Long Bone, Epiphyseal, Irregular or Stippled



Long Bone, Epiphyseal, Irregular or Stippled


B. J. Manaster, MD, PhD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Normal Variant in Child (Mimic)


  • Osteonecrosis


  • Legg-Calvé-Perthes (LCP)


  • Juvenile Idiopathic Arthritis (JIA)


Less Common



  • Rickets


  • Hypothyroidism


  • Osteomyelitis


  • Complications of Warfarin (Coumadin)


  • Chondrodysplasia Punctata


  • Trevor Fairbank (Dysplasia Epiphysealis Hemimelica)


  • Spondyloepiphyseal Dysplasia


  • Nail Patella Disease (Fong)


Rare but Important



  • Thermal Injury, Frostbite


  • Complications of Dilantin


  • Hypoparathyroidism


  • Hyperparathyroidism


  • Hypopituitarism


  • Acromegaly


  • Trisomy 18


  • Down Syndrome (Trisomy 21)


  • Fetal Alcohol Syndrome


  • Mucopolysaccharidoses


  • Multiple Epiphyseal Dysplasia


  • Pseudoachondroplasia


  • Homocystinuria


  • Ollier Disease/Maffucci (Mimic)


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • May be able to separate into irregular vs. stippled epiphyses



    • Common diagnoses for “irregular” epiphyses



      • Normal variant, knee


      • Osteonecrosis


      • Legg-Calvé-Perthes


      • Juvenile idiopathic arthritis


      • Rickets


      • Osteomyelitis


      • Trevor Fairbank


      • Spondyloepiphyseal dysplasia


    • Common diagnoses for “stippled” epiphyses



      • Hypothyroidism


      • Warfarin embryopathy


      • Chondrodysplasia punctata


Helpful Clues for Common Diagnoses



  • Normal Variant in Child (Mimic)



    • Seen in adolescents


    • Located on posterior aspect of femoral condyles



      • Seen best on AP notch view, which profiles posterior femoral condylar surface


      • Generally not visible on regular AP view


      • May be seen on lateral


    • MR shows overlying cartilage to be normal


    • Do not confuse with pathologic process, such as osteochondral injury or JIA


  • Osteonecrosis



    • Prior to significant flattening, may see punctate fragments in bed site of necrosis


  • Legg-Calvé-Perthes (LCP)



    • Femoral head osteonecrosis in child (usual age range 4-8 years)


    • Capital epiphyseal flattening, increased density, fragmentation


    • Results in coxa magna deformity


  • Juvenile Idiopathic Arthritis (JIA)



    • “Crenulated” irregularity of carpal bones


    • Irregularity on femoral condylar articular surface


Helpful Clues for Less Common Diagnoses



  • Rickets



    • True abnormality is metaphyseal/physeal widening and fraying


    • With weakened physis, epiphysis may slip, resulting in irregularity and fragmentation


  • Hypothyroidism



    • Infant: Stippled epiphyses


    • Toddler: Severe delay in skeletal maturation



      • Fragmentation of femoral capital epiphysis


  • Osteomyelitis



    • Prenatal or childhood infections may cross from metaphysis to involve epiphysis



      • Epiphysis may slip


      • Destructive change results in irregularity, fragmentation


  • Complications of Warfarin (Coumadin)



    • Maternal ingestion during early pregnancy


    • Stippled epiphyses


    • Hypoplastic nose, eye malformations, mental retardation



  • Chondrodysplasia Punctata



    • Stippled epiphyses


    • Nonrhizomelic type: Conradi Hunermann; nonlethal & autosomal dominant


    • Rhizomelic type: Lethal autosomal recessive; multiple other abnormalities


  • Trevor Fairbank (Dysplasia Epiphysealis Hemimelica)



    • Cartilaginous proliferation at epiphysis



      • Considered analogous to epiphyseal osteochondroma


    • Irregular lobulations superimposed on epiphyses


    • Lower limb (knee, ankle, hip) most frequently affected


    • May be polyarticular


    • Monomelic


  • Spondyloepiphyseal Dysplasia



    • Group of disorders resulting in short trunk dwarfism


    • Congenita and tarda forms, with spectrum of abnormalities


    • Platyspondyly


    • Generalized delay in epiphyseal ossification


    • Once epiphysis forms, it is flattened and irregular


    • May have metaphyseal flaring


    • Develops coxa vara, genu valgum


    • Early osteoarthritis


  • Nail Patella Disease (Fong)

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Long Bone, Epiphyseal, Irregular or Stippled

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