Growth Plate, Widened Physis
B. J. Manaster, MD, PhD, FACR
DIFFERENTIAL DIAGNOSIS
Common
Physeal Fracture
Chronic Repetitive Trauma
Slipped Capital Femoral Epiphysis (SCFE)
Renal Osteodystrophy (Renal OD)
Rickets
Less Common
Osteomyelitis
Legg-Calvé-Perthes (LCP)
Blount Disease
Total Parenteral Nutrition
Gigantism
Mucopolysaccharidoses
Osteogenesis Imperfecta (OI)
Hypophosphatasia
Rare but Important
Hypothyroidism
Scurvy
Copper Deficiency (Menkes Kinky-Hair Syndrome)
Metaphyseal Dysplasias
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Involvement of all physes rather than a single or few sites seen in several processes
Rickets and renal OD
Total parenteral nutrition
Gigantism
Mucopolysaccharidoses
Osteogenesis imperfecta
Hypophosphatasia
Hypothyroidism
Copper deficiency
Metaphyseal dysplasias
Helpful Clues for Common Diagnoses
Physeal Fracture
Salter 1: Fracture through physis; difficult to visualize unless displaced
Salter 2: Fracture through physis, extending through metaphysis
Metaphyseal portion may be subtle; easier to visualize if displaced
Salter 3: Fracture through physis, extending through epiphysis
Salter 4: Fracture through epiphysis, physis, & metaphysis; generally does not result in physeal widening
Salter 5: Crush fracture of physis; does not result in widening
Chronic Repetitive Trauma
In child, repeated microtrauma to a physis results in resorption and appearance of widening
Analogous to Salter 1 injury
Associated with competitive athletes
Distal radius/ulna: Gymnasts
Distal tibia/fibula: Runners
Proximal humerus: Baseball pitchers
Slipped Capital Femoral Epiphysis (SCFE)
Slip direction generally posterior and medial
Results in appearance of widened physis and “short” capital epiphysis
Bilateral in 20-25% but need not be synchronous
Optimal age range: 8-14
Renal Osteodystrophy (Renal OD)
Combined findings of rickets and hyperparathyroidism (HPTH)
Rickets results in widening of physis
Watch for HPTH as well
Subperiosteal resorption
Subchondral resorption with collapse (particularly sacroiliac joints)
Rickets
Similar appearance, whether renal or nutritional etiology
Results from lack of mineralization of osteoid laid down at metaphyseal zone of provisional calcification
Widened physis, often with fraying of metaphyses
Decreased bone density, smudgy trabeculae
Helpful Clues for Less Common Diagnoses
Osteomyelitis
If metaphyseal osteomyelitis crosses physis, may result in slip of physis and appearance of widening
Watch for osseous destruction, periosteal reaction
Legg-Calvé-Perthes (LCP)
Osteonecrosis of femoral capital epiphysis
Increased density, flattening, fragmentation of epiphysis
Associated appearance of widened physis
Optimal age range: 4-8
Blount Disease
Fragmentation and abnormal ossification of medial tibial metaphysis
Focal “widening” of physis medially
Usually bilateral; results in tibia vara
Total Parenteral Nutrition
Premature infant dependent on total parenteral nutrition for long period of time
Diffuse widening of physes, thought to be due to nutritional deficiency of copper
Indistinguishable from rickets, though true rickets does not appear prior to 6 months of age
Gigantism
With overgrowth of gigantism, physes may appear mildly widened diffusely
Mucopolysaccharidoses
Delay in epiphyseal ossification may give appearance of relatively widened physis
Other manifestations: Fan-shaped carpus, oar-shaped ribs, narrow inferior ilium with steep acetabular roof
Osteogenesis Imperfecta (OI)
OI tarda may show physeal widening and mild slip of epiphyses
Other manifestations: Osteoporosis and more fractures than normally expected in a child
Hypophosphatasia
Nearly indistinguishable from rickets
Diffuse widening of physes
Osteopenia
Ranges from mild tarda form to severe destructive form
Bowing of long bones with excrescences may help differentiate from rickets
May have “button sequestra” in skull
Helpful Clues for Rare Diagnoses
Hypothyroidism
Severe retardation of skeletal maturation
Widened physes, short broad phalanges
Hip may show fragmentation of femoral capital epiphysis
Appearance may be similar to Legg-Calvé-Perthes; watch for abnormal bone age to differentiate
Infant shows stippled epiphyses
Scurvy
Osteopenia, with sclerotic metaphyseal line (white line of Frankel) and sclerotic rim of epiphysis (Wimberger sign)
Corner metaphyseal fracture may cause a slip and mild physeal widening
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