Physeal Involvement Research Articles

Diagnosis of Osteomyelitis in Children: Utility of Fat-Suppressed Contrast-Enhanced MRI

The purpose of this study was to determine whether the use of fat-suppressed contrast-enhanced MRI, compared with unenhanced MRI alone, increases reader confidence in the diagnosis of osteomyelitis and its complications in children. MRI studies of 78 skeletally immature children and adolescents (median age, 3.6 years) with suspected nonspinal osteomyelitis were reviewed in consensus by two readers. Unenhanced images were evaluated first and then contrast-enhanced MR images. Images were scored for the presence or absence of osteomyelitis, abscess, septic arthritis, and physeal involvement on a 5-point scale ranging from definitely absent to definitely present. Forty-two additional studies were evaluated to test interobserver agreement. Osteomyelitis was clinically diagnosed in 40 cases (51%). There was no significant difference between the sensitivity and specificity of unenhanced MRI (p = 1.0) and those of contrast-enhanced MRI (p = 0.77) for the diagnosis of osteomyelitis. Nonetheless, there was a significant (p < 0.001) increase in confidence in the diagnosis of osteomyelitis and its complications. This increase in confidence was most pronounced for the diagnosis of abscess (46%). The addition of contrast enhancement was least useful in findings deemed definitely absent on unenhanced MR images. Although it does not increase the sensitivity or specificity of the diagnosis, use of contrast-enhanced MRI does increase reader confidence in the diagnosis of osteomyelitis and its complications in cases in which bone or soft-tissue edema is found on unenhanced images. In the clear absence of edema on unenhanced images, however, contrast enhancement is not needed.

Solitary Epiphyseal Enchondromas

Enchondromas originating in the epiphyses of long bones are rare. The purpose of the present study was to evaluate the prevalence as well as the radiographic and clinical characteristics of epiphyseal enchondromas among patients who had been referred to the Armed Forces Institute of Pathology and Walter Reed Army Medical Center. We performed a retrospective review of 761 patients who had been referred to our two institutions over an approximately fifty-five-year period and who received a final diagnosis of enchondroma. All lesions had been biopsied, and the pathological diagnosis had been confirmed. Lesions of the hands, feet, or axial skeleton (253 patients) as well as lesions that appeared to originate in the metaphysis or diaphysis (475 patients) were excluded. Only enchondromas of the long bones that originated in the epiphysis were analyzed. The study group included thirty-three patients (twenty male patients and thirteen female patients) with a mean age of 26.7 years, including eleven patients with open physes. We performed additional descriptive analyses with regard to patient age, gender, lesion location, clinical presentation, and treatment as well as an extensive radiographic analysis. The most common locations were the proximal part of the humerus (ten lesions; 30%) and the distal part of the femur (six lesions; 18%). The most common presenting symptom was pain (twenty-three patients). Radiographic analysis demonstrated extensive matrix mineralization in association with twenty-three lesions. Twenty-eight of the thirty-three lesions were geographically well defined; of these, twenty-one had sclerotic borders, and seven did not. Although all lesions were centered and were predominantly located within the epiphysis, twenty of the thirty-three lesions demonstrated radiographic evidence of metaphyseal extension, including four of the eleven lesions in patients with open physes. Twenty-four lesions extended into the subchondral bone. The mean size of the thirty-three enchondromas in greatest radiographic dimension was 2.7 cm (range, 1.1 to 4.9 cm). Twenty-six of the thirty-three lesions were amenable to surgical treatment with curettage with or without bone-grafting, with only one recurrence. With the limited follow-up available, no lesion underwent sarcomatous degeneration. Epiphyseal enchondromas are rare lesions. Although their biologic behavior appears to mirror that of conventional metaphyseal enchondromas, their proximity to the joint space may lead to more frequent painful symptoms, a propensity for physeal involvement, and the need for earlier definitive surgical intervention.

SOLITARY EPIPHYSEAL ENCHONDROMAS

Background: Enchondromas originating in the epiphyses of long bones are rare. The purpose of the present study was to evaluate the prevalence as well as the radiographic and clinical characteristics of epiphyseal enchondromas among patients who had been referred to the Armed Forces Institute of Pathology and Walter Reed Army Medical Center. Methods: We performed a retrospective review of 761 patients who had been referred to our two institutions over an approximately fifty-five-year period and who received a final diagnosis of enchondroma. All lesions had been biopsied, and the pathological diagnosis had been confirmed. Lesions of the hands, feet, or axial skeleton (253 patients) as well as lesions that appeared to originate in the metaphysis or diaphysis (475 patients) were excluded. Only enchondromas of the long bones that originated in the epiphysis were analyzed. The study group included thirty-three patients (twenty male patients and thirteen female patients) with a mean age of 26.7 years, including eleven patients with open physes. We performed additional descriptive analyses with regard to patient age, gender, lesion location, clinical presentation, and treatment as well as an extensive radiographic analysis. Results: The most common locations were the proximal part of the humerus (ten lesions; 30%) and the distal part of the femur (six lesions; 18%). The most common presenting symptom was pain (twenty-three patients). Radiographic analysis demonstrated extensive matrix mineralization in association with twenty-three lesions. Twenty-eight of the thirty-three lesions were geographically well defined; of these, twenty-one had sclerotic borders, and seven did not. Although all lesions were centered and were predominantly located within the epiphysis, twenty of the thirty-three lesions demonstrated radiographic evidence of metaphyseal extension, including four of the eleven lesions in patients with open physes. Twenty-four lesions extended into the subchondral bone. The mean size of the thirty-three enchondromas in greatest radiographic dimension was 2.7 cm (range, 1.1 to 4.9 cm). Twenty-six of the thirty-three lesions were amenable to surgical treatment with curettage with or without bone-grafting, with only one recurrence. With the limited follow-up available, no lesion underwent sarcomatous degeneration. Conclusions: Epiphyseal enchondromas are rare lesions. Although their biologic behavior appears to mirror that of conventional metaphyseal enchondromas, their proximity to the joint space may lead to more frequent painful symptoms, a propensity for physeal involvement, and the need for earlier definitive surgical intervention. Level of Evidence: Prognostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Analysis of 51 Tibial Triplane Fractures Using CT with Multiplanar Reconstruction

We determined the most common patterns of triplane fractures and assessed the risk of epiphyseal separation in each pattern. Fifty-one children with tibial triplane fractures underwent CT, and the resultant scans underwent multiplanar reconstruction. We categorized epiphyseal and physeal involvement, the number of fragments, the appearance of the Salter-Harris fracture in each plane, and the degree of separation of the epiphyseal fragments. The classic two-fragment type of fracture with medial epiphyseal extension occurred most frequently (33/51). All three-fragment types (8/51) of fractures resulted in a separate anterolateral fragment. Extension to the medial malleolus was common (12/51). None of the four reported fractures types involving anteromedial physeal separation was seen. Children with epiphyseal separation requiring surgery were older (odds ratio [OR] = 1.7) and had plafond involvement (OR = 5), CT and multiplanar reconstruction of triplane fractures improve the understanding of patterns of injury and their relative prevalence.

Prognostic Evaluation of Legg–Calvé–Perthes Disease by MRI Part II: Pathomorphogenesis and New Classification

The most widely used system of grading Legg-Calvé-Perthes disease (LCPD) is still the radiographic grouping by Catterall, although it lacks interobserver reliability, especially in the early stages. The predictive value of Salter-Thompson classification and Herring's "lateral pillar" classification are still being studied. In Part 1, we demonstrated the good reliability and the predictive value of four magnetic resonance imaging (MRI) indices (extension of necrosis, lateral extrusion, physeal involvement, metaphyseal changes) through their correlation to clinical and radiographic conditions of the hips at follow-up. The same good results were obtained by submitting to statistical analysis a second group of 31 patients (French series). On the basis of these statistical studies, a new classification has been proposed. It takes into account the extent of necrosis and two MRI risk signs: lateral extrusion and physeal involvement. The extent of necrosis up to or more than 50% separates two main groups, A and B. The associated MRI risk factors distinguished six classes with different prognoses. Appropriated treatment also is suggested for each class. Our experience on MRI in LCPD led us to draw a pathomorphogenetic model called "packed capsule." According to this biomechanical model, the femoral head is considered a segment of a sphere made of viscoelastic material and hermetically sealed. The deformation of the head depends on the behavior of the necrotic fluid collected inside the capsule under the weight-bearing forces. Finally, our suggestion in the treatment of Perthes disease is to relieve weight bearing up to the fragmentation stage, whether the diagnosis has been made by the use of MRI or without it. During the fragmentation stage, MRI is extremely useful in performing prognosis; at this time our classification can be applied, and the corresponding treatment can be followed.

Prognostic Evaluation of Legg–Calvé–Perthes Disease by MRI Part I: The Role of Physeal Involvement

Twenty-eight unselected hips affected by Legg-Calvé-Perthes disease (LCPD) in 24 patients from 1987 to 1994 had magnetic resonance imaging (MRI) performed. The patients were retrospectively reviewed at a mean follow-up of 5.4 years. An interobserver blind analysis was made to establish the reliability of four MRI parameters: extent of epiphyseal necrosis (EXT), lateral extrusion of the femoral head (LAT), physeal involvement (PHY), and metaphyseal changes (MET). The interobserver analysis resulted in a good reliability for all MRI parameters (concordance, >80%; K index, >0.45). A statistical correlation study (Spearman test) was then done between each MRI parameter and the condition of the hips at follow-up evaluated by Stulberg class and a personal scored system (total score) of clinical-radiographic condition. All MRI parameters appeared well correlated to the Stulberg class and to the total score (S > 0.66; p < 0.05). PHY resulted the strongest correlated parameter (S = 0.84 for Stulberg class; S = 0.91 for total score). Finally our statistical correlation study demonstrates physis involvement to have a high predictive value in LCPD; therefore it can be assumed as the main risk factor in formulating prognosis.

SOLITARY BONE CYST WITH EPIPHYSEAL INVOLVEMENT: CONFIRMATION WITH MAGNETIC RESONANCE IMAGING. A CASE REPORT AND REVIEW OF THE LITERATURE

Documented epiphyseal extension of a solitary unicameral bone cyst in the presence of an open physis is extremely rare3,15. Epiphyseal extension by such cysts has been noted on plain radiographs3, on computed tomography15, and intraoperatively10. We report an unusual case of a skeletally immature child in whom magnetic resonance imaging clearly demonstrated extension of a solitary bone cyst into the proximal humeral epiphysis. The portions of the cyst in the epiphysis and metaphysis communicated through a defect in the physis that was probably due to erosion by the cyst. Progressive limb-shortening developed. The purpose of the current report is to describe the natural history and pathogenesis of physeal involvement by a unicameral bone cyst. A fourteen-year-old boy was seen in the emergency room of the Children's Hospital Medical Center in Cincinnati with a history of a twisting injury of the right arm. He had been managed for a pathological fracture of the humerus on the same side when he was nine years old. Roentgenograms made at that time had revealed a fracture through a unicameral bone cyst (Figs. 1-A and 1-B). He had had no specific problems since that time except that the right arm was noticeably shorter than the left. Figs. 1-A through 1-F: Roentgenograms and magnetic resonance images of a boy who had a unicameral bone cyst. Fig. 1-A: Roentgenogram, made when the patient was nine years old, showing a pathological fracture through a typical unicameral bone cyst in the proximal part of the humerus. The cyst abuts the physis and extends one to five centimeters from it. There is a small area where the cyst wall forms an interface with the physis. The growth plate otherwise appears intact, and the fracture does not extend to the physis. …

Solitary Bone Cyst with Epiphyseal Involvement

GUPTA, ANIL K. M.B., B.S., M.S.(ORTH.)†; CRAWFORD, ALVIN H. M.D.‡, CINCINNATI, OHIO Author Information

Manifestations of Ischemic Necrosis Complicating Developmental Hip Dysplasia

Ischemic or avascular necrosis of the hip is a serious complication of the treatment of developmental hip dysplasia. The degree of ischemic insult can be classified based on an understanding of the vascularity of the proximal femur. Physeal involvement and subsequent growth disturbance, producing late deformity of the proximal femur, can compromise long-term results. Early recognition of ischemic necrosis patterns can be helpful in planning further treatment.

Growth disturbance of the proximal part of the femur after treatment for congenital dislocation of the hip.

The radiographs of ninety patients in whom treatment of unilateral congenital dislocation of the hip was complicated by disturbance of growth of the proximal part of the femur were studied retrospectively. All patients were followed until closure of the affected proximal femoral physis. We divided the patients into three groups, according to the degree of vascular insufficiency: patients who had mild vascular insufficiency of the hip, which had little effect on growth; those who had moderate vascular insufficiency, which produces partial arrest of growth; and those who had severe vascular insufficiency, which causes complete arrest of growth. Good correlation was found between the initial degree of vascular insufficiency and the radiographic results at the most recent follow-up. The radiographic signs that were used to predict the extent of physeal involvement were a crescent-shaped epiphysis, medial bowing of the femoral neck (a shorter and more concave curve between the lesser trochanter and the proximal femoral metaphysis [the lateral portion of the Shenton line]), lateral tilting of the capital epiphysis, and premature physeal closure. Signs that were diagnostic of existing physeal involvement were elevation of the greater trochanter and shortening of the affected extremity. The presence and severity of these signs correlated well with the degree of vascular insufficiency. Medial bowing was the most reliable prognostic factor for the determination of the fate of the hip joint at maturity.

ペルテス病の成長障害について

Radiological findings of the physeal involvement reported by Keret were studied in 52 unilateral Perthes' disease. All cases were treated conservatively and twenty and half years was a mean age at the time of review. Forty-three of 52 had one or more of 5 findings. Although the curvature of the physis was closely related with lateral protrusion of the capital nucleus and medial bowing of the femoral neck, premature physeal closure seemed to make the shape of physis flattened. Physeal involvement also resulted in elevation of the tip of the greater trochanter. A child has the abundant growth cartiage in the proximal femur. Overactivity due to hyperemia of the normal perichondral ring and the cartilage in the trochanteric growth plate, and pathological proliferation of the cartilage around the secondary ossification center and physis produce deformed haed characteristic of perthes' disease. Especially premaure closure of the physis seems to play a important role in this process.

Physeal and epiphyseal involvement in chronic recurrent multifocal osteomyelitis (CRMO)

Physeal and epiphyseal involvement in chronic recurrent multifocal osteomyelitis (CRMO)

Physeal involvement in chronic recurrent multifocal osteomyelitis.

Chronic recurrent multifocal osteomyelitis is a recently recognized disease characterized by remissions and exacerbations of multiple bone lesions which radiographically and pathologically have the appearance of hematogenous osteomyelitis. No consistent etiology can be identified, and antimicrobial agents seem to have no beneficial effect. A review of the appearances on imaging modalities and the clinical and pathologic manifestations is undertaken in seven cases of CRMO. No therapeutic regimen resulted in consistent clinical or radiographic improvement. We suggest the sequelae of this process are not as benign as previously reported.

Coxa plana--the fate of the physis.

Eighty patients who had unilateral coxa plana and who had been treated conservatively were followed to a mean age of sixteen and one-quarter years, and their cases were reviewed for radiographic evidence of a disturbance of the femoral capital growth plate. This physeal involvement was inferred by the presence of one or more of five findings: premature physeal closure, overgrowth of the greater trochanter, change in physeal shape, lateral protrusion of the capital nucleus, and medial bowing of the femoral neck. Premature physeal closure, which was more common in the girls than in the boys, occurred in 25 per cent of the affected femoral heads, and 90 per cent of the patients showed some interference with normal physeal growth in the affected femoral head. A direct correlation was found between the severity of the physeal involvement and the ultimate deformity of the femoral head. The possible causes of interference with physeal growth and damage are discussed.