Long Bone, Metaphyseal Bands and Lines



Long Bone, Metaphyseal Bands and Lines


Cheryl A. Petersilge, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Growth Arrest Lines


  • Chronic Illness


  • Trauma


  • Normal Variant


  • Disuse Osteoporosis


  • Chemotherapy


  • Malnutrition or Prolonged Hyperalimentation


  • Hyperemia


  • Heavy Metal or Chemical Ingestion


  • Rickets


  • Radiation


Less Common



  • Leukemia


  • Juvenile Idiopathic Arthritis (JIA)


  • Ankylosing Spondylitis


  • Complications of High Dose Drug Therapy (Non-Chemotherapeutic)


  • Metastases


  • Osteoporosis


Rare but Important



  • Complications of Vitamin D


  • Osteopetrosis


  • Hypothyroidism, Treated


  • Complications of Fluoride


  • Hypoparathyroidism


  • Pseudohypoparathyroidism


  • Idiopathic Hypercalcemia


  • Scurvy


  • Congenital Infection


  • Aminopterin Fetopathy


  • Hypophosphatasia


  • Erythroblastosis Fetalis


  • Osteopathia Striata


  • Primary Oxalosis


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Manifestations include: Dense horizontal bands (DB), lucent bands (LB), alternating dense and lucent bands (AB), vertical dense bands (VB)



    • AB indicate multiple insults separated in time


  • Most are systemic, involve multiple physes



    • Especially at knee, wrist (sites of greatest growth)


  • Isolated physeal involvement: Trauma, radiation, metastatic disease, disuse osteoporosis, hyperemia


Helpful Clues for Common Diagnoses



  • Growth Arrest Lines



    • DB, VB: Sharply defined, thin dense lines


    • Variable distance from metaphysis depending on age of insult


    • Underlying insult may not be identifiable


  • Chronic Illness



    • LB, VB: Any illness, including sickle cell anemia, rickets, osteogenesis imperfecta, neoplasm


    • LB: Nonspecific manifestation of illness


    • May develop DB during healing


  • Trauma



    • LB: Acute injury, early healing


    • DB, VB: Healing Salter fractures, chronic injury, stress fracture



      • ± metaphyseal cupping/fraying


  • Normal Variant



    • DB, LB: Otherwise normal skeleton


    • Normal fibula helps differentiate from other conditions, such as lead poisoning


  • Disuse Osteoporosis



    • LB: Regional distribution


  • Chemotherapy



    • LB, VB


  • Malnutrition or Prolonged Hyperalimentation



    • LB


  • Hyperemia



    • LB: Bone resorption leads to osteoporosis


    • Arthritis, infection


  • Heavy Metal or Chemical Ingestion



    • DB, AB: Lead most common; lines are late manifestation


  • Rickets



    • LB, VB (healing): Manifestation of bone resorption of hyperparathyroidism


  • Radiation



    • VB, LB, DB; ± physeal widening, fraying


    • DB, AB during healing


Helpful Clues for Less Common Diagnoses



  • Leukemia



    • LB: May also see osteolytic lesions, periostitis


    • DB, during healing


    • 2-5 years old


  • Juvenile Idiopathic Arthritis (JIA)



    • LB due to hyperemia and chronic illness



    • Monoarticular to symmetric polyarticular


    • Uniform joint space narrowing, marginal erosions, periostitis


  • Ankylosing Spondylitis



    • LB due to osteoporosis, hyperemia


    • Anterior and posterior spinal fusion


    • Symmetric sacroiliitis


    • Hip, shoulder arthritis; enthesopathy


  • Complications of High Dose Drug Therapy (Non-Chemotherapeutic)



    • DB


  • Metastases



    • LB, DB (during healing), especially neuroblastoma, lymphoma



      • Osteolytic lesions and periostitis from direct tumor invasion


  • Osteoporosis



    • LB: Juvenile idiopathic, Cushing disease


Helpful Clues for Rare Diagnoses

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Long Bone, Metaphyseal Bands and Lines

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