Lam, PW

Peh, WCG

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Title Radiological conference. RicketsAuthor(s) Lam, PW; Peh, WCGCitation Hong Kong Practitioner, 1997, v. 19 n. 4, p. 209-213Issued Date 1997URL http://hdl.handle.net/10722/44659Rights Creative Commons: Attribution 3.0 Hong Kong LicenseRADIOLOGICAL CONFERENCEClinical History:A 4-month-old baby boy was noted to be irritable and was thriving poorly. Imaging included radiographs of bothupper limbs (Figures 1 and 2).Figure 1: Frontal radiograph of the left upper limbFigure 2: Frontal radiograph of the right upper limb and right upper chestAnsweronpage 210What is the diagnosis?a) Ricketsb) Scurvyc) Acute leukaemiad) Caffey's diseasee) Non-accidental injuryThis radiology case was prepared by: Dr. P.W. Lam,Senior Medical Officer.Dr. W.C.G. Peh, Associate Professor,Department of Diagnostic Radiology,The University of Hong Kong,Queen Mary Hospital.209Radiological ConferenceRADIOLOGICAL CONFERENCEAnswer:a) RicketsRadiological findingsThese radiographs show abnormalities in themetaphyses, epiphyses and diaphyses of the bones of allfour limbs:Metaphyses:There is fraying, splaying and cupping of themetaphyses of the long bones (Figures 3-5).Similar deformities of the anterior rib ends give riseto the typical "rachitic rosary" (Figure 4). Corticalspurs are seen projecting at right angles to themetaphyses to surround the uncalcified growthplates.Epiphyses:The growth plates are irregular and widened. Theepiphyseal centres are poorly mineralized (Figures3-5).Diaphyses:Generalized periosteal new bone formation due toossification of subperiosteal osteoid is present.This appearance only develops with treatment. Theunderlying cortex is indistinct (Figures 3-5).Figure 3: Figure is identical to Figure 1 with addition of arrows. There is splaying and cupping of themetaphyses of the distal radius and ulna, with thin metaphyseal spurs (curved arrows). Themetaphyses are frayed (small white arrows). The growth plate at the wrist is widened.Generalized periosteal reaction is present (small back arrows)Figure 4: Figure is identical to Figure 2 with addition of arrows. Metaphyseal splaying, cupping andspurs (curved arrows) are best seen at the proximal humerus and distal forearm bones.Periosteal reation affects the shafts of all the long bones (small white arrows). Rachiticrosary deformities of the anterior rib ends are arrowed (small black arrows)210Hong Kong Practitioner 19 (4) April 1997RADIOLOGICAL CONFERENCEFigure 5: Frontal radiograph of both femurs. Metaphyseal widening and spurs (curved arrows), aswell as generalized periosteal reaction (small white arrows), are seenDiscussionRickets is the childhood form of osteomalaciawhich occurs during enchondral bone growth. Theradiographic appearances are due to increaseduncalcified osteoid in the immature skeleton. Earlychanges include indistinctness of the mataphysealmargin, progressive fraying, and widening of the growthplate due to lack of normal calcification in the zone ofprovisional calcification. Bones subjected to stress suchas the ankles, knees and wrists, are particularlyinvolved. The uncalcified osteoid which is produced isdeposited in the subperiosteal location, causingelevation of periosteum and indistinct cortical outlines.With treatment, mineralization of the subperiostealosteoid gives rise to the bone-in-bone appearance seenin our patient.Apart from those described above, other findingsinclude flattening and invagination of skull base due tobone softening (craniotabes), delayed dentition,scoliosis and biconcave vertebral bodies. Bowing oflong bones in lower limbs usually occurs after the onsetof weight-bearing. The various possible causes ofrickets are summarized in the table.•>'.-'? • • '. : • 'l. Deficiency: dietary, malabsorption, lack of• •• . 2, Defective conversion to active form due to:....; : ' - • ' . , . : : .'' .I I , A b n o r m a l p h o s p h a t e m e t a b o l i s m : . . . . . .; " 1. Phosphate deficiency '•.'."•• • •' ' : '" ' .• , ,'.' - .. ';' ' " ''.• .'2. Renal tubular disorder ; ' .. : .' ..' -~ 3. Oncogenic hypophosphataemia . ' : - " " : . :'. . . ' .' : ;'" ' 'III. Calcium deficiency:". •. . .',1".;.. Dietary deficiency , . ; • • - . • . . , ; . ; :* , ; . • • • . - : --..- -Calcium.211Radiological ConferenceScurvyScurvy is due to the deficiency of vitamin C, withresulting defective collagen and bony matrix formation.The age of onset is usually at 6-9 months, as maternalvitamin C lasts for the first 6 months of life. Clinically,there is tenderness and weakness of the lower limbs, aswell as gum bleeding.The typical signs of scurvy are:1. Wimberger's sign: small epiphysis with loss ofdensity and a very thin, sharply-marginated rim.2. Frankel's white line: a dense white line at thegrowing metaphysis due to excessive calcificationof osteoid in the zone of provisional calcification.3. Triimmerfeld zone: a lucent metaphyseal bandbeneath the zone of provisional calcification due tolack of mimeralized osteoid.4. Pelkan spurs: metaphyseal spurs projecting at rightangles to the shaft axis.5. Parke corner sign: metaphyseal corner fracturesthrough the weakened lucent metaphyses.6. Periosteal reaction: subperiosteal haematoma withcalcification of elevated periosteum.The age of onset and the absence of the first threesigns in our patient excludes the diagnosis of scurvy.Acute leukaemiaChildren with acute leukaemia are usually very illwith signs such as fever, splenomegaly andlymphadenopathy. The radiographic features of bonyinvolvement are due to leukaemic infiltrates in variousparts of the bone.1. Metaphyseal translucency is the most characteristicsign. This is a transverse radiolucent band of up to5 mm in width, crossing the metaphysis at rapidlygrowing areas such as the knees, wrists, and ankles.It is due to rapidly proliferating leukaemic cells inthe marrow-containing metaphysis.2. Metaphyseal cortical erosions occur at the medialside of the proximal humeral and tibial shafts andare usually bilateral.3. Diffuse demineralization is seen in the long bonesin 30% of cases. Destruction of fine trabeculaecauses the appearance of trabecular coarsening.Involvement of spongiosa and later the cortexcauses multiple ovoid osteolytic lesions.4. Periosteal reaction is smooth, lamellar or sunburstin appearance due to subperiosteal penetration bysheets of leukaemic cells.5. Sclerotic lesions are seen late in the disease due toreactive osteoblastic proliferation.Unlike rickets, leukaemic infiltration is usuallyasymmetrical and does not have a generalized pattern,The lesions are due to bony destruction rather thandefective mineralization, and are therefore moreirregular and ill-defined.Caffey's disease (Infantile cortical hyperostosis)Caffey's disease is a self-limiting entity manifestingas asymmetrical hyperostosis affecting the diaphyses oftubular bones, with sparing of the metaphyses andepiphyses. The distribution of bony involvement thusreadily differentiates this condition from rickets. Theage of onset is less than 6 months, with a mean ofaround 9 weeks. Deeply situated tender soft tissueswellings are associated with cortical changes in theunderlying bones. Soft tissue swellings appear beforethe bony changes and may disappear long before bonyresolution. The sites of involvement, in decreasingorder of frequency, are the mandible, clavicle, ulna andthen other sites. The phalanges and vertebrae areusually spared.Non-accidental injuryThe diagnosis of non-accidental injury (or childabuse) should be suspected in any child presenting with212Hong Kong Practitioner 19 (4) April 1997multiple bone fractures. The most specific fracturetypes are metaphyseal fractures of the long bones andrib fractures, with 80% of fractures occurring in childrenless than 18 months old. Unlike rickets, the metaphysesin the abused child are sharply defined and fracturesusually occur in bones with normal density. Theperiosteal reaction is localized around the fracture sitewhile it is generalized in rickets. In non-accidentalinjury, fractures and other injuries in the body aretypically of different ages with poor correlation to ahistory of injury. |References1. Dahnert W. Radiology Review Manual. 2nd ed. Williams & Wilkins,Baltimore. 1993; pp 61-64, 94-96.2. Sutton D. Textbook of Radiology and Medical Imaging. 4th ed.Churchill Livingstone, Edinburgh. 1987; pp 77-78, 196, 221-225.3. Silverman FN, Kuhn JP. Essentials of Caffey's Pediatric x-rayDiagnosis. Year Book Medical Publishers, Chicago. 1990; pp 895-897, 901, 984-986, 954-957.4. Duncan AA, Chandy J. Multiple neonatal fractures - dietary ordeliberate? Clin Radiol 1993; 48: 137-139.Kwelcomes your comments.Please contact us:College of General Practitioner8th Floor, Duke of Windsor Building, 15 Hennessy Road, Hong Kong: ^ ^" " . .. :;;Tel: 2528-6618 (2 lines)' : ' 'Fax : 2866-0616 : . ' ;: ^,' ;!/ "' - *We welcome comments for publication, queries and concerns, and suggestions for articles.213

Radiological conference. Rickets

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