed occult hip dysplasia, may seek treatment
in an E.D. for an abdominal condition. If an abdominal
radiograph is ordered on such a patient, the diagnosis
may be apparent radiographically if one is astute
enough to survey the bony structures.
Failing to identify a congenital hip dislocation on a
radiograph may result in liability if the patient's condition
is ultimately diagnosed after irreversible hip damage is
sustained. Protection from liability is not afforded even
if the radiograph was ordered for a different reason.
Radiographs are usually kept indefinitely. Thus, at any
time in the future, our interpretation of a radiograph may
be subjected to a retrospective review.
In older children with a well ossified hip, it is usually
obvious if the hip is dislocated since the well developed
femur head is easily seen to fit symmetrically within the
acetabulum bilaterally. In younger children where the
acetabulum is not fully ossified and the femur head is
non-ossified or is just beginning to ossify, the
relationship between the femoral head and the
acetabulum is not easy to assess radiographically. In
infants, ultrasound of the hip may be the diagnostic
method of choice in defining the anatomy of a
suspected dysplastic hip.
View Hip Diagram.
A horizontal line is drawn as shown (through the
triradiate cartilages). Vertical lines are drawn as shown
(through the lateral edge of the acetabulum). The black
arc drawn over the patient's left hip (right side of the
image) outlines the upper border of the acetabulum.
The vertical lines are drawn through the lateral edge of
this border. These perpendicular lines form four
quadrants about each hip. The ossified femoral head
should be normally located in the inferior medial
quadrant. In this case, the femoral heads are not
ossified so it is not visible on the radiograph. It is not
hard to imagine the position of the femoral head
(epiphysis) located proximal to the femur along its long
axis. The patient's left femoral head (right side of the
image) would be in the superior lateral quadrant
(indicating dislocation), while the patient's right femoral
head (left side of the image) would be in the inferior
medial quadrant (normal position). If the femoral head
is not ossified, the medial "beak" of the proximal
femoral metaphysis should be in the medial inferior
quadrant. In this case the white arrows point to the
"beaks" on both sides. The patient's left femoral beak
is in the inferior lateral quadrant (indicating dislocation),
while the patient's right femoral beak is located in the
medial inferior quadrant (normal position).
Shenton's line is a smooth arc drawn from the
medial femoral neck through the superior margin of the
obturator foramen. If this arc cannot be drawn
smoothly, dislocation is suspected. Note the smooth
arc of Shenton's line drawn on the patient's normal right
hip (white arc) while this arc cannot be drawn over the
patient's dislocated left hip. In the abnormal left hip, the
arc is discontinuous.
Children may occasionally present to the E.D. for
evaluation of a limp if they have no primary care
provider or if the patient's primary care provider fails to
properly evaluate the child to the parent's satisfaction.
When the child begins walking, the most common
diagnostic sign is an abnormal gait. This can be so
subtle that it may be difficult to appreciate. It is often
best to rely on the parents' assessment of the child's
gait since they are usually more sensitive at observing
such subtle abnormalities. Other signs may be subtle
and difficult to appreciate. There may be asymmetry in
lower extremity length measurements. Because
asymmetry may not be present in bilateral hip
dysplasia, this may be more difficult to detect than
unilateral disease. Radiographs should be more
reliable in identifying abnormalities in the well ossified
hip. Ultrasound is more accurate in defining the hip
anatomy in infants.
Most infants with congenital hip dysplasia can be
detected by screening exam measures. This
responsibility rests largely with primary care physicians.
However, not all children have access to a primary care
physician. Infant growth and development changes the
musculoskeletal structure of the hip such that screening
exam measures become less reliable in detecting hip
dysplasia as the infant grows. The Ortolani and Barlow
signs have usually disappeared by six weeks of age.
Detection of congenital hip dysplasia outside of this age
relies on the identification of subtle findings such as
lower extremity length asymmetry, loss of the normal
hip flexion contracture, buttock fullness, a hollow
anterior groin, asymmetry of the perineal, gluteal or
thigh folds/creases, or a palpably dislocated femoral
The Ortolani sign (reduction of the dislocated hip by
abduction) and the Barlow sign (dislocation of a
reduced hip by adducting and applying longitudinal
pressure on the femur) used in newborn screening refer
to the sequential series of maneuvers testing the
reducibility and dislocatability, respectively, of the hips.
If the nomenclature is confusing, it may be more useful
to describe a hip as being dislocatable/reducible and/or
The Hip. In: Renshaw TS. Pediatric Orthopedics.
Volume 28 in the Series, Major Problems in Clinical
Pediatrics. Philadelphia, W.B. Saunders, 1986, pp.
Herring JA. Congenital Dislocation of the Hip. In:
Morrissy RT (ed). Lovell and Winter's Pediatric
Orthopedics, 3rd edition. Philadelphia, J.B. Lippincott
Co., 1990, pp. 815-851.
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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine