2018 SPR Annual Meeting & Postgraduate Course May 15-19, 2018 • Nashville, Tennessee

Differential Diagnosis for Findings on Skeletal Survey vs. Child Abuse Jeannie K. Kwon, M.D. University of Texas Southwestern Children’s Health Dallas, TX

Value-added Pediatric Radiology Objectives • Review features of entities that have findings resembling child abuse on skeletal survey Topics • Normal variants • Menkes Syndrome • Osteogenesis Imperfecta • Birth injury/Iatrogenic • Skeletal dysplasias • Congenital syphilis – Metaphyseal chondrodysplasia, Schmid • Copper deficiency type – Spondylometaphyseal • Scurvy dysplasia, Sutcliffe/corner • Rickets (next talk!) fracture type

Normal Variants • Contour changes of the metaphysis: Step-off, Beak, Spur – Distinguishable from metaphyseal abuse injuries – No radiolucent separation between fragment and metaphysis • Proximal Tibial Cortical Irregularity

• Kleinman PK, Belanger PL, Karellas A, Spevak MR. AJR Am J Roentgenol. 1991 Apr;156(4): 781-3. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse.

Normal Bone bark metaphysis = perichondral collar resorption of trabeculae = subperiosteal bone collar bone collar extends = ring of Lacroix to form spur Primary spongiosa = mineralized cartilage in the primary developing metaphysis. bone collar spongiosa The adjacent metaphyseal margin is formed by the trabeculae of the primary spongiosa, which have been exposed by osteoclastic resorption (curved arrow).

Kleinman PK. Pediatr Radiol (2008) 38 (Suppl 3):S388-S394. Normal variant: Metaphyseal step -off

• Indistinct cortical margin and focal paucity of cortical bone due to subperiosteal bone collar • 90 degree cortical angulation at metaphysis near physis

Normal variants: Metaphyseal step -off

14 mo 9 mo Normal variant: Beak • Medial projection of metaphysis – Proximal humerus (16%) – Proximal tibia (1%) – Bilateral (77%)

Normal variant: Beak

Kleinman PK, et. Al. AJR Am J 3 mo Roentgenol. 1991 Apr;156(4): 781-3. Normal variant: Beak

14 mo Normal variant: Spur • Discrete linear projection of bone • Extension of bone bark around unossified physis • Continuous with the cortex • Extends beyond metaphyseal margin beneath perichondrial ring

Normal variant: Spur

2 mo, from Kleinman PK, et. Al. AJR Am J 3 mo Roentgenol. 1991 Apr;156(4): 781-3. Normal variant: Proximal Tibial Cortical Irregularity • Medial projection of metaphysis – 4% – Bilateral 25% • –May be associated with physiologic periosteal reaction

Normal variant: Proximal Tibial Cortical Irregularity

1 mo, from Kleinman PK, et. Al. AJR Am J 3 mo Roentgenol. 1991 Apr;156(4): 781-3. Osteogenesis Imperfecta Osteogenesis Imperfecta

• Heterogeneous group of genetic mutations controlling collagen synthesis • Most common disease causing fracture predisposition • Variable presentation and severity, mild to perinatal lethal – Blue sclera – Hearing loss – Dentinogenesis imperfecta – Kyphoscoliosis  respiratory complications – In utero fractures • COL1A1, COL1A2, and IFITM5 gene testing Osteogenesis Imperfecta

Mild, nondeforming Perinatal lethal Severe, progressively deforming

Marini, J. C., A. Reich, et al. (2014). "Osteogenesis imperfecta due to mutations in non-collagenous genes: lessons in the biology of bone formation." Curr Opin Pediatr 26(4): 500-507 Osteogenesis Imperfecta Osteogenesis Imperfecta

9 mo Irritability with diaper change, Older sister with unexplained fractures.

Osteogenesis Imperfecta 2 mos later Return to ED with “neck pain”

Osteogenesis Imperfecta 2 mos later From Return to ED prior with “neck skeletal pain” survey

Osteogenesis Imperfecta 2 mos later From Return to ED prior with “neck skeletal pain” survey

Osteogenesis Imperfecta 2 mos later Return to ED with “neck pain”

OI type VI SERPINF1

Osteogenesis Imperfecta

OI type III Severe, progressively deforming COL1A2 Dysplasias Dysplasias • Most dysplasias with metaphyseal irregularities present with notable clinical, radiologic or laboratory findings • Exceptions – Metaphyseal chondrodysplasia, Schmid type – Spondylometaphyseal dysplasia, Sutcliffe/corner fracture type • Follow-up skeletal survey will not change Dysplasias – Metaphyseal chondrodysplasia, Schmid type • Autosomal dominant • Non-familial cases present > 1yo or later • Enlarged capital femoral epiphysis • Pelvis almost always normal • coxa vara • distal ≥ proximal femoral metaphysis involved • anterior rib changes • Normal spine, metacarpals, phalanges

Dysplasias – Metaphyseal chondrodysplasia, Schmid type

• 11 mo • Enlarged femoral heads • Normal pelvis

Lachman, R. S. Pediatric radiology 18.2 (1988): 93-102. Dysplasias – Metaphyseal chondrodysplasia, Schmid type • 3 yo • Enlarged femoral heads • coxa vara • distal ≥ proximal femur • Femoral bowing

Lachman, R. S. Pediatric radiology 18.2 (1988): 93-102. Dysplasias – Metaphyseal chondrodysplasia, Schmid type

• 8 yo • Anterior rib changes • Normal spine

Lachman, R. S. Pediatric radiology 18.2 (1988): 93-102. Dysplasias – SMD Sutcliffe/ Corner-fracture type Dysplasias – SMD Sutcliffe/ Corner-fracture type • Skeletal changes become more pronounced as patient becomes weight-bearing • Predominant: metaphyses of long bones • Subtle: vertebral bodies

Dysplasias – SMD Sutcliffe/ Corner-fracture type • Predominant: long bone metaphyses – Metaphyseal irregularity and sclerosis, "fracture-like" – Marked bilateral coxa vara, nearly vertically oriented physes – Tibia vara/Blount disease- like change Dysplasias – SMD Sutcliffe/ Corner-fracture type • Subtle: vertebral bodies – Mild biconvex vertebral endplates – Very mild platyspondyly – Odontoid hypoplasia

Menkes Syndrome Menkes Syndrome • AKA Kinky hair disease • X-linked recessive • Prevalence 1 in 100,000-250,000 • Symptoms appear in infancy; mild forms in childhood Erik N. Swartz CMAJ 2002;166:1442-1443 Menkes Syndrome • Disorder of copper transport from intestinal cells • Neurodevelopmental/ growth delay • Hypotonia • Seizures • Scant, stubby, coarse, yellow/white hair

Credit: Alila Medical Media/Shutterstock.com Menkes Syndrome • Metaphyseal widening, spurs • Long bone fractures • Wormian occipital bones • Hydronephrosis • Ureteral dilatation • Bladder diverticula • Tortuous intracranial arteries • Cerebral and cerebellar atrophy • Chronic subdural hemorrhages

Menkes Syndrome • Metaphyseal spurs, fractures, irregularity, • Periosteal new bone formation

3 mo with seizures Menkes Syndrome

3 mo: atrophy tortuous intracranial arteries Wormian bones Birth injury/Iatrogenic Birth injury • Correlate with age, expected healing ~10 days • Metaphyseal fracture, Epiphyseal separation – Breech, armling presentation • Long bone shaft fracture – Caesarean section • Clavicle fracture – High birth weight, cephalic presentation Iatrogenic • Club foot deformity manipulation and casting

Kleinman PK. Pediatr Radiol (2008) 38 (Suppl 3):S388-S394. Iatrogenic

• VACTERL • Vertebral body anomalies • Imperforate anus • Renal agenesis • Anhydramnios • Pulmonary hypoplasia • PROM at 20 weeks • Born at 27 weeks • L knee contracture • (outside institution) Iatrogenic Congenital syphilis Congenital Syphilis • Transplacental infection by Treponema pallidum spirochete • Disseminated throughout fetus • 1/3 stillbirth; 1/3 contracts; 1/3 unaffected • +/- symptomatic at birth Congenital Syphilis • Periostitis – Mild  severe • Osteitis – Localized  diffuse • Metaphysis – Dense/lucent/alternating – Serrations – Exuberant callus – Wimberger’s sign – focal prox tib

Rasool MN, Govender S. The skeletal manifestations of congenital syphilis. A review of 197 cases. Bone & Joint Journal. 1989 Nov 1;71(5):752-5. Congenital Syphilis

2 mo – Periostitis – Osteomyelitis • Pathologic fractures • Metaphysis • Diaphysis

Lim HK, Smith WL, Sato Y, Choi J. Congenital syphilis mimicking child abuse. Pediatric radiology. 1995 Sep 1;25(7):560-1.

Congenital Syphilis

• Early congenital syphilis • Late congenital syphilis – Prematurity – Saddle nose – Hepatosplenomegaly, – Sabre shin jaundice – Frontal bossing – Nasal chondritis, “runny – Hutchinson’s triad nose” • Hutchinson’s teeth – Generalized • Interstitial keratitis lymphadenopathy • CN VIII deafness – Maculopapular rash Congenital Syphilis

36 week preterm newborn, mother RPR+ Copper deficiency Copper Deficiency

• Copper required for endochondral bone, collagen • Rare: ~100 cases in 1987 • Full term infants body stores sufficient for 5-6 months • Low birth weight infants have 2 months • Modern formulas and breastfeeding should not cause • Plasma copper < 40 μg/dl • Ceruloplasmin < 13 mg/dl • Other clinical findings: sideroblastic anemia, neutropenia, hypotonia, psychomotor retardation, pallor

Copper Deficiency

• 5 mo with irritability • Bilateral metaphyseal irregularity and lucency • Loss of cortical sharpness • Midshaft bowing • Metaphyseal cupping • Metaphyseal spurs in medial distal femurs • Osteopenia • Increased density in zone of provisional calcification

5 mo, from Christian, States. AJR Am J Roentgenol. 2017 May;208(5): 982-90. Scurvy Scurvy • Hypovitaminosis C • Bleeding tendency • Impaired collagen synthesis • Osteoporosis • Impaired wound healing Scurvy • Osteopenia • “pencil point” Cortical thinning • Trummerfeld zone (“field of rubble”) metaphyseal lucencies • Pelkan spur causing metaphyseal cupping • Frankel line: dense zone of provisional calcification Scurvy

Trummerfeld zone Frankel line

Pelkan’s spur

Noordin, Shahryar, et al. Case reports in orthopedics 2012 (2012). Topics • Normal variants • Menkes Syndrome • Osteogenesis Imperfecta • Birth injury/Iatrogenic • Skeletal dysplasias • Congenital syphilis – Metaphyseal chondrodysplasia, Schmid • Copper deficiency type – Spondylometaphyseal • Scurvy dysplasia, Sutcliffe/corner fracture type References

• Christian CW, States LJ. Medical mimics of child abuse. American Journal of Roentgenology. 2017 May;208(5):982-90. • Kleinman PK. Problems in the diagnosis of metaphyseal fractures. Pediatric radiology. 2008 Jun 1;38(3):388. • Kleinman PK, Belanger PL, Karellas A, Spevak MR. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. AJR. American journal of roentgenology. 1991 Apr;156(4):781-3. Dwek JR. The radiographic approach to child abuse. Clinical Orthopaedics and Related Research®. 2011 Mar 1;469(3):776-89. • Lachman RS, Rimoin DL, Spranger J. Metaphyseal chondrodysplasia, Schmid type clinical and radiographic deliniation with a review of the literature. Pediatric radiology. 1988 Feb 1;18(2):93-102. • Langer Jr LO, Brill PW, Ozonoff MB, Pauli RM, Wilson WG, Alford BA, Pavlov H, Drake DG. Spondylometaphyseal dysplasia, corner fracture type: a heritable condition associated with coxa vara. Radiology. 1990 Jun;175(3):761-6. • Lim HK, Smith WL, Sato Y, Choi J. Congenital syphilis mimicking child abuse. Pediatric radiology. 1995 Sep 1;25(7):560-1. • Marini JC, Reich A, Smith SM. Osteogenesis Imperfecta due to Mutations in Non-Collagenous Genes-Lessons in the Biology of Bone Formation. Current opinion in pediatrics. 2014 Aug;26(4):500. Noordin S, Baloch N, Salat MS, Rashid Memon A, Ahmad T. Skeletal manifestations of scurvy: a case report from Dubai. Case reports in orthopedics. 2012;2012. • Rasool MN, Govender S. The skeletal manifestations of congenital syphilis. A review of 197 cases. Bone & Joint Journal. 1989 Nov 1;71(5):752-5. • Stephens JR, Arenth J. Wimberger sign in congenital syphilis. The Journal of pediatrics. 2015 Dec 1;167(6):1451.