The images are part of pelvic projections to evaluate osseous integrity for a non-visible decubitus ulcer. This is a pelvic outlet view and hence the sacrum is undervisualised but is intact. The images demonstrate bilateral hip subluxation/dislocation with shallow dysplastic acetabular fossae. This raises concern that potentially the patient does not walk. This is likely confirmed by the presence of mottled density in the perineal region due to faeces in an incontinence pad. What is the cause? Review of the lower lumbar spine is telling demonstrating multilevel loss of the spinous processes with wide separation of the posterior elements that indicates dysraphism (failure of closure of the posterior elements). Now look in the right iliac fossa. What is that tubing? The lower aspect of a ventriculoperitoneal shunt, a further indication of a generalised neurodevelopmental disorder. Recall that in patients with spina bifida and myelomeningocele Arnold Chiari type II malformations are common and approximately 90% will develop obstructive hydrocephalus.
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