Alan E. Oestreich

The periphysis and its effect on the metaphysis. I: Definition and normal radiographic pattern

The zone of Ranvier and the ring of LaCroix, together with the membranous bone bark they produce, are termed the periphysis in order to emphasize their normal effect (the metaphyseal collar) on the metaphysis of the infant and young child. In the first 7 years of life, the normal collar at the wrist is 1–3 mm wide. The step-off between the metaphyseal collar and the curvilinear metaphysis, at the margin of the periphysis, should not be mistaken for abuse fracture. The periphyseal bone bark may be radiologically visible at the edge of the physis at the distal ulna in 9% of infants and should not be mistaken for fracture or rickets.

The periphysis and its effect on the metaphysis

The metaphyseal collar due to the periphysis is lost (in 98% of 49 subjects) as an early sign of rickets and returns with recovery. The term “pseudophysis” refers to that unossified metaphyseal osteoid and cartilage as in rickets. The collar is intact in metaphyseal chondrodysplasias (a helpful sign in differential diagnosis from rickets), is shortened in achondroplasia, and frequently is spared in osteomyelitis, luetic bone disease, and Caffey infantile cortical hyperostosis. The periphyseal bone bark is thinned, but often apparent, in rickets, and is not thinned in cases of tyrosinosis and phenylketonuria.

Mega os trigonum in progressive pseudorheumatoid dysplasia

Background. Progressive pseudorheumatoid dysplasia (PPRD), a noninflammatory condition, needs to be differentiated diagnostically from juvenile rheumatoid arthritis (JRA). Objective. Demonstration of an unusually large and often early-appearing os trigonum helps distinguish PPRD from JRA. Materials and methods. Ankle images in four children with PPRD were reviewed. Results. The os trigonum was abnormally enlarged in all PPRD subjects and was shown to have appeared or fused earlier than normal in two subjects. Conclusion. A large and early os trigonum ossification helps differentiate PPRD from JRA.

Cerebro-costo-mandibular syndrome with stippled epiphysis and cystic fibrosis

We present a patient with cerebro-costomandibular syndrome who also had cystic fibrosis, hydrocephalus, and multiple ossification centers of the calcaneus.

Prominent transverse (Bowdler) bone spurs as a diagnostic clue in a case of neonatal hypophosphatasia without metaphyseal irregularity

Transverse midshaft spurs allowed a diagnosis of hypophosphatasia in a newborn infant without metaphyseal irregularity.

Child abuse fracture through physiologic periosteal reaction.

Because infants from 1 to 6 months of age often normally show symmetric diaphyseal periosteal reaction, careful analysis of the reaction at a midshaft fracture site is needed to date the fracture, especially in a child-abuse evaluation. We present a case of an acute fracture through such physiologic reaction.

MR demonstrates cartilaginous megaepiphyses of the hips in Kniest dysplasia of the young child

MR imaging of a 2-year-old girl with Kniest dysplasia revealed abnormally large cartilaginous femoral heads. Although ossification of the femoral head is delayed in Kniest dysplasia, it is nonetheless also a megaepiphyseal growth center with respect to the cartilage model.

Plain film emergency radiology of child abuse: a strategy

SummaryA strategy is proposed for the dedicated interpretation of possible radiographic plain film signs that are suspicious for indicating child abuse. For each sign, the features “PRO” raise the question of abuse, while radiographic or clinical findings “CON” suggest an alternate explanation. Birth trauma, oesteogenesis imperfecta, rescue trauma, and metastatic neuroblastoma are among the many entities cited. A triad of situations may lead a radiologist to look systematically for changes from abuse; a triad of resolutions may result from the search. Periosteal reaction is the major factor in dating of fractures; physiologic periosteal reaction of infancy and periosteal reaction from previous fracture must be considered when so dating fractures.ZusammenfassungEs wird eine Strategie für die genaue Interpretation röntgenologischer Befunde, die auf eine Kindesmißhandlung hindeuten können, vorgeschlagen. Für jeden Befund werfen die unter „PRO“ aufgeführten Merkmale die Frage nach einer Kindesmißhandlung auf, während radiologische und klinische Befunde unter „CON“ andere Erklärungen nahelegen. Geburtstrauma, Osteogenesis imperfecta, Rettungstrauma und metastasierendes Neuroblastom sind unter den vielen zitierten Differentialdiagnosen. Drei mögliche Situationen können den Radiologen dazu veranlassen, systematisch nach Zeichen einer Kindesmißhandlung zu suchen, 3 mögliche Lösungen können aus dieser Suche hervorgehen. Eine Periostreaktion ist ein Kardinalbefund zur Datierung von Frakturen. Physiologische Periostreaktionen im frühen Kindesalter und Periostreaktionen durch frühere Frakturen müssen bei einer solchen Datierung von Frakturen mitbedacht werden.

Kindliche Arthrosen als Folge enchondraler Schädigungen Am Beispiel von Erfrierungen, der Kashin-Beck-Erkrankung, Rattenbissen und anderen Ursachen

ZusammenfassungZiel dieser Arbeit ist es, die radiologische Gleichartigkeit enchondraler Wachstumsschädigungen im Rahmen von Erfrierungen, der asiatischen Kashin-Beck-Erkrankung und (Ratten-)Bissverletzungen darzustellen. Alle 3 Krankheitsbilder zeigen Veränderungen, die mit einer lokalen Schädigung enchondraler Ossifikationszonen in Verbindung zu bringen sind. Zu diesen Ossifikationszonen zählen auch die sog. “Akrophysen”. Das sind Wachstumszonen, die nicht zwischen Epi- und Metaphyse liegen, sondern am Rande der Wachstumszentren bzw. in den nichtepiphy-sialen Enden der kleinen Röhrenknochen.Das radiologisch ähnliche Erscheinungsbild deutet darauf hin, dass Erfrierungsschäden, die in China endemische Kashin-Beck-Erkrankung, aber auch Rattenbissverletzungen gleiche ätiologische Ursachen haben. Die Lokalisationen der Veränderungen sind allerdings unterschiedlich. Erfrierungen treten vorwiegend akral auf und befallen nebeneinanderliegende Gelenke. Die Kashin-Beck-Erkrankung ist dagegen diffuser verteilt. Bei all diesen Krankheitsbildern können sich im weiteren Verlauf Sekundärarthrosen entwickeln. Aufgrund von Magnetresonanztomographien kann eine “Akutdiagnose” gestellt werden. Dies könnte in Zukunft eine therapeutische Beeinflussung des Krankheitsverlaufes erlauben.AbstractPurpose. To review the similarities of the radiographic changes in frostbite, the Asian disease of Kashin-Beck, and long term growth damage from injury such as rate bite.nn Materials and Methods. Radiographs and literature from subjects with these diagnoses were analyzed for the common features and differences. Included was an infant with hand changes 8 months after unwitnessed rat bites.nn Results. Each condition revealed findings consistent with the hypothesis of localized damage to sites of enchondral ossification, including at acrophyses – the growth plates that are not between epiphysis and metaphysis, but instead lie at the margins of growth centers, including carpal and tarsal bones, and the non-epiphyseal ends of small tubular bones.nn Discussion. The patterns observed support a final common pathway of damage in frostbite due to cold injury, Kashin-Beck disease (endemic in China) of unknown etiology, and damage from toxines associated, for example, with rat bite. In frostbite, the distribution is acral because of the site of exposure, while the distribution in Kashin-Beck is more diffuse and often less contiguous. In each condition, arthrotic sequelae may be expected in the natural course of follow-up. MRI may play a role in acute diagnosis that might modify the course of each disease.

The lateral clavicle hook — An acquired as well as a congenital anomaly

The lateral clavicle hook (LCH), an excessive upward convexity of the lateral clavicle, was formally defined by Igual and Giedion, and reported as always present in thrombocytopenia-radial aplasia syndrome and sometimes in other congenital malformations. Additional malformation syndrome including camptomelia are added. In addition, the hook may be seen in acquired upper extremity weakness such as in persistent brachial plexus injury after birth trauma and in severe osteogenesis imperfecta.